Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis: A Case Study

CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 257 Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis: A Case Study Rahul Singh 1 , Ish Garg 2 , Ved Prakash Sahu 3 , Sujata Yadav 4 1,2,3 Post Graduate Scholar, PG Department of Kayachikitsa, A & U Tibbia College & Hospital, University of Delhi, New Delhi, India. 4 HOD & Associate Professor, PG Department of Kayachikitsa, A & U Tibbia College & Hospital, University of Delhi, New Delhi, India. I NTRODUCTION Psoriasis is a common dermatologic disease, affecting up to 1% of the World’s population, [1] both males and females suffering equally [2] The word Psoriasis is derived from Greek word ‘Psora’ means ‘itch’ and ‘sis’ meaning ‘acting condition’. Psoriasis is a noninfectious, chronic inflammatory disease of skin, characterized by well-defined erythematous plaques with silvery white scales with a predilection for the extensor surface and scalp, and a chronic fluctuating course [3] In psoriasis, Address for correspondence: Dr. Rahul Singh Post Graduate Scholar, PG Department of Kayachikitsa, A & U Tibbia College & Hospital, University of Delhi, New Delhi, India. E-mail: rahulsingh 95959@gmail.com Submission Date: 12/05/2023 Accepted Date: 21/06/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.7.47 main abnormality is of increased epidermal proliferation due to excessive multiplication of cells in the basal layers. The transit time of keratinocyte is shortened and epidermal turnover is reduced to 5-6 days from 28-30 days [4] Even though the aetiology is unknown, the factors involved are genetic, biochemical and immunopathological [5] Trauma, infections, sun exposure, some medications, and stress are examples of precipitating causes that might exacerbate the condition. As there is no available cure for the disease it has remained a great problem for the patients [6] Other than physical problems, patients also suffer mental and social distress. Diagnosis of the disease is made mainly on the basis of clinical symptoms [7] that is, ▪ Erythematous sharply defined plaques, covered with silvery white scales. ▪ Extensor surface primarily involved such as the knees and elbows. ▪ Koebner ’ s phenomenon present in the active phase of the disease. A B S T R A C T Psoriasis is one of the most common dermatologic diseases, affecting up to 1% of the world ’ s population. It is a non-contagious inflammatory skin disorder clinically characterized by erythematous, and rounded plaques, covered by silvery scale. It can be correlated with Ekakushtha which is having Asvedanam, Mahavastu and Matsyashakalopamam Avastha . This case is about Ayurveda treatment of a 27-year-old male patient with plaque psoriasis presented with erythematous plaques on the anterior surface of the legs, arms and forearms, front and back of trunk region. The Auspitz sign and Koebner phenomenon were positive. The treatment protocol was adopted as per Ayurvedic Samprapti (pathophysiology) and the patient cured completely without reporting any adverse events after 3 month of treatment. No recurrence observed even after one year of the halted treatment. The importance of a wholesome diet ( Pathya and Apathy ) as a health promoter is also revalidated. Photographic documentation was recorded with the proper consent of the patient during successive treatment and regular follow-ups. Altogether, multimodal Ayurveda treatment led to speedy and substantial recovery from a chronic case of psoriasis. Key words: Auspitz sign, Ayurveda, Ekakushtha, Psoriasis, Shodhan, Virechan.

Rahul Singh et al. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 258 ▪ Wornoff ’ s ring often present in the healing phase of the disease. Auspitz sign and candle grease sign are other classic presentations of the disease. The goal of the treatment for the disease is to reduce the symptoms which interfere with the patient ’ s life both physically and socially. There are several types of Psoriasis which can be related to certain diseases described in Samhitas . While the description of Kushtha is present since Vedic period, Ekakushtha is described in Garuda Purana [8] and almost all Ayurvedic classics after that period i.e., Brihattrayi , Laghutrayi and all texts afterwards. Ekakushtha is mentioned in all Ayurvedic classics under Kshudra Kushtha and has predominance of Vata and Kapha Dosha [9] Ekakushtha and Kushtha has same causative factors. Dietary factors as Viruddha Aahara , excessive consumption of Drava, Snigdha, Guru Aahar, Navanna, and Vega Dharana specially of vomiting are major etiologies. Indulgence in sinful act and ill Manovritti (negative mentality) are associated mental factor for causing the disease [10] Acharya Charaka has mentioned the symptoms of Ekakushtha as Aswedanam, Mahavastu, and Matsyashakalopamam [11] and Acharya Sushruta described its symptoms as Krishna-Aruna Varnata [12] The etiological factor leads to vitiation of Tridosha especially Vata and Kapha . These Dosha through Tiryakvahini Siras proceed to Bahya Rogamarga i.e ., Twacha, Rakta, Mamsa, and Lasika and cause the symptoms of disease [13] Repeated Samshodhana along with Samshamana is main line of treatment [14] Both Antah Parimarjan and Bahiparimarjan therapies have been indicated in Kushtha Roga. A IM AND O BJECTIVE To evaluate the role of Samshodhana and Samshamana Karma in management of Psoriasis. M ATERIALS AND M ETHODS Place of study The present case study was done in the Dept. of Kayachikitsa, A & U Tibbia College, Karol Bagh, New Delhi. C ASE R EPORT A 27 year old male patient came to the Kayachikitsa OPD with complain of Reddish silvery plaque with itching, burning sensation on bilateral legs(upper and lower),back and front and back of trunk and bilateral arms and forearm, he was taking antihistaminics and immunosupressants for relief since 6 months. Clinical Findings The patient presented with erythematous plaques on the anterior, posterior and lateral surface of the trunk, Bilateral flexor and extensor surface of arms and forearms, and bilateral upper and lower legs (front surface). The affected skin was found with an erythema and the surface covered with large silvery scale. The patient was suffering from itching and burning all over the body. At the time of the case presentation, the Auspitz sign and Koebner phenomenon found positive. No signs of psoriatic arthritis and nail bed psoriasis were found. General examination Body temperature (97.4°F), Pulse (84/min), and Blood Pressure (118/76) were within normal limit. Systemic examination In systemic examination, respiratory and cardiovascular system found normal. The patient was disturbed due to itching and burning sensation over psoriatic lesions and due to social stigma Diagnostic assessment All routine blood tests were within a normal range. Based on clinical presentation, distribution of the skin damage, and positive Auspitz sign, the case diagnosis was confirmed as plaque psoriasis. Treatment Plan Treatment was based on the Ayurvedic principles of – 1 Nidanparivarjana 2 Shodhan 3 Shaman Considering the clinical signs, symptoms & aggravating factors initial Shaman treatment with Pathaya-

Rahul Singh et al. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 259 Apathya direction was given to the patient for a month (Table 1) and then Shodhan treatment viz. Virechan was planned for patient according to Bala & Kala . After Virechan, Shaman treatment was continued with Pathya -Apathya .(Table 3) Table 1: Shaman Chikitsa before Shodhan Medicine Dose Anupa na Route of administrati on Durati on Arogyavardh ani Vati 250 mg BD after meals Luke warm water oral 30 days Haridrakhand a 1/2 tsf BD after meals Luke warm water Oral 30 days Kaishore Gugglu 2 BD after meals Luke warm water Oral 30 days Mahamanjist adi Kwath 25 ml BD after meals 100 ml of Luke warm water Oral 30 days Pinda Taila Local applicati on q.s. Topical 30 days Shodhan Karma Patient was admitted for Shodhan Karma viz. Virechan and following treatment plan was adopted – 1 Chitrakadi Vati was given 2 tds with lukewarm water for Deepan & Paachan before Snehana for 2 days 2 Snehana was started with Panchtikta Gugullu Ghrita with starting dose of 20 ml and increasing as follows for 7 days.(Table 2) Table 2: Snehapaan before Virechan Karma Medicine Dose Anupana Panchtikta Gugullu Ghrita 20 ml Luke warm water Panchtikta Gugullu Ghrita 40 ml Luke warm water Panchtikta Gugullu Ghrita 60 ml Luke warm water Panchtikta Gugullu Ghrita 80 ml Luke warm water Panchtikta Gugullu Ghrita 100 ml Luke warm water Panchtikta Gugullu Ghrita 120 ml Luke warm water Panchtikta Gugullu Ghrita 140 ml Luke warm water 3 Virechan was given on third day of Snehan completion with Trivritta Avaleh 40 gms mixed in lukewarm milk and 2 tab. of Abhayadi Modak . A total of 27 Vegas was observed which is a Pravar Shudhi with all the signs of Samyak Virechan . 4 Patient was advised to follow Samsarjana Karma as per Shudhi . Table 3: Shaman Chikitsa after Shodhan Medicine Dose Anupa na Route of administrati on Durati on Arogyavardh ani Vati 250 mg BD after meals Luke warm water Oral 60 days Haridrakhand 1/2 tsf BD after meals Luke warm water Oral 60 days Kaishore Gugglu 2 BD after meals Luke warm water Oral 60 days Mahamanjist adi Kwath 20 ml BD after meals 100 ml of Luke warm water Oral 60 days Pinda Taila Local applicati on q.s. Topical 60 days

Rahul Singh et al. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 260 Outcomes & Follow Ups Outcomes were assessed on the basis of PASI score that is Psoriasis Area Severity Score. (Table 4) Patient was treated for a period of around 3 months including Shodhan period and was monitored on follow ups. There was remarkable reduction in PASI score before and after the treatment. (Table 5) (Figure 1) Photographic documentation was recorded with the proper consent of the patient during successive treatment and regular follow-ups.(Figure 2) The patient was kept on a regular follow up and he is free of any sought of lesions till date. Table 4 : PASI (Psoriasis Area Severity Index) scoring Lesion score Percentage of area affected Area score Plaque characteristics Erythema Induration Thickening Lesion sum score (A) 0 - None 1 - Slight 2 - Moderate 3 - Severe 4 - Very severe Area Score (B) Degree of involvement as a percentage for each body region affected (score each region in between 0 -6) 0 = 0% 1 = 1% - 9% 2 = 10% -29% 3 = 30% -49% 4 = 50% -69% 5 = 70% -89% 6 = 90% - 100% Multiply Lesion Score Sum (A) by Area Score (B), for each body region, to give 4 individual subtotals (C). Subtotal (C) Multiply each of the Subtotals (C) by amount of body surface area represented by that region, i.e. x 0.1 for head, x 0.2 for upper body, x 0.3 for trunk, and x 0.4 for lower limbs Body surface area x .1 x .2 x .3 x .4 Totals (D) Table 5 : PASI (Psoriasis Area Severity Index) score before and after treatment Plaque characteristics Upper limbs Lower limbs Trunk BT AT BT AT BT AT Erythema 4 0 4 0 4 0 Induration 4 0 4 0 4 0 Scaling 2 0 2 0 4 0 Area score 6 0 6 0 6 0 PASI SCORE 12 0 24 0 21.6 0 Figure 1: Changes in PASI score before and after treatment Figure 2: Leisons before and after treatment. DISCUSSION Psoriasis is an autoimmune disease where genetic and environmental factors have a significant role. Furthermore, keratinocytes, the inflammatory cascade, and cytokines all play a significant part in the pathogenesis of psoriasis. As all the Kushtha are said to be Tridoshaj . In the present case, Patient had scaling ( Kharta ), itching ( Kandu ) which is Vata , Kapha

Rahul Singh et al. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 261 symptoms and erythema, burning, inflammation which also shows Pitta vitiation so here too all the Doshas were involved, and Rasadhatu, Raktadhatu, and Mamsadhatu were the Dushyas . The treatment protocol was adopted for Samprapti Bhedan . It includes Shodhan Chikitsa , in this case virechan was adopted to normalise the vitiated Doshas especially Pitta and Shaman included Agnidipana (improvement of the biological fire), Aampachana , Rasaprasadana (improvement in the quality of blood), and Raktaprasadana (purification of the blood) were achieved with the help of all the internal medicines. Thus, in the present case, the strict dietary regimen ( Pathya ) has been advised as the mitigating intervention along with Ayurveda medicines. Kaishor Guggulu is a polyherbal preparation. Furthermore, Kaishor Guggulu acts as an antiallergic, antibacterial, and blood purifying agent [15] Therefore, it helps to reduce redness, inflammation and acts as a natural blood cleanser by its pacifying effects on deep sited vitiated Doshas of psoriasis. 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, Deepani (appetiser), Pachani (digestive), Tridoshasham Aka (pacify all Doshas ), and is indicated in Kushtha treatment. Haridrakhand has Haridra as main ingredient which has Kaphahar , Kustaghana and Kandughan property. It has blood purification properties ( Raktashodhana ) and it also helps to eliminate inflammatory mediators like cytokines and by its immunomodulatory property helps to reduce inflammation. Mahamanjishtadi Kwatha [16] It has drugs like Manjishtha ( Rubia cordifolia Linn.), Amrita ( Tinospora cordifolia Miers), Haridra ( Curcuma longa L.), Daruharidra ( Berberis aristata DC.), Arishta ( Azadirachta indica A. Juss.), Patolamula ( Trichosanthes cucumerina Linn.), Katuka ( Neopicrorhiza scrophulariiflora Royle ex Benth.), Bhringa ( Eclipta prostrate L.), Magadha Piper, Trayanti ( Gentiana kurroo Royle), Patha ( Cyclea peltata LAM.), Asana ( Pterocarpus marsupium ROXB.), Aragvadha ( Cassia fistula L.) etc. All these drugs are having properties like Varnya , Kapha Pittashamak, Shothahar (Oedema reducing), Kushtaghna (Curing skin diseases), Vranropak (Wound healer). Most of the drugs are Tridoshaghna (Pacify aggravated Dosha) or Kapha Pittahara property by virtue of Tikta (Bitter), Katu (Pungent), Kashaya Rasa (Astringent), Laghu (Light), Ruksha Guna (Rough property), and Ushna Veerya (Hot potency); Katu Vipaka (Pungent postdigestive effect). Manjistha is Varnya and Rakta Prasadana (Blood purifying), Nimba is Kandughna , Haridra is Kusthaghna (Reduce itching). Vacha is Sroto Shodhana (Channel cleanser). All these drugs perform the therapeutic pharmacological action on the basis of innate qualities i.e., Rasa (Taste), Guna (Properties), Veerya (Potency), Vipaka (Final transformation) and Prabhava (Specific potency) altogether and follow the Samprapti Vighatana Chikitsa Siddhanta (Breaking of etiopathogenesis as a principle of treatment). Virechana (medically induced purgation) is one of the Panchkarama procedure which is used in detoxification. Snehan brings all the Doshas to alimentary canal ( Koshtha ) from where it is brought out of the body via rectal pathway. It reduces the proinflammatory cytokines in body and normalizes the vitiated doshas thus brings internal homeostasis. Pinda Taila was used for local application which has Manjista, Saariva, Sarjarasa, Madhuchhista as ingredient. The ingredients have Pitta Shaman property which reduces the inflammation and also acts as anti-oxidant and reduces erythema, scaling and inflammation and overall disease activity. CONCLUSION In the present case, the treatment protocol was adopted as per Ayurvedic Samprapti and the treatment response was observed. Shodhan and Shaman treatment with external application has shown remarkable improvement in signs and symptoms of psoriasis which is evident from reduction in PASI score.

Rahul Singh et al. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 262 REFERENCES 1 Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo; Harrison ’ s Principal of Internal Medicine. Vol- 1; U.S.A.; 17 th edition; McGraw Hill Companies; pg 315. 2 Lee Goldman and Andrew I. Schafer; Goldman ’ s Cecil medicine.24 th Edition; Elsevier Saunders. Eczemas, photodermatoses, Papulosquamous diseases.pg no. 2517. 3 Z. Zaidi and S.W.Lanigan; Dermatology in Clinical practice, 2010 Springer- Verlag London Limited, Immune system of the skin, pg 185. 4 Davidson ’ s . Principles and practice of medicine. 21 st edition. Churchill livin stone publication, 2010, Chapter – (Diseases of the skin) Pg -900. 5 Michael Hertl; Autoimmune diseases of skin; third edition; Springer Wein New York; pg no. 328-331. 6. 6 Neena khanna; Illustrated synopsis of Dermatology and Sexually transmitted diseases; Ed 2005; Jaypee publishers and distributors; Pg no. 38. 7 De Korte J, Sprangers MAG, Mombers FMC et al .Quality of life in patients of Psoriasis: A systemic literature review. J invest Dermatol symp Proc 2004;9:140-7. 8 Ram Shankar Bhattacharya; Garuda Purana: Maharshi Vedvays; Varanasi; Edition 1964 Chaukhambha Sanskrit Series (Ga. Pu. 1/164/20) Pg no. 38. 9 Pandit Kashinath Pandey and Dr. Gorakhnath Chaturvedi; Charak Samhita, Savimarsha VidyotiniHindi Vyakhya; Varanasi; Ed 2011; Chaukhamba Sanskrit Sansthana Pg no. 253. (Ch. Chi. 7/29-30). 10 Pandit Kashinath Pandey and Dr. Gorakhnath Chaturvedi; Charak Samhita Poorvardh, Savimarsha Vidyotini- Hindi Vyakhya; Varanasi; Ed 2011; Chaukhamba Sanskrit Sansthana Pg no. 643. 11 Pandit Kashinath Pandey and Dr. Gorakhnath Chaturvedi; Charak Samhita, Savimarsha VidyotiniHindi Vyakhya; Varanasi; Ed 2011; Chaukhamba Sanskrit Sansthana Pg no. 252. (Ch. Chi. 7/21) (Ch. Chi. 7/41). 12 Kaviraj Ambikadatta Shastri; Sushruta Samhita, Ayurveda tatva sandipika, Varanasi; Ed. 2007; Publication- Chaukhambha Sanskrit Sansthana. Pg no. 321. (S. Ni. 5/10). 13 Brahmananda Tripathi; Ashtang Hridaya, Nirmala Hindi Tika, Varanasi; Ed. 2010, Chaukhamba Sanskrit Sansthana pg no. 369. (A. H. Ni. 14/3). 14 Pandit Kashinath Pandey and Dr. Gorakhnath Chaturvedi; Charak Samhita, Savimarsha VidyotiniHindi Vyakhya; Varanasi; Ed 2011; Chaukhamba Sanskrit Sansthana Pg no. 255 (Ch. Chi. 7/21) (Ch. Chi. 7/41). 15 Bharati PL, Agrawal P, Prakash O. A case study on the management of dry gangrene by kaishore guggulu, sanjivani vati and dashanga lepa. Ayu 2019;40(1):48 e 52 16 Acharya Sharangdhara, Sharngadhara Samhita, Madhyam Khanda 2, Jivanprada Hindi commentary, Editing by Shailaja Srivastava, Chaukhambha orientalia, Varanasi, 2011. p. 137- 42. ******************************* How to cite this article: Rahul Singh, Ish Garg, Ved Prakash Sahu, Sujata Yadav. Role of Ayurveda in management of Ekakushtha w.s.r. to Psoriasis: A Case Study. J Ayurveda Integr Med Sci 2023;07:257-262. http://dx.doi.org/10.21760/jaims.8.7.47 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 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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