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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 51-56

Effect of an Ayurveda treatment in palmoplantar psoriasis: A case study


Department of Rasa Shastra and Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P, India

Date of Submission25-May-2020
Date of Acceptance29-Jul-2020
Date of Web Publication16-Oct-2020

Correspondence Address:
Dr. Guruprasad C Nille
Assistant Professor, Department of Rasa Shastra and Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_24_20

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  Abstract 


Psoriasis is an immune-mediated disease characterized by chronic inflammatory changes in the skin. Around 5% of all the psoriasis sufferers have palmoplantar psoriasis, which is challenging to treat a variety of psoriasis. Ayurveda is rich in herbs having proven anti-psoriatic action. However, the complex and multifactorial pathogenesis of psoriasis needs a multimodal treatment approach. In the present case report, a 45-year-old female patient presented with soles of feet partially covered, thickened, red skin having sharp, and noticeable borders demarking the psoriasis patches from unaffected skin. There were painful cracks over the soles and thickened erythematous plaques on the right elbow. Clinical examination revealed the involvement of Tridosha (~three biological humors) in the Samprapti (~pathophysiology). The multimodal treatment including Patolakaturohinyadi kashaya, Kaishora guggulu, Mahatiktaka ghrita, Gandhaka rasayana, and Khadirarishta as internal medicines, whereas Winsoria oil and Panchavalkala kwatha as external medicines showed promising results. Within six months of the treatment, the psoriatic lesions and associated signs and symptoms healed effectively. Altogether, multimodal Ayurveda treatment can be an effective and safe solution for palmoplantar psoriasis.

Keywords: Ayurveda, psoriasis, Samprapti, Vipadika


How to cite this article:
Nille GC, Chaudhary AK, Gupta LN. Effect of an Ayurveda treatment in palmoplantar psoriasis: A case study. J Ayurveda Case Rep 2020;3:51-6

How to cite this URL:
Nille GC, Chaudhary AK, Gupta LN. Effect of an Ayurveda treatment in palmoplantar psoriasis: A case study. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Dec 3];3:51-6. Available from: http://www.ayucare.org/text.asp?2020/3/2/51/298292




  Introduction Top


Psoriasis is an immune-mediated disease characterized by chronic inflammatory changes in the skin. It affects about 2% - 4% of the world's population. Around 5% of all the psoriasis sufferers have palmoplantar psoriasis.[1] The patients of palmoplantar psoriasis have a greater negative impact on their personal and social life than the patients having plaque psoriasis alone. Extreme difficulties in daily activities, self-care challenges, and mobility impairments with topical medicine dependency worsen the patient's quality of life.[1] Palmoplantar psoriasis is challenging to treat a variety of psoriasis and having poorly defined epidemiology.[2] Palmoplantar psoriasis can be a separated entity or may coexist along with the plaque psoriasis.[3] The complex and multifactorial pathogenesis of psoriasis always sets a barrier to the treatment approach and shows a recurrence pattern. In Ayurveda, various types of skin ailments and their holistic treatment modalities have collectively described in a single chapter, i.e., Kushta chikitsa. Moreover, chronic and autoimmune diseases need a multimodal treatment approach covering Vatarakta chikitsa, Jirnajwara chikitsa, and Rasayana chikitsa along with Kushta chikitsa. In the present case, the multimodal Ayurvedatreatment approach reported successful outcomes from all the signs and symptoms of palmoplantar psoriasis, plaques over the elbow joint, and arthralgia.


  Case Report Top


A 45-year-old female homemaker, presented with soles of feet partially covered with thickened, red skin having sharp and noticeable borders demarking the psoriasis patches from unaffected skin. There were painful cracks with intermittent bleeding over the soles of feet. Less scaly patches and other skin changes found over the palms of hands. The patient also had thickened erythematous plaques on the right elbow presenting the characteristics of plaque psoriasis. At the time of clinical examination, the patient was suffering from moderate joint pain, painful soles with difficult walk, itching and burning sensation over all the affected areas, and anxiety. Based on clinical presentation, consulting dermatologist had diagnosed the case as Palmoplantar Psoriasis and had prescribed topical and systemic standard allopathic treatment. The patient discontinued the allopathic treatment due to personal reasons and came for Ayurveda treatment from December 03, 2019 for further management. All routine blood tests were within normal range. For tissue biopsy, the patient was not ready due to the high cost.

Therapeutic interventions

The involvement of Vata, Pitta, and Kapha dosha is confirmed by the clinical signs and symptoms such as Shoola (~pain), Raktavarnata (~redness), Daha (~burning sensation), Kandu (~itching), and other characteristics of skin lesions presented in the case. Vitiated Tridoshas found involved in the pathological progress. The internal and external medications prescribed as per the involved Samprapti. The internal medications namely Patolakaturohinyadi kashaya, Kaishora guggulu, Mahatiktaka ghrita, Gandhaka rasayana, and Khadirarishta. The external medications namely Winsoria oil and Panchavalkala kwatha were advised to use topically and to wash the lesions, respectively. All the details of medicines, including their dosage form, therapeutic dose, frequency and time of drug administration, and adjuvant along with dietary regimens as Pathya and Apathya have depicted in graphical presentation [Figure 1].
Figure 1: The details of therapeutic interventions and dietary regimens (Pathya-Apathya)

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  Timeline Top


In the present case, the treatment continued for six months. The timeline of the treatment has shown graphically [Figure 2].
Figure 2: The timeline of the treatment and progressive clinical outcomes

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  Follow up and Outcome Top


At the end of the six month treatment, all the signs and symptoms of palmoplantar psoriasis found cured. The substantial improvement was observed in erythematous plaques over the right elbow. The treatment protocol found safe and effective. No adverse events were noted during the treatment period. Periodical improvement has shown with photographs captured [Figure 3], [Figure 4], [Figure 5].
Figure 3: Plantar view before treatment

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Figure 4: Before the treatment

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Figure 5: After the treatment of 6 months

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  Discussion Top


In Ayurveda, different types of Kushta (~skin disorders) have mentioned. Vidarika has similar characteristics like palmoplantar psoriasis that involves all the Tridosha in the pathogenesis. Vidarika is a Tridoshaja vikara andquite difficult to treat.[4] Similarly, palmoplantar psoriasis has limited successful clinical outcomes due to incompletely understood and under-researched etiology. The published data explains the involvement of the immune system, inflammatory cascade, cytokines, and keratinocytes in the pathogenesis. Various cytokines have established their major role in disease progression. Thus, psoriasis is the result of a cytokine storm.[5] There is a need for a multimodal Ayurveda treatment approach to target multiple pathways involved in the disease process. Also, the chronic and relapsing nature of the disease requires long and sustained treatment. In the present case, the treatment protocol has adopted as per the Ayurvedic samprapti and to treat possible targets of the pathogenesis. A multimodal treatment approach covering Vatarakta chikitsa, Jirnajwara chikitsa, Rasayana chikitsa, and Kushta chikitsa has adopted to treat the present case.

Patolakaturohinyadi kashaya is a poly herbal decoction mentioned under the heading of Shodhanadi gana in Astangahridaya.[6] Patolakaturohinyadi kashaya contains Patola (Trichosanthes dioica Roxb.), Katuka (Picrorhiza kurroa Royal ex Benth), Shwetachandana (Santalum album Linn.), Murva (Marsdenia tenacissima W. and A.), Guduchi (Tinospora cordifolia Willd Miers.), and Patha (Cissampelos pareira Linn.). It has Kushtaghna, Jwaraghna (~anti-pyretic), and Vishaghna (~anti-poison)properties and pacifies Kapha and Pitta doshas. It also possesses Rasaprasadana (~improvement in the quality of blood), Raktaprasadana (~purification of the blood), Amapachana (~removal of undigested toxins), and Agnidipana (~improvement of the biological fire) properties due to its Tikta rasa. It helps to detoxify the liver and pacify the vitiated Pitta and Kapha doshas carried by Rakta dhatu and Rasa dhatu. Various phytochemical constituents of Kashaya may help to correct the pathophysiology of palmoplantar psoriasis.[7]

Guggulu is very effective in chronic inflammatory conditions including psoriasis. It shows potent anti-inflammatory and antioxidant activities due to steroidal and terpenoidal constituents, flavonoids, and guggulsterols present in the Guggulu.[8],[9] Guggulu also has anti-infective and antibacterial properties.[10] The Yogavahi (~synergistic) property of Guggulu in the Kaishora guggulu, potentiates the action of other herbs constituting the formulation such as Guduchi, Triphala, Trikatu etc. Kaishora guggulu has mentioned in Vatarakta chikitsa and also indicated for Kushta and Vrana (~wound).[11] It shows Kantikara (~improve skin's natural radiance) effects by its blood purifying action. In the present case, it relieved pain, redness, and inflammation by its anti-inflammatory and anti-bacterial properties.[12]

The use of medicated Ghrita prepared with Tikta and Kashaya rasa dominating herbs has mentioned in Kushta chikitsa. It pacifies the Tridoshas. However, the strong bitter taste of such formulations limits their internal use. In the present case, to overcome the palatability problem, Mahatiktaka ghrita has used in capsulated form. It has indicated in all types of Kushta, Visarpa (~ herpes zoster), Vatarakta, and Visphota (~bullous lesions).[13] It delivers active pharmaceutical ingredients present in the form of various phytoconstituents, possibly by its liposomal drug delivery action.[14]

Gandhaka rasayana is the herbomineral formulation containing Gandhaka (~sulfur) fortified with different liquid media. It has Kledaghna (~removal of toxins), Amapachana, Kushtaghna, Jirna jwarahara (~useful in chronic fever), Kandughna (~anti-itching), and Rasayana (~rejuvenation) properties.[15] Externally, the sulfur bath is useful in psoriasis.[16] The strong anti-inflammatory and antioxidant potential of sulfur may play an important role in chronic inflammatory conditions like psoriasis and related arthritis.[17]

Khadirarista is useful in Sarvakushta (~all types of skin ailments) including psoriasis.[18] Different ingredients of khadirarishta have proven efficacy in psoriasis and work through different modes of action. Khadira (Acacia catechu Willd.) has immunomodulatory, anti-inflammatory, and antioxidant properties that can play a beneficial role in autoimmune and chronic inflammatory conditions like psoriasis.[19] As psoriasis is a product of cytokine storm, Khadira can control the secretion of pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-α) by increasing the secretion of interleukin-10, which augment the proliferation of β cells, thymocytes, and mast cells.[20] Daruharidra (Berberis aristata DC.) possesses anti-inflammatory properties and showed anti-psoriatic action in experimental animals.[21] Bakuchi (Psoralia corylifolia Linn.) is also known as Kushtanashini, has immunomodulatory, anti-inflammatory, antioxidant, anti-psoriatic, anti-leprotic, and antibacterial properties. It acts through regulating multiple pathways to correct the pathophysiology of chronic skin ailments.[22] Dhataki pushpa (Woodfordia fruticosa Kurz.) contains various phytochemicals in its ethanolic extract and showed anti-psoriatic potential by its multi-target mechanism.[23]

All the internal medicines worked together through the possible synergistic way to target different pathways involved in the pathological process and found effective in treating the pathophysiology. The possible mechanisms involved are immunomodulatory, anti-inflammatory, antioxidant, cytokine inhibitory, and keratinocyte proliferation inhibitory actions. The internal medications possibly resulted in Rasaprasadana, Raktaprasadana, Amapachana, and Agnivardhana. They ultimately led to Samprapti vighatana (~correction of pathophysiology) by creating a balance between the Tridosha.

In the present case, Winsoria oil and Panchavalkala kwatha have prescribed for external use. Winsoria oil is a proprietary medicine useful in psoriasis and eczema. Coconut oil (Cocos nucifera [L.] Kuntze) has used to prepare Winsoria oil. The cytokines have a major role in the disease process. The coconut oil has an inhibitory action on various inflammatory markers, including cytokines such as TNF-α, Interleukin 6, Interleukin 5, Interleukin 8, and interferon-γ.[24] The moisturizing and emollient effects of coconut oil help to relieve itching, dryness, and pain in palmoplantar psoriasis. It acts as a drug permeation enhancer for other active ingredients to cross the skin's barrier.[25] The other ingredients of Winsoria oil, such as Vidaphala (Wrightia tinctoria R. Br.), Manjishta (Rubia cordifolia Linn.), and Sariva (Hemidesmus indicus R. Br.) have also reported their anti-inflammatory, antipsoriatic, and immunomodulatory effects.[26],[27],[28] The use of Winsoria oil helped in healing the lesions of palmoplantar psoriasis.

Panchavalkala contains Ashwattha (Ficus religiosa Linn.), Udumbara (Ficus glomerulata Roxb.), Plaksha (Ficus lacor Buch.-Ham.), Vata (Ficus bengalensis Linn.), and Parisha (Thespesia populenea Soland. ex corea.). Panchavalkala kwatha has Vranaropana (~ wound healing) property.[4] Its decoction has used to wash the affected areas of the psoriatic lesions in the present case. Panchavalkala kwatha has reported for its anti-psoriatic action. The Vranashodhana action of Panchavalkala kwatha has also been validated clinically in the infected wounds.[29] In the present case, it showed the healing of skin lesions effectively when used in combination with other remedies.

Although the patient has cured within six months, all the treatment continued for the next months to assure the complete reversal of pathophysiology as required in Tridoshajavikaras. The successful outcomes in the present case are the results of a multimodal treatment approach, including a strict dietary plan as shown in [Figure 1]. The possible actions of Ayurveda drugs and their targets in the pathomechanism have depicted in [Figure 6]. The patient shared her perspective on the treatment she received for the last six months. She shared that the painful cracks, difficulty in walking, burning sensation, and cracks in the soles have used to be the satisfactory level and she is free from all the signs and symptoms after the Ayurveda treatment. The patient also told that all the medicines were tolerable and no uneasiness experienced.
Figure 6: The possible actions of Ayurveda drugs and their targets in the pathomechanism

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  Conclusion Top


The chronic inflammatory and autoimmune nature of psoriasis needs a multimodal treatment approach for its comprehensive cure. In the present case, the Ayurveda treatment showed promising results in palmoplantar psoriasis. No adverse events were noted with the treatment. Altogether, multimodal Ayurveda treatment can be an effective and safe solution for palmoplantar psoriasis.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Pettey AA, Balkrishnan R, Rapp SR, Fleischer AB, Feldman SR. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: Implications for clinical practice. J Am Acad Dermatol 2003;49:271-5.  Back to cited text no. 1
    
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Chung J, Duffin KC, Takeshita J, Shin DB, Krueger GG, Robertson AD, et al. Palmoplantar psoriasis is associated with greater impairment ofhealth-related quality of life compared to moderate-to-severeplaque psoriasis. J Am AcadDermatol 2014;71:623-32.  Back to cited text no. 2
    
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Kunnumakkara AB, Banik K, Bordoloi D, Harsha C, Sailo BL, Padmavathi G, et al. Googling the Guggul (Commiphora and Boswellia) for Prevention of Chronic Diseases. Front Pharmacol 2018;9:686.  Back to cited text no. 8
    
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Sunil MA, Sunitha VS, Radhakrishnan EK, Jyothis M. Immunomodulatory activities of Acacia catechu, a traditional thirst quencher of South India. J Ayurveda Integr Med 2019;10:185-91.  Back to cited text no. 20
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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