PSORIASIS – AYURVEDIC MANAGEMENT

Vaidya Ruchi Gulati, MD(Ayu)SukhAyurveda

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OVERVIEW

5. Summary2

4. Managing psoriasis

3. Diagnosing psoriasis

2. Clinical presentation

1. Introduction

WHAT IS PSORIASIS? Inflammatory and

hyperplastic disease of skin

Characterised by erythema and elevated scaly plaques

Chronic, relapsing condition

Course of disease often unpredictable

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PSORIASIS

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EPIDEMIOLOGY

Common skin disorder

Prevalence variable: ~ 0.3–2.5%

Prevalence equal in males and females

Estimated incidence: ~ 60 per 100,000 per year

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AGE OF ONSET

Mean age: ~ 23–37 years

Current theory: 2 distinct peaks with possible genetic associations Early onset (16–22 years)

More severe and extensive More likely to have affected first-degree family member

Late onset (57–60 years) Milder form Affected first-degree family members nearly absent

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PSORIASIS IS A T-CELL MEDIATED, AUTOIMMUNE DISEASE1

Current hypothesis: Unknown skin antigens stimulate immune

response Antigen-specific memory T-cells are

primary mediators

Leads to impaired differentiation and hyperproliferation of keratinocytes7

COMMON TRIGGER FACTORS FOR PSORIASIS

Infections (e.g. streptococcal, viral) Skin trauma (Koebner phenomenon) Psychological stress Drugs (e.g. lithium, beta blockers) Sunburn Metabolic factors (e.g. calcium deficiency) Hormonal factors (e.g. pregnancy)

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SAMPRAPTI

Mind(Stress)

Lifestyle(Diet/

Relationships/ Daily Routine

/Seasonal Routine)

Impact on the body

(Alters Immune System)

Psoriasis(Excessive

Skin production)

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CLINICAL PRESENTATION: CLASSIC PSORIASIS Well-defined

and sharply demarcated

Round/oval-shaped lesions

Usually symmetrical

Erythematous, raised plaques

Covered by white, silvery scales

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COMMON SITES AFFECTED BY PSORIASIS

Can affect any part of the body – typically scalp, elbow, knees and sacrum

Extent of disease varies

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PSYCHOSOCIAL IMPACT

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TYPES OF PSORIASIS

Chronic plaque Guttate Flexural Erythrodermic

Pustular Localised and generalised

Local forms Palmoplantar Scalp Nail (psoriatic

onychodystrophy)

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CHRONIC PLAQUE PSORIASIS Most common type –

affects approximately 85%

Features pink, well-defined plaques with silvery scale

Lesions may be single or numerous

Plaques may involve large areas of skin

Classically affects elbows, knees, buttocks and scalp

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CHRONIC PLAQUE PSORIASIS

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CHRONIC PLAQUE PSORIASIS

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CHRONIC PLAQUE PSORIASIS

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CHRONIC PLAQUE PSORIASIS

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GUTTATE PSORIASIS Numerous and small

lesions – ~ 1 cm diameter

Pink with less scale than plaque psoriasis

Commonly found on trunk and proximal limbs

Typically seen in individuals < 30 years

Often preceded by an upper respiratory tract streptococcal infection

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FLEXURAL PSORIASIS

Lesions in skin folds articularly groin, gluteal cleft, axillae and submammary regions

Often minimal or absent scaling

May cause diagnostic difficulty when genital or perianal region is affected in isolation 1 20

ERYTHRODERMIC PSORIASIS

Generalised erythema covering entire skin surface

May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon

Patients may become febrile, hypo/hyperthermic and dehydrated

Complications include cardiac failure, infections, malabsorption and anaemia

Relatively uncommon21

PUSTULAR PSORIASIS

Two forms: Localised form More common Presents as deep-

seated lesions with multiple small pustules on palms and soles

Generalised form Uncommo Associated

with fever and widespread pustules across the body

inflamed body surface

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PALMOPLANTAR PSORIASIS

Can be hyperkeratotic or pustular

May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis

Possibly aggravated by trauma

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SCALP PSORIASIS

Varies from minor scaling with erythema to thick hyperkeratotic plaques

May extend beyond hairline

Patient scratching may produce asymmetric plaques

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NAIL PSORIASIS May be present in

patients with any type of psoriasis

Can take several forms:

Pitting: discrete, well-circumscribed depressions on nail surface

Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate

Onycholysis: nail separates from nail bed at free edge

‘Oil-drop sign’: pink/red colour change on nail surface

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NAIL PSORIASIS

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PSORIATIC ARTHRITIS

Approximately 5–20% have associated arthritis

Five major patterns of psoriatic arthritis:

Distal interphalangeal involvement

Symmetrical polyarthritis

Psoriatic spondylarthropathy

Arthritis mutilans Oligoarticular,

asymmetrical arthritis Clinical expressions

often overlap27

DIAGNOSING PSORIASIS Other dermatological disorders

can resemble psoriasis

Diagnosed clinically according to appearance, distribution, history of lesions and family history

Important to consider non-cutaneous complications

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DIFFERENTIAL DIAGNOSIS Localised

patches/plaques Tinea Eczema Superficial basal cell

carcinoma and Bowen’s disease

Seborrhoeic dermatitis Cutaneous T-cell

lymphoma (mycosis fungoides)

Guttate Pityriasis rosea Drug eruption Secondary syphilis

Flexural Tinea Eczema Candidiasis Seborrhoeic dermatitis

Erythrodermic Eczema Cutaneous T-cell

lymphoma Pityriasis rubra pilaris Lichen planus Drug

Palmoplantar Tinea

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CLINICAL APPROACH Dosha chikitsa

-Vatakapha/kapha/vata/pitta Dushya chikitsa -Rasa, Rakta

Prasadana Avasthanusara Chikitsa -Saama/Niraama

-Navina/ Jirna Vyadhi pratyaneeka chikitsa Manobala vardhaka chikitsa Rasayana(Naimittika)

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MANAGING PSORIASIS Goals of management

Tailor management to individual and address both medical and psychological aspects

Improve quality of life Achieve long-term remission and disease control Minimise drug toxicity Evaluate and monitor efficacy and suitability of

individual treatments Remain flexible and respond to changing needs

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MANAGING PSORIASIS Before starting treatment

Establish relationship of trust with patient Provide patient with information

Emphasise benign nature of disease Explain that psoriasis tends to be chronic and

recurrent

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TREATING PSORIASIS: GENERAL MEASURES

Reduce/eliminate potential trigger factors: Stress Smoking Alcohol Trauma Drugs Infections

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FACTORS FOR SELECTION OF TREATMENT Age: childhood, adolescence, young adult hood,

middle age,>60 yrs Type of psoriasis: Plague, palmar, generalised

pustular, etc Site and extent of involvement: localised to scalp,

palms, scattered plaques but <5% involvement: generalised and >30% involement.

Previous treatment: Systemic glucocorticoids, methotrexate

Associated medical disorders(eg. HIV, CVD) Duration of Disease: <1month, <1 yr, >1yr

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PROTOCOL-1 Mild symptoms Recent origin Localized

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CHIKITSA Sadya Virechana with Avipatti choornam-20gms for

1day if saama lakshanas are seen - Shaddharana(5gm) /

panchakola choorna) Mahatiktakam kashaya - 15ml bd for 1st week Kaisoraguggulu - 1 tab bd for first week Manasamitra vataka - 1 tab bd for 2 weeks Gandhaka rasayan - 100mg with honey bd

(throughout) Vitpala kera taila - external application followed by

sun exposure

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PROTOCOL 2 MODERATE SYMPTOMS HISTORY OF 2-6 MONTHS AFFLICTED TO A LARGER AREA

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CHIKITSA Mahatiktakam ghrutha -15 gm(inc acc to agni bala X 7 days for

snehan (along with Abhyangam and sarvanga swedanam) SadyoVirechana with Avipatti choorna - 20gm for 1st week. Tiktakam kashaya - 15ml bd X 2 weeks ( if saama lakshanas are seen - 5-6gm shaddharana choorna

/gutika) Kaishore Guggulu - 1 tab tds X 2 weeks Arogya vardhini gutika - 1 tab tds X 2weeks Gandhaka Rasayan- 100mg with honey (throughout) Haridrakhandam -12gm bd X 2weeks Manasmitra vatakam – 2 tabs bd X 2weeks Vitpala kera taila - external application followed by sun exposure

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EXTERNAL TREATMENTS Vitpala kera taila Vitpala snana/Sidharthaka snana

choorna Takra dhaara (musta,amalaki)

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PROTOCOL 3 SEVERE SYMPTOMS HISTORY OF 6 MONTHS AND MORE SPREAD EXTENSIVE AREAS WITH SEVERE MENTAL STRESS

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CHIKITSA Starting with the previous protocol according to the bala,

avastha of Roga and Rogi, moving on to the additional treatments.

Rookshana – Takra dhaara(musta,triphala,aragwadhadi) Deepana-pachana -Panchakola churna with takra/usna jala Snehapana -dose acc. to agni bala. (Mahatiktakam

ghrutha/guggulutiktakam ghruta) Abhyangam - vitpala Swedana - usna jala snana, atapa sevan Nasya - shadbindu taila Vamana - madana,vacha,yashti,pippali+madhu Virechana - avipatti choorna/ trivrut leha

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FOLLOW UPNeed of Rasa-Rakta prasadana - Manobala

vardhaka -Rasayana chikitsa. Rasa-Rakta parasadana

Mahamanjishtadi kashaya. 15ml bd X 1 month

Krumimudgar ras 1 hs X 1week Manasamitra vataka 1bd X 1 month Kalayana ghrutha 12gm hs X 1month Gandhaka Rasayana 1tab bd X 1month

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PATHYA For a minimum of 3 months to control symptoms

and relapse Ahara :Avoid Virudha, vidaahi , guru , abhishyandi,

navaanna, matsya, anupa mamsa, kanda varga. : reduce the use of lavana : include more haridra, rasona, pepper in the diet. : avoid pickles, dadhi at night ,fermented food items. : avoid bakery items (maida), oily and spicy foods. : strictly avoid egg,beef and pork. : Avoid ready to cook items, tinned foods etc. : avoid re-cooking refrigerated foods.

Vihaara : maintain hygiene in all aspects. : practice Achara rasayana.

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MANAGEMENT OF PSORIASIS: SUMMARY

Chronic, inflammatory disease of skin Classic presentation characterised by

red, scaly plaques Management should address both

medical and psychological aspects Treatments include externaltherapy,

panchkarma, Rasa-Rakta prasadana - Manobala vardhaka -Rasayana chikitsa. Rasa-Rakta parasadana

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THANK YOU

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