An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) - A Case study

CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 194 An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) - A Case study Akshatha K. Shirwar 1 , Ashwinikumar S. Bharati 2 1 Post Graduate Scholar, Department of Agadatantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India. 2 Professor and HOD, Department of Agadatantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India. I NTRODUCTION Psoriasis is a common, long-term (chronic) skin disease. In India the prevalence of psoriasis varies from 0.44 to 2.8% [1] Onset of psoriasis is most common in the second to fourth decades. It is a chronic disease marked by periods of remissions and exacerbations. Remissions may last for a week to many years. Psoriasis is characterized by the development of Address for correspondence: Dr. Akshatha K. Shirwar Post Graduate Scholar, Department of Agadatantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India. E-mail: akshataakshu [email protected] Submission Date: 13/05/2022 Accepted Date: 21/06/2022 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA erythematous, well defined, dry, scaly papules and plaques of size ranging from a pinhead to palm-sized or larger [2] The scales are abundant, loose, dry and silvery white. The most common type of psoriasis is plaque psoriasis causes dry, itchy, raised skin patches (plaques) covered with scales. There may be few or many. They usually appear on the elbows, knees, lower back and scalp. After scraping the surface in plaque psoriasis lesion becomes red. In Ayurveda all the skin disease are broadly classified under the concept of Kushta which is divided into Mahakushta and Kshudrakushta . Kitibha Kushta is one among Kshudra Kustas where the signs and symptoms of which simulates with that of Plaque psoriasis. Kitibha Kusta having symptoms like Shyava Varna (discoloration), Kinakhara Sparsha (rough in touch/scaly), Parushatva (hard), Ruksha (dry) [3] Every Kusta manifests due to dearrangement of seven factors like Vata, Pitta, Kapha, Twak (skin), Rakta (blood), Mamsa (Muscle and Lasika (lymphatic A B S T R A C T Skin disease makes a great impact as other serious medical conditions when assessed by effects on health-related quality of life. Skin diseases are ranked as the fourth most common cause of human illness, resulting in an enormous non-fatal burden. According to Global burden of diseases, skin and subcutaneous diseases are increasing at an alarming rate since few decades. Due to altered lifestyle, lack of physical exercise, unhygienic, mental stress, over eating, nutrition deficiency, skin diseases are commonly observed. All the skin diseases in Ayurveda have been discussed under the broad heading of Kushta which is further divided into Mahakusta and Kshudra Kusta . Kitibha Kusta is included under Kshudra Kusta which simulates with signs and symptoms of Psoriasis. Psoriasis is chronic disorder which is commonly encountered in day today’s clinical practices accounting for wide spared prevalence. As it is relapsing in nature it requires treatment for long duration. In this case study, 41 years old male patient had come to OPD of Agadatantra with chief complaint of Kandu (itching), dry silvery white patches over both the elbow, blackish discoloration over lower limbs, abdomen and back treated with Shodhana Chikitsa [Body purification] using Virechana Karma and Shamana Chikitsa using Panchatikta Guggulu Ghrta, Bilvadi Gutika, Manjista Choorna as Lepa and Marichadi Taila for application. Thus, this paper highlights a case study of Kitibha Kusta (Plaque Psoriasis) treated with Ayurvedic principles. Key words: Kitibha Kusta, Virechana, Panchatikta Guggulu Ghrita, Avipattikara Choorna, Case Report

Akshatha K. Shirwar et al. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) ISSN: 2456-3110 CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 195 system) [4] According to Acharya Charaka as a Samanya Chikitsa , disease with Bahudoshavastha necessarily needs to be treated with Shodhana line of management for elimination of aggravated Doshas. [5] As the multiple lesions were found in Adhobhaga, Virechana was chosen as a line of treatment for Shodhana. C ASE R EPORT A patient xyz, aged 41 years, male had come to OPD of Agadatantra SDMCAH, Hassan complaining of blackish brown, rough and whitish scaly multiple lesions associated with itching over bilateral elbow, over both lower limbs, abdomen, back associated with severe itching and pain since 6 months. History Patient was said to be normal 3 years back. Noticed with blackish brown, rough and whitish scaly lesions associated with itching. Initially found over bilateral elbow succeedingly over both lower limbs, abdomen, back associated with severe itching and pain. Took symptomatic treatment with the Ayurvedic medications. As he did not find any relief he was admitted on May 17 th 2019 at SDM, Hassan and underwent Virechana. Symptoms were subsided. Presently the same complaint relapsed once again [Failure in following of Pathya (Ahara, Vihara )] with the similar features aggravated with multiple lesions since 6 month. As the symptoms were aggravating, patient approached our hospital and opted for an admission on physician’s advice for better management. Not known case of HTN or DM or any other pathological conditions. No any family history found regarding Psoriasis or any other dermatological conditions. All the blood investigation reports were within normal limits Personal history ▪ Appetite - decreased ▪ Bowel - irregular ▪ Micturition - regular (4-5 times /day) ▪ Sleep - disturbed due to itching ▪ Addiction - Alcohol 2 times in a week ▪ Diet - Mixed (takes non veg food thrice a week) General examination ▪ Pallor : Absent ▪ Icterus : Absent ▪ Cyanosis : Absent ▪ Clubbing : Absent ▪ Lymph node : not palpable ▪ Oedema : Absent ▪ BP : 130/90 mmhg ▪ Pulse : 78 bpm ▪ Respiratory rate : 18/min ▪ Temperature : 98°F Ashtasthana Pariksha ▪ Nadi - Kapha vata ▪ Mala - Vibhanda ▪ Mutra - Prakruta ▪ Jihva - Alipta ▪ Drik - Prakruta ▪ Shabdha - Prakruta ▪ Sparsha - Khara sparsha ▪ Aakriti - Madhyama Dashavidha Pariksha ▪ Prakriti - Pitta vata ▪ Vikriti - Kapha vata ▪ Satva - Madhyama ▪ Sathmya - Madura, Katu ▪ Ahara Shakti - Madhyama ▪ Vyayama Shakti - Madhyama ▪ Sara - Asthi ▪ Samhanana - Madhyama

Akshatha K. Shirwar et al. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) ISSN: 2456-3110 CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 196 ▪ Agni Shakthi - Madyama ▪ Vaya - Madhyama Samprapti Ghataka ▪ Dosha : Vata (Vyana Vayu), Pitta (Bhrajaka), Kapha (Kledaka) ▪ Dhatu : Rasa (Toda, Vaivarnya), Rakta (Sweda), Mamsa ▪ Upadhatu : Tvacha ▪ Agni : Jataragni Mandya ▪ Srotas : Rasa, Rakta, Mamsa ▪ Sroto Dusti Prakara : Sanga ▪ Udbhava Sthana : Amashaya ▪ Sancharasthana : Sarvasharira ▪ Adhistana : Twak, Rakta, Mamsa, Lasika ▪ Vyakta Sthana : Tvak ▪ Roga Marga : Bahya ▪ Swabhava : Chirakari ▪ Sadhyasadhyata : Krichrasadhya Anga Pratyanga Pareeksha Per Abdomen Examination Inspection : shape of abdomen – distended Umbilicus - normal, inverted Hyperpigmentation scars over abdomen Palpation : Soft, no tenderness, no organomegaly Percussion : Tympanic sounds heard except the area of liver dullness Auscultation : Sound - absent Central Nervous System Patient is conscious, well oriented to time, place and person. Respiratory System Inspection : Shape of chest - bilaterally symmetrical Palpation : Trachea – centrally placed Tactile vocal fremitus - Normal Percussion : Resonant sounds heard except the cardiac dullness Auscultation : Normal Vesicular breath sounds heard Cardiovascular System Inspection : No scar, no swelling Palpation : Non tender Percussion : Defined area of cardiac dullness Auscultation : Apex beat felt at 5 th intercostal space S 1 and S 2 heard, No added sounds or murmurs heard Integumentary System Examination Inspection Location - bilateral lower limb, upper limb, back, abdomen Shape - circular lesion Color - blackish white Discharge - Absent Palpation Temperature - felt Texture of lesion - rough and scaly Tests ▪ Candle grease test - positive ▪ Auspitz sign - negative ▪ Koebner phenomenon - positive ▪ Distribution of lesion - symmetrical M ATERIALS AND M ETHODS Centre of study: This study was carried out in OPD of Agadatantra SDM College of Ayurveda and Hospital, Hassan, Karnataka. Table 1: Hetu (Causative factor) [6] Aahara Anupa Mamsa Sevana (3 times a week) Madya (weekly twice)

Akshatha K. Shirwar et al. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) ISSN: 2456-3110 CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 197 Vihara Ratri Jagarana Sweda Atipravrutti (sports) Manasika Chinta Bhaya Shoka (from personal illness and social stigma) Treatment [7] Table 2: First line of treatment : Deepana Pachana Day 1 and Day 2 Chitrakadi Vati Panchakola Phanta 1-1-1 (B/F) 50 ml-50 ml-50 ml (B/F) Table 3 : Second line of treatment : Shodhana Day 3 rd Snehapana with Panchatiktaguggulu Ghrita - 40 ml (7 AM) Ganji when felt hungry Night - Kichadi Day 4 th Snehapana with Panchatiktaguggulu Ghrita - 80 ml (7 AM) Day 5 th Snehapana with Panchatiktaguggulu Ghrita - 120 ml (7 AM) Day 6 th Sarvanga Abhyanga with Yeshtimadhu and Marichadi Taila followed by Bashpa sweda. Diet: Morning and Afternoon - rava idli / rice rasam Night : kichadi Day 7 th Sarvanga Abhyanga with Yeshtimadhu [8] and Marichadi Taila followed by Bashpa sweda. Day 8 th Sarvanga Abhyanga with Marichadi Taila [9] followed by Bashpa Sweda. Virechana with Avipattikara Choorna – 50 g and Draksha Kashaya 100 ml . Taken Ganji once felt hungry (4:40 pm) Patient had 14 Vegas during Virechana Karma, Madhyama Shuddi. Samsarjana Karma for 5 days with 2 Annakala was explained to patient. Samsarjana karma was included with Peya, Vilepi, Yusha, Krushara for 5 days. Shamana Oushadhi after Virechana (Discharge Medicine) Medicine Dose Duration Manjista Lepa 10 gm (daily twice) External Application 20 days Bilwadi Agada 1-1-1 A/F (Internally) 20 days Marichyadi Taila 10 ml (daily twice) External Application 20 days Kantisnana Choorna 10 gm (once daily) External Wash 20 days Septilin Syrup 10 ml-10 ml-10 ml A/F (Internally) 20 days Avipattikara Choorna 1 tsp at night A/F (Internally with warm water) 20 days DISCUSSION In Ayurveda all skin diseases are categorized under “ Kushtha ” Kitibha Kushta is one among Kshudra

Akshatha K. Shirwar et al. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) ISSN: 2456-3110 CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 198 Kustas where the signs and symptoms of which simulates with that of Plaque psoriasis Even if it is cured relapses are common. It is the Vyadhi of Raktavahastrotas , having Sampraptighataka of Vata and Kapha Dosha, Twak, Lasika, Rakta and Mamsa . Acharya Charaka has highlighted the role of Panchakarma therapy by stating that the disease treated by Shodhana will never recur, whereas the treatment with Shamana therapy may reoccur in due course of time. Among the Shodhana, Virechana Karma is opted as the accumulation of Doshas predominantly seen in Adhobhaga. In the present study Shodhana, Shamana and Bahirparimarjan Chikitsa was given to the patient. The treatment schedule was started by following the sequence of Purvakarma, Pradhankarma and Paschyat Karma . In Purvakarma, Deepan – Pachana Dravya Chitrakadi Vati and Panchakola Churna were given which are Agnivardhak and Amapachak for 2 days. After that Abhyantara Snehapana was given with the Panchatikta Guggulu Ghrita for 3 days for the purpose of Vatashamana. For the Bahya Sneha, Sarvanga Abhyanga with Yeshtimadhu and Marichyadi Taila for 2 days. It reduces the dryness, Desquamation (scaling) followed by Sarvangaswedana . It does the Doshavilayana (liquefies the Doshas ) and brings them from Shakhas to Koshta to eliminate them. It also removes the Strotorodha (obstruction in the Strotas ). Later Virechana with Avipattikara Choorna 50 g and Draksha Kashaya 100 ml Action of Snehapana = Panchatikta Guggulu Ghtrita The ingredients were predominantly of Tikta Rasa, Ruksha and Laghu Guna . It acts mainly on Kleda, Meda, Lasika, Rakta, Pitta and Kapha which helps in balancing the vitiated Dosha and Dhatu . It subsides the symptoms like Rukshata , Daha , etc., It has properties like Deepana, Pachana, Strotoshodhak, Raktashodhak, Raktaprasadak, Kushtaghna, Kandughna and Varnya. The Ghrita has lipophilic action which helps to carry drugs to the target organs, it enters to its cellular level and delivers to mitochondria and nuclear membrane. It maintains the normal texture of skin. Action of Abhyanga with Marichyaditaila For the purpose of Abhyanga or Bahyasnehana (external oleation) the Marichyaditaila is used. The most of Dravyas of Marichyaditaila are having properties like Katu, Tikta, Kashaya Rasa and Ushna Virya which does the Shamana of Kapha and Vata Dosha . Its Snighdha Guna reduces the Rukshatva, Kharatva and Parushata . It has properties like Raktashodhana, Kushtaghna and Kandughna. The nature of Taila is Sukshmagamitva means it helps drugs to go into the minute channels and does the proper absorption. The Kashaya Rasa of these Dravyas helps to reduce the Kleda . Marichyadi Taila is antiseptic, antifungal, anti-inflammatory, anti-immuno modulatory property. Thus, Marichyadi Taila is effective in subsiding symptoms of Kitibha Kushta due to these properties. Action of Virechana Karma The Virechana Dravyas which are having properties like Ushna, Tikshna, Sukshma, Vyavayi, Vikasi it reaches to the heart due to their potency it enters into Dhamanis and circulates throughout the Sthula and Sukshmastrotas. By its Agneya Guna it liquefies the Dosha Sanghat . This Doshasanghat gets Chhinna - Bhinna and circulates throughout the Strotas and didn’t get sticks any where because the Snehana was done in the Purvakarma , as like honey not sticks to the vessel which is coated by oil. This Doshasanghat passes through the minute capillaries and moves towards the Koshtha and ultimately reaches to the Amashaya . The Virechana drug has the predominance of the Jala and Prithvimahabhuta , so it acts as a Adhobhagaharaprabhava . It does the elimination of the vitiated Dosha from the Gudamarga [10] Action of Manjista Lepa As imbalanced Pitta Dosha vitiates the blood and impairs its normal functioning. Manjista is one of the most useful herbs helps to purify the blood and treats all type of skin disorders. This is due to its Pitta balancing and Raktashodhaka (blood purifier) properties.

Akshatha K. Shirwar et al. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) ISSN: 2456-3110 CASE REPORT July 2022 Journal of Ayurveda and Integrated Medical Sciences | July 2022 | Vol. 7 | Issue 6 199 CONCLUSION In Kushta Chikitsa both Shamana and Shodhana therapy plays very important role. Plaque Psoriasis and Kitibha Kushta shares the similar symptoms. By this case study we can infer that Kitibha Kushta can be cured with Virechana Karma followed by Shamana Chikitsa using Bilwadi Gutika, Avipattikara Choorna , Septilin syrup, Marichyadi Taila as an external application for 20 days. Modalities of Shodhana and Shamana Chikitsa along with Bahirparimarjana Chikitsa are yielded for achieving better results. REFERENCES 1 Dogra S, Mahajan R. Psoriasis: Epidemiology, clinical features, co-morbidities, and clinical scoring. Indian Dermatol Online J. 2016;7(6):471. 2 Tveit KS. Effect of Herring Roe Lipids on Mild Psoriasis. Nord Congr Dermatology Venereol [Internet]. 2019;63(April):278 – 85. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 5389 757/ 3 Chalapathi RS, Maheswar T, Subhose V, Swamy RK. Critical Evaluation of Kshudra Kustas of Charaka Samhitha: an Ayurvedic Treatise in Light of Modern Medicine. Int JRes Ayurveda Pharm. 2016;7(1):13 – 9. 4 Abhilesh VS, Prathibha CKB, Anandaraman PVS. Management of Erythrodermic Psoriasis through Ayurveda - A Case Report. Perm J. 2021;25:1 – 9. 5 Mangal G, Sharma R, Mangal G. Clinical efficacy of Shodhana Karma and Shamana Karma in Mandala Kushtha (Psoriasis). AYU (An Int Q J Res Ayurveda). 2012;33(2):224. 6 Sharma RK, Dash B. English translation on charaka Samhita of Agnivesha’s. Reprint 2014.Chikitsa sthana; kushta chiitsa: chapter 5, verse 6: Varanasi (India): chowkhamba Sanskrit series office,2014;p.70. 7 Sharma RK, Dash B. English translation on charaka Samhita of Agnivesha’s. Reprint 2014. Chikitsa sthana; kushta chiitsa: chapter 5, verse 4: Varanasi (India): chowkhamba Sanskrit series office,2014;p.68. 8 Shri govind Das. Bhaishajya Ratnavali. Shri kavirajAmbikadutta shastry Ayurvedacgarya, Varanasi: chaukambha prakashan; 2014. Kshudraroga prakaranam(60 th chapter), 1285 th verse,p.946 9 Shri govind Das. Bhaishajya Ratnavali. Shri kavirajAmbikadutta shastry Ayurvedacgarya, Varanasi: chaukambha prakashan; 2014. kustachikits prakaranam (54 th chapter), 1285 th verse,p.890 10 Rais A, Bhatted S. Clinical study to evaluate the effect of Virechanakarma on serum electrolytes. AYU (An Int Q J Res Ayurveda). 2013;34(4):379. ******************************* How to cite this article: Akshatha K. Shirwar, Ashwinikumar S. Bharati. An Ayurvedic Management of Kitibha Kushta (Plaque Psoriasis) - A Case study. J Ayurveda Integr Med Sci 2022;6:194-199. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2022 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Dosha, Shodhana, Rasa, Ayurveda, Ushnavirya, Virechana, Panchakolaphanta, Snehapana, Agadatantra, Medical science, Skin disease, Chronic disease, Ayurvedic principle, Family history, Vata, Pitta, Kapha, Causative factor, External application, Blood-purifier, Vata and Kapha, Aggravated Dosha, Internal application, Skin patches, Personal history, Lower limb, Respiratory system, Shamanacikitsa, Clinical study, Samsarjana Karma, Virechana Karma, Shodhana Therapy, Bahirparimarjana chikitsa, Case report, Clinical Practice, Ayurvedic Management, Rakta (blood), Case study, Kandu (itching), Shodhana Chikitsa, Raktashodhak, Shri Dharmasthala Manjunatheshwara College, Ayurvedic medication, Psoriasis, General examination, Severe itching, First line of treatment, Raktashodhaka, Deepana Pachana, Shodhana and Shamana, Shamana and Shodhana, Global Burden, Kitibha Kushta, Sarvanga Abhyanga, Poorva Karma, Blackish discoloration, Avipattikara choorna, Integumentary system examination, Vata Kapha Dosha, Snighdha Guna, Panchatikta Guggulu, Panchatikta Guggulu Ghrita, Chronic skin disease, Plaque Psoriasis, Marichadi taila, Kshudra Kusta, Katu, Tikta, Kashaya, Bahirparimarjan Chikitsa, Erythematous papule, Multiple lesions, Health related quality, SDM College, Pitta (Bhrajaka).