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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 66-73

Ayurveda multimodal treatment approach for the management of generalized plaque psoriasis: a case report


Department of Rasashastra and Bhaishajya Kalpana, ITRA, Jamnagar, Gujarat, India

Date of Submission25-Nov-2021
Date of Decision02-Feb-2022
Date of Acceptance02-Mar-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr. Nikhil A Mehere
Department of Rasashastra and Bhaishajya Kalpana including Drug Research, ITRA, Jamnagar 361008, Gujarat.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_94_21

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  Abstract 

Background: Plaque psoriasis typically presents with large, oval-circular plaques over the scalp, trunk, and extensor body surface. In Ayurveda, all the skin diseases depict under the heading “Kustha” (skin diseases). Among them, “Ekakustha” (psoriasis) is further explained under the title “Kshudra Kustha” (minor skin diseases). It is characterized by the hyperproliferation of the epidermal cells resulting in plaque formation over the lesions and may get severe and progress into the pustular subtype. Aim: Plaque psoriasis is compared with Ekakushtha in Ayurveda because of its resemblance to disease condition that is described in the Ayurveda classics. The aim of this study was to treat a patient with Ayurveda multimodal treatment approach. Materials and Methods: We, herein, reported a case of a woman aged 29 years complaining about reddish lesions over the scalp, peripheral area of eyes, trunk, back, and upper and lower extremities with intense pruritus since the last 8 months. Itching leads to scaling and trickling of blood from lesions. The patient was diagnosed with generalized plaque psoriasis. This case was treated by internal as well as topical medicament with the cessation of known etiological factors. Results: A significant reduction in the symptoms within 98 days of treatment without reported relapse manifestation of previous symptoms. The scores of 18, 10, and 2 were observed before treatment, after treatment, and after follow-up period, respectively, on the symptomatic relief in signs and symptoms of Ekakushtha. The Psoriasis Area Severity Index (PASI) score was adopted as the assessment of severity of case. The PASI score is zero after the treatment and 12.2 before the treatment. The Ayurveda multimodal treatment approach gives miraculous result in this type of complex nature of psoriasis disease.

Keywords: Ekakushta, generalized plaque psoriasis, Kshudrakushta, psoriasis


How to cite this article:
Mehere NA, Makwana SM, Chaudhary SY, Bedarkar P, Patgiri B J. Ayurveda multimodal treatment approach for the management of generalized plaque psoriasis: a case report. J Indian Sys Medicine 2022;10:66-73

How to cite this URL:
Mehere NA, Makwana SM, Chaudhary SY, Bedarkar P, Patgiri B J. Ayurveda multimodal treatment approach for the management of generalized plaque psoriasis: a case report. J Indian Sys Medicine [serial online] 2022 [cited 2022 May 27];10:66-73. Available from: https://www.joinsysmed.com/text.asp?2022/10/1/66/342321




  Introduction Top


Psoriasis has a multifactorial etiology. Plaque psoriasis typically presents with large, oval-circular plaques over the scalp, trunk, and extensor body surface. The plaques have an extensive amount of scaling due to the hyperproliferation of the epidermal cells. Most of the patients with plaque psoriasis have acute flares and relapses, which may become severe and progress into the pustular subtype.[1] Psoriasis is caused by inappropriate activation of the immune system defined by a series of linked cellular changes in the skin that include keratinocyte hyperplasia, altered T-cell function, and angiogenesis, the most important cell series being the helper T cells.[2] Reviewing from available researches, the prevalence of psoriasis in India ranges from 0.44% to 2.8%.[3] In Ayurveda, various herbal, minerals, and metals Bhasma have proven effectiveness in psoriasis, but the multifaceted etiology of the disease needs a multimodal treatment approach including internal and external Ayurveda medicines and strict dietary modifications.[4] Skin diseases and their treatment approach are exclusively described under Kushtha Roga in Ayurveda. This principle has been adopted in this case of plaque psoriasis because of the convoluted pathophysiology and chronic and relapsing nature of psoriasis disease.


  Patient Information Top


A 29-year-old woman who is nondiabetic, non hypertensive, doing housework visited outpatient department of Rasa Shastra and Bhaishajya Kalpana of the institute. She has chief complaints of reddish lesions over the scalp, peripheral area of eyes, trunk, back, and upper and lower extremities since the last 8 months. White plaque-like appearance was observed over the lesion site with intense pruritus. On itching, scaling was observed followed by trickling of blood from the lesions. Pain and burning sensation were not present over the lesions. The onset of lesions observed with a pink color papule on the whole body. The patient has chronic constipation for 2 years prior to the disease onset. Mouth ulcers were observed from a week by the patient herself. The patient has taken modern medicines for chief complaints but did not get significant relief. Allopathic treatment was taken by the patient for the 1-month duration [Table 1]. Later, the patient approached the outpatient department of the institute for further Ayurveda treatment. The patient had normal menstrual history. There was no family history of any skin manifestations. The patient used to take two glasses of normal water in the morning in empty stomach. The patient was more likely to take fermented foods twice a week like idli, dhokla, etc. The patient used to eat pickles, curd, and salad in her daily diet. Anorexia (Mandagni) and hyperacidity (Amlapitta) are found in patient’s history. No surgical history has been reported from the patient.
Table 1: Allopathic medication taken by the patient

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  Clinical Findings Top


The patient had normal systemic functions. On local examination, lesions are circular, red papules with silvery-white, dry scale with asymmetrical distribution on the scalp, peripheral area of eyes, trunk, back, and upper and lower extremities. Plaques are thick, well-demarcated, and in red color with silvery-white scale [Figure 1]A, [Figure 2]A and B, and [Figure 3]A. Nail, oral mucosa, and tongue were not affected with the psoriatic lesions. Koebner phenomenon was positive at the time. Psoriatic arthritis was not present. Body temperature (97°F), pulse rate (78/min), and blood pressure (110/80) were within normal limit.
Figure 1: Facial photographs with significant improvement at affected areas

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Figure 2: Photographs of affected trunk with progressive marked improvement

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Figure 3: Photographs of affected fore-legs with progressive marked improvement

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Timeline

The patient was properly counselled about the severity and prognosis of the disease. The patient was advised properly to avoid consumption of Apathya Aahara-Vihara (causative factors) as mentioned in the classics.[5 The detailed timeline of the case is described in [Table 2].
Table 2: Case timeline

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  Diagnostic Assessment Top


Diagnosis was made upon the clinical observations, history, and findings of thorough dermatological examination and questionnaire. Differential diagnoses include lichen planus, tinea corporis, atopic dermatitis, secondary syphilis, contact dermatitis, and pityriasis rosea.[6] The patient was not willing for biopsy because of high financial expenses. This is the one limitation of this study.

According to chief signs and symptoms, Matsyashakalopamam (scaling), Rukshata (dryness), Aswedanam (anhidrosis), Daha (burning sensation), Srava (discharge), Unnati (elevation), Mahavastu (extent of lesion), and discoloration, gradation was applied in the range of 0–4 [Table 3]. Scores were observed as 18, 10, and 2 before treatment, after treatment, and after follow-up period, respectively [Table 4]. Assessment criteria are taken according to the Psoriasis Area Severity Index (PASI) score, which is based on plaque characteristics, i.e., erythema, thickness, scale, and area score. The assessment was done before and after treatment. Before treatment, the PASI score was 12.2. The resulted score is included under moderate severity score.[7]
Table 3: Criteria for the assessment of Ekakushtha (psoriasis)

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Table 4: Therapeutic effect on clinical signs and symptoms for the treatment protocol

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  Therapeutic Interventions Top


The treatment protocol was decided as per the disease “Ekakushtha,” which is described under the heading Kushtha in the Ayurveda classics and the Dosha predominance in its associated symptoms [Table 5]. All modern internal and topical medications were stopped, and then this treatment was followed.
Table 5: Prescribed treatment protocol

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Pathyapathya (wholesome and unwholesome) was followed as per the classical guidelines.[8] Light food that digests on the proper time was advised. The patient was advised to take old cereals, green gram, seasonal fruits, green vegetables such as Vastuka (Chenopodium album Linn.), Methika (Trigonella foenum-graecum Linn.), Patola (Trichosanthes dioica Roxb.), and Amalaki (Phyllanthus emblica Linn.). Unwholesome dietary and living habits have not been advised, i.e., curd, fish, canned food, junk foods, milk and milk products, heavy diet, spicy, salty, oily, sour and fermented food products, consumption of food at the inappropriate time, Ratrijagarana (late night sleep), and Divaswapa (day sleep).


  Follow-up and Outcomes Top


Subsequent observational data of disease condition are depicted in [Table 2]. No adverse events were reported during the treatment period. Photographs of affected skin lesions were taken during initiation, between, and after treatment [Figure 1][Figure 2][Figure 3]. Plated photographs show recovery in skin lesions, scaling, and erythematous plaque. The treatment was given for the duration of 98 days. Then all medications (internal and external) were stopped and Rasayana Churna was given during follow-up period for the duration of 30 days. The recurrence of symptoms was not found during the follow-up period of 30 days after 98 days of treatment. The severity and outcome of the disease were measured based on symptomatic relief in signs and symptoms and based on the PASI score, which is a point-based system quantifying the quality and area. It measures erythema, thickness of skin, and desquamation (scaling) on a scale of 0–4, 4 being the most severe. In the present case study, the PASI online calculator[9] was used where the PASI score was 12.2 before treatment, and after treatment, the score was 0 (complete recovery). Erythema, scaling, and thickness of skin are completely improved [Figures 1G], [2B] and D, and [3] F].


  Discussion Top


Ekakushtha is one among all types of skin diseases, which is distinguished by Mahavastu (which covers entire body), Matsyashakalawat Twacha (skin resembles scales of fish), and Aswedanam (anhidrosis).[10 Lower immunity, stress, Viruddha-ahara (incompatible diet), and dietary habits play crucial role in causing skin disease according to the Ayurveda classics.[11] In Ayurveda, all skin diseases are demonstrated under the heading of “Kushtha.” In the present case, the patient is stressed because of the ugly skin appearance of skin. The patient has a routine history of sour food intake in daily diet such as curd, fermentative food (pickle, idli, dhokla, etc.). All these are accountable for the disease progression. Therefore, the first step for the management of the disease is to avoid the Nidana (causative factors). It terminates the further progression of the disease by regulating the vitiation of Dosha.[12] Accordingly, the patient has been advised to avoid probable causative factors of the disease that are noted during history taking. The present case is found to have Vata, Pitta, Kapha, and Rakta Dosha. The treatment protocol was adopted according to its Dosha involvement.

Many of the researches published on psoriasis that is treated by Ayurveda employed various procedures and oral and topical medication. It has been pointed out in the WHO’s recent Global Report on psoriasis that there are many unmet research gaps on psoriasis addressing various aspects such as epidemiology, etiology, association with comorbidities, treatment, and ways to improve healthcare services.[13] We, herein, treated the chronic case of psoriasis with multimodal Ayurveda treatment approach such as avoiding causative factors and external application and internal administration of drugs.

Erandbhrishta Haritaki Churna is a well-known Ayurvedic formulation having mainly “Anulomana” (a purging medicine stimulates evacuation of the bowels) action. It helps the patient get significant relief from chronic constipation. In quick excretion, there is a possibility of increase in intestinal motility.[14] It has been reported that the fruits of Haritaki (Terminalia Chebula Retz) contain phytoconstituents such as anthraquinones, tannins, and polyphenolic compounds. One or the combination of these phytoconstituents may be responsible for the observed effect of Churna.[15]P. Emblica, Shunthi Churna (Zingiber Officinale Rosc.), and Shankha Bhasma (incinerated conch shell) were used for the Amlapitta (gastritis) and proper generation of Prakruta Pitta.[16] The antioxidative properties of ginger protects human against many chronic diseases. 6-Shogaol has revealed the most potent antioxidant and anti-inflammatory properties in ginger, which can be assigned to the presence of alpha, beta unsaturated ketone moiety.[17]Manjisthadi decoction was introduced for the purpose of blood purification from Dosha.[18]Erandmoola decoction has Vrushya Vata Doshahara properties. It is used to treat the predominance of Vata and Kapha Dosha in the condition of psoriasis. It may relieve white dry scale symptom due to Vata Shamaka property of Erandmoola decoction. It nourishes the overall skin of body because of its “Vrushya” property.[19]Arogyavardhini Rasa is a well-known preparation indicated in Kustharogadhikara as it has Kushthaghna (antidermatosis) and Kandughna (antipruritic) properties.[20] The salient component of Arogyavardhini Rasa is Kutaki (Picrorrhiza kurroa Royle ex Benth), which has choleretic effects, and other herbal and mineral ingredients act as a Pitta Virechaka, Deepana (promote appetite), Pachana (digestion), and antidermatosis.[21],[22]

Gandhaka Rasayana is frequently used in the management of different skin disorders. It is a herbomineral formulation containing Shodhita Gandhaka (processed sulfur) levigated with various prescribed liquid media for Bhavana.[23] Indications such as Shula (pain), skin diseases, Kandu (itching) and for Rasayana (rejuvenation) purpose are narrated for Gandhaka Rasayana. It is described to have significant antibacterial and antifungal actions.[24] The strong anti-inflammatory and antioxidant potential of sulfur may play a key role in chronic skin disease conditions such as psoriasis.[25],[26]Khadira Chuna has Twachya (beneficial to skin), which has antipruritic and antidermatosis properties.

Guduchi (Tinospora cordifolia (Wild) Miers) is well-explored nootropic herb in Ayurveda, which manifests antistress activity.[27] Psychological disturbance is a prime etiological factor in psoriasis. Hence, Guduchi Churna may help relieve psychological disturbance. It holds berberine that has benefits against skin disease.[28]

Panchavalkala contains Ashwattha (Ficus Religiosa Linn.), Udumbara (Ficus Glomerulata Roxb.), Plaksha (Ficus Lacor Buch.-Ham.), Vata (Ficus Bengalensis Linn.), and Parisha (Thespesia Populenea Soland. ex corea.). The dominancy of Kashaya Rasa (astringent) ingredients of Panchavalkala decoction helps in cleaning and scraping of lesions at the affected site. Panchavalkala decoction has Vrana Prakshalana (wound cleaning), Shothahara (anti-inflammatory), and Vranaropana (wound healing) property.[29],[30],[31] Its decoction has used to wash the affected areas of the psoriatic lesions in the present case, which also helped in healing the psoriatic lesions. Jatyadi Taila carries Tikta (bitter), astringent-dominant ingredients, and has Pitta-Kaphahara, Vrana Shodhana (wound cleansing), wound healing, Vedana Sthapana (pain relieving) attributes.[32],[33] Curcumin present in Haridra has anti-inflammatory, antiseptic, antibacterial, and antimicrobial properties. Salicylic acid present in Jati (Jasminum Grandiflorum Linn.) has antibacterial, antifungal, and anti-inflammatory properties.[34]

The therapeutic effect on the signs and symptoms of disease are depicted in [Figure 4]. After treatment and after follow-up period, the score was decreased, which is shown in line chart. It denotes that therapeutic effect is increased during follow-up period too without the recurrence of disease. The improvement of lesions was calculated based on the PASI score. The PASI score was zero after the treatment as compared to that before treatment. One interesting thing is that she has not observed recurrence till the completion of follow-up period.
Figure 4: Therapeutic effect on assessment criteria

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Psoriasis may associate with significantly lowered 25-hydroxy vitamin D levels and increased levels of ischemia-modified albumin correlating with disease severity suggesting increased systemic inflammation and oxidative stress in psoriasis.[35] Genetic susceptibility, environmental factors, and immune dysregulation have been shown to contribute to the disease onset. T cells, dendritic cells, macrophages, and keratinocytes are critically involved in the pathogenesis of psoriasis.[36] In this case, all the formulations used to treat plaque psoriasis possess anti-inflammatory, immune-modulatory, and antistress activities. Thus, these supportive references may break the pathogenesis of plaque psoriasis by their reported biological activities.

This positive outcome in the present case is the result of a multimodal treatment approach including internal and external Ayurveda medicines and strict dietary modifications in counteracting the pathophysiology of psoriasis.


  Conclusion Top


Generalized plaque psoriasis is chronic skin disorder, which needs Ayurvedic multimodal treatment protocol for long duration. In the present case, an Ayurveda treatment showed promising results with substantial recovery in generalized plaque psoriasis. No adverse events were recorded throughout the treatment and during the follow-up period. As this is a single case report, a clinical study with larger sample size is necessary for its scientific rationale.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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