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| CASE REPORTS |
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| Year : 2019 | Volume
: 7
| Issue : 4 | Page : 231-239 |
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Management of Eka-Kushtha (Chronic Plaque Psoriasis) in Ayurveda: A case study
Sourabh G Deshmukh1, Trupti I Thakre2
1 Department of Kayachikitsa, Mahatma Gandhi Ayurved College Hospital and Research Centre, Wardha, Maharashtra, India
2 Department of Kaumarabhrutya, Mahatma Gandhi Ayurved College Hospital and Research Centre, Wardha, Maharashtra, India
| Date of Submission | 16-Dec-2019 |
| Date of Decision | 16-Jan-2020 |
| Date of Acceptance | 05-Feb-2020 |
| Date of Web Publication | 14-Apr-2020 |
Correspondence Address:
Dr. Sourabh G Deshmukh
Department of Kayachikitsa, Mahatma Gandhi Ayurved College Hospital and Research Centre, Salod, Wardha 442001, Maharashtra.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JISM.JISM_54_19
Background: In Ayurveda, all the skin diseases are explained under Kushtharoga and are classified as Maha Kushtha (major skin disorders) and Kshudra Kushtha (minor skin disorders). In Samhita (classical literatures), it is described that all Kushta to have involvement of Tri Dosha (three bodily humors) but the type of Kushtha depends on the predominance of particular Dosha. The signs and symptoms of Eka-Kushtha (chronic plaque psoriasis) are similar to that of psoriasis explained in modern science. Aim: The aim was to evaluate the role of Ayurveda treatment modalities in Kushtha. Materials and Methods: A male patient aged 51 years presented with the signs and symptoms of well-defined, slightly raised silvery scales over the lower back region, over the both knee joints and hands, and over the trunk region along with severe dryness in whole body, powdery discharge with severe itching, diagnosed it as Eka-Kushta (chronic plaque psoriasis) and was treated with both external and internal therapy, which included Shodhana (purificatory) and Shamana (palliative). Shodhana was given by Sadhya Snehan (proper oleation) followed by Vamana Karma (therapeutic emesis), in which vitiated Doshas (three fundamental bodily bio-elements) are expelled through Urdhvamarga (upward direction through mouth), and Shamana was given by Aushadhi (internal medicine). The total content of Vamana Aushadhi taken by patient was 2800mL and had (Vamana Vega) vomited 10 times (2150mL was output). Results: At the end of Vamana, Pittantik Vamana was achieved. Patient felt notable reduction from Kandu (itching), scaling, and gradual reduction of erythema during treatment. Conclusion: This case study revealed the efficacy of Ayurveda therapy, including both external and internal medications, for 1 month in the management of Kushtha. Keywords: Chronic plaque psoriasis, Eka-Kushtha, Shamana, Shodhana
How to cite this article:
Deshmukh SG, Thakre TI. Management of Eka-Kushtha (Chronic Plaque Psoriasis) in Ayurveda: A case study. J Indian Sys Medicine 2019;7:231-9 |
| Introduction | |  |
In Ayurveda, almost all the skin diseases are described under Kushtha-Rogadhikara.[1] There are seven Maha-Kushtha (major variety of skin disorders) and eleven Kshudra Kushtha (minor variety of skin disorders).[2]Eka-Kushtha is one among all varieties of Kushtha, and it is main among the eleven Kshudra Kushtha, which is characterized by Aswedanam (dryness), Mahavastu (which covers entire body), and Matsyashakalawat Twacha (skin resembles scales of fish), which means Kushtha. It is painless, which does not sweat, also extensively spreads over wide area, and resembles fish scale, also in this, the skin becomes black and pink color. Acharya Bhavaprakasha describes that the lesions of Eka-Kushtha are Chakrakara (circular) and Abhrakapatrasama, that is, silvery scales such as mica.[3] These features of Eka-Kushtha are similar to that of psoriasis explained in modern medicines, Aswedana, which means dry and rough lesions, Mahavastu, which covers the entire body, Matsyashakalawat is well demarked raised patches with large silvery loose scaling (skin resembles scales of fish), and Krishna-Aruna Varnata (blackish in color). As per Acharya Charak, the vitiation of Tri Dosha along with Twak (skin), Mamsa (muscular tissue), Rakta (blood), and Lasika (fluid and lymph) have major role in the pathogenesis of Kushtha.[4] But still the signs and symptoms produced in Kushtha depend on the type of predominance of Dosha (biological energies) in it. So, the Dosha can be understood on the basis of clinical features, and the line of treatment is planned. Kushtha is considered to be under Ashtamahagad Rogas (eight psychoneurosis)[5] and Aupsargika Rogas (communicable diseases). As per the Dosha Avastha (distressed/excited state of Dosha), that is, Bahu (more severe) or Alpa (less) Dosha, one should choose the Shodhana for Bahu Dosha Avastha and Shamana Chikitsa for Alpa Dosha Avastha. The line of treatment of skin diseases are Shodhana and Shamana therapy. Shodhana has great importance because it removes the morbid Dosha from body, which is the root cause of diseases; it makes the disease to be cured easily. Vamana Karma and Virechana Karma followed by internal medications are considered as the best line of management for skin disorders.[6]
Acharya Charak defined Vamana as a process in which waste products or toxins (Doshas) are eliminated through upper channels, that is, mouth. Acharya Sharangdhar explains that in the process of Vamana Karma, Apakwa Pitta and Kapha are forcibly expelled out through Urdhvamarga (upward direction through mouth). Likewise, in Virechana Karma, Pitta and Kapha are expelled out through Adhomarga (downward direction through anus). The Lakshanas of Eka-Kushtha described by Acharya can be compared with psoriasis, and hence, it has been taken as the equivalent to psoriasis. Psoriasis is a common, long-lasting, persistent inflammatory disease of the skin caused due to unidentified cause, categorized by well circumscribed erythematous dry plaques with several sizes and shapes, covered with fishlike scale. All these conservative medicines were used for the pacification of Tri Dosha. Thus, it was presumed that Shodhana procedure along with Shaman Aushadhi and Nidan parivarjana (avoidance of etiological factors) would be helpful in the treatment of Eka-Kushtha.
| Case Report | | |
A 51-year-old male patient with Eka-Kushtha presented to the outpatient department (OPD) of Mahatma Gandhi Ayurved Hospital Salod, Wardha, Maharashtra, India, with OPD Registration number: 1901280072 and IPD Number: 1901280028, residence of Chandrapur, Maharashtra, with a chief compliant of chronic plaque over the lower back region, over both the knee joints, hands, and over the trunk region with Kandu (powdery discharge with itching), Daha (burning sensation), and Vaivarnya (discoloration all over body) since the last 13 years.
History of Present Illness
Patient was well before 13 years. Since 13 years, he gradually developed plaques over abdomen, back, both hands, and then legs associated with powdery discharge, hard dry plaques along with severe itching. He underwent various conservative treatments along with local application. But he did not get better relief.
- Past history: No significant medical history
- Personal history:
- Profession: shopkeeper
- Diet: Mixed diet
- Sleep: Disturbed due to itching
- Bowel: Constipation
- Addictive habits: Chewing tobacco [Table 1]
Skin Examination
- Inspection:
- Size shape—Erythematous lesion lower back, both knee joints, hands, and over the trunk region
- Color—White silvery scales
- Uniformity—Generalized plaques
- Thickness—More than 0.5cm in diameter
- Lesions—Plaques
- Palpation:
- Moisture—Dryness, no sweating
- Temperature—Warmth of the skin
- Texture—Roughness
- Mobility and turgor—Reduced
- Note: Sign
- Oil drop sign—Positive
- Candle Greece Sign—Positive
- Auspitz Sign—Positive
Treatment Plan
The treatment was carried out in the following two stages:
First stage
In Samshodhana Karma, Vamana was advised, which was strictly followed with Purvakarma and Paschyatkarma (pre- and post-procedural care).
Purvakarma: In Purvakarma, Trikatu churna for Deepan (appetizers), Pachan (digestion), and Panchatikta Guggul Ghrita for Snehapan were given for a period of 3 and 7 days, respectively, followed by Abhyanga with Marichadi Taila were give as detailed in [Table 2] and [Table 3]. | Table 2: Details of dosage, route, Kala (time), and Anupan (vehicle) of medicine
Click here to view |
,
Pradhankarma—Vamana: After a rest of 1 day, on the ninth day, the patient was kept on nil by mouth (NBM) till the process of Vamana start. Previous day to Vamana Karma, the patient was educated to consume food, such as curd, mash, ice cream, and milk, that promotes the production of Kapha or that has the quality of Kapha Utklesha (increase lubrication in body). Examination of the pulse, blood pressure, and respiration rate was reported, Vamana Karma was performed during Kapha Kala, and patient underwent Abhyanga (oil massage) with Marichadi Taila and Mrudu Sweda (mild sudation). After that, Dugdha (milk) 2500mL and drugs such as Yashtimadhu Phanta (Glycyrrhiza glabra) 1000mL, Madanphala Choorna (Randia dumetorum Lam.) 3g, and Vacha Choorna (Acorus calamus) 5g are given as mentioned in [Table 4]. By this, Kapha gathered in the body is effectively removed by Vamana [Table 5] and [Table 6]., ,
Inference/Observations
Paschyatkarma: Dhumapana[12] was given after the rest of 10min with a stick made of Aguru (Aquilaria agallocha) for 3–4 times by each nostril. Then, Samsarjana (dietetic protocol) was advised to follow the dietetic and behavioral restriction regimen of 7 days. The sequence of regimen was planned as Peya, Vilepi, Akrita Mudga Yusha, Krita Mudga Yusha, and rice with Mamsarasa were served for three Aaharkaala (diets) [Table 7]. | Table 7: Samsarjan Karma[13] (post procedure of dietetics and behavioral restriction): 12th to 16th days recommended
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Duration of Vamana Karma: Vamana procedure—16 days
Total number of Vamana: 10 Vega
Types of Vamana Shudhi: Uttama Shudhi
The whole process of Vamana Karma was completed in 70min. Patient felt lightness symptoms, such as Kandu (itching) and plaques were reduced, and got good results, which are shown in [Figure 1][Figure 2][Figure 3]. After Vamana Karma, in Paschyatkarma, Dhumapana (therapeutic smoke inhalation) is given., ,
Second stage
After Shodhana, oral medication was administered followed by Nidan parivarjana. The oral medications, such as Ghadhaka Rasayana, Panchatikta Ghrita, and Vetapalai oil, were given [Table 8].
Grading: PASI (Psoriasis Area Severity Index) score[15]: The body is divided into four sections: head—10% of a person’s skin, arms—20%, trunk—30%, and legs—40%. Each of these areas are scored itself and then combined into the final PASI. The percent of area of skin involved is estimated and then transformed into a grade from 0 to 6 [Table 9][Table 10][Table 11].,  | Table 10: Area involvement grading wise erythema (redness), induration (thickness), and desquamation (scaling)
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,  | Table 11: Changes in erythema, induration, desquamation, and itching during each follow-up in signs and symptoms
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Outcome of the Treatment
Erythema (redness) was fully reduced after treatment, induration (thickness) was rough before treatment but it was reduced after three follow-ups, desquamation (scaling) was huge before treatment and it was fully reduced after third follow-up, and itching, which was more before treatment, was reduced after Shodhana and Shamana.
| Discussion | | |
During the 16 days course of Vamana, the patient had reported 90% improvement in his symptoms. He had got 80% relief from itching. The discolored skin and red scaly patches had been improved by 40%. The silver scales were reduced. The treatment was planned in two phases. In the first phase of the management, the patient underwent Vamana karma. The principle of Vamana is to expel out the morbid Doshas from the body. It acts mainly on Doshas, which is vitiated, and produces disease. In Purvakarma, the patient was administered Trikatu Choorna for 3 days, followed by Panchatikta Guggul Ghrita in an increasing manner from 4th to 7th day. The ingredients of Panchatikta Guggul Ghrita are Nimba, Patola, Vyaghri, Guduchi, Vasa, Triphala, and Ghrita. The drugs possess Ushna (hot), Tikshna (sharp), Vyavayi (spreading), Vikashi (separate), Katu (pungent), Tikta Rasatmaka (bitter in taste), and Katu Vipaka (alkaline phase). It is indicated in Kushtha and also observed that the action of drugs was mainly due to properties of these drugs, which have Dipan (appetizer), Pachana (digestion), Amapachaka (digestion of Aam), Strotoshodhaka (clear the channels), Raktaprasadan, Raktashodhaka (blood purifier), Kandughna (remove itching), Kushthaghna (remove psoriasis), and Varnya (improve complexion). They act on vitiated Doshas to eliminate from whole body and brought them into Koshtha. It also pacified the symptoms of aggravated Vata and Kapha Doshas, such as itching, discoloration, and dryness. The main components of Vamana and their actions are as follows:
Probable Mode of Action of Vamana
Dipana—Pachana mainly acts as an Amadosha Nashaka and Agni Vardhaka. Snehapana acts on Vata, which decreases Daha (burning sensation), and Abhyanga mainly decreases scaling and dryness. Sarvanga Sweda decreases obstruction and increases Swedana (Sroto Shodhaka). Vamana mainly act as Kapha Doshanashaka and it helps to increase Agni. Samsarjana Karma works on Agni Dipaka and increases immunity. Eka-Kushtha (chronic plaque psoriasis) is a Kapha Dosha predominant, and in Kapha predominant disease, Vamana is indicated. It will help to enhance the immune mechanism and to prevent the reversion of disease. Snehana is indicated in Kushtha after Shodhana Karma.[12] Hence, for Shamana Snehana, Panchatikta Ghrita is advised after Vamana procedure. In Eka-Kushtha, for the prevention of increasing Vata Dosha, Snehana is to be given. According to Acharya Charak, Kushtha is Rakta prdoshaj Vikar, so while adopting the Chikitsa modalities, one should take care of Rakta Dhatu. The main site of formation of Rakta Dhatu is Yakrita and Pleeha, and drugs such as Vasa, Amrita, Patola, and Nimba have potent hepatoprotective action.[16] The formation site of the Rakta Dhatu is acted on by these drugs and leads to the breakdown of the basic pathogenesis of Kushtha.
Gandhaka Rasayana[17]: Contains purified Gandaka, cinnamon (Cinnamomum zeylanicum), Ela (Elettaria cardamomum), Patra (Cinnamomum tamala), Nagakesara (Mesua ferrea), Guduchi (Tinospora cordifolia), Harithaki (Terminalia chebula), Amalaki (Emblica officinalis), Vibhithaki (Terminalia bellirica), Sunthi (Zingiber officinale), and Bhringaraja (Eclipta alba). Gandhaka Rasayana has antibacterial, antiviral, and antimicrobial properties. It is useful in the treatment of skin diseases such as itching and pruritus. It can improve digestion and skin complexion. Purified sulfur is used in the treatment of variety of diseases. It has stimulant action on secreting organs such as skin and mucous membrane. It has diuretic and laxative action. It increases bile and is useful in skin diseases. In combination with mercury, it is used in almost every disease. Sulfur is used both internally and externally for the treatment of skin diseases. Study shows that Gandhaka Rasayan contains carbohydrates, steroids, tannins, and essential micronutrients. Carbohydrates act as antidiarrheal and are used in wound healing.
Mode of Action of Panchatikta Ghrita
Ghrita is indicated in classics in Kushta Chikitsa. Panchatikta Ghrita has Vata Pitta Shamaka property (pacifying Vata and Pitta), improves complexion (Tvachya), and has the property to incorporate other substances when it is added. All the ingredients have the property to alleviate skin diseases (Kushthaghna). Kushtahar drugs as such as Panchatikta Guggul Ghrita and Panchatikta Ghrita.[12],[14]
Mode of Action of Vetapalai Oil
Svetakutaja (Wrightia tinctoria) is used as anthelmintic (to destroy parasitic worms), antipyretic (fever), aphrodisiac (to stimulate sexual desire), astringent (skin-related problems), carminative (gastric problems), and depurative (removes wastes and toxins from the body). The Ayurvedic herbs also help to pacify vitiated Tri Doshas, fever, stomach ache, skin diseases, especially psoriasis and obesity, hair fall, and cancer. Coconut oil (Cocos nucifera) is a fantastic natural skin moisturizer and softener, and is absorbed rapidly by the skin. This ability to deeply penetrate the skin also helps to smoothen the skin. It has Kushthaghna, antibacterial, antiviral, anti-inflammatory, antifungal, and antimicrobial properties. It is useful in the treatment of skin diseases such as itching, pruritus, and psoriasis. All the ingredients are Vata Pitta Kapha Shamaka (pacifying Vata, Pitta, and Kapha), Tvachya (improves complexion), and has a remarkable property to moisturize the skin.[18]
For the basis of improvement of lesions, erythema (redness), induration (thickness), desquamation (scaling), and itching were very severe before treatment, but after treatment of Shodhana and Shaman, the patient got significant results in erythema, induration, desquamation, and itching. PASI scale was considered. Before starting the treatment, his PASI score was 27.1. After 1 month, it was 10.4, after 2 months it was reduced to 4.2. Present treatment schedule gave him 80% relief from the symptoms after Shodhana treatment, that is, he was discharged in an improved condition; after Shamana medicines, the patient got 100% relief.
Future Direction
Consideration of psychological condition and status of Agni if one should do repeated Shodhana, Shamana, and takes a Rasayana drugs it gives better results in Eka-Kushtha.
| Conclusion | | |
Chronic plaque psoriasis can be correlated with Eka-Kushtha on the basis of sign and symptoms.
Kushtha Chikitsa, both Shodhana Karma (body purification therapy) and Shamana Karma (palliative and conservative therapy) play an important role.
As per the Dosha Avastha, if Bahu (more severe) or Alpa (less) then one should choose the Shodhana (Bahu Dosha Avastha) and Shamana chikitsa (Alpa Dosha Avastha), respectively.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]
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