|Year : 2020 | Volume
| Issue : 4 | Page : 138-142
Management of plaque psoriasis through ayurvedic treatment approaches: A case report
Meenakshi Sharma1, Sisir Kumar Mandal2
1 Department of Rog Nidana Evum Vikriti Vigyan, All India Institute of Ayurveda, Sarita Vihar, New Delhi, India
2 Department of Vikriti Vigyan, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh, India
|Date of Submission||30-May-2020|
|Date of Acceptance||20-Jan-2021|
|Date of Web Publication||18-Mar-2021|
Dr. Sisir Kumar Mandal
Professor, Department of Vikriti Vigyan, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Psoriasis is a chronic autoimmune condition caused due to rapid over-production of new skin cells resulting in scaling. Inflammation and redness around the scales are common. Among all types of psoriasis, plaque psoriasis makes up 90% of cases. Its contemporary treatment has some limitations thus affecting quality of life of patients. In this report, the management of a diagnosed case of plaque psoriasis is presented. The patient was treated through Ayurvedic multimodal approach using Shamana chikitsa (~pacifying therapy) including oral administration of decoctions, medicated ghee and external application of medicated coconut oil processed in presence of leaves of Shweta kutaja (Wrightia tinctoria Roxb.), Eranda taila (~castor oil) and Dadhi (~curd). Although Shodhana is treatment of choice in Kushta (~skin diseases) considering age factor of the patient, Shamana chikitsa was planned. Significant relief was noticed with no relapses until after six months of follow-up inferred efficacy of Ayurvedic protocol in the management of such autoimmune disorders.
Keywords: Eka kushta, Mahatikta ghrita, Psoriasis, Shamana, Udvartana
|How to cite this article:|
Sharma M, Mandal SK. Management of plaque psoriasis through ayurvedic treatment approaches: A case report. J Ayurveda Case Rep 2020;3:138-42
|How to cite this URL:|
Sharma M, Mandal SK. Management of plaque psoriasis through ayurvedic treatment approaches: A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Oct 27];3:138-42. Available from: http://www.ayucare.org/text.asp?2020/3/4/138/311501
| Introduction|| |
Psoriasis is a chronic proliferative and inflammatory condition of the skin. It is characterized by erythematous plaques covered with silvery scales particularly over the extensor surface, scalp, and lumbosacral region., It affects approximately 0.5%–3% of the general population making it a global health burden. The exact etiology is unknown but considered it to be auto immune disease mediated by T lymphocytes. It has strong psychosocial impact, interfering with patient's quality of life. There are several subtypes of psoriasis but plaque type is most common and lesions occurs on trunk, extremities, and scalp. Systemic therapies (corticosteroids, methotrexate, and cyclosporine) constitute its treatment in contemporary science that may cause cumulative toxicity of organs along possibilities of drug interactions.
In Ayurveda, Psoriasis can be correlated to Eka kushta, which is a type of Vata-kapha predominant manifestation characterized by symptoms such as Aswedanam (~absence of sweating), Mahavastu (~extensive lesions), Matsyasha kalopama (~silvery scales like fish), and Krishna aruna varna (~reddish black coloured patches). Classics explained the Nidana (~causative factor) of Eka kushta as consumption of Viruddha ahara (~incompatible food), Vega dharana (~suppression of natural urges), following Diva svapa (~day sleep) and Papakrma (~indulgence in sinful acts) indulgence in sinful acts etc. Herein, a case of plaque psoriasis was managed through Ayurvedic approaches considering the case of Eka kushta.
| Case Report|| |
A 72-year-old male, farmer, presented with chief complaints of red patches with scaling and itching on abdomen and chest since 5 years. He developed a small red circular patch on chest. Gradually such patches were developed on abdomen with severe itching and scaling those later turned to silvery in appearance. The condition was diagnosed as plaque psoriasis by dermatologist and treatment (corticosteroids, methotrexate) was given for three years, but the patient got no significant relief. No history of diabetes, hypertension or any major illness was found. No any drug allergy or previous surgery was reported. No history of addiction of alcohol, smoking or any other drugs was found. Appetite and thirst was normal. Sleep was disturbed due to severe itching. Bowels were sometime constipated, while bladder was regular.
Atura bala pramana (~strength of individual) was assessed by Dashavidha atura pariksha (~ten-fold examination of patient). Prakriti (~constitution) of patient was Kapha-vataja; Sara (~proper nourishment of tissue), Samhanana (~body built), Pramana (~body proportion), Ahara and Jarana shakti (~digestive and metabolic capacity) and Satva (~psychological strength) were Madhyama (~medium); Vyayama shakti (~physical strength), Satmya (~compatibility) and Vaya (~age) were Avara (~low); Vikriti (~morbidity) was Vata-kaphaja.
Doshik dominance was Vata-kapha. Dushya (~vitiated dhatus) were Tvak (~skin), Rakta (~blood), Mamsa (~muscle tissue), Ambu (~blood plasma); Srotas (~channels) involved were Rasavaha (~channels carrying plasma and lymphatics), Raktavaha (~channels carrying blood). Adhisthana (~source of origin) of disease was Tvak; Agni (~digestive and metabolic capacity) was Manda (~mild) and Svabhava (~nature of disease) of disease was Chirakari (~chronic).
Patient was fair and afebrile. Vitals were normal. Pallor, icterus, clubbing, cyanosis, and lymphadenopathy were absent. Examination of cardiovascular, respiratory, urinary, and central nervous systems revealed no abnormality.
Examination of skin revealed reddish scaly papules over abdomen and chest. Presentation was asymmetrical. The patches were well demarcated. Auspitz sign, Koebner's phenomenon and Candle grease sign were present. Patches were dry with rough surface, firm, and slightly elevated.
On the basis of observed symptoms, the case was diagnosed as Eka kushta.
| Timeline|| |
Considering involved Dosha and Dushyas, patient was given Shamana chikitsa (~pacifying therapy) along with dietary restrictions (excessive sour, salty, spicy and junk and packaged food, curd, jaggery, meat, fish, sesame seed, etc.). He was advised to avoid day sleep and suggested to maintain personal hygiene. He was prescribed medicines for oral and topical applications [Figure 1]. The assessment was done before treatment, after treatment and after follow-up to evaluate efficacy of treatment [Table 1].
| Follow up and outcome|| |
The patient was taking corticosteroids that were withdrawn gradually during treatment. After one month of treatment, the patient showed considerable relief in itching, scaling, and healing of old lesions with complete cessation of new lesions [Graph 1]; [Figure 2] and [Figure 3]. Auspitz sign, Koebner's phenomenon and Candle grease signs were absent after one month treatment. He was advised to continue same treatment for the next two months. By the end of third month, marked healing in lesions and associated symptoms with no recurrence was noticed. Further, he was advised to continue Mahatikta ghrita and Udvartana for one more month to maintain skin health. The medicines were stopped after this period. The patient was advised to follow the dietary restriction. He was further follow-up for the next six months. After completion of the follow-up, scaling, itching, and erythema were totally subsided with no signs of relapse [Graph 1] and [Figure 4].
| Discussion|| |
The main causative factors in manifestation of pathology of Eka kushta are Vata-kapha pradhana tridosha that vitiates Tvak, Rakta, Mamsa and Lasika. Consumption of Nidana, leads to simultaneous vitiation of Doshas and Shaithilyata (~derangement) in Dhatus (Tvak, Rakta, Mamsa and Lasika). Vitiated Doshas further affect Shithila dhatus leading to manifestation of kushta. In present case unwholesome diet (milk and salt, curd in excess, excessive salty and sour food items) and sleeping during the day time by the patient might triggered the vitiation of Doshas that possibly lead the manifestation of Eka kushta. Exact mechanism of such pathogenesis in modern terms need to be understood. Based on involved Dosha and Dushya in this present case, Vata-kapha shamaka (~ pacifying Vata and Kapha) treatment was given along with Pathya (~wholesome) diet including light easily digestible food, vegetables having bitter taste like pointed gourd, bitter guard, and neem patra, pulses such as red lentil, red gram, green gram, and old cereals.
Probable mode of action of interventions
Punarnava (Boerhavia diffusa L.) has Madhura, Tikta, and Kashaya rasa (~sweet, bitter, astringent taste), Laghu, Ruksha guna (~light, dry properties), Ushna virya (~hot potency), Katu vipaka (~pungent as end taste of digestion). It pacifies Vata dosha due to Madhura rasa and Ushna virya and Kapha dosha due to Tikta and Kashaya rasa, Ushna virya, Katu vipaka and Laghu, ruksha guna. Punarnava is Shothahara (~anti-inflammatory) and Vata kaphahara (~pacify Vata and Kapha dosha). Acharya sushruta also explained Shothnashaka and Vatashamaka quality of green leaves of Punarnava. Studies suggested its immune-modulatory, anti-oxidant, hepatoprotective, anti-inflammatory, and anti-proliferative effect.
Manjistha (Rubia cordifolia L.) possess Tikta, Kashaya and Madhura rasa; Guru, Ruksha guna; Ushna virya and Katu vipaka. It is Kapha shamaka (~pacify Kapha) due to Tikta, Kashaya rasa; Ushna virya and Katu-vipaka while Pitta shamaka due to Madhura, Tikta, Kashaya rasa; Guru and Ruksha guna. Therapeutic indications of Manjistha enumerated in Ayurvedic text are Varnya (~improves complexion), Kushtaghna (~anti-leprotic), Rakta sodhaka (~blood purifier), Krimighna (~ anti-microbial), Shothahara, Vedana sthapaka (~analgesic) and Shonita sthapaka (~anti-coagulant). Studies have reported analgesic, anti-inflammatory, anti-microbial, anti-oxidant, anti-cancer activities of Manjistha.,
Guduchi [Tinospora cordifolia (Willd.) Hook. f. and Thoms] has Tikta, Kashaya rasa; Laghu, Snigdha guna; Ushna virya and Madhura vipaka. It has Tridosha shamaka, Jvaraghna (~anti-pyretic), Krimighna, Kushtaghna, Vishaghna (~antidote) and Rasayana (~rejuvenative) effect. Studies demonstrated anti-inflammatory, immunosuppressive, anti-leprotic, anti-ulcer, anti-oxidant, hepatoprotective and immunomodulatory properties of Guduchi.
Mahatikta ghrita is well known formulation having superior Kushtaghna property and Vata-pitta shamaka effect. It removes Kleda (~stickiness) leading to Sroto shodhana (~cleansing micro channels), pacifies vitiated Doshas and thus breaks pathogenesis of Eka kushta.
Dadhi has Snigdha, Guru guna and Ushna virya, which attributes toward its Vata pacifying action. Local application of curd helps in preventing dryness and scaling. It possess anti-microbial potential that is revealed by clinical studies.
Eranda taila (Ricinus communis L.) possess Sukshma (~subtle), Tikshna (~sharp), Sara (~mobile) and Snigdha (~oily) Guna (~quality); Ushna virya; Madhura vipaka and Vata-kapha shamaka effect. Due to Sukshma, Sara and Tikshna guna, it quickly enters into micro-channels and reduce local symptoms like Daha (~burning sensation), Raga (~erythema) and Kandu (~itching). Anti-inflammatory, analgesic and wound healing potential of castor oil is well documented through clinical studies.
Medicated coconut oil processed in presence of Shweta kutaja (Wrightia tinctoria Roxb.) leaves was chosen for topical application. Coconut oil is proven to have anti-inflammatory and skin protective potential. The moisturizing and emollient effect of coconut oil reduces itching, dryness and redness in the lesion. Moreover, it acted as a vehicle for medicine to cross the skin barrier. The leaf extract of W. tinctoria showed prominent anti-psoriatic and anti-oxidant activities in all the essays, hence used for treatment of psoriasis.
Udvartana yoga (powders of Haridra [Curcuma longa L.], Vacha [Acorus calamus L.], Krishna tila [Sesamum indicum L.] and Sarshapa [Brassica nigra L.] in equal proportion) with Sarshapa taila (~mustard oil) was used for massage at morning time before bath. Dryness and scaling are the most common symptoms of psoriasis, hence, Snigdha udvartana (~herbal powder mixed with oil) was chosen. Udvartana possess Kapha hara, Vata hara, Stheerikaranam anganam (~provide stability to body parts), Tvak prasadakaram (~rejuvenates the skin), Kanduharam (~alleviates itching), Malaharam (~removes dirt and dust), Swedaharam (~removes sweat), Sharira parimarjana (~cleanses the body) effects. It increases blood supply of superficial fascia, reduces congestion and associated symptoms like erythema and itching.
| Conclusion|| |
The case proved potential of ayurveda management through Shamana modalities in Psoriasis where Panchakarma therapies are contra-indicated. The treatment significantly controlled the symptoms of psoriasis in short span of time with no relapse even after six months of follow-up period. No untoward effects were noticed with the medicines during the treatment period, inferring safety aspects in the given condition. However, efficacy is needed to be studied in larger samples to reach up to any conclusion. This case has provided some leads toward the application of Shamana treatment approaches in the management of psoriasis that is a hope for all such patients, who are not eligible for Panchakarma.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Elman SA, Weinblatt M, Merola JF. Targeted therapies for psoriatic arthritis: An update for the dermatologist. Semin Cutan Med Surg 2018;37:173-81.
Yiu ZZ, Warren RB. Ustekinumab for the treatment of psoriasis: An evidence update. Semin Cutan Med Surg 2018;37:143-7.
Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Identification and Management of Psoriasis and Associated Comorbidity (IMPACT) Project Team. Global epidemiology of psoriasis: A systematic review of incidence and prevalence. J Invest Dermatol 2013;133:377-85.
Nguyen CT, Bloch Y, Składanowska K, Savvides SN, Adamopoulos IE. Pathophysiology and inhibition of IL-23 signaling in psoriatic arthritis: A molecular insight. Clin Immunol 2019;206:15-22.
Langley RG, Krueger GG, Griffiths CE. Psoriasis: Epidemiology, clinical features, and quality of life. Ann Rheum Dis 2005;64 Suppl 2:ii18-23.
Weidmann A, Foulkes AC, Kirkham N, Reynolds NJ. Methotrexate toxicity during treatment of chronic plaque psoriasis: A case report and review of the literature. Dermatol Ther (Heidelb) 2014;4:145-56.
Acharya JT, editor. Charaka Samhita of Charaka, Chikitsa Sthana. Ch. 7., Ver. 21. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 451.
Acharya JT, editor. Sushruta Samhita of Sushruta, Nidana Sthana; Ch. 5, verse 10. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 285.
Acharya JT, editor. Charaka Samhita of Charaka, Chikitsa Sthana; Ch. 7., Ver. 4-8. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 450.
Acharya JT, editor. Charaka Samhita of Charaka, Vimana Sthana. Ch. 8., Ver. 94. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 276.
Jain A, Mandal SK. Dissertation on Role of Raktaja Krimi in Pathogenesis of Kustha W.S.R. to Psoriasis. Jaipur: National institute of Ayurveda; 2016. p. 163-5.
Acharya JT, editor. Charaka Samhita of Charaka, Chikitsa Sthana. Ch. 7., Ver. 9-10. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 450.
Acharya JT, editor. Charaka Samhita of Charaka, Nidana Sthana. Ch. 5., Ver 3. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 216.
Sen GD, editor. Bhaishajya Ratnavali of Kaviraj Govind Das Sen edited with “Siddhiprada Hindi Commentary” by Prof. Siddhi Nandan Mishra, Shloka No. 372-378. Varanasi: Chaukhamba Surbharti Prakashan; 2016. p. 914-5.
Sharma PV, Dravyaguna Vijnana-II. Varanasi: Chaukhambha Bharti Academy; 2006. p. 631-3. [Reprint 2009].
Acharya JT, editor. Sushruta Samhita of Sushruta, Sutra Sthana. Ch. 46., Ver. 255. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 232.
Mungantiwar AA, Nair AM, Shinde UA, Dikshit VJ, Saraf MN, Thakur VS, et al
. Studies on the immunomodulatory effects of Boerhaavia diffusa
alkaloid fraction. J Ethenopharmacol 1999;65:125-31.
Olaleye MT, Akinmoladun AC, Ogunboye AA, Akindahunsi AA. Antioxidant activity and hepatoprotective property of leaf extracts of Boerhaavia diffusa
Linn against acetaminophen-induced liver damage in rats. Food Chem Toxicol 2010;48:2200-5.
Mishra S, Aeri V, Gaur PK, Jachak SM. Phytochemical, therapeutic, and ethnopharmacological overview for a traditionally important herb: Boerhavia diffusa
Linn. Biomed Res Int 2014;2014:808302.
Sreeja S, Sreeja S. An in vitro
study on antiproliferative and antiestrogenic effects of Boerhaavia diffusa
L. extracts. J. Ethnopharmacol 2009;126:221-5.
Sharma PV, Dravyaguna Vijnana-II. Varanasi: Chaukhambha Bharti Academy; 2006. p. 800-1. [Reprint 2009].
Sharma PV, Dravyaguna Vijnana-II. Varanasi: Chaukhambha Bharti Academy; 2006. p. 802. [Reprint 2009].
Shen CH, Liu CT, Song XJ, Zeng WY, Lu XY, Zheng ZL, et al
. Evaluation of analgesic and anti-inflammatory activities of Rubia cordifolia
L. by spectrum-effect relationships. J Chromatogr Biomed Life Sci 2018;1090:73-80.
Barlow R, Barnes D, Campbell A, Apente RK, Singh P. Antioxidant, anticancer and antimicrobial, effects of Rubia cordifolia
aqueous root extract. J Adv Biol Biotechnol 2015;5:6-14.
Sharma PV, Dravyaguna Vijnana-II. Varanasi: Chaukhambha Bharti Academy; 2006. p. 761-3. [Reprint 2009].
Pendse VK, Dadhich AP, Mathur PN, Bal MS, Madam BR. Anti-Inflammatory, immunosuppressive and some related pharmacological actions of the water extract of Neem Giloe (Tinospora cordifolia
): A preliminary report. Indian J Pharmacol 1977;9:221-4. [Full text]
Asthana JG, Jain S, Mishra A, Vijaykant MS. Evaluation of antileprotic herbal drug combinations and their combination with Dapsone. Indian Drugs 2001;38:82-6.
Bafna PA, Balaraman R. Anti-ulcer and anti-oxidant activity of pepticare, a herbomineral formulation. Phytomedicine 2005;12:264-70.
Bishayi B, Roychowdhury S, Ghosh S, Sengupta M. Hepatoprotective and immunomodulatory properties of Tinospora cordifolia
in CCl4 intoxicated mature albino rats. J Toxicol Sci 2002;27:139-46.
Tripathi B, editor. Ashtanga Hridyam of Vagbhatta, Chikitsa Sthana. Ch. 19., Ver. 8-10. Varanasi: Chaukambha Surbharti Prakashana; Reprint 2018. p. 783.
Acharya JT, editor. Charaka Samhita of Charaka, Sutra Sthana. Ch. 27., Ver. 225-228. Varanasi: Chaukhambha Orientalia; Reprint 2018. p. 165.
Sharma C, Singh BP, Thakur N, Gulati S, Gupta S, Mishra SK, et al
. Antibacterial effects of Lactobacillus
isolates of curd and human milk origin against food-borne and human pathogens. 3 Biotech 2017;7:1-9.
Sharma PV, Dravyaguna Vijnana-II. Varanasi: Chaukhambha Bharti Academy; 2006. p. 58-60. [Reprint 2009].
Vieira C, Evangelista S, Cirillo R, Lippi A, Maggi CA, Manzini S. Effect of ricinoleic acid in acute and subchronic experimental models of inflammation. Mediators Inflamm 2000;9:223-8.
Varma SR, Sivaprakasam TO, Arumugam I, Dilip N, Raghuraman M, Pavan KB, et al
. In vitro
antiinflammatory and skin protective properties of Virgin coconut oil. J Tradit Complement Med 2019;9:5-14.
Dhanabal SP, Raj BA, Muruganantham N, Praveen TK, Raghu PS. Screening of Wrightia tinctoria
leaves for anti psoriatic activity. Hygeia 2012;4:73-8.
Tripathi B, editor. Ashtanga Hridyam of Vagbhatta, Sutra Sthana. Ch. 2., Ver. 15. Varanasi: Chaukambha Surbharti Prakashan; Reprint 2018. p. 32.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]