Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report

Case Report This work is licensed under a CC BY 4.0 License International Research Journal of Ayurveda & Yoga Vol. 5 (7),127-131, July, 2022 ISSN: 2581-785 X; https://irjay.com/ DOI: 10.47223/IRJAY.2022.5716 Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report Mahesh P Savalagimath 1 , Neha K Pol 2 , Ajith Krishnan M 3 , Pooja Gurupad Jiragale 4 1- Reader, Department of Agada Tantra, KAHER’S Shri BMK Ayurveda Mahavidhyalaya, Belagavi, Karna taka 2- PG Scholar, Department of Agada Tantra, KAHER’S Shri BMK Ayurveda Mahavidhyalaya, Belagavi, Karnataka 3- PG Scholar, Department of Agada Tantra, KAHER’S Shri BMK Ayurveda Mahavidhyalaya, Belagavi, Karnataka 4- PG Scholar, Department of Agada Tantra, KAHER’S Shri BMK Ayurveda Mahavidhyalaya, Belagavi, Karnataka INTRODUCTION Psoriasis is a chronic systemic inflammatory disease that can affect any body part. In majority of the cases scalp will affect the first , and over 80% of people with psoriasis eventually develop scalp psoriasis 1 Psoriasis is a noninfectious, chronic, inflammatory auto immune disease of the skin, characterized by well-defined erythematous plaques with silvery scale, with a predilection for the extensor surfaces and scalp, and a chronic fluctuating Article Info Article history: Received on: 01-06-2022 Accepted on: 22-07-2022 Available online: 31-07-2022 Corresponding author- Mahesh P Savalagimath, Reader, Department of Agada Tantra, KAHER’S Shri BMK Ayurveda Mahavidhyalaya, Belagavi, Karnataka E-Mail: vaidyamaheshps@gmail.com ABSTRACT: Psoriasis is a chronic, debilitating disease that commonly involves the scalp. Despite a wide range of therapy options, scalp psoriasis remains challenging to treat, highlighting a long-standing unmet need for the safe and effective treatments. Many topical therapies for scalp psoriasis are also difficult or unpleasant to apply, resulting in decreased adherence and efficacy. In brief, the high level of patient dissatisfaction with currently available treatments for psoriasis supports the need for new, effective and well-tolerated treatment options for scalp psoriasis. Two cases of Scalp Psoriasis approached our outpatient department of dermatology complaining of whitish gray skin lesions over scalp with mild itching. The medical, social, and family history was insignificant. As the treatment protocols available for scalp psoriasis in modern science includes only such as topical corticosteroids, topical vitamin D analogues, topical tar-based preparations, topical salicylic acid, etc., a full cure for scalp psoriasis is difficult due to the condition's recurrent nature. Hence, a treatment protocol is necessary to accelerate the healing process, preventing its spread and recurrence and for cosmetic reasons. When it comes to Psoriasis, irrespective of type of psoriasis, the main cause is disturbed Immunity or Autoimmunity which can be related with the term “ Krimighnatva ” of the body in Ayurveda . Hence the present twin case reports of scalp psoriasis which has shown encouraging results serves as an example in providing the role of Krimighna Chikitsa in management of scalp psoriasis. Key Words: Scalp psoriasis, krimighna, chikitsa

Mahesh et. al “ Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report” : 2022; 5 (7):127-131 128 course 2 . In Autoimmune disease, the immune system tends to destroy one's own cells for reasons unknown. Psoriasis is one such disease. Scalp psoriasis is not only a physical burden but also creates significant psychological stress. The choice of treatment for scalp psoriasis relies on the severity of the disease as well as the condition of the patient. The quality of life for patients may be diminished by the chronic nature of scalp psoriasis 3 . Most of the contemporary treatment methods such as Emollients and Moisturizers 4 , Anthralin (Dithranol) 5 , Coal Tar, Topical Corticosteroids having side effects 6 . Few reported cases demonstrated significant improvement with biomedicine, but recurrence also noticed. As per Ayurveda , these symptoms are closely similar to symptoms of Eka kushtha , as its symptoms are Matsyashakalopamam (Fish like silver white colored scaling), Aswedanam (low or no sweating), Mahawastu (covers large surface area of skin) closely resembles with symptoms of Psoriasis 7 . Ayurveda focuses on treating the root cause of the disease instead of just managing the symptoms. Here in this case of scalp psoriasis , the treatment principles adopted were Vishghna , Krimighna and Rasayana which all have its effect indirectly in improving the strength and immunity of the body. CASE REPORT Two different cases approached our outpatient Department of Dermatology with similar complaints. Case -1 A 22 years old male approached the Nirvisha OPD at KLE Ayurveda Hospital with the complaints of whitish gray skin lesions over lower scalp region and above the ears since 2 and 1/2 month associated with itching.( Figure 1,2&3) Case - 2 A 21 years old male approached the outpatient department complaining of whitish gray skin lesions over lateral side of scalp region and above the ears since 2 months associated with occasional itching.( Figure 7,8&9) Based on the clinical presentation and examination the condition was diagnosed as scalp psoriasis and she was treated with Agada Principles which includes Rakshoghna , vishaghna, krimigna, kandugna etc. Patient had good relief in symptoms and good quality of life On Examination - All vitals were stable Local Examination 1 Surface - Dry 2 Skin - Whitish grey colored with scales 3 Plaques - Scaly plaques + 4 Pain - Absent 5 Blisters – absent 6 Demarcation – absent 7 Foul smell – absent The pertinent medical, social, and family history was noncontributory Treatment Given In the first visit, combination of Haridra Choorna (30 gm), Vidanga Choorna (25 gm), Amalaki Choorna (50 gm), Triphala Choorna (30 gm) was given 1 teaspoon 3 times a day with warm water followed by jaggery as anupana after food and Kutaja taila was given for external application for 20 days. RESULTS (OUTCOME &FOLLOW UP) Lesions were reduced as observed on the 15 th day of the treatment. Itching was absent in 10 days. Almost all the lesions had disappeared and there were no scar marks as observed on 25 th day. (Fig 4,5,6 &10,11) DISCUSSION The scalp is one of the most commonly affected regions in psoriasis. However, scalp psoriasis can be difficult to treat because of challenges in the delivery of therapy. In addition to the physical symptoms of pain and pruritus, psoriasis, especially with involvement of the scalp, can lead to significant psychosocial impairment 8 . Due to the presence of hair, poor accessibility, and unacceptable cosmetic appeal of topical therapy, patients also tend to have poor adherence and satisfaction with treatment 9 . Effective management of scalp psoriasis is essential for improving a patient’s quality of life. Consequently, the management by adopting Krimighna chikitsa in this condition has yielded good response. Haridra (Curcuma longa) which is Katu, Tiktha Rasa , Ruksha, Laghu guna , Ushna veerya , Katu Vipaka and having Vishaghna, Varnya, Siro virechana, Kandughna and Lekhana actions helped in reducing the symptoms in the patient. Also, as Haridra has Raktadhatu shodhan property& Raktaprasadana property which act on dushta raktagata kapha helped in pacifying the itching and scaling in the patient. The chemical constituents are also proved to have anti-inflammatory and bactericidal properties. Vidanga (Embelia ribes) has been described as one of the most potent krimighna dravya’s in ayurvedic literatures 10 . Vidanga has Katu, Tikta rasa, Laghu, Ruksha, Tikshna

Mahesh et. al “ Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report” : 2022; 5 (7):127-131 129 guna, Ushna Virya and Katu Vipaka 11 Katu Rasa does Deepana, Pachana, Kaphahara . Katu Rasa is mentioned as a Krimighna also 12 . The Ushna Virya of the drug again help in Agni Pradeepana , correction of Dushta Kapha and Ama . It also acts as Kapha vatahara . The presence of Katu Vipaka and Katu Rasa also helps in Srotoshodhana. Acharya Charaka consider Vidanga as Krimin Hinasti . As Vidanga having Krimighna, Kushthghna, Deepana, Pachana, Anulomana, Shirovirechana 13 can contribute in the present clinical condition. As per recent researches Vidanga has proved to be anthelmintic, astringent, carminative, alternative and stimulant actions 14 The Amalaki (Embilcal officinalis) is a traditional food and medicine having many known nutritional and medicinal benefits and uses. It is a natural, efficacious antioxidant with the richest natural source of Vitamin C. Numerous studies conducted on Amla fruit suggest that it has antibacterial, anti-viral, anti-fungal, antioxidant, cardioprotective, Gastroprotective, anti-Helicobacter pylori and antistress activity 15 . Amalaki having Lavana varjitha pancha rasa ,laghu ruksha guna , sheeta virya is said to be Vaysthapana, Rasayana and Kushtaghna . Along with the Vidanga and Haridra it can contribute in promoting better rasayana activity thereby improving the immunity of the body. Triphala is a powerful polyherbal formula with myriad efficacious therapeutic uses for maintaining homeostasis as well as the prevention and treatment of disease 16 Triphala is classified as a tridoshic rasayana , meaning that the energetics are appropriate for Vata, Pitta , and Kapha or all types of patients. Charaka describes rasayana as having the qualities of supporting strength and immunity 17 . Given these qualities and the tonic energetics, Triphala can be considered for use in the very young, the infirmed, and the elderly. Other classical Ayurvedic classifications attributed to the formula are shukrala , digestive, mild laxative at normal doses, bowel tonic at low dose, purgative at high doses, carminative, expectorant, antispasmodic, and bronchodilator 18 . It shows that by the virtue of Haridra and its multifarious actions like Varnya, Kandughna and Vishaghna may be possible to reduce the clinical findings. Soshatva of Haridra quality may be the predominant feature to reduce the excessive secretion 19 Psoria oil contains Stri Kutaja (Wrightia tintoria) and Coconut oil. It is used in Psoriasis, Dandruff, Scaling and fungal skin disease. It helps in balancing the Vata and Pitta Doshas . Coconut oil in Psoria oil is Tridoshaghna and reduces Rookshata over skin. Tiktarasa pradhanyata of the combination of churnas and snighdhata of taila helps in reducing both Vata and Pitta. Krimighna, vishaghna , lekhna , Kushtaghna and Rasayana properties of drugs like Vidanga and Triphala helped in counteracting this pathology. CONCLUSION The two patients of scalp psoriasis have shown encouraging results when treated with Agada principles which includes Krimigna, Rakshoghna, Vishagna, Kandugna etc . The results exhibit patient compliant, single sitting, and cost-effective management for scalp psoriasis without any local or systemic side-effects and recurrence. Even though a single case study may not be adequate to demonstrate the importance of any particular treatment, it does provide us with a general concept of the plan of action to take in such conditions and aid in the development of a protocol for research studies large samples of individuals Acknowledgement: Nil Financial support: Nil Conflict of Interest: Nil ORCID Mahesh P Savalagimath , https://orcid.org/ 0000-0001-8145-5004 REFERENCES 1 Chan CS, Van Voorhees AS, Lebwohl MG, Korman NJ, Young M, Bebo BF Jr, et al. Treatment of severe scalp psoriasis: from the medical board of the national psoriasis foundation. J Am Acad Dermatol. 2009;60(6):962–71. 2 Nicki R. Colledge. Brian R. Walker. Stuart H. Ralston(editors).Davidson’s Principles and Practice of Medicine.21 sted.Churchill Livingstone:Elsevier;2010.p.1260 3 Wang TS, Tsai TF. Managing Scalp Psoriasis: An Evidence-Based Review. Am J Clin Dermatol. 2017 Feb;18(1):17-43. doi: 10.1007/s 40257-016-0222-4. PMID: 27650520 4 Nola I, Kostovic K, Kotrulja L, Lugovic L. The use of emollients as sophisticated therapy in dermatology. Acta Dermatovenerol Croat. 2003;11:80–7 5 Loffler H, Effendy I, Happle R. Skin susceptibility to dithranol: Contact allergy or irritation? Eur J Dermatol. 1999;9:32–4

Mahesh et. al “ Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report” : 2022; 5 (7):127-131 130 6 Torsekar R, Gautam MM. Topical Therapies in Psoriasis. Indian Dermatol Online J. 2017 Jul-Aug;8(4):235-245. doi: 10.4103/2229-5178.209622. PMID: 28761838; 7 Vijeyta, S., & Alok Kumar, S. (2015). Ayurvedic Management Of Psoriasis (Ekakushta) With Panchakarma Chikitsa. International Journal of Ayurveda and Pharma Research, 3(1). Retrieved from https://www.ijapr.in/index.php/ijapr/article/view/171 8 Koo J, Marangell LB, Nakamura M, et al. Depression and suicidality in psoriasis: review of the literature including the cytokine theory of depression. J Eur Acad Dermatol Venereol JEADV. 2017;31(12):1999–2009 9 Chan CS, Van Voorhees AS, Lebwohl MG, et al. Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2009;60(6):962–71., Zeichner JA, Lebwohl MG, Menter A, et al. Optimizing topical therapies for treating psoriasis: 36] 10 Kalasannavar SB, Sawalgimath MP. Molluscum contagiosum: A novel Ayurvedic approach. Anc Sci Life. 2013 Jul;33(1):49-51. doi: 10.4103/0257-7941.134606. PMID: 25161331; PMCID: PMC 4140023 11 Sharma RM , Cakrapanidatta, Agniveas´’s Caraka samhita: Text with English Translation & Critical Exposition Based on Cakrapani Datta’s Ayurveda dipika, 1 st ed. Varanasi, India: Chowkhamba Sanskrit Series Office, 1976 12 Kalasannavar SB, Sawalgimath MP. Molluscum contagiosum: A novel Ayurvedic approach. Anc Sci Life. 2013 Jul;33(1):49-51. doi: 10.4103/0257-7941.134606. PMID: 25161331; PMCID: PMC 4140023 13 Srinivas C, Prabhakaran KV. Haridra (curcuma longa) and its effect on abhisayanda (conjunctivitis). Anc Sci Life. 1989 Jan;8(3-4):279-82. PMID: 22557662; PMCID: PMC 3336727 14 Patil U; From the proceedings of Insight Ayurveda 2013, Coimbatore. 24 th and 25 th May 2013 . OA 02.14. Krimigna action of vidanga against clinical isolates of multidrug resistant bacteria, importance of correct identification. Anc Sci Life. 2013 Jan;32(Suppl 2):S 20. doi: 10.4103/0257- 7941.123834. PMCID: PMC 4147489 15 Acharya YT, Sushruta: Sushruta Samhita, with Nibandha Sangraha Teeka by Dalhana, Published by Chaukambha Surbaharati Prakashan, Varanasi, Edition Reprint Sutra Sthan 38/24-25, 2013;p.298 16 Gurgesh R, Laboratory Identification of Parasites of Public Health Concern. Atlanta: Center for Disease Control & Prevention, USA. Pathogenic factor in Ascaris” Trop Medicine and Hyg. CDC (2010). DPDx: 37,209-214, 1934 17 Vaidya YT, editor. Charaka Samhita by Agnivesha, Vimana Sthana; Vyadhitarupiyam Adhyayam: Chapter 7, Verse 10. Varanasi: Chaukhambha Prakashan, Reprint 2009; p.258 18 Prakash L. Hegade, Harini A. A Text Book Of Dravyaguna Vigyana. Revised edition, Choukhambha Sanskrit Sansthan, 2016;p.32 19 Mishra S Amalaki (EmblicaofficinalisGaertn.): A Review from texts of Modern Period. Int. J. of Adv. Res. 5 (Jul). 574-580] 2007 (ISSN 2320-5407 How to cite this article: Savalagimath M.P, Pol N.K , Krishnan A, Jiragale G.P “ Krimighna Approach In The Management Of Scalp Psoriasis – A Twin Case Report” IRJAY.[online]2022;5(7); 127-131. Available from: https://irjay.com DOI linkhttps://doi.org/10.47223/IRJAY.2022.5716

Mahesh et. al “ Krimighna Approach in the Management of Scalp Psoriasis – A Twin Case Report” : 2022; 5 (7):127-131 131 Case 1 - Before Treatment (Fig 1,2&3) Fig-1 Fig-2 Fig-3 Case 1 - After Treatment (Fig 4,5&6) Fig-4 Fig-5 Fig-6 Case 2 Before Treatment (Fig 7,8&9) Fig-7 Fig-8 Fig-9 After Treatment (Fig 10&11) Fig-10 Fig-11

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Ayurveda, Rasayana, Krimighna, Rakshoghna, Chikitsa, Agadatantra, Curcuma longa, Embelia ribes, Vishghna, Coconut oil, Autoimmune disease, Treatment Protocol, Case report, Cost effective management, Chronic inflammatory disease, Kandugna, Triphala choorna, Topical therapies, Scalp Psoriasis, Agada Principles, Amalaki Choorna, Systemic side effects, Topical corticosteroid, Chronic systemic inflammatory disease, Tridoshic Rasayana, Erythematous plaques, Local side effects, Silvery Scale, Haridra Choorna, Psoria oil, Stri Kutaja.