First page 1st Author name:- Dr Nandadeep V Chodankar Assistant Professor in department of Kayachikitsa RJVS Bhaisaheb Sawant Ayurved Mahavidyala, Sawantwadi, Maharastra. Email Id- dr.chodankar@gmail.com Address for correspondence:- Dr Nandadeep V Chodankar F 129 salaiwada, Panchayat samitti Road Sawantwadi, District- Sindhudurga Pin code- 416510 Email Id- dr.chodankar@gmail.com 2nd Author Dr Subodhan Kashalikar General Practitioner at Sawantwadi Email Id:-drsubodhan@gmail.com 3rd Author Prajkta Gajanan Chaudhari Intern Doctor at R.J.V.S. Hospital, Sawantwadi. Email Id:- prajktachaudhari799@gmail.com 4th Author Smita Nathilal Tiwari Intern Doctor at R.J.V.S. Hospital, Sawantwadi. Email Id:-Smitatiwari1998@gmail.com 5th Author Dr Akbar R Walandkar Professor and HOD Shalyatantra Hon Shri Annasaheb Dange Ayurved Medical Collage, Ashta. Email Id- akbar.walandkar@gmail.com mailto:dr.chodankar@gmail.com mailto:dr.chodankar@gmail.com mailto:drsubodhan@gmail.com mailto:Smitatiwari1998@gmail.com mailto:akbar.walandkar@gmail.com MANAGEMENT OF PSORIASIS (EKAKUSHTHA) ACCORDING TO AYURVEDIC PATHO- PHYSIOLOGY:-A CASE STUDY ABSTRACT- Immune response of a human body to the uncertain factors leads to the accelerated inflammatory proliferation of the ailing cells of the skin known as psoriasis. Although the condition found described many decades ago, the etiology and treatment look under-researched. In Ayurveda many herbs have proven efficacy in psoriasis, but multifaceted etiology of the disease needs a multimodal treatment approach. We report about ayurveda treatment in 62 yrs old male patient with plaque psoriasis presented with erythematous patches. On the anterior surface of legs, hands, back of foot sole. The treatment protocol was adopted as per ayurvedic samprapti (pathophysiology) and patient was cured completely without reporting any adverse event or recurrence after the 6 month of therapy. INTRODUCTION- Psoriasis is a chronic immune-mediated inflammatory condition mainly affecting the skin and joints. Its prevalence in India is about 0.44-2.8 percent. Males are being affected by psoriasis two times more common than female1. Various sites of the body such as scalp, face, trunk, limbs, palms and soles involve in psoriasis. The diagnosis of psoriasis depends on tissue biopsy and distribution of skin damage. Plaque psoriasis (psoriasis vulgaris), Inverse psoriasis, Gutlate psoriasis, Pustular psoriasis And erythrodermic psoriasis are a few of the clinical patterns, reported in psoriasis cases2. The chronic nature, recurring pattern, and visibility of psoriasis produce a great adverse impact on the psychological and social aspects of patient’s life. Psychological disability affects their daily work, as well as social interactions. In recent studies, stress is found to be the important leading cause of psoriasis. In Ayurveda, all skin diseaseare described under the umbrella of kushta. Ekakushta is one of the kshudrakushta describe in Ayurvedic text. In charak Samhita chikitsasthan(chap.7)3,Ekakushta is described as vat-kaphaj disease. Ekakushta4 has signs and symptoms i.e.aswedanam(absence of sweating), mahavastu (big size lesions) and matsyashaklopaman(scaling) which can be compared with psoriasis. As in Ayurveda, Ekakushta is mention as krucchasadhya (difficult to treat). As in Modern medicine, the treatment approach is symptomatic and not focus to the root cause. So it leads to reaggravation of symptoms in favorable environment. As in Ayurveda our main aim is to focus on root cause of disease. And by destructive the root cause we can achieve the fruitful results. Ayuveda has good results in psoriasis. In ayurveda many herbs have proven effective in psoriasis; but the multifeatured etiology of disease need a multimodal treatment approach, in which Aampachak, Agnidipana, Dhatugatjwarchikitsa, Kushtachikitsa, is adopted. In the present case, the multimodal Ayurveda treatment approach resulted in early recovery from psoriatic lesion with no recurrence so far. AIMS AND OBJECTIVES- To evaluate the role of Ayurvedic medicine in management of psoriasis. MATERIALS AND METHODS- Ayurvedicsamhita Ayurvedic research articles Ayurvedic journals Official records Photographs NEED OF STUDY- Psoriasis is recurring chronic disease for which it is difficult to treat. PLACE OF STUDY- The present case study done in department of Kaychikitsa RJVS Sawantwadi, Maharashtra. CASE REPORT- Information of patient- Patients OPD case Number:- 426383 Age-62 yrs, sex- Male Religion- Hindu Socioeconomic status- lower class Occupation- cobbler Diet-mix diet pattern PRADHANVEDANA (Present Complaints)- Erythematous patches on both hands, legs, back and foot soles -: 3 yrs Itching and rashes with scaling on scratchingnodaha VARTAMAN VYADHIVRITTA (H/O PRESENT ILLNESS)- The patient was symptomatic before 3 yrs after that he developed complain of scaly rashes on his back and which gradually progressed and involved his both upper and lower extremities at anterior aspect of leg along with itching and scaling after scratching. He took allopathic medicine for 2 yrs, which provided symptomatic relief till treatment continues. On discontinuation of the treatment, again the symptoms aggravated. PURVAVYADHIVRITTA (HISTORY OF PAST ILLNESS)- Patient has no significant past history of any chronic illness. KULAJVRITTA (FAMILY HISTORY)- No any history. VYAKTIKA VRITTA (PERSONAL HISTORY)- Appetite was low. Predominant rasa in aahara was madhur, milk products, fish, excess drinking of water. sleep was disturbed due to itching. ON EXAMINATION- General condition was fair and afebrile vitals were normal S/E- CVS- S1S2 normal RS- AEBE clear CNS- NAD INVESTIGATIONS- General investigations like CBC, BSL, URINE ROUTINE AND MICROSCOPIC were completely under normal values. ASTHAVIDHA PARIKSHA- NADI-kaphaditridoshaj MUTRA-frequency and colour within normal range with no “daha” MALA-normal JIVHA-sama SHABDA-clear and fluent SPARSHA-Ruksha DRIK- H/O using spectacles since 20 yrs. AAKRITI- sthool LOCAL EXAMINATION- INSPECTION- -Scaly lesions present on back, both hands and legs -They were symmetrical and well demarcated. COLOUR- Initially it was reddish in appearance which by time changes to blackish. PROGRESSION- Slow DURATION- It increases in winter and hot climate. -AUSPITZ SIGN28- Present (appearance of small bleeding points after successive layers of scale have been removed from the surface of psoriatic papules or plaques) -CANDLE GREASE SIGN28- Present (when scratched, psoriatic scales fall off, revealing a shiny candle like surface) DIAGNOSIS-EKAKUSHTA (PSORIASIS) As per ayurvedic text, the symptoms of Ekakushta are Aswedanam Mahavastu Matsyashakalopaman SIGNS AND SYMPTOMS- 1. Aswedanam(absence of sweat) - present at scaly region 2. Mahavastu (big size legion) - Present 3. Matsyashakalopaman(scaling)-Present 4. Candle grease sign- Present 5. Auspitz’s sign- Present NIDANPANCHAK- NIDAN- Viruddhaaaharsevaan27 - (simultaneous use of milk and milk product and fish) Raktadushtikaraahar and vihar Excessive use of salty food, curd, butter milk, sleeping after lunch SAMPRAPTI- Dosha- pitta, kapha, rakta Dushya- rasadhatu, raktadhatu, mansadhatu Agni- mand Aama- jatharagni and dhatwagnijanya Strotas- rasavaha, raktavaha, mansavaha Adhisthan- twaka Rogmarg- bahya Vyadhiswabhava- chirkari (Chronic) Sadhyasadhyatva- krucchasadhya(difficult to treat) TREATMENT AND OBSERVATION- 1ST VISIT- Table 1.1 (Treatment given on first visit) FORMULATION DOSE TIME ANUPANA DURATION 1.Kumariaasav+paripathadi kadha 15ml (1:1) M/E 6am/6pm Koshnajala(luke warm water) 2 weeks 2.Rasapachak (kalinga, patol, katukarohini)equal proportion 250 mg BL/BD Koshnajala(luke warm water) 2 weeks 3.Gokshuradi guggulu 250 mg 8am/8pm Dhanyakphanta 2 weeks 4. Shwetkutajsiddataila L/A Morning after bath - 2 weeks 5. Udwartana (Yashtimadhu+ Sariva+Vacha+Haridra+Manjishta) L/A Before bath - 2 weeks 2nd visit- Observation seen:- Reduction in Dryness of skin, Agni- Agnivriddhi(Appetite increases); Jivha- Niram Table 1.2 (Treatment given on second visit) FORMULATION DOSE TIME ANUPANA DURATION 1.Kumariaasav+paripathadi kadha 10 ML M/E 6am/6pm Koshnajal 2 weeks 2. Raktapachak 250 mg BL/BD Koshnajal 2 weeks 3.Gokshuradi guggulu 250 mg 8am/8pm Dhanyakphanta 2 weeks 4. Haridrakhandapak 2 tsp AL/AD 2 weeks 5. Udwartana (Yashtimadhu+ Sariva+Vacha+Haridra+Manjishta) L/A Morning before bath 2 weeks 6.Shwetkutajsiddataila L/A Morning after bath 2 weeks 3rdvisit:- Observation seen:- kandureduced,dryness of skin reduced, scaly patches on elbow region decreased. Table 1.3 (Treatment given on third visit) FORMULATION DOSE TIME ANUPANA DURATION 1 Paripathadikadha 10 ML 6am/6pm Water 2 weeks 2 Raktapachaka 250 mg BL/BD Koshnajala(luke warm water) 2 weeks 3 Udwartana (Yashtimadhu+ Sariva+Vacha+Haridr a+Manjishta) L/A At the time of bath - 2 weeks 4 Shwetkutajsiddataila L/A After bath 2 weeks 5 Haridrakhandapaka 2 tsp BL/BD 2 weeks 4 th visit- Observation seen:- blakish discoloration on patches start changing to reddish, patch on Right leg reduced in size Table 1.4 (Treatment given on fourth visit) FORMULATION DOSE TIME ANUPANA DURATION 1. Raktapachak 250mg Before Koshnjal(luke 2 weeks 5th visit- Observation seen:- patches present on both hand and back reduced significantly, scale formation on both soles reduces Table 1.5 (Treatment given on fifth visit) FORMULATION DOSE TIME ANUPANA DURATION 1. Manshapachak 250 mg Before lunch/ Before dinner Koshnjal(luke warm water) 2 weeks 2. Dwipantarvacha 30 mg Morning/evening 2 tsp milk 2 weeks 3. Udwartana (Yashtimadhu+ Sariva+Vacha+Harid ra+Manjishta) L/A At the time of bath - 2 weeks 4. shwetktajsidda Taila L/A After bath - 2 weeks 6th visit- Observation seen:- scale formation on both soles start reducing with formation of healthy skin Table 1.6 (Treatment given on sixth visit) FORMULATION DOSE TIME ANUPANA DURATION 1. 1.Manshapachak 250 mg Before lunch/ Before dinner Koshnjal(luke warm water) 2 weeks 2. 2.Dwipantar vacha 30 mg Morning/evening 2 tsp milk 2 weeks 3. 3.Udvartana L/A At the time of bath - 2 weeks lunch / before dinner warm water) 2. Haridrakhand 2tsp After lunch / after dinner Koshnjal(luke warm water) 2 weeks 3. Shwetkutajsiddataila L/A After bath - 2 weeks 4. Udwartana (Yashtimadhu+ Sariva+Vacha+Haridra+Manjishta) L/A At the time of bath - 2 weeks 4. 4.shwetktaj sidda Taila L/A After bath - 2 weeks 7th visit- Observation seen:- After healing of all patches, discolouration of skin were there and preventing the recurrence of disease following medication given. Table 1.5 (Treatment given on fifth visit) FORMULATION DOSE TIME ANUPANA DURATION 1.Laghumanjishtadi kadha 10 ml Morning/evening water 1 month 2.Haridra siddha taila L/A At night - 1month Before treatment - After treatment- DISCUSSION- In the present case, pitta, kapha and rakta were the doshas and rasadhatu, raktadhatu, mansadhatu were the dushya.Doshadushyasamurchana was taken place due to the circulation of vitiated doshas and their sthanashanshraya at twaka with clinical presentation of vyadhilakshana. The treatment protocol was adopted for sampraptibhedana(to counter act the the pathophysiology). Where, pitta-kaphara, kushtaghana, kledanashak, aushadiyogas were performed. Alsoagnidipana,raktaprasadaka, rasaprasadaka were achieved with the help of all internal and external medicine. The treatment protocol was adopted for sampraptibhedana(to counter act the pathophysiology and dhatwagnivardhan). The intake of viruddhaaahara is one of the important causative factors in the etiopathogenesis of skin disease. The patient was told to avoid viruddhaaahara for better treatment response, speedy recovery and to avert the recurrence in chronic skin ailments. The ongoing pathological changes were attenuated and corrected following internal medications such as Kumriaasav, Paripathadikwath,Rasapachaka, Gokshuradiguggulu, Upatana, Shwetkuttaj siddha narikeltaila, Haridrakhandapaka, Dwipantervacha, Raktapachaka, Mansapachaka, Laghumanjishtadikwath and Hridra siddha taila. 1st visit- (Table 1.1) 1. Kumariaasava +Paripathadikwath- As in kumariaasava9, the main content is kumari(Aloe vera tourn) having tikta rasa, katuvipaka and sitavirya. It mainly workon liver which is an important organ for normal functioning of pitta dosha and raktadhatu. It improves appetite and aids in digestion due to aamapachakaand jatharagnivardhaka properties. Also work as rechak. 2. Paripathadikadha- In paripathadikadha the main content is paripatha(fumaria officinalis)20 having tikta rasa, ushnavirya,katuvipaka. It mainly reduces the excess heat present in the body especially in Rakta dhatu and also having the properties of vishaghna help in exfoliation of chronic dosha from body and maintain the anushanaguna of rakta dhatu. In combination with kumariaasavait work as dosha nashak and pittarechaka and by giving it empty stomach at kapha kala the effect of medicine occur faster. 3.GOKSHURADI GUGGULU- As gokshur(tribulus terrestris)16 comes under MutravirechakGana and work as kledakanashaka, Saraka, Bastishodhak with help of this properties. It help in exfoliation of kledafrom Mutra marg which is the faster and easiest passage to remove kleda from body. Gokshuradiguggulu with anupana of Dhanyakphant(Coridandrum Sativum) help in reducing the ushnagunadharma( heat) from body. 4. RASAPACHAKA10- As according to pathophysiology patient having symptoms of agnimandya which leads vikrutito uttarakthordhatu utpatti and cause dhatwagnimandya. Rasapachaka contain kalinga(Holarrhena Antidysentrica)(9) Patola(Tricossanthes diociaroxb) Katurohini, Nimbapatra(Azardiracehta Indica)(26) As, we know this kalpa is use in Dhatugatjwar where, dosha mainly affecting Rasadhatuand cause Rasadhatwagnimandya(slow) leads to vikrut (Inapropriate) dhatu utpatti. As said by Aacharya. By correcting dhatuagni we can exfoliate the dosha out of the body. Top layer of skin is upadhatu(superior by product) of Rasadhatu. Considering that rasapachakwas given. Kalinga reduces dravata, Patola as Ushnatanashak(heat decreasing). Kutkiremovesdosha through mala( Defication). Nimbaworks as Krumighna and Vishagna. 5.SHWETKUTAJSIDDA TAILA- Aacharyacharak has mentioned kutaj(Holarrhena Antidysentrica)9 in kandughnaGana. It is tikta in Rasa, katuVipaka and sitavirya work as vranshodhak and vranropan, kushtagna and pittasarak in nature. It is prescribe for external use in which coconutoil has processed with shwetkutaj. As shwetkutajsiddataila retards Hyperkeratinisation, silvery scales, inflamematory response, reduce exfoliation. It prevents itching and formation of scales and sores; Coconut oil improves symptoms of skin disorders by its moisturizing, soothing and emollient effects. 6. UDVARTAN- In psoriasis, already the skin is dry with scale formation, on application of soap and chemical products ; it increase the dryness by replacing soap with udvartandravya which are Sariva(Hemidesmus Indicus)13, Manjishth(Rubia cordifolia)12, Yashtimadhu(Glycyrriza glabra)22, Lodhra(Symlocos Racemola roxb)21 , Vacha(acours calmus)14 comes under KushtagnaGana Maintain kanti(texture) of varnya (apperence) of skin. 2nd visit- (Table1.2) As patient has complain of kandu (itching) on patches. Haridrakhandwere added. HARIDRAKHANDAPAK- The main content is Haridra(Curcuma Longa)17. AacharyaCharak has mentioned Haridra in kushtaghna, kandughnaGana and AacharyaSushrut has mention it in shleshmashanshamana..Haridra is tikta ,katu in Rasa with ushnavirya. On internal use of Haridrakhand. It work as kaphaghna and kandughnawithpittarechaka and krumighna. 3rdvisit- (Table1.3) As discoloration of patches which are blackish color reduces. Raktapachak is added. RAKTAPACHAk10- containsPato(Trichsanthes diocia), Sariva(Hemidesmus indicus)13, Musta(Cyperus rotundus), Kutaki(Picrorhiza kurrooa), Patha(Cissamplelos pareira)20 This drug mainly work on Raktadhatu by exfoliating dosha and increasing Dhatu agni, which helps in formation of prakrutRaktadhatu. 4th visit- (Table1.4) As patient having good effects with no any other complain. The same medication is continues for 2 weeks. 5th visit- (Table 1.5) MANSHAPACHAK10- As dosha were reach till mansadhatu.Mansdhatudushti was there to correct the dhatuagnimanshpachak were given which are- Patol(Trichosanthes dioica),Nimba(azadiracehta indica), Manuka(Vitis vinifera), Musta(Cyperus rotundus),Kutaj(Holarrhena antidysentrica) , Triphala-Haritaki(Terminelia chebula),Aamlki(Embilica offcinalis),Bibhitaki(Terminalia bellirica). DWIPANTERVACHA11- Dwipantervacha (Smilex china) works on Rasa-Rakta-Mansa dhatu. If any kstrav( secretion) is present on patches. It helps in reducing and helps in fast healing of patches. 6th visit – as patient having good recovery,continue the pervious treatment for next 2 weeks 7thVisit- (Table1.7) As psoriasis is relapsing disease to reduce the recurrence, Laghumanjishthadikadha5is continue for next 1 month, which work as Raktaprasadaka. As after healing of psoriasis patch, discolouration of skin were there to make even tone of skin Haridra17siddataila was given for local application which act as varnya. CONCLUSION- In present case, the treatment protocolwere adopted as per Ayurvedic sampraptiand the treatment response was observed much earlier as compared to previous allopathic treatment. No recurrence reported after the end of active treatment. The importance of a wholesome diet as a health promoter is also revalidated. The external and internal medications of Ayurveda help to correct the complex patho- physiology of psoriasis like chronic disease. Altogether, multimodal Ayurveda treatment lead to speedy substantial recovery from a chronic case of psoriasis. REFERENCES– 1.Thappa DM Muniscamy,Research on Psoriasis in India ; where do we stand ?Indian J Med Res 2017; 146(2): 147-9 https:\\doi.org\10.4103 iJmr-1296-17|0.4|03% Fijmr.|JMR|296-17. 2.Rendon A, schakes k. psoriasis pathogenesis and treatment int.Jmo|sci 2019:20;1475 https://doi.org|10.3389|fimmu 2019-00657. https://doi.org|10.3389|fimmu/ 3.Dr. Bramhanad Tripathi, charak Samhita, 2009 edition chaukhambhasurbhartiprakashan ,varansi (ch.chi7). 4..Dr. Bramhanad Tripathi, charak Samhita, 2009 edition chaukhambhasurbhartiprakashan , varansi (ch.chi7|21,27 pg no305-306) 5.Bhavprakash uttrardh , shri bhramshankarmishr ,chaukhambha Sanskrit prakashan, forth edition (shlok no. 99-100) 6.5.Bhavprakash-Part 1 , shri bhramshankarmishr ,chaukhambha Sanskrit prakashan, Sanskrit series 130. 7.Bhaisajya Ratnavali, shri Ambikaduutasastri, chaukhamba Sanskrit prakasan edition 2004 (pg no.641,shlok no 13-17). 8.Sahastryogam Dr.Ramnivassharma |Dr.surendrasharma ,chaukhamba Sanskrit prakashan edition 2004(pg no 173) 9.Dravyagun vijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 463) 10.Dr. Bramhanad Tripathi, charak Samhita, 2009 edition chaukhambhasurbhartiprakashan ,varansi (ch.chi 03/200-202) 11.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 804) 12.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 802) 13.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 800) 14.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 125) 15.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 117) 16.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 632) 17.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 162) 18.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 253) 19.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 753,755) 20.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 626) 21.9.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 616) 22.9.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 256) 23.Dravyagun vijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 133) 24.Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 162) 25. Dravyagunvijnana vol2 prof p.vsharma , chaukhamba Bharti academy, reprint year 2019 (pg no 149) 26.kumar;et al.(2010). Robbin’s Text book of pathology. New Delhi:Elsevier.p.841.ISBN 978-81-312- 1036-9. 27.Dr. Bramhanad Tripathi, charak Samhita, 2009 edition chaukhambhasurbhartiprakashan ,varansi (ch.vi 05/13) 28.Auspitz sign: A view from the top - Journal of the American Academy of Dermatology (jaad.org) https://www.jaad.org/article/S0190-9622(19)31127-2/fulltext