Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in the management...

[Full title: Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in the management of Psoriasis (Ekakustha)]

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[Find the meaning and references behind the names: Sneha, Jan]

ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 23 Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in the management of Psoriasis (Ekakustha) Dr. Sweety J. Ruparel, 1 Late Dr. Sudhaben Vyas. 2 1 Professor & HOD, Department of Panchkarma, Govt. Akhandanand Ayurved College, Ahmedabad, Gujarat, India, 2 Ex. Reader, Dept. of Kayachikitsa, I.P.G.T. & R.A., GAU, Jamnagar, Gujarat, India. I NTRODUCTION Importance of the beauty exists in the society since ancient time. So the skin diseases are taken up as a social stigma, due to altered appearance [1] Psoriasis Address for correspondence: Dr. Sweety J. Ruparel Professor & HOD, Department of Panchkarma, Govt. Akhandanand Ayurved College, Ahmedabad, Gujarat, India E-mail: sweetyruparel@gmail.com Submission Date : 13/02/2017 Accepted Date: 27/02/2017 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.v 2 i 1.7482 is one of the most repulsive skin diseases which may disturb patient’s life. It is non infectious, easily diagnosable in its typical form usually running a chronic course with remission and exacerbations [2] As far as treatment is concerned modern medical science has number of therapeutic measures which provide temporary relief accompanied by side effects and which make the patients to take lifelong treatment. So it is a need to find out an effective radical cure for psoriasis through Ayurveda . According to Ayurveda all skin diseases are taken under generalized term ‘ Kustha’ [3] In present study Psoriasis is considered as Ekakustha , one type of Kshudra Kustha . Present study is an attempt to find out most effective remedy for psoriasis. Selection of drug and therapy As Shodhana therapy is essential in the management of all skin diseases, Virechana Karma was selected because it is the only procedure which acts upon all A B S T R A C T Skin diseases are taken up as a social stigma, due to altered appearance. Psoriasis is one of the most repulsive skin diseases which may disturb patient’s life. It usually runs a chronic course with remission and exacerbations. As far as treatment is concerned modern medical science has number of therapeutic measures which provide temporary relief accompanied by side effects and which make the patients to take lifelong treatment. So it is a need to find out an effective radical cure for psoriasis through Ayurveda . According to Ayurveda all skin diseases are taken under generalized term Kustha . In present study psoriasis is considered as Ekakustha , one type of Kshudrakustha . As Shodhana therapy is essential in the management of all skin diseases, Virechana Karma was selected because it is the only procedure which acts upon all three Doshas and Raktadi Dushyas which are vitiated in Kustha . After Virechana Karma , Shamana treatment was also given to alleviate remaining Doshas and to continue the normal state of Dhatus . This clinical trial was conducted on total 13 patients of psoriasis ( Ekakustha ) to compare the effect of Virechana Purvaka Shamana with only Shamana. For Shamana purpose Shamana Sneha ( Panchatikta Ghrita ) along with some Rasayana drugs were used. Duration of Shamana treatment was 2 months in both groups. Patients of both the groups showed significant results. But Virechana Purvaka Shamana was found to be more effective than only Shamana. Key words: Ekakustha, Psoriasis , Rasayana, Shamana Sneha, Panchtikta Ghrita.

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[Find the meaning and references behind the names: Bala, Rasa, Heart, Honey]

Dr. S. J. Ruparel et.al. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in Psoriasis. ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 24 three Doshas and Raktadi Dushyas which are vitiated in Kustha [4] After Virechana Karma , Shamana treatment was also given to alleviate remaining Doshas and to continue the normal state of Dhatus . For this purpose Panchatikta Ghrita [5] was given as a Shamana Sneha along with Triphaladi Rasayana Vati [6] In psoriasis Vata Pradhana Tridosha is vitiated. So Shamana Sneha is very important to eliminate Rukshata of Vata . Besides this Rasayana drugs are also necessary to maintain the normal status of the skin. O BJECTIVES To assess and compare the efficacy of Virechana Purvaka Shamana Sneha with Rasayana drugs and only Shamana in the management of psoriasis. M ATERIAL AND M ETHODS Selection of the patients For present study the patients fulfilling the clinical criteria for diagnosis of psoriasis ( Ekakustha ) were randomly selected irrespective of their age, sex, religion etc. from O.P.D. section of Kayachikitsa department, I.P.G.T.& R.A., Jamnagar. Inclusion criteria ▪ As per clinical sign and symptoms of Psoriasis ( Ekakustha ) described in classical Ayurvedic text and modern literature. ▪ Patients having age of 20 to 60 years. Exclusion criteria ▪ Virechana Ayogya as per classical text. ▪ Patients having complicated diseases like Cancer, T.B., Heart diseases, D.M., H.I.V., Gastric or duodenal ulcer etc. ▪ Below 20 years and above 60 years of age. Diagnostic criteria Signs and symptoms of the Psoriasis ( Ekakustha ) described in modern literature as well as classical Ayurvedic text. Investigations 1 Blood: HB%, TLC, DLC, ESR, FBS, PPBS 2 Urine: Routine and Microscopic. All the above investigations were done to evaluate healthy status and exclude other pathology according to necessity. Design of groups and management After diagnosis, the patients were randomly categorised into the following two groups. Group-A (Virechana with Shamana) ▪ Dipana Pachana - Trikatu Churna till Agnideepana was attained. ▪ Snehapana - Panchatikta Ghrita ▪ Sarvanga Abhyang with Bala oil followed by Baspa Swedana (for 3 days) ▪ Virechana drug - Ichhabhedi Rasa 250-500 mg with Trifala Kvatha (100-200 ml) with Erand Sneha (10-30 ml). ▪ Sansarjana Krama ▪ Shamana - as per Group B. No of patients - 7 (1 patient discontinued) Duration - Days of Virechana Karma + 2 months Group-B ( Shamana ) Internal ▪ Panchatikta Ghrita - 10 gm in morning. ▪ Anupana - Ushnodaka ▪ Trifaladi Rasayana Vati - 6 gm (each Vati of 500 mg) twice a day with honey and ghee. External ▪ Erand Sneha - Q.S. No of patients - 9 (2 patient discontinued) Duration - 2 months Pathya - Apathya All the patients were advised to avoid the factors (Aahara and Vihara) which causes Kustha as per classical references, especially to avoid salty and sour food, soaps, synthetic cloths and to take bath with water boiled with Neem leaves. Patients were also instructed to do Yogasana if possible. Follow Up Follow up study was done after the completion of treatment for 4 weeks.

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Dr. S. J. Ruparel et.al. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in Psoriasis. ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 25 Criteria for Assessment Assessment was done by observing clinical improvement in signs and symptoms of the disease as per performa. All the signs and symptoms were given scores depending upon their severity before and after the treatment. The total effect of the therapy was assessed considering the overall improvement in signs and symptoms. For this purpose, following categories were maintained. ▪ Complete remission : 100 % relief in signs and symptoms. ▪ Marked improvement : More than 75% improvement in signs and symptoms ▪ Moderate improvement : 51% to 75% improvement in signs and symptoms ▪ Mild improvement : 26% to 50% improvement in signs and symptoms ▪ No Improvement : Less than 25% reduction in signs and symptoms Statistical Analysis This was assessed in terms of Mean score, Standard Deviation, Standard Error, t test. P > 0.05 : Non significant result P < 0.05 : Significant P < 0.01 and p < 0.001 : Highly significant Ethical clearance Initially ethical clearance was taken from institutional ethics committee for present clinical study. O BSERVATIONS In the present study total 16 patients of psoriasis were registered, out of which 6 patients were treated under Group-A and 7 patients were treated under Group-B. The remaining 3 patients discontinued the treatment. Table 1: Type of Psoriasis wise distribution of 16 patients of Psoriasis Type of Psoriasis No. of Patients Total % Group- A Group- B Nummular 6 8 14 87.50% Gyrate 0 1 1 6.25% Erythrodermic 1 0 1 6.25% In the present study maximum number of patients (87.5%) were having nummular type of psoriasis. Table 2: Dietary analysis of 16 patients of Psoriasis including etiological factors. Dietary aspect No. of Patients Total % Rasa Pradhanta Group- A Group- B Madhura 2 6 8 50.00% Amla 1 3 4 25.00% Lavana 2 2 4 25.00% Katu 6 7 13 81.25% Tikta 0 1 1 6.25% Kashaya 0 1 1 6.25% Vidhitah Vishamashana 0 3 3 18.75% Adhyashana 5 3 8 50.00% Viruddhashana 2 2 4 25.00% None of above 1 2 3 18.75% Dietary analysis reveals that maximum number of patients (81.25%) were taking Katu Rasa Pradhana Ahara followed by Madhura Rasa (50%) Pradhana Ahara . Adhyashana was found in maximum 50% of the patients. Table 3: Viharaj Niidana wise distribution of 16 patients of Psoriasis. Viharaj nidana No. of Patients Total % Group- A Group- B Vegavidharana 2 0 2 12.50% Divaswapna 4 3 7 43.75% Shitoshna 2 3 5 31.25%

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Dr. S. J. Ruparel et.al. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in Psoriasis. ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 26 Viparyaya Ratrijagarana 1 1 2 12.50% None of above 1 3 4 25.00% In present study maximum no. of patients i.e. 43.75% gave a history of Divaswapna followed by Shitoshna Viparyaya (31.25%) as a causative factors . Table 4: Cardinal symptoms wise distribution of 16 patients of Psoriasis. Scaling, Vaivarnya, Bahalatva, Rukshata, Aswedanam were found in 100% patients while Kandu was found in 93.5% of patients. Table 5: Present signs of Psoriasis wise distribution of 16 patients of Psoriasis. Type No. of Patients Total % Group- A Group- B Auspitz’s sign 7 8 15 93.75% Candle grease sign 7 8 15 93.75% Koebner’s phenomena 5 2 07 43.75% Auspitz sign and Candle grease sign were present in 93.75% patients each. Koebner’s Phenomena was found in 43.75% of patients. R ESULTS Table 6: Effects of therapy on individual criteria in Group-A (Virechana Purvak Shamana). N o. Paramet ers Mean % age Reli ef SD ± SE ± T P BT AT 1. Scaling 4.0 0 0.3 3 91.6 7 1.4 6 0.5 5 6.6 3 ˂ 0.0 01 2. Vaivarny a 3.0 0 0.6 7 77.6 3 0.5 2 0.2 1 11. 04 ˂ 0.0 01 3. Bahalatv a 2.3 3 0.0 0 100 0.5 2 0.2 1 11. 04 ˂ 0.0 01 4. Aswedan am 2.0 0 0.3 3 83.5 0 0.5 2 0.2 1 7.9 1 <0.0 01 5. Kandu 2.3 3 0.0 0 100 0.8 1 0.3 3 6.9 9 <0.0 01 6 Rukshta 2.1 7 0.1 7 92.1 7 0.8 9 0.3 6 5.4 8 <0.0 1 7 Daha (n=2) 0.3 3 0.0 0 100 - - - - 8. Auspitz’s Sign 1.0 0 0.1 7 83.3 3 0.4 1 0.1 7 4.9 9 <0.0 1 9. Candle grease sign 1.0 0 0.1 7 83.3 3 0.4 1 0.1 7 4.9 9 <0.0 1 10 Koebner’ s phenom ena 1.0 0 0.2 5 75.0 0 - - - - From above table it can be seen that in Group-A, highly significant relief was found in Scaling , Vaivarnya, Bahalatva, Aswedanam at the P level <0.001 and in Rukshata , Auspitz’s Sign, Candle grease sign also (P<0.01) Table 7: Effect of therapy on individual criteria in Group- B (only Shamana ). N o. Parame ters Mean % Reli ef SD ± SE ± T P BT AT 1. Scaling 2. 71 1. 14 57. 93 0. 79 0. 3 5.2 9 ˂ 0.0 1 Parameters No. of Patients Total % Group-A Group-B Scaling 7 9 16 100% Vivarnya 7 9 16 100% Kandu 6 9 15 93.5% Daha 2 2 04 25% Bahalatva 7 9 16 100% Rukshaata 7 9 16 100% Aswedanam 7 9 16 100%

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[Find the meaning and references behind the names: Guna]

Dr. S. J. Ruparel et.al. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in Psoriasis. ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 27 2. Vaivarn ya 3. 0 1. 57 47. 67 0. 53 0. 2 7.0 8 ˂ 0.0 01 3. Bahalat va 2. 0 0. 57 71. 50 0. 53 0. 2 7.0 8 ˂ 0.0 01 4. Asweda nam 2. 0 0. 57 71. 50 0. 53 0. 2 7.0 8 <0.0 01 5. Kandu 2. 0 0. 14 93. 00 0. 38 0. 14 13. 07 <0.0 01 6 Rukshta 1. 57 0. 29 81. 91 0. 49 o. 18 6.9 9 <0.0 01 7 Daha (n=5) 1. 40 0. 00 100 .0 - - - - 8. Auspitz’ s Sign 1. 00 0. 33 66. 67 0. 52 0. 21 3.1 7 <0.0 5 9. Candle grease sign 1. 00 0. 17 83. 33 0. 41 0. 17 4.9 8 <0.0 1 1 0 Koebner ’s phenom ena (n=2) 1. 00 0. 5 50. 00 - - - - In Group B also highly significant improvement was noted in all symptoms except Auspitz’s sign, Daha and Koebner’s phenomena Table 8: Overall Effect of Therapy in both Groups . Results Group A (n=6) Group B (n=7) No. of Patients % No. of Patients % Cured 1 16.67% 0 0% Markedly Improved 4 66.67% 3 42.86% Moderately Improved 1 16.67% 4 57.14% Mildly Improved 0 0% 0 0% Unchanged 0 0% 0 0% Overall result shows that in Group-A, maximum number (66.67%) of patients were markedly improved followed by cured and moderately improved i.e. 16.67% each. In Group-B no any patient was cured as well as mildly improved, but maximum i.e. 57.14% patients were moderately improved, while remaining 42.86% patients were found markedly improved. DISCUSSION Ekakushtha being a Kshudra Kushtha has involvement of Tridosha and Vata Kapha predominance. Practically it needs repeated Shodhana therapy as Aacharya Sushruta had said in Su.Chi.9./43. Adhyashana , Divaswapna and Shitoshna Viparyaya may have a leading role in developing Ekakushtha . Probable mode of Action Virechana Karma - Virechana Karma is very effective Panchkarma procedure in Tridoshaja Vyadhi like Psoriasis. It excrete outs the vitiated Doshas from the body and removes the Vigunata of Vata that can be taken as cause of hyperkeratinization, absence of granular layer and excessive shedding of epidermis found in pathogenesis Panchtikta Ghrita - Panchtikta Ghrita is effective for Snehana before Virechana Karma in the patients of Psoriasis. Due to Tikta Rasa possess Dipana Pachana properties, it purifies the Rakta Dhatu . And Panchtikta Ghrita pacifies all three Doshas Trifaladi Rasayana Vati - After Virechana Shamana is also important to continue its effect and to sustain Dhatusamyata . Triphaladi Rasayan Vati has Rasayan drugs which maintain healthy status of Dhatus and Panchtikta ghrita pacifies remaining Doshas . The dose of the Shamana sneha should be decided according to the Agni of the patient Erand Sneha - It smoothens and softens the skin by virtue of Snigdha and Sukshma Guna . It contains keratolytic agent helps in removing scales. It normalizes the cell proliferation and thus stimulates healthy tissue formation Highly significant results were found in both the groups, but patients of Virechana Group (Group-A) showed better results as compared to Shamana group (Group B). 16.67% patients were found completely cured in only Group-A Marked improvement was found in 66.67 % patients in group A and 42.86% patients in group B Moderate improvement was found in 16.67% patients in group A and 57.14%

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[Find the meaning and references behind the names: Sharma, Haridas, Thomas, Ajaykumar, Nil, Med]

Dr. S. J. Ruparel et.al. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in Psoriasis. ISSN: 2456-3110 ORIGINAL ARTICLE Jan-Feb 2017 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2017 | Vol. 2 | Issue 1 28 patients in group B In present study no one patient showed mild improvement or remain unchanged CONCLUSION It can be concluded that Virechana Karma using Panchatikta Ghrita followed by Shamana therapy with Panchatikta Ghrita as a Shamana Sneha along with Triphaladi Rasaya Vati is the best choice of treatment for Ekakushtha . No adverse reaction was reported by patients during treatment and follow up. Results of this study are very encouraging but the study was conducted on a small group of patients, so a trial should be conducted on a larger sample size. REFERENCES 1 Thomas P. Habif. Clinical dermatology. 4 th edition. Mosby, Edinburgh, chapter 8. 2 A.F.Golwalla. Medicine for Students. Fourteenth edition, India Publishing Works, Bombay, p.934 3 Ajaykumar Sharma. Kayachikitsa. Reprint edition, Chaukhamba Publishers, Varanasi, 2009,p.812 4 Vaidya Haridas Shridhar Kasture. Ayurvediya Panchkarma Vigyana. 4 th edition, Vaidyanath Ayurved Bhavana, p.308, 5 Rajeshwardutta Shashtri. Bhaishajya Ratnavali, Vidhyotini Hindi Commentary, 13 th edition, Reprint 1999, Chaukhanba Sanskrit Samsthan, Varanasi, 1999;p.633-634 6 Asthanghrdayam (Gujarati), published by Sastsu Sahitya vardhak karyalaya, Ahmedabad, 4 th edition, 19 th Adhyaya, 35 th Shloka, p.528 ******************************* How to cite this article: Dr. Sweety J. Ruparel, Late Dr. Sudhaben Vyas. Role of Virechana Purvaka Shamana Sneha with Rasayana drugs in the management of Psoriasis (Ekakustha). J Ayurveda Integr Med Sci 2017;1:23-28. http://dx.doi.org/10.21760/jaims.v 2 i 1.7482 Source of Support: Nil, Conflict of Interest: None declared.

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Samana, Kandu, Kushtha, Tridosha, Adhyashana, Ekakushtha, Vaivarnya, Raktadhatu, Rukshata, Kshudrakushtha, Panchatiktaghrita, Katurasa, Dipanapachana, Skin disease, Highly significant, Modern literature, Statistical analysis, Group A, Significant result, Inclusion criteria, Exclusion criteria, Diagnostic criteria, Virechana Karma, Shodhana Therapy, Ethical Clearance, Marked improvement, Moderate improvement, Complete remission, Clinical criteria, Ayurvedic text, Mild improvement, Divaswapna, Vata Kapha predominance, Tridoshaja vyadhi, Aacharya Sushruta, No improvement, Candle grease sign, Auspitz's sign, Dhatusamyata, Rasayana drug, Shamana treatment, Vata Pradhana Tridosha, Scaling, Aswedanam, Erand Sneha, Keratolytic agent, Group B, Psoriasis (Ekakustha).