|Year : 2020 | Volume
| Issue : 1 | Page : 51-56
Chronic palmoplantar psoriasis management through Ayurveda: A case study
Swarnima Mishra, Abhay K Prajapati, Vitthal G huddar
Department of Kaya chikitsa, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||18-Mar-2020|
|Date of Decision||20-Apr-2020|
|Date of Acceptance||12-May-2020|
|Date of Web Publication||2-Jul-2020|
Dr. Swarnima Mishra
Department of Kaya Chikitsa, All India Institute of Ayurveda, New Delhi.
Source of Support: None, Conflict of Interest: None
Psoriasis is a chronic inflammatory skin ailment described by thickened, silvery-scaled patches. It has been related with inflammatory and immune mechanisms, probably associated with a genetic predisposition that can be triggered by stress. Psoriasis can badly influence the quality of life of patients. Various medicines are available, which may permit transient improvement and long-haul control of the sickness; however, these measures do not completely cure psoriasis. This study reports the case of a 58-year-old married male patient who presented at the skin outpatient department (OPD), All India Institute of Ayurveda, with severe palmoplantar psoriasis (PPP), and had been managed with Ayurveda medicines and three times of Virechana Karma (medicated purgation) along with control diet and yoga since the last 16 months. After adherence to prescribed treatment for the last 16 months, the patient responded with complete resolution of psoriatic patches on his body. The efficacy of treatment was measured by “Psoriasis Area and Severity Index (PASI)” scale. Total two assessments were carried out before starting Ayurveda treatment and after completion of 16 months of treatment based on the scoring of PASI, and it was found that the score reduced by 95.5%, from 9.1 to 0.4. Virechana Karma (medicated purgation) is very effective in providing relief in the signs and symptoms of chronic PPP. Hence, it may be concluded that classical Ayurveda measures are helpful to the patients with chronic PPP to achieve complete cure. Present findings can only be generalized when large sample study is undertaken.
Keywords: Ekakushtha, palmoplantar psoriasis, Psoriasis Area and Severity Index, Virechana
|How to cite this article:|
Mishra S, Prajapati AK, huddar VG. Chronic palmoplantar psoriasis management through Ayurveda: A case study. J Indian Sys Medicine 2020;8:51-6
|How to cite this URL:|
Mishra S, Prajapati AK, huddar VG. Chronic palmoplantar psoriasis management through Ayurveda: A case study. J Indian Sys Medicine [serial online] 2020 [cited 2020 Aug 14];8:51-6. Available from: http://www.joinsysmed.com/text.asp?2020/8/1/51/288804
| Key Messages:|| |
Virechana Karma (medicated purgation) is very effective in providing relief in the signs and symptoms of chronic PPP.
| Introduction|| |
Psoriasis is a typical, chronic, deforming, inflammatory, and proliferative state of skin, in which both hereditary and ecological impacts play a critical role. Beside skin, it influences nails and joints, and is currently being portrayed as a metabolic issue., The characteristic lesions consist of red, scaly, well-demarcated plaques, mainly over extensors and scalp. Prevalence of Psoriasis varies in different parts of the world. A study from tertiary health care centre in north India, showed that psoriasis accounted for 2.3% of all dermatology outpatients. Chronic plaque type psoriasis was found to be the most common type (90% cases), followed by palmoplantar psoriasis. Diagnosis of psoriasis is usually clinical as characterized by scaly patches with silvery scales, which are accentuated on scratching. PPP typically represents a difficult to treat variety of psoriasis, unlike plaque-type psoriasis. The thickened horny layer of palmar and plantar epidermis partially causes low bioavailability of classic topical anti-psoriatic drugs, hence the unsatisfactory results even after prolonged usage. The involvement of these sites may lead to a marked impairment of quality of life, interfering with work place activities, leisure, and social activities. For sustained relief, patients seek the help of physicians for various skin problems. PPP can be correlated with Ekakushtha. This report deals with a case of a patient with PPP, who underwent standard line of care from contemporary medicine with unsatisfactory results.
| Case Presentation|| |
A 58-year-old married man came to Kayachikitsa outpatient department (OPD) with complaints of severe itching, cracks, scaly lesion, with redness and thickening of the skin on both dorsal and ventral side, on bilateral hands, in scalp, and medial malleolus of left lower limb (Psoriasis Area Severity Index [PASI] score of 9.1) since last 3 years. At the time of the first visit in OPD, restricted movement of interphalangeal joint of bilateral hand was found due to thickening of skin in both hands. Flexion and extension of the fingers was painful (pain assessment done through Visual Analog Scale, and score was 4). No history of diabetes, hypertension, smoking, and other habits was noted. No history of such condition was observed in his family. The patient was not on any specific medications for any other illness for long time as such. No incidence of contact with any topical irritants was reported. The lesions on the both palms were gradually progressive, and the onset was insidious. The patient had visited a dermatologist before presenting to our health center, and was diagnosed as PPP and had taken allopathic medicines for the same for 2 years but did not get sustained and satisfactory relief. The lesions were present symmetrically on both the hands. The condition was progressive, and it started affecting the mental status of the patient. A rheumatologic assessment showed no clinical joint involvement, and the blood investigations for inflammation and infections were negative.
| Clinical Assessment|| |
On examination, the patient had bilateral well-demarcated erythema, hyperkeratosis, and desquamation [Figure 1]A–D. The patient was diagnosed as “PPP” on the basis of clinical signs and symptoms and dermatological examination, and according to Ayurveda, he was diagnosed as “Ekakushtha.” To measure the efficacy of treatment, “PASI” scale was used. Total two assessments were carried out (one before starting treatment and one after 16 months of completion of treatment [Table 3] and [Table 4], which were based on the scoring of PASI). PASI is the most widely used tools for the measurement of severity of psoriasis. The patient was strongly instructed to follow the suggested diet plan (not to take sour, spicy, and street food), along with regular yoga (keep continuing with Anuloma–Viloma and other pranayama with om chanting).
|Figures 1: Before treatment and after treatment. (A–D) Before treatment. (E–H) After first Virechana Karma. (I–L) After second Virechana Karma. (M–P) After third VirechanaKarma|
Click here to view
Ayurveda has included all the skin diseases under the name of Kushtha, and PPP is one among them, particularly Ekakushtha. Ekakushtha is characterized by Aswedanam (absence of sweating), Mahavaastu (affects a large area), and Yan-matsya-shakalo-pamam (presentation of skin-like the scales of fish, i.e., scaling). It is one among Kshudra Kushtha (minor skin disease) with Vata (one of three humors of body) and Kapha Dosha (one of three humors of body) involvement with Rakta Dushti (vitiated blood).
| Treatment and Management|| |
Initially treatment started with Shamana Aaushadhis (alleviating medicines to pacify vitiated bodily humors) to control the aggravating symptoms of the disease. As the specific features of Vata such as Rookshata (dryness), Parushyata (roughness), Arunavbhasata (redness), and Sankochanam (tightness) were clearly observed along with features such as Raaga (erythema) and Angavidaran (eruption of skin) of Pitta; treatment started with the interventional drug given in [Table 1].
First Shaman therapy was started which was continued for eight months after that Shodhan therapy (body purificatory procedures ) out of five Shodhan procedures, Virechana (medicated Purgation) chosen according to the involvement of Doshas in the formation of the disease. For Virechana Karma, the patient was admitted in the inpatient department (IPD) of All India Institute of Ayurveda (AIIA) for 14 days [Table 2].
|Table 2: Plan of Virechana (14 days procedure of medicated purgation therapy)|
Click here to view
After Virechana Karma, the patient was discharged from IPD and was suggested to start Samsarjana Karma (posttherapeutic diet regimen was Manda, Vilepi, Yusha, and Yavagu—rice preparations) for 3 days. Same treatment [Table 1] was continued after first Virechana Karma for 5 months. He got significant relief during 2 months of post Virechana treatment, and he continued the same medicines.
A drastic improvement was noticed in clinical symptoms immediately after 1 week of Virechana Karma. Itching, scaling, thickness, cracks, and contracture of fingers got reduced by 40% after first Virechana Karma. The size of lesions also reduced in both palms, sole, and scalp after first Virechana Karma [Figure 1E–H]. However, as the winter started, the disease started aggravating as this condition usually aggravates in winter season, and the Shamana Aaushadhi prescribed seem insufficient to manage the condition. This condition involves comparatively more vitiation of Doshas, That’s why repeated Shodhana procedure has been told. Hence, the second course of Virechana was planned in similar pattern, and the patient purged for 14 times; 70% relief in symptoms was seen after this course of Virechana. Reduction in redness, thickness/induration, scaling, and the percentage of area affected in both palms and soles was observed in the patient during follow-up [Figure 1I–L]. Shatavari Ghrita, Yashtimadhu Churna, Avipattikar Churna, Gandhak Rasayana, and Yasthimadhu Taila for local application were prescribed at the time of discharge (after second Virechana Karma). Along with internal medication, diet protocol and yoga suitable for the patient and the disease were advised to prevent the recurrence of disease. After 3 months of continuation of the aforementioned medications, third Virechana Karma was planned for the prevention of further disease aggravation, and for the suppression of the rest of the Doshas. A 95.5% resolution of the symptoms such as erythema, hyperkeratosis, and desquamation was marked after third Virechana Karma [Figure 1M–P]. After that, the patient was continued on immunity booster medications, that is, Rasayana Chikitsa (rejuvenation therapy) with Madhusnuhi Rasayana, Yasthimadhu Churna, Avipattikar Churna, Gandhak Rasayana, and Yasthimadhu Taila for local application, and follow-up of the patient was done regularly.
| Results|| |
Psoriasis with its lifelong remissions and exacerbations causes further mental stress to the patient (stress being one of the triggering factors also). When the patient first visited, his total PASI score was 9.1, and it reduced to 0.4 after the third Virechana. In severe psoriasis, 70% improvement is clinically meaningful improvement, indicative of success. In this case, Virechana Karma (medicated purgation) proved to be very effective in reducing PASI score by 95.5% (9.1 to 0.4), and providing relief in the signs and symptoms. However, to draw a conclusive inference to prove its public health significance, a larger trial should be carried out.
| Discussion|| |
This case report shows an approach to treat PPP with a unique blend of Virechana Karma (medicated purgation) and Ayurveda medicines. The Shamana Aushadhi comprised Shatavari Ghrita, which contains mainly Shatavari (Asparagus racemosus) that leads to substantial reductions in skin thickness, tissue weight, and also inflammatory cytokine production, neutrophil-mediated myeloperoxidase activity, and various histopathological indicators.Ghrita has a property such as Yogavahi, which is helpful in increasing the bioavailability of other drugs without losing its own property. Alcoholic extract of Operculina turpethum showed the presence of glycosides, saponins, flavonoids, steroids, and carbohydrates. Turpethin, an active chemical constituent present in O. turpethum, is mainly responsible for purgative action. Therefore, it removes toxic material from the body. It also has anti-inflammatory property.Guduchi (Tinospora cordifolia) is a rich source of trace elements (zinc and copper), which acts as antioxidant and protects cells from the damaging effects of oxygen radicals generated during immune activation. The anti-stress actions of Guduchi have made it therapeutically more important. It is clear that zinc affects multiple aspects of the immune system, from the barrier of the skin to the gene regulation within lymphocyte. It has been established that the application of free radical scavenging compounds has healing effect and property of protecting tissue from oxidative damage. Recently, antioxidant property of methanolic leaf extracts of Holarrhena antidysenterica (Kutaja) was found to scavenge superoxide ions and hydroxyl ions, and it reduced the capability of converting Fe3+ into Fe2+. Chitrakadi Vati contains Piper nigrum, Piper longum, and Plumbago zeylanica as major ingredients, which stimulates digestive fire. Roots of Chitraka (P. zeylanica) are best appetite stimulant (Deepana) and digestive (Pachana); therefore, it helps in the digestion of Ghrita and checks untoward events due to digestion during Snehapana. So Chitrakadi Vati was given before the administration of Ghrita. For the purpose of Snehapana (internal oleation), Tiktaka Ghrita was chosen to check Pitta, also Vata and Kapha Dosha. It was suggested that the drugs present in the Ghrita may have some affinity toward the target organ (skin). Snehapana by virtue of its vitiating nature of Dosha, separates toxins and vitiates Dosha out of the body at cellular level and helps to bring Doshas from Shakha (periphery of the body) to Koshta (center of the body, i.e., to the intestines), which later will be expelled out of the body by the Virechana. Nalpamaradi Taila (medicated oil) contains various ingredients, which have anti-inflammatory, antimicrobial activity, and its ingredient sandalwood, which has anti-inflammatory, antioxidant, and related properties, also helps in healing. Moreover, studies conducted have proved the healing, anti-ulcer, anti-inflammatory, and skin regeneration activity of Yasthimadhu (Glycyrrhiza glabra) Taila (oil). Sodium glycyrrhizinate possessed anti-ulcer activity and stimulation of regeneration of skin.Gandhaka Rasayana (sulfur preparation) is a proprietary drug used in treating skin diseases. In Capsule Imupsora, T. cordifolia is the main ingredient, and the plant T. cordifolia has been subjected to chemical investigations extensively, and a number of chemical constituents belonging to the different groups, namely terpenoids, alkaloids, lignans, and steroids have been reported. The compounds also give rise to significant increases in immunoglobulin G (IgG) antibodies in serum. Humoral and cell-mediated immunity is also independently enhanced. To maintain healthy state of patient, Madhusnuhi Rasayana was prescribed. It has antioxidant property, and immunomodulatory and adaptogenic action, and thus it is known to improve skin complexion and texture, increase the immunity to protect from the diseases, and help in preventing recurrence.
We would like to acknowledge and extend our heartfelt gratitude to Dr. Anil Kumar, Research Advisor, for thorough corrections in writing of this case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nisa N, Qazi MA. Prevalence of metabolic syndrome in patients with psoriasis. Indian J Dermatol Venereol Leprol 2010;76:662-5.
] [Full text]
Venkatesan A, Aravamudhan R, Perumal SK, Kannan R, Thirunavukkarasu V, Shukla S. Palmoplantar psoriasis - Ahead in the race- A prospective study from a tertiary health care centre in south India. 2015;9:WC01-3.
Bedi TR. Psoriasis in north India. Geographical variations. Dermatologica 1977;155:313-4.
Adişen E, Tekin O, Gülekon A, Gürer MA. A retrospective analysis of treatment responses of palmoplantar psoriasis in 114 patients. J Eur Acad Dermatol Venereol 2009;23:814-9.
CEM Griffiths, S-J Jo, L Naldi, R Romiti, E Guevara-Sangines, T Howe, et al
. multidimensional assessment of the burden of psoriasis: Results from a multi national dermatologist and patient survey. Br J Dermatol 2018;179:17381.
Diwedi L, Diwedi BK, Goswami PK. Chakrapani Commentary on Charak Samhita. Varanasi, India: Chaukhambha Bharati Academy. 2007. Chapter 7 of Chikitsa Sthana, verse 21. p.281.
Shastri SN, Pandeya K, Chaturvedi G. Charak Samhita Vidyotini Hindi Vyakhya. Vol. 1, Chaukhambha Bharati Academy, Varanasi, India;2009. Chapter 20 of Sutra Sthana, verse 12,14. p.401, 403.
Diwedi L, Diwedi BK, Goswami PK. Chakrapani Commentary on Charak Samhita. 2007.Varanasi, India: Chaukhambha Bharati Academy. Chapter 7 of Chikitsa Sthana, verse 39, p.284.
Shastri SN, Pandeya K, Chaturvedi G. Charak Samhita Vidyotini Hindi Vyakhya. Vol. 1. Chaukhambha Bharati Academy, 2007. Varanasi, India. Chapter 15 of Sutra Sthana, verse 16, p.313.
Available from: https://www.everydayhealth.com/psoriasis/guide/By Cathy Cassata Medically Reviewed by Ross Radusky, MD. Lastupdated: 21 November 2019. [Last accessed on 27 May 2020].
Psoriasis Area and Severity Index PASI 01.10 bad.org.uk. Available from: www.bad.org.uk/shared/getfile.ashx?itemtype=document&id=1654 Title: Microsoft word Psoriasis Area and Severity Index _PASI_ 01.10.12. Created date: 1 October 2012. [Last accessed on 27 May 2020].
Noorul H, Nesar A, Shaikh Z, Mohd K, Juber A. Asparagus racemosus
:For medicinal uses & pharmacological actions. IJAR 2016;4:259-67.
Babul A, Mahto RR, Dave AR, Shukla VD. Clinical study on Sandhigata Vata w.s.r. to osteoarthritis and its management by Panchatikta Ghrita Guggulu. Ayu 2010;31:53-7.
Sharma V, Singh M. Operculina turpethum
as a panoramic herbal medicine: A review. IJPSR 2011;3:21-5.
Kuchewar VV, Borkar MA, Nisargandha MA. Evaluation of antioxidant potential of Rasayana drugs in healthy human volunteers. Ayu 2014;35:46-9.
] [Full text]
Shankar AH, Prasad AS. Zinc and immune function the biological basis of an altered resistance to infection. Am J Clin Nutr 1998;68:447.
Sinha S, Sharma A, Reddy PH, Rathi B, Prasad NVSRK, Vashishtha A. Evaluation of phytochemical and pharmacological aspects of Holarrhena antidysenterica
(Wall.): A comprehensive review. J Pharm Res 2013;6:488-92.
Kashinath S, Gorakhanath C, Hindi commentator.The Charak Samhita of Agnivesha. Part I.Varanasi, India: Chawkhamba Bharati Academy;1998. p. 467-71.
Kumar MA, Pujar M. Critical appraisal of virechana karma in psoriasis. Int J Res Ayurveda Pharm 2013;4:595-8.
Moy RL, Levenson C. Sandalwood album oil as a botanical therapeutic in dermatology. J Clin Aesthet Dermatol 2017;10:34-9.
Das D, Agarwal SK, Chandola HM. Protective effect of Yashtimadhu (Glycyrrhiza glabra) against side effects of radiation/chemotherapy in head and neck malignancies. Ayu 2011;32: 196-9.
] [Full text]
Acharya Panashara Radhakrisna, Sharangdhara Samhita of Sharangdhara, Fourth Edition,Allahabad; Shri Bhaidyanath Ayurved Bhavan Ltd.; 1994. p.612
Sinha K, Mishra NP, Singh J, Khanuja SPS. Tinospora cordifolia (Guduchi), a reservoir plant for therapeutic applications: A review. Indian J Traditional Knowledge 2004;3:257-70.
Kumarsingh A, Kumargupta A, Manish, Singh PK. Rasayana therapy: A magic contribution of Ayurveda for healthy long life. Int J Res Ayur Pharm 2004;5:41-7.
[Table 3], [Table 4], [Table 1], [Table 2]