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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 4  |  Page : 278-283

Ayurveda interventions in management of chronic plaque psoriasis (Ekakushtha)


1 Department of Rog Nidan Evum Vikariti Vigyan, All India Institute of Ayurveda (AIIA), Delhi, India
2 Department of Vikriti Vigyan, Faculty of Ayurveda, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India
3 Department of Translational Research Biostatician, All India Institute of Ayurveda, New Delhi, India

Date of Submission30-Jun-2021
Date of Decision12-Jul-2021
Date of Acceptance10-Nov-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Prof. Sisir Kumar Mandal
Department of Vikriti Vigyan, Faculty of Ayurveda, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi, Uttar Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jism.jism_62_21

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  Abstract 

Psoriasis is a chronic inflammatory disease skin disease that is associated with different clinical phenotypes and that may show a variety of clinical manifestations such as interaction of genetic, and immunological and environmental factors. Plaque-type psoriasis (PP) is the most common form of psoriasis, occurring in 85%–90% of all cases. The classical symptoms of PP correspond to Ekakushtha in ayurveda, which is explained under Kushtha (skin) disease. The clinical sign and symptoms, dermatological examination, and previous history confirmed the case as “Plaque psoriasis.” According to classics, the case was diagnosed as Ekakushtha. Internal administration of decoction of drugs Punarnava, Manjistha, and Ushira, and Arogyavardhini Vati along with local application of 777 oil and Jivantyadi Yamaka was suggested to the patient initially for 1 month. After 1 month of treatment, there was a significant improvement in subjective assessment of itching, scaling, dryness, and erythema and PASI score, which was initially 43.6, was reduced to 5.2. Then along with above medication Mahatikta Ghrita was prescribed for 6 months. After 6 months of treatment, there was complete regression of all the symptoms and PASI score was found to be 0. In follow-up period even 10 months without medication, there were no signs of relapse. This case proved efficacy of ayurveda interventions in treating such cases where other systems of medicines have their own limitation.

Keywords: Arogyavardhini Vati, Ekakushtha, Jivantyadi Yamaka, Mahatikta Ghrita, psoriasis, Shamana


How to cite this article:
Sharma M, Mandal SK, Kumar A. Ayurveda interventions in management of chronic plaque psoriasis (Ekakushtha). J Indian Sys Medicine 2021;9:278-83

How to cite this URL:
Sharma M, Mandal SK, Kumar A. Ayurveda interventions in management of chronic plaque psoriasis (Ekakushtha). J Indian Sys Medicine [serial online] 2021 [cited 2022 Jan 28];9:278-83. Available from: https://www.joinsysmed.com/text.asp?2021/9/4/278/334261




  Introduction Top


Psoriasis is a chronic inflammatory skin disease having strong genetic predisposition and autoimmune traits. Globally, the prevalence of psoriasis is approximately 2%.[1] Plaque-type of psoriasis (PP) forms approximately 90% of psoriasis cases. The clinical manifestations of PP are sharply demarcated, erythematous, and pruritic plaques covered with silvery scales. These plaques can coalesce and cover large areas of skin. Common locations include the trunk, the extensor surfaces of the limbs, and the scalp.[2],[3] The location of lesions often restrict patient in performing routine activities. Depending on the clinical severity of the lesions, the percentage of affected body surface area, and patient quality of life, psoriatic patients are categorized into two groups: mild or moderate to severe.[4] Psoriasis Area Severity Index score (PASI) is the most adequate available tool extensively used in clinical trials.[5] In ayurveda, various skin disease and their holistic treatment modalities are described under the umbrella of Kushtha Chikitsa. According to symptomatology, Ekakushtha finds similarity with psoriasis, which is a Vata–Kapha-dominant Kushtha characterized by symptoms such as Aswedanam (absence of sweating), Mahavastu (extensive lesion), and Matsyashakalopama (scaly lesions) as character.[6] The common sites of occurrence of psoriasis are scalp, elbow, knee, earlobes, and sole, which are also considered as the location of Vata and Kapha. The derangement of seven factors including Tridoshas (three humors present in the body), Twak (skin), Rakta (blood tissues), Mamsa (muscle tissues), and Lasika (blood plasma) provides the base for vitiation of Srotas (the transporting channels).[7] These vitiated factors spread into the deeper Dhathus (body tissue elements) and underlying Srotas producing scaly lesion. However, exact mechanism of such pathogenesis need to be understood at molecular levels. Due to the complexity in manifestation involving Sapta-Dushyas (the seven factors involved in disease Kushtha), Shodhana Chikitsa is preferred as main line of treatment. But the treatment is time-consuming, hazardous, and depends on the strength of patients as well as disease. In the present case due to lower physical and psychological strength of the patient, Shamana Chikitsa (pacifying therapy) was planned and it reported successful outcomes during 6 months of treatment and in follow-up period even 10 months without medication no sign of relapse was reported.


  Case History Top


A 26-year-old male patient presented to the outpatient department (OPD) of All India Institute of Ayurveda (AIIA), New Delhi with chief complaints of pinkish-white lesions on abdomen, chest, lower and upper limbs, and scalp with inching, redness, scaling, burning, and dryness. Other than psoriasis he had no past medical or surgical history, no known allergy. Prior treatment included clobestalol propionate lotion, Tazarotene cream, Taclonex topical ointment along with methotraxate 20 mg once a week for the last 8 years. On further inspection, he revealed that initially he developed small red patches on abdomen 8 years ago, which gradually spread to the other parts of body. He consulted a qualified dermatologist and was diagnosed as plaque psoriasis. He followed the prescription of dermatologist including systemic steroids and ultraviolet (UV) therapy for 7 years but got only symptomatic relief. Many a time his condition aggravated and he got depressed. He was feeling psychological as well as economical distress due to his illness and even discontinued his study. Then he visited AIIA for the search of Ayurveda treatment.

Clinical Examination

Ten-fold examination of patient revealed that Prakriti (body constitution) of patient was Pitta-Kapha. Vikriti (morbidity) was Vata Kaphaja. Sara (tissue excellence), Samhana (compactness), Pramana (body built), and Vyayama Shakti (exercise power) were Madhyama (average). His Vaya (age) and Aharashakti (intake and digestion capacity) were Pravara (high). Further examination revealed that Satmya and Satva (psychological power) were Avara (subnormal).[8]

Physical Examination

His general appearance was fair and afebrile. Vitals were stable (blood pressure 128/80 mm Hg, heart rate 82/min, respiratory rate was 18/min). He was in chronic stress due to illness. Localized symmetrically distributed pink to silvery white patches were present in different body parts more predominately over abdomen and back.

Dermatological examination

The following were the findings of dermatological examination:

  • (1) Well-demarcated, symmetrical, erythematous, medium-to-large size, elevated plaques scattered on trunk, scalp, and limbs with silvery scaling [Figure 1]A–E.


  • (2) Candle grease sign was positive.


  • (3) Auspitz’s sign was positive.


  • (4) PASI scoring––PASI score was 43.6.
Figure 1: (A-E) Lesions of abdomen, back, scalp, and extremities before the treatment

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Diagnosis

The clinical sign and symptoms, dermatological examination, and previous history confirmed the case as “Plaque psoriasis.” According to classics, the case was diagnosed as Ekakushtha.[6]


  Management Top


The patient was put on Ayurveda conservative outpatient management after the case conceptualization as per involved Samprapti (pathogenesis). He was advised to maintain personal hygiene and avoid day sleep. In dietary restriction, he was suggested to consume light and easily digestible food items, vegetables having bitter taste such as bitter guard, pointed gourd, ridged gourd, neempatra, and pulses including red lentil, green gram, and old cereals. Unwholesome food items such as excessive sour and salty item, milk and salt, and curd were strictly restricted. The detail of interventions along with dosage form, therapeutic dose, and time and frequency of administration are depicted in [Graphic 1].
Graphic 1: Internal and external medications advised

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  Final Outcome Top


After 1 month of interventions, scaling and itching were completely subsided and complete cessation of formation of new lesions was noticed. Other symptoms such as erythema, dryness, and scaling were reduced to approximately 80%. Candle grease sign and Auspitz’s sign were absent and PASI score, which was initially 43.6, was reduced to 5.2 [Figure 2]A–[E]; [Graph 1] and [Graph 2]. The patient was advised to follow same treatment in addition to Mahatikta Ghrita for the next 6 months. He visited again after 6 months of baseline treatment. Disappearance of all the symptoms along with declination of PASI score to zero was noticed [Figure 3]A–[E]; [Graph 1] and [Graph 2]. He was further advised to continue the medication [Mahatikta Ghrita and 777 oil (LA)] for the next 1 month and there is no reoccurrence till June 28, 2021. The patient responded well to medication. No adverse effect or drug reaction was noticed during and after completion of therapy.
Figure 2: (A-E) Lesions of abdomen, back, scalp, and extremities after 1 month of treatment

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Figure 3: (A-E) Lesions of abdomen, back, scalp, and extremities after 6 months of treatment

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Graph 1: Subjective assessment of symptoms before, after 1 month, after 6 months treatment and in follow-up

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Graph 2: Objective assessment by PASI score before treatment, after 1 month, 6 months treatment and follow-up

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  Discussion Top


Case Conceptualization and Prognosis

According to symptomatology, the confirmed case of plaque psoriasis was diagnosed as Ekakushtha in classics. In the present case, patient was consuming snacks with tea, excessive curd, and salty food items and having day sleep. All these Nidana (causative factors) might have triggered vitiation of Doshas leading to manifestation of Ekakushtha. However, exact mechanism of such pathogenesis need to be understood in modern terms.

Clinical examination revealed the strength of disease as Pravara (high) and that of patient as Madhyama (average).The disease was Sukha-Sadhya (easily curable) as the Doshic dominance of patient was not congruent to that of disease.[9] After case conceptualization, the management was planned. The case was treated on the line of Ekakushtha. Although Shodhana (purification) is the main treatment in Kushta, in the present case due to lower psychological strength of patient Shamana Chikitsa was planned. Early recovery of patient within 1 month of treatment along with complete declination of symptoms and PASI score of 0 after 6 months of treatment evidenced the effectiveness of therapeutic interventions, and Pravara (high) Vaya and Ahara Shakti of patient might have contributed for the same.

Rationale of Interventions

The decoction made of stem of Punarnava (Boerhavia diffusa L.), Ushira root (Vetivera zizanioides L.), and Manjistha stem (Rubia cordifolia L.) was chosen after inspection of the Prakriti (body constitution) of patient and disease.

Punarnava has Vata-KaphaShamaka (pacify Vata and Kapha), Lekhana (scrapping) Shothahara (anti-inflammatory), Kushthahara (antileprotic), and Rasayana (rejuvenation) properties.[10] Clinical studies documented immunosuppressive,[11] analgesic,[12] antioxidant, hepatoprotective,[13] antibacterial,[14] and wound-healing activities[15] of Boerhaavia diffusa.

Manjistha (Rubia cordifolia L.) is Kapha-Pitta Shamaka (pacify Kapha). It has Kushthaghna (antileprotic), Krimighna (antimicrobial), Raktashodhaka (blood purifier), Shothahara (anti-inflammatory), and Varnaropaka (wound healing) action.[16] The anti-thrombotic and pro-angiogenic activities of Rubia cordifolia have not been well investigated.[17] Clinical and cell-line studies have documented antibacterial, analgesic, anti-inflammatory, wound healing, antioxidant, and anti-allergic, radio-protective properties of Rubia cordifolia.[18],[19]

Ushira (Vetivera zizanioides L.) pacifies Pitta Dosha and has Kushthaghna, svedopnayana (regulate sweat formation), Tvakadoshahara (pacify skin ailments), Vishaghna (pacify toxic effect), and Dahaprashmana (pacify sense of heat).[20] Its use is indicated in various skin disorders and it works as stress reliever as well.[21] Various studies revealed its antibacterial, antiseptic, anti-inflammatory, and wound-healing activities.[22],[23]

The combination of all the herbs might have shown Vyadhipratyanika (Kushthahara) and Dosha Pratyanika (Vata-Kapha Shamaka) effect. As the body constitution of patient was Pitta Kapha; hence, Pittashamaka effect of Vetiveria zizanioides was used along with Vata-Kapha shamaka effect of other formulations to resolve the pathogenesis of Ekakushtha. Moreover, the stress of patient which was responsible for reoccurrence of his illness also alleviated due to V. zizanioides.

Mahatikta Ghrita is one of the most potent drugs for Kushtha. It works as Vyadhiprtyanika, Dhatus Poshaka, and is Sarva-Doshahara (pacify all doshas). It has Amalaki (Emblika officinales L.) as main ingredient that not only helps to remission of the symptoms but also prevents the relapse of the disease.[24]

Arogyavardhini Vati has Kutki as main ingredient that has anti-pruritic and antioxidant properties and works as Dhatu Poshaka (promotes body tissue), hence resolving morbidity at Dhatu level. It is Hridya (cardiotonic), Deepani (appetiser), Pachani (digestive), Tridoshashamaka (pacify all doshas), and is indicated in Kushtha treatment.[25] In an animal experimental study, significant hypolipidemic activity of Arogyavardhini vati was reported.[26] Hence, it works as srotosodhaka and removes kleda, thus breaking pathogenesis of Kushtha.

777 oil is a Siddha preparation made by processing of coconut oil in the presence of Shweta Kutaja (Wrightia tinctoria Roxb.) leaves used in the treatment of psoriasis.[27] The leaf extract of W. tinctoria shows prominent anti-psoriatic and anti-oxidant activities as evidenced in clinical studies. Coconut oil has anti-inflammatory action and skin protective properties.[28] The moisturizing and emollient effect of coconut oil reduces inflammation, dryness, burning, and itching in the lesion and works as a vehicle for medicine to cross the skin barrier.[29]

Jivantyadi Yamaka is a classical preparation made up of ghee, oil, Sarjarasa (Vetivera indica L.), Madhucchista (Apis cerana), and herbs namely Arka (Calotropisgigantea), Manjishtha (Rubiacordifolia), Jivanti (Leptadeniareticulata), and Darvi (Berberisaristata). It is indicated in the treatment of Eka Kushta in classics.[30] Antibacterial, antimicrobial, antifungal,[31],[ 32] immunomodulatory, and antioxidant properties[33] of L. reticulate are evidenced by cell line and in vitro studies. Bee wax, one of its ingredients, is reported to have potent antimicrobial properties.[34] The ghee and oil provides base to the medication. When a lepa is applied over skin opposite to the direction of hairs on skin, it gets absorbed by Bhajaka Pitta and enters in circulation through Siramukha and Svedvahi Srotas (channels carrying sweat) which are already purified by the drugs advised. After which there is formation of new metabolites and vitiated Dosha were pacified.

Combined effect of all the medications helped in removal of Kleda (toxic substances) leading to purification of channels, thus breaking the pathogenesis of Ekakushtha. Vyadhipratyanika (disease antagonizing), Doshapratyanika (antagonizing doshas), and immune-modulation, anti-inflammatory, antimicrobial, emollient, analgesic, and anti-psoriatic effect of the formulation not only resolved the pathogenesis of Ekakushtha but also increased skin immunity (Bhrajaka pitta), which is evidenced by no sign of relapse of the disease even after 10 months without medication [Graphic 2].
Graphic 2:

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  Conclusion Top


This case report suggested that Ayurveda intervention not only helped in curing this particular chronic case of plaque psoriasis, there was no recurrence till date without medications. The treatment adopted was personalized, economical, safe, effective, and free of adverse effect. It can be concluded from the study that Ayurveda interventions have enough potential to successfully manage such chronic disease where there is reoccurrence tendency. However, large sample sized, multicenter randomized, and controlled clinical trial are needed to establish the efficacy by clinical trials.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/care giver 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

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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