By

Chandramouleeswaran P.

Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences,Karnataka, Bangalore.

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI M.D. (PANCHAKARMA)

In

PANCHAKARMA

Under the guidance of

Dr. G. Purushothamacharyulu,M.D. (Ayu)

And co-guidance of

Dr. Shashidhar.H. Doddamani,M.D. (Ayu)

Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College,

Gadag – 582103.

2006.

Evaluation of the Efficacy of Takradhara in Kitibhakushta (Psoriasis)

Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore.

DECLARATION BY THE CANDIDATE

hereby declare that this dissertation / thesis entitled

“Evaluation of the Efficacy of Takradhara in Kitibhakushta

(Psoriasis)” is a bonafide and genuine research work carried out

by me under the guidance of Dr. G. Purushothamacharyulu, M.D.

(Ayu), Professor and H.O.D, Post-graduate department of

Panchakarma and co-guidance of Dr. Shashidhar. H. Doddamani,

M.D.(Ayu), Assistant Professor, Post graduate department of

Panchakarma.

Date:Place:

Chandramouleeswaran P.

I

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Evaluation

of the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafide

research work done by Chandramouleeswaran P. in partial fulfillment of

the requirement for the degree of Ayurveda Vachaspathi. M.D.

(Panchakarma).

Date:

Place: Dr. G. Purushothamacharyulu, M.D. (Ayu).

Professor & H.O.D

Post graduate department of Panchakarma.

ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF

THE INSTITUTION

This is to certify that the dissertation entitled “Evaluation of

the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafide

research work done by Chandramouleeswaran P. under the guidance of

Dr.G. Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Postgradu-

ate department of Panchakarma and co-guidance of Dr. Shashidhar.H.

Doddamani, M.D. (Ayu), Assistant Professor, Post graduate department of

Panchakarma.

Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil.

Professor & H.O.D, Principal.

Post graduate department of Panchakarma.

CERTIFICATE BY THE CO- GUIDE

This is to certify that the dissertation entitled “Evalua-

tion of the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a

bonafide research work done by Chadramouleeswaran P. in partial ful-

fillment of the requirement for the degree of Ayurveda Vachaspathi.

M.D. (Panchakarma).

Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).

Place: Assistant Professor,

Post graduate Department of Panchakarma.

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and dissemi-

nate this dissertation / thesis in print or electronic format for academic /

research purpose.

Date:

Chandramouleeswaran P.

Place:

© Rajiv Gandhi University of Health Sciences, Karnataka.

I

Acknowledgement

“Many hands make light work”. I take this opportunity to mention my

deep gratitude to several personalities who have helped me in the successful completion

of this work.

I express my obligation to my honorable Guide Dr. G.

Purushothamacharyulu M.D. (Ayu), H.O.D., P.G. Department of Panchakarma,

P.G.S&R, D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for the

completion of this work.

I am extremely grateful and obliged to my co-guide Dr. Shashidhar.H.

Doddamani, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for his guidance and

encouragement at every step of this work.

I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C,

Gadag, for his encouragement as well as providing all necessary facilities for this

research work.

I express my sincere gratitude to Dr. P. Shivaramudu M.D (Ayu),

Assistant Professor and Dr. Santhosh. N.Belavadi MD (Ayu), Dr. M.D. Samudri,

Lecturers for their sincere advices and assistance.

I express my sincere gratitude to Dr. V. Varadacharyulu M.D (Ayu),

Dr.M.C.Patil M.D (Ayu), Dr. Mulgund M.D (Ayu), Dr. K. S. R. Prasad M.D (Ayu), Dr.

Dilip Kumar M.D (Ayu), Dr. R.V. Shetter M.D (Ayu), Dr. Kuber Sankh M.D (Ayu),

Dr.G.Danappagowda M.D (Ayu) Dr. Jagadish Mitti M.D (Ayu) Dr. Nidagundi M.D

(Ayu) and other PG staff for their constant encouragement.

I also express my sincere gratitude to Dr.B.G.Swamy, Dr.U.V.Purad,

Dr.K.S.Paraddi, Dr.G.Yargeri, Dr.S.H.Radder and other undergraduate teachers for their

support in the clinical work. I thank to Shri. Hadapad (Statistician) Shri. Nandakumar

(Statistician), Shri. V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (lab

technician), Shri. Basavaraj (X-Ray technician) and other hospital and office staff for

their kind support in my study.

II

I express my sincere thanks to my colleagues and friends Dr. Udaykumar

A.A.N., Dr. Ratnakumar K., Dr. Ashwinidev, Dr. Krishnkumar K., Dr. Sreena, Dr.

Soumya, Dr. Devanathan, Dr. Subin V., Dr.Satheesh. R.Warrier, Dr. Febin .K. Anto,

Dr.Renjith.P.Gopinath, Dr. Prassannakumar L., Dr.Shajil.N, Dr. Shyju Ollakode, Dr.

Gavi Patil., Dr.Santhosh.L.Y, Dr.Varsha.S.Kulkarni, Dr. Anjaykannan, Dr. Krishnkumar

K.M., Dr. Jayaraj Basarigidad, Dr. Kendadamath, Dr.V.M.Hugar, Dr. Shaila.B, Dr.

Suresh Hakkandi, Dr.Manjunath Akki, Dr. L. R.Biradar, Dr.Vijay Hiremath, Dr. Sajjan,

Dr. Bhingi, Dr. Sunita, Dr. Veena Dr. venkareddy, Dr. Kalamath B.L., Dr. Pradeep, Dr.

Basavaraj Ganti., Dr. Anitha., Dr. Shibaprasad, Dr. H.S. Madhushri., Dr. Devendrappa

Budi., Dr. Payyappagoudar., Dr. Ashok., Dr. Sharanu., Dr. Anand Doddamani., Dr.

Kumbar., Miss Meena B. and other post graduate scholars for their support.

I pay my respect to my philosopher and uncle Late Dr. Srinivasan LI.M.

who had been a source of inspiration for me and prime cause for taking this noble

profession.

I would like to mention the support and inspiration provided by Dr. S.N.

Suresh., Dr. Krishnkutty Nair and also acknowledge the support and inspiration provided

by my teachers Dr. Ramadass., Dr. S. Swaminathan., Dr. Vasudev Reddy., Dr.

Saikumar., Shri. Venugopal. I also thank Shri. Habib I. Khatib and family for the support

and encouragement provided during my stay at Gadag.

I acknowledge my patients for their wholehearted consent to participate in

this clinical trial. I express my thanks to all the persons who have helped me directly and

indirectly with apologies for my inability to identify them individually.

I also express my wholehearted thanks to my family members Mr. & Mrs.

Balasubramnyam and Mr. & Mrs. Ganesan, Shivaramkrishnan, Kartikeyan, Soundarya

and Ravikumar.

Finally I dedicate this work to my respected parents Shri. Parameswaran

K., Sreemati Subbulakshmi P. and my brother Er. Jayaraman P. who are the prime

reasons for all my success.

Date : Signature of the scholar Place : Gadag. (Dr.Chandramouleeswaran P.)

III

Abbreviations

01. C.S. – Charaka Samhita.

02. S.S. – Sushruta Samhita.

03. A.H. – Ashtanga Hridaya.

04. B.S. – Bhela Samhita.

05. K.S. – Kahsyapa Samhita.

06. M.N. – Madhava Nidana.

07. B.P. – Bhavaprakasha.

08. Y.R. – Yoga Ratnakara.

09. B.R. – Bhaishajya Ratnavali.

10. PASI – Psoriasis Area severity Index.

11. C.R. – Complete remission.

12. Bt.R. – Best reduction.

13. Mo.I. – Moderate improvement.

14. Mi.I. – Mild improvement.

15. N.I. – No improvement.

IV

Abstract

The study “Evolution of the efficacy of Takradhara in Kitibha Kushta

(Psoriasis)” is focused on an important technique Takradhara and a common

psychosomatic disorder Kitibha kushta (Psoriasis).

The objectives of this study are – 1. To evaluate the efficacy of Takradhara in

Kitihba kushta (Psoriasis), 2. To evaluate the efficacy of Aragwadi gana kashaya

Takradhara in Kitibha kushta (Psoriasis).

The aim of the study was to find out the psychosomatic effect of Aragwadadi

Gana kashaya Takradhara in Kitibha kushta (Psoriasis). The study design selected for the

present study was an observational study,

After treatment out of 30 patients 8 patients (26.66%) got complete remission

form the symptoms, 4 patients (13.33%) showed marked improvement, 7 patients

(25.90%) got moderate improvement and 5 patients (16.66%) showed mild improvement.

No response was found in 6 patients (20%). Among all the parameters Itching and

Scaling showed high significant in all the parts. Other parameters like Erythema and

Thickness were not significant in body and legs (As by using paired t test).

Triggering factors like Bhaya, Krodha Chettodvega and Shoka were also studied

and they showed high significant response.(As by using paired t test)

Kitibha kushta is a form of kshudra kushta. Based on the similarities of symptoms

and other description available in the medical literature many of the Ayurvedic

researchers who have worked on skin disorders have equated it to Psoriasis. Psoriasis is

more stress sensitive than other Skin disorders.Aragwadadi gana kashaya Takradhara,

which was selected for the study showed that it is having the role in reducing vitiated

manasika as well as shareerika doshas.

V

TABLE OF CONTENTS Chapters Page No.

1. Introduction 1-3

2. Objectives 4-7

3. Review of literature 8-90

4. Methodology 91-107

5. Results 108-137

6. Discussion 138-162

7. Conclusion 163-164

8. Summary 165

9. Bibliography

10. Annexure

VI

List of Tables

Table No.

Showing the Page No.

01. Layers of skin according to Charaka 17 02. Layer of the skin according to Sushruta 17 03. Correlation between the Ayurvedic & Modern skin layers 18 04. Relation between skin and hormones 26 05. Difference between Maha Kushta and Ksudra kushtas 47 06. Classification of Kushta according to different Acharyas 47 07. Relation between doshas and kushtas 48 08. Symptoms according to dosha predominant 49 09. Aharaja Nidana of Kitibha kushta 49 10. Viharaja Nidana of Kitibha 50 11. Daivapacharaja Nidana of Kitibha 51 12. Poorvaroopas mentioned by different acharyas 60 13. Lakshanas of Kitibha Kushta 61 14. Comparison between the kitibha kushta lakshana and psoriasis 66 15. Differential diagnosis of Kitibha kushta 67 16. Pharmacodynamics of drugs of Aragwadadi Gana 91 17. Pharmacodynamics of Drugs Used For Moorchana of

Tilataila 93

18. Chemical composition of the drugs used in Tilataila moorchhana

95

19. Showing the Pharmacaodynamics of drugs of Gandharva Hastadi Kashaya

96

20. Drugs used for preparing of Medicated Milk 97 21. Qualities of Takra 97 22. Method to assess PASI score 104 23. Distribution of patients by Age 108 24. Distribution of patients by Sex 109 25. Distribution of patients by Occupation 109 26. Distribution of patients by Economical status 109 27. Distribution of patients by Religion 110 28. Distribution of patients by Marital status 110 29. Distribution of patients by Dietary habits 110 30. Distribution of patients by Addiction 111 31. Distribution of patients by Agni 111 32. Distribution of patients by Koshta 111 33. Distribution of patients by Nidra 112 34. Distribution of patients by Deha prakriti 112 35. Distribution of patients by Satmya 112 36. Distribution of patients by Sara 113 37. Distribution of patients by Samhana 113 38. Distribution of patients by Satwa 113

VII

39. Distribution of patients by Ahara shakti 114 40. Distribution of patients by Vyayama shakti 114 41. Distribution of patients by Onset 114 42. Distribution of patients by Dominant rasa 115 43. Distribution of patients by Nidana 115 44. Distribution of patients by Viruddha ahara 116 45. Distribution of patients by Mithya ahara 116 46. Distribution of patients by Mithya vihara 117 47. Distribution of patients by Manasika Nidana 117 48. Distribution of patients by Family history 118 49. Distribution of patients by Chronicity 118 50. Distribution of patients by Medication 119 51. Distribution of patients by Aggravating season 119 52. Distribution of patients by Types of Psoriasis 119 53. Distribution of patients by Chief complaints 120 54. Distribution of patients by Associated complaints 120 55. Distribution of patients by Confirmation test 121 56. Distribution of patients by Precipitating factor 121 57. Distribution of patients by Psoriasis with different site of

involvement 121

58. Distribution of patients by Particular site involvement 122 59. Overall response to the treatment 122 60. Distribution of patients with different severity scorings in Head 123 61. Distribution of patients with Itching Head 123 62. Distribution of patients with scaling Head 124 63. Distribution of patients with Erythema Head 124 64. Distribution of patients with Thickness Head 125 65. Distribution of patients with Area Head 125 66. Distribution of patients with different coverage area in Head 126 67. Distribution of patients with Head total PASI score 126 68. Distribution of patients with different severity scorings in Arms 127 69. Distribution of patients with Itching Arms 127 70. Distribution of patients with Erythema Arms 127 71. Distribution of patients with scaling Arms 128 72. Distribution of patients with Thickness Arms 128 73. Distribution of patients with Area Arms 129 74. Distribution of patients with different coverage area in Arms 129 75. Distribution of patients with Arms total PASI score 130 76. Distribution of patients with different severity scorings in Body 130 77. Distribution of patients with Itching Body 131 78. Distribution of patients with Erythema Body 131 79. Distribution of patients with scaling Body 132 80. Distribution of patients with Thickness Body 132 81. Distribution of patients with Area Body 133 82. Distribution of patients with different coverage area in Body 133

VIII

83. Distribution of patients with Body total PASI score 133 84. Distribution of patients with different severity scorings in Legs 134 85. Distribution of patients with Itching Legs 134 86. Distribution of patients with Erythema Legs 135 87. Distribution of patients with scaling Legs 135 88. Distribution of patients with Thickness Legs 136 89. Distribution of patients with Area Legs 136 90. Distribution of patients with different coverage area in Legs 137 91. Distribution of patients with Legs total PASI score 137 92. Total PASI scoring for all 30 patients 138 93. After treatment statistical results of PASI score of different areas 139 94. After treatment statistical results of PASI score of different

symptoms of head 139

95. After treatment statistical results of PASI score of different symptoms of arms

140

96. After treatment statistical results of PASI score of different symptoms of body

140

97. After treatment statistical results of PASI score of different symptoms of legs

141

98. After treatment statistical results of PASI score of total PASI for all parts

141

99. Statistical results of manasika bhavas 141

IX

List of Graphs

01. Graph No. 01. Showing the distribution of patients by Age groups.

02. Graph No. 02. Showing the distribution of patients by Deha prakriti.

03. Graph No. 03. Showing the distribution of patients by Onset.

04. Graph No. 04. Showing the distribution of patients by Samanya Nidana.

05. Graph No. 05. Showing the distribution of patients by Manasika Nidana.

06. Graph No. 06. Showing the distribution of patients by Family history.

07. Graph No. 07. Showing the distribution of patients by Chronicity.

08. Graph No. 08. Showing the distribution of patients by Aggravating factor.

09. Graph No. 09. Showing the distribution of patients by Type of Psoriasis.

10. Graph No. 10. Showing the distribution of patients by Chief complaints.

11. Graph No. 11. Showing the distribution of patients by Associated complaints

12. Graph No. 12. Showing the distribution of patients by Confirmation test.

13. Graph No. 13. Showing the distribution of patients by Sites of involvement.

14. Graph No. 14. Showing the Overall response to the treatment.

List of flow charts

1. Samprapti of Kushta according to Charaka 55

2. Samprapti of Kushta according to Sushruta 55

3. Samprapti of Kushta according to Vagbhata 56

4. Samprapti of Kushta according to Bhela 56

5. Samprapti of Kitibha Kushta 57

List of Figure

01. Figure No. 01. Showing Histology of skin.

02. Figure No. 02. Showing histological changes in skin of Psoriasis.

List of Photographs

01. Photo No. 01. Showing the medicaments used for Takradhara.

02. Photo No. 02. Showing the procedure of Takradhara and the effect of therapy

before and after treatment.

INTRODUCTION

yurveda the eternal science took birth with world itself and is not liable to change

at any time or in any part of the world. Aim of Ayurveda is to promote health and cure

diseases. Ayurveda has designed a variety of treatment modalities among which

Panchakarma is the most superior. Panchakarma mitigates the root causes of the diseases

and promotes health.

A

Man, the gifted creature of God is running behind everything today. Nobody

wants to spend sufficient time on required day-to-day activities. Due to the fast moving

life style all the daily activities of the man turned up side down and gave to two types of

disorders viz. Somatic and Psychosomatic. The main discussion of this thesis, Kitibha

kushta (Psoriasis) is a disorder of psychosomatic in nurture, which arises due to the faulty

life style.

Position of anything that made of silver is identified as a sign of wealth. But not

the silvery scales, which is the cardinal symptom of Psoriasis. This obnoxious illness

though not contagious, isolates the patient from their family and society or else the

patient himself hesitates to move with his family and society fearing dejection.

The history of psychosomatic problem is as old as the history of human

civilization. Till today somatogenic and psychogenic solution are put forward although

both are extremists. In our classics Manas and Shareera are regarded as separate entities

but not in the sense of separation, because an organism is a complex combination of

Atma, Manas, and Shareera i.e. soul, mind and body. So Ayurvedic approach to a disease

is definitely psychosomatic in nature. For example – Kushta is due to disrrespective given

to Gurus, Bramahanas, doing Papakarmas, etc. So our Acharyas has given more emphasis

to the integrated aspect of mind and body.

Introduction 1

Kitibha kushta of Ayurveda closely resembles the clinical symptoms of Psoriasis.

As per the of disease nature, this is a chronic recurrent dermatosis. The primary lesion is

an epidermal papule. The Psoriatic papule is pink in colour of various intensities. The

fresh lesions are brighter and older ones are darker. The papules are flat and have rough

surface covered with silver white microlamellar scales, which scrap off easily. At first the

papules have a regular round, countour and a diameter of 1-2 mm each. Later they spread

peripherally after attaining size with an intensive itching sensation of the skin. If we

consider the above symptoms they closely resembles the symptoms of Kitibha kushta.

And also the researchers those who worked on skin disorders have correlated Kitibha

kushta with Psoriasis. So the present study entitled “The Evaluation of The Efficacy of

Takra Dhara in Kitibha Kushta (Psoriasis)” was undertaken.

The main aim of the study is to focus the psychosomatic treatment for Psoriasis. It

is more stress sensitive than other skin disorders since anxiety and tension aggravate the

condition. As stated before Shareera and Manas go hand-in-hand in causing the disease,

hence a humble attempt is made to pacify vitiated Manasika and Shareerika bhavas.

Ayurveda considers Kushta as an important disease and categorized it as a

“MAHAROGA”. Though curative and preventive measures are in full swing and under

the guidance of W.H.O., the central and state governments and voluntary organizations,

several measures are being persuaded for warding of Kushta. The grim reality would be

to reveal all steps already taken and still in progress or quite insufficient for immunizing

of this dreaded disease. In this circumstances along with Ayurvedic physicians and

scientists, practitioners of Unani, Siddha, and other allied systems should also raise equal

to the occasion and work whole heartedly and dedicated spirit for eradicating this dreaded

disease from the world permanently.

Introduction 2

Science is a gradual evolution; it is not a sudden invention. Ayurveda as a science

is not an exception for it. The imperishable fundamentals of Ayurveda, which were laid

down by great sages of the olden days, are still applicable because of scientific and

eternal background. Such fundamentals must be subjected to scientific research not only

to prove its certainty but also to add something new to the existing knowledge. By

keeping this in mind the present study was undertaken.

Introduction 3

NEED FOR THE STUDY

akradhara is one among the Keraleeya chikitsa krama. It is said to be the best for

dhatu shaithilya and all kinds of doshakopa. It is the process in which the medicated

buttermilk is poured in a continuous stream on the head especially on the forehead in the

specific manner.

T

Procedure of any kind of Dhara has been mentioned in our classics. But in

different contexts the word Parisheka has been mentioned which is equated to dhara.

Vagbhata considered Seka as one of the type of Moordhini taila. Bhavaprakasha in his

netra roga chikitsa adhikara mentioned Seka for the eyes, which means a sukshma dhara.

Kitibha kushta is a form of Kshudra kushta. Based on the similarities of

symptoms and other description available in the medical literature, many of the

Ayurvedic researchers and authors of recent past who have worked on skin disorders

have equated to Psoriasis. However the correlation of Kitibha kushta to Psoriasis or

detailed description of Psoriasis is not the subject of the study.

Psoriasis affects 1-3% of the world population. It occurs with almost equal

frequency in males and females, however a high prevalence in males (24%) to females

(0.8%) is noted in earlier studies. Contemporary systems of medicine has paid a lot of

attention to counter this dreadful disease. The modalities of the management of Psoriasis

are only palliative and recurrence oriented. The external applications and the internal

medications provide only a temporary relief to the patient and also most of the drugs used

for the remission of this disorder are known for their side effects.

In the above situation Ayurveda has got the answer for the treatment of such skin

diseases. Among the various treatment modalities, which are good for various skin

ailments, Takradhara plays pivotal role and is stated best for both Shareerika and

Manasika doshas, as stress and tension aggravate the Psoriasis.

4

PREVIOUS WORK DONE ON KITIBHA KUSHTA (PSORIASIS)

Trivendrum : -

01. Dr. Patil 1980. Worked on the effect of Snehapana in Kushta (W.S.R.T.

Psoriasis).

02. Jayarama 1988. Studied classical management of Kushta (W.S.R.T. Psoriasis).

03. Dr. Mohan 1984. Studied the role of Takradhara in the Management of Kitibha

Kushta (Psoriasis).

Jamanagar : -

01. Dr. Makwana 1979. Worked on Efficacy of Arogyavardhini and Gandhaka

Rasayana internally, Gandhaka Malahara externally Kitibha (Psoriasis).

02. Dr. Sabu 1988. Worked on Comparative Efficacy of Raktamokshana and Brihat

Manjishtadi Kashaya with Talasindhoor in Kitibha (Psoriasis)

Ahamedabad : -

01. Dr. Kale 1993. Worked on Comparative Efficacy of Virechana and Shamana

with Panchatikta Ghrita Guggulu and Chandamaruta Sindhoora externally in

Kitibha (Psoriasis).

B.H.U. : -

01. Dr. Tangoria 1989. Studied the Management of Kitibha (Psoriasis) by an

indigenous drug Stree Kutaja.

02. Dr. Anken 1991. Studied Concept of Kitibha in Ayurveda and Modern

medicine and its Treatment with Stree Kutaja – A further study.

5

Banglore : -

01. Dr. Rajeshwari 1986. Studied Jalokavacharana in Kitibha Kushta (Psoriasis).

02. Dr. Jayashree 1986. Studied Efficacy of Panchakarma in the Management of

Kitibha kushta (Psoriasis).

03. Dr. Rekha 1995. Studied The effect of Vamana and Virechana on Psoriasis.

Takradhara is a simple technique; ingredients are easily available and economical

and is also indicated in dhatu shaithilya and doshakopa, which is normally seen in

Kushta. Considering the utility of Seka and Takra in different Kushtas the expanded

version will be studied as Takradhara.

6

OBJECTIVES OF THE STUDY

01. To Evaluate the efficacy of Takradhara in Kitibha kushta (Psoriasis)

02. To Evaluate the efficacy of Aragvadadi gana kashaya Takradhara in Kitibha

kushta (Psoriasis).

7

HISTORICAL REVIEW

KARMA

t is essential to know any Panchakarma procedures or any Keraleeya

Chikitsakrama, which are available in Vedas. As they are the prime sources of ancient

wisdom, from the research point of view one must search for such and possible

evidences. Such search of Vedas for reference regarding Panchakarma, Keraleeya

chikitsakrama, Seka or Dhara in particular was not fruitful. But, if we go through our

Samhita granthas carefully, we can find ample references for Seka. Among all the

Samhita granthas Charaka Samhita (1000 B.C.)1 was the first to describe Seka in

different diseases.

I

Acharya Bhela2, Kashyapa3, Sushruta Samhita4, Vagbhat5, had considered seka as

the type of moordhini taila. The latter texts such as Bhavaprakasha6, Yoga Ratnakara7,

Chakradutta8 have also mentioned about Seka. Even though the therapeutic utility of

Seka in various disorders has been mentioned in our classics the utility of Takraseka or

Takradhara has not been explained. Reference for the Takra is available from the Vedic

period to Samhita kala. Takra is said to be Amruta9 and it is even difficult for Indra10 to

get it. Different forms of takra and its kalpanas11 are also mentioned in classics.

Textbooks on Ayurveda originated form Kerala such as Dharakalpam12,

Keraleeya chikitsakramam13, Chikitsa Sangraham14, Ayurvedic treatments of Kerala15

had described Takradhara as an effective technique for all kinds of doshakopa16 and

dhatu shaithilyata17, which is normally seen in Kushta.

8

VYADHI

01. Vedic Period18

Vedas are considered as the oldest and the first available literature of the world.

The history of Indian medicine starts with Vedas, so the history of Twak rogas begins

from vedic period. Many references regarding kushta are found in Vedas.

A. Rigveda18a – In Rigveda there is no complete description of kushta. But some

description indicates that kushta was prevalent in that period also.

The Charmaroga of Aapala was cured by the Lord Indra.

Ghosa was suffering form Kushta roga. She was disliked by her husband because

of her ugly looks due to kushta roga. By administration of proper medication she got

cured and ultimately accepted by her husband.

B. Yajurveda18b – Shukla Yajurveda mentioned various medicines having kushta

nashahara properties.

C. Atharvana Veda18c – In Atharvana veda, the various sites for disease have

been described and amongst them skin has been described as one of the chief site of the

disease. The names of the various diseases have been illustrated where by kushta has

been described as Kshatriya roga. There is description of some herbs like Rama, Neeli,

Asaru, Shyama, etc. for the treatment of kushta. Shringa i.e. Horn of deer possessing a

property of twak rogahara has been mentioned.

02. Purana Kala

A. Mahabharata18d – It is mentioned that the person suffering from twak dosha

is not fit to be a king. This reference highlights that at that time people suffering form

kushta were looked down by the society.

9

B. Agni Purana18e – Kushtahara medicines are mentioned under the heading of

Nanarogahara aushadhani.

C. Garuda Purana18f – In various chapters of Garuda purana description about

Twak roga has been explained viz. Kushta, Sidhma kushta, etc.

D. Panini18g – In Ashtadhyaya of Panini grammatical literature about the disease

is explained. The diseases like Atisara, Arsha, Kushta have been explained and also the

diseases caused by Anuvamshika doshas and vyadhis are also been explained.

E. Kaushika Sutra18h – The reference of Kushta and its treatment is mentioned

in Kaushika Sutra like chanting Mantras, external application of paste made up of drugs

like Bhringaraj, Haridra, Indravaruni, Neelika pushpa, etc.

03. Samhita kala19

A. Charaka Samhita – Charaka described in detail for the first time, a long range

of skin diseases with their etiology, pathogenesis and specific classification under the

heading of Kushta. Charaka has described eighteen types of kushta. Seven types of

kushtas have been described under the category of Mahakushta in Nidanasthana19a. In

Chikitsasthana19b eighteen types of Kushta have been classified under seven Mahakushta

and eleven Kshudra kushta.

Apart from these; description of kushta is available in the following chapters –

01. Kushta is described as samanya hetu of Nija shotha19c.

02. Kushta is considered as a Santarpanajanya vyadhi19d.

03. It is included as one of the disease caused by the rakta19e.

04. Use of stamabana dravyas in the initial stage of Raktapitta, Raktarsha, and

Amatisara leads to kushta.

10

05. Kushta is noted in Lekhana yogya and Pracchana yogya vyadhis19f.

06. Agni karma is contraindicated in kushtaja vrana19g.

B. Sushruta Samhita – Acharya Sushruta, for the first time clearly described the

Anuvamshika (Hereditary) and Krimija (Infectious), nidanas as a causative factors for

kushta20. Kushta has been included in Aupasargika roga which may spread from one

person to other21. He also explained dhatugatatwa and uttarottara dhatu pravesha of

kushta roga22. The number of kushta rogas described by Sushruta is the same as that of

Charaka, but Dadru has been mentioned under Mahakushta and Siddhma under kshudra

kushta. Sushruta describes the chikitsa in two chapters i.e. Kushta chikitsa and

Mahakushta chikitsa. Guggulu, Shilajatu, Shweta bakuchi, etc and rasayana drugs are

also mentioned.

C. Ashtanga Hridaya – Vagbhata has followed Sushruta regarding classification

of Mahakushta and Kshudrakushta23. But Kitibha kushta has been mentioned under

kshudrakushta with some lakshanas as described by Charaka24.

D. Bhela Samhita25 – Bhela Samhita has described kushta roga in both nidana

and chikitsasthana. He has mentioned that polluted water is the main etiological factor of

kushta.

E. Kashyapa Samhita26 – Kashyapa samhita has described eighteen types of

kushtas as Charaka except the Shwitra, Vishaja kushta and Sthul ruksha kushta, Instead

of Charma kushta, Alasaka and Visphotaka. Kahsyapa has given the classification of

kushta on the basis of sadhyasadhyata. Thereby nine kushtas are described as Sadhya

while others as Asadhya.

11

04. Sangraha Kala

A. Madhava Nadana27 – Madhava has described Nidana panchaka of kushta

according to Charaka and Vagbhata. While dhatugatatwa, sadhyasadhyata and

Sankramakata (contagious) have been described according to Sushruta.

B. Sharangadhara Samhita28 – Classification of kushta has been described in

Poorvakhanda. He describes Tamra which is the fourth layer of skin is the site for all

types of kushtas.

C. Vangasena29 – Vangasena has mentioned seven types of special causes of

kushta i.e. Taila, Kulatha, Valmika linga roga, Mahisha dugdha, Mahisha dadhi and

Vruntaka.

D. Bhavaprakasha30 – Bhavaprakasha has described a detail description of

kushta roga. He has followed Charaka for classification and nomenclature of kushta. The

dhatugatatwa and sahdyasadhyata are compiled form Sushruta.

F. Yogaratnakara31 – Yogaratnakara describes kushta according to the earlier

classics, contagious aspect of kushta is also described by him.

G. Rasaratna Samucchya32 – In third chapter, while explaining Gandhaka gunas

he mentioned that it is useful in kushta.

H. Rasatarangini33 – In Gandhaka prakara, Gandhaka taila is indicated is

Mahakushta and other skin diseases.

12

VYUTPATTI & PARIBHASHA

The word Takradhara is comprised of two words viz. Takra and Dhara.

Takra34 – This word is derived form Tak + Rak pratyaya. It is napumsakalinga,

if ¼th of water is added to it then is called as Takra.

Dhara35 – Means, Dharabhir Nivruttam | It is napumsakalingam, Dhara which is

characterized by streams – means the fall of liquid substance in a stream.

Vyutpatti of Kushta (Derivation of Kushta)

The word kushta is derived form the root “Kush” which means that which comes

out from inner part to outer part36.

In the term kushta the word “Kush” is added to “Hani” to form kushta, which

gives a meaning that it gives an ugly look to the body37a.

The word kushta is derived form the dhatu “Kush” meaning; the morbid factor

mainly rakta is drawn towards the region of twak so as to cause kushta37b.

Paribhasha (Definition of Kushta)

According to Arundutta, kushta is defined as that which causes disfigurement to

the body38.

Nirukti & Paribhasha of Kitibha kushta

The term Kitibha is constituted by the combination of “Kiti” and “Bha”. The word

Kiti refers to variety of insects, which is black in colour, stays in kesha pradesha or in

hair39.

The word “Kiti” is also termed as “Akuna” by Hemadri. This indicates that it is

either a louse or some other insect, which is similar to louse.

Vyutpatti & Paribhasha 13

The word “Bha” refers to the resemblance or similarity. So the term Kitibha,

which is constituted by suffixing “Bha” to “Kiti”, suggests something, which resembles

louse.

The similarity is mentioned only in colour (Krishna), as it resembles, the colour of

louse but not referred to its shape or size.

So the definition of Kitibha is “A pathological skin condition where the colour of

skin is black like Kiti i.e. Louse. Sushruta has also given one more meaning to Kitibha; it

is an upadrava caused as a result of the bite of the poisonous variety of insect40.

Etimology of Psoriasis – The word “Psoriasis” is derived from the Greek work

“Psora” which means “itch” or “scale”.

Definitions of Psoriasis

Psoriasis is defined as a skin disorder, which have been classified and discussed

under various headings. Keratinization disorder is one group, in which there will be

hyperkeratinization of the basal cells of epidermis. Kitibha kushta is which skin becomes

hard or horny, as like psoriasis in contemporary context. Psoriasis is one among the

kearatinization disorders of the skin, which also involves either genetic or immunological

derangements.

According to various authors the psychosomatic disorder, psoriasis is defined and

characteristic features are established as under –

01. Psoriasis is characterized by the development of erythmatous, well defined,

dry, scaly papules and plaques of sizes ranging from a pin head to larger lesions

(Pavitram K 1994.).

Vyutpatti & Paribhasha 14

A common genetically determined disease of the skin consisting of well defined

pink or dull red lesions surrounded by the characteristic silvery scale. (Baker Harvey &

Wilkinson. D. S. 1986.)

A chronic disease characterized by sharply defined patches of erythema covered

by silvery scales (Kirbua John D. 1986.)

It is a common chronic and non-infectious skin disease characterized by well-defined,

slightly raised, dry erythematous macules with silvery scales and typical extensor

distribution. (Bhela P. N. 1987.)

Vyutpatti & Paribhasha 15

RACHANA SHAREERA OF TWAK

Beauty is an important part of human experience. Beauty without perfect blemish

less skin is incomplete. Clean skin suggests absence of acquired or inherited health

disorders. Hence, people spend much time and money to restore skin to a more normal or

youthful appearance.

Ayurvedic View

In Ayurveda, the word “Twacha” or “Charma” is used for skin41. Twacha is

derived from “Twacha Samvarne” dhatu means – the covering of body. It can be defined

as body substance that covers the internal tissues like Rakta, Mamsa, Medas, and other

dhatus.

Synonyms of Twacha

Twak, Charma, Sparshanendriya, etc.

Formation of the skin

Sushruta described the process of formation of twacha in the developing foetus.

He says that after formation of the ovum twacha develops just like a cream on the surface

of the milk42. In the uterus during the course of development of garbha differentiation of

the layers of the skin takes place and is produced by all three doshas particularly by pitta

dosha. Twacha develops consecutively in seven layers by the synchronized peculiar

action of dosha.

Vagbhata described the formation of twacha due to paka of rakta dhatu by its

dhatwagni in the foetus. After paka, it dries up to form twacha just like the deposition of

the cream over the surface of the boiled milk43.

Shareera 16

Layers of the Twacha

A. There are differences of opinion regarding the layers of skin. Charaka has

described six layers of the skin. Out of these six he has given names to the first and

second layer. The rest four layers have been described in terms of the disease44.

Table No. 01. Showing layers of skin according to Charaka.

No. Layer Disease

01. Udakadhara -

02. Raktadhara -

03. Triteeya Sidhma, Kilasa

04. Chaturtha Dadru, Kushta

05. Panchama Alaji, Vidradi.

06. Shashta Arhsa, Bhagandhara

B. Sushruta has described seven layers of the skin along with the specific names.

He has also mentioned the thickness of each layer along with the disease, which are prone

to that layer45.

Table No. 02. Showing the layer of the skin according to Sushruta.

No. Name Thickness Disease

01. Avabhasini 1/18th of Vrihi (0.05-0.06 mm) Sidhma, Padmakantaka

02. Lohita 1/16th of Vrihi (0.06-0.07mm) Tilakalaka, Nyachya, Vyanga

03. Shweta 1/12th of Vrihi (0.08-0.9 mm) Charmadala, Mashaka,

Ajagallika.

04. Tamra 1/8th of Vrihi (0.12-0.50 mm) Kilasa, Kushta.

05. Vedini 1/5th of Vrihi (0.2-0.3mm) Kushta, Visarpa

06. Rohini 1 Vrihi (1-1.1mm) Shleepada, Arbuda, Granthi,

Apachi, Galaganda

07. Mamasadhara 2 Vrihi (2-2.1 mm) Arsha, Bhagandara, Vidrudhi

Shareera 17

C. Vagbhata has described seven layer of skin without naming them.

Commentators Arunadutta and Hemadri named them according to Sushruta46.

D. Sharangadhara has also mentioned seven layers of the skin along with the

probable onset of disease. The names of the six layers of the skin are same as Sushruta

but seventh layer is named as Sthula, which is the site of Vidradhi47.

Dr. Ghanekar, the commentator of Sushruta shareerasthana has correlated the

layers of the skin with the latest modern anatomy.

Table No. 03. Showing the correlation between the Ayurvedic & Modern skin layers.

No. Ayurvedic Terminology Modern Terminology Types of Skin

01. Avabhasini Stratum corneum Epidermis

02. Lohita Stratum lucidum Epidermis

03. Shweta Stratum granulosum Epidermis

04. Tamra Malpighian layer Epidermis

05. Vedini Papillary layer Dermis

06. Rohini Reticular layer Dermis

07. Mamsadhara Subcutaneous tissue & Muscular layer Dermis

Kriya Shareera of twak

The Kriya Shareera of the twaka can be understood by knowing its relation with

the dosha, dhatu, mala which are the basic structural and functional units of the body.

01. Twak & Tridosha – Twacha is said to be one of the sites of Vata and Pitta dosha48.

A. Twacha & Vata Dosha – Charakacharya has described Twacha as a

sparshanendriya adhishthana. Sparsha i.e. touch sense is the subject of

sparshanendriya which is performed by Vata dosha49.

Shareera 18

B. Twacha & Pitta dosha – Bhrajaka pitta, which is located in the skin is

responsible for the luster of the skin. It is also called as Bhrajakagni.

Charaka did not specified about the types of pitta, but he has said that the

production of normal and abnormal temperature as well as the normal and abnormal

colour of the skin is due to the pitta dosha. Commenting on this Chakrapani says body

heat regulation and variation in the colour of the body are the functions of the bhrajaka

pitta50.

Sushruta describes it as a bhrajakagni and it enables the digestion and utilization

of substances used through Abhyanga, Pariseka, Alepa, Avagaha, etc. It indicates the

glow of one’s natural complexion51.

According to Bhela bhrajaka pitta is that which is responsible for the

manifestation of the specific characteristics of the body. It emphasizes its importance in

creating different prabhas (Hues) of the head, hand, feet, sides, back, abdomen, thighs,

face, nails, eyes and hair. It also brightens them52.

Vagbhata mentioned bhrajaka pitta is situated in the skin. It is so called because it

imparts lusture to the skin and makes it radiate. Arundutta says it is so called because it

performs deepana-pachana of substances used for abhyanaga, lepa, pariseka, etc.

C. Twacha & Kapha dosha – The Snigdhata, Shlakshnata, Mriduta, Sheetata,

Prasannata are the attributes to the presence of kapha dosha in the skin. Ropana

karma i.e. self healing process is also one of the function of kapha dosha.

02. Twacha & Saptadhatu –

A. Rasa dhatu – In Several places twacha has been used as synonym of rasa dhatu

like Twaka sara purusha, etc. Sushruta mentioned that in early stages Kushta is

situated only in Twacha. Dalhanan commented on that and says it as

Twachashrita i.e. Rasashrita kushta53.

Shareera 19

B. According to Chakrapani, Udakadhara which is the first layer of skin maintains

water content of the body. Rasadhatu is jalamahabhoota pradhana in its

panchabhautika constitution. This declairs the relation between rasadhatu and

twacha.

C. Twacha and raktadhatu – Sushruta has described varnaprasadana as one of the

functions of raktadhatu i.e. it imparts the colour to skin. Raktadhatu is also

responsible for the proper conduction of tactile sensation of the skin54.

D. Twak and Mamsa dhatu – Twacha is an upadhatu of Mamsa dhatu. Development

and nourishment of twacha is depending on the dhatupakavastha of Mamsa

dhatu55.

03. Twacha and Trimala – Mala, Mutra and Sweda are the three main malas are the

outcome of sarakitta vibhajana process during dhatwagni viparyaya. The kitta part is

excreted out from the body. The sweda is the mala of Medo dhatu, which is excreted out

from the swedavahi strotas of twacha. Sweda maintains luster and humidity of the skin56.

According to our science nails and hairs are the mala of asthi dhatu and twachagat

sneha is the mala of Majja dhatu57.

Kustha involve morbidity of seven dravyas. They are Tridosa and four Dhatus

(Rasa, Rakta, Mamsa and Lasika). So from above description one can easily understand

the importance of these units. The Vikrti of these seven essentials leads to the occurrence

of many skin diseases i.e. Occurrence of many Kustha Rogas.

Shareera 20

Modern View – Anatomy of Skin58

Skin is one of the largest organ in the body in surface area and weight. In adults

the skin covers an area of about two square meters and weights 4.5-5 kgs. It ranges in

thickness from 0.5-4.0 mm. depending on location. From all the body’s organs none is

more easily inspected or more exposed to infection, disease and injury than the skin

because of its visibility. Skin reflects our emotions some aspects of normal physiological

process, which are held in our body.

All the constituents are derived from ectoderm or mesoderm.

01. The epithelium structure i.e. epidermis pilosebaceous / apocrine units, eccrine

sweat units and nail units are ectodermal derivations.

02. Melanocytes, nerves and specialized sensory receptors arise from the neuro-

ectoderm.

03. The other elements in the skin i.e. Langer Han’s cells, macrophages, mast cells,

fibroblasts, blood vessels, lymph vessels, muscles and lipocytes originate from

mesoderm.

Microanatomy of Skin

Structurally the skin consists of two principal parts –

A. The superficial thinner portion, which is composed, of epithelial tissue is called

epidermis.

B. The epidermis is attached to the deeper thicker connective tissue called dermis.

C. Deep to the dermis there is a subcutaneous layer, which is called superficial

fascia or hypodermis, which consists areolar and adipose tissue.

Shareera 21

Epidermis

The epidermis is defined as squamous epithelium, which is about 0.1 greater up to

0.8-1.4 mm on the palm and sole. Its prime function is to act as a protective barrier.

Keratinocyte is the main cell of this layer, which produces a protein keratin. The

four layers of the epidermis represent the stages of maturation of keratin by keratinocytes.

01. Basal layer – Stratum basale.

02. Prickle cell layer – Stratum spinosum.

03. Granular layer – Stratum granulosum.

04. Stratum lucidum

05. Horny layer – Stratum corneum.

Stratum Basale – The basal cell layer of the epidermis is comprised mostly of

keratinocytes which are either dividing or non dividing. The cells contains keratin,

tonofibrins are secured to basement membrane by hemidesmosomes. Melanocytes make

up 05-10% of the basal cell population. These cells synthesis melanin and transfer it via

denritic process to neighboring keratinocytes. Melanocytes are most numerous on the

face and other exposed sites and are of neural crust origin. Merkel cells are also found a

bit in frequently in the basal cell layer. These cells are closely associated with terminal

filaments of cutaneous nerve and seem to have a role in sensation. Their cytoplasm

contains neruopeptid granules as well as neurofilaments and keratin.

Stratum spinosum – Daughter basal cells migrates upwards to form these layer of

polyhedral cells, which are interconnected by dermosomes. Keratin tonofibrils form a

supportive mesh in the cytoplasm of these cells. Langer Hans cells are mostly found in

this layer.

Shareera 22

Stratum granulosum – Cells become flattened and loose their nuclei in the

granular cell layer. Keratohyalin granules are seen in the cytoplasm together with

membrane coating granules, which expel their lipid contents into the intercellular space.

Stratum lucidum – Normally only thick skin of the palms and the soles has this

layer. It consists of 3-5 rows of clear flat dead cells that contains droplet of an

intermediate substance that is formed from keratohyalin and is eventually transformed to

keratin.

Stratum corneum – The end result of keratinocytes maturation can be found in the

horny layer which is comprised of sheets of overlapping polyhedral cornified cells with

no nuclei (corneocytes). The layer is several cells thick on the palms and the soles but

less thick else where. The corneocyte cells envelop is broadened and the cytoplasm is

replaced by keratin tonofiriles in a matrix formed from the keratohyalin granules cells

which are struck together by a lipid glue which is partly derived from membrane coating

granules. Dermis

The dermis is derived as a tough supportive connective tissue matrix containing

specialized structures found immediately below and intimately connected with epidermis.

It varies in thickness being thin 0.6 mm on the eyelids and thicker more than 3 mm on

palm and soles.

The dermis chiefly consists of white fibrous tissue, elastic fibers and non-striped

muscles and contains blood vessels, nerves, hair, sweat gland, sebaceous glands and

nerve corpuscles. The outer portion of dermis is about 1/5th of the thickness of the total

layer is named as papillary region. The deeper portion of the dermis is called as reticular

region. It consists of dense irregular connective tissues containing interlacing bundles of

collagen and coarse elastic fibers.

Shareera 23

The reticular region is attached with underlying organs such as bone and muscles

by the subcutaneous layer also called as hypodermis or superficial fascia.

PHYSIOLOGY OF SKIN59

The skin is metabolically active organ with vital functions including the

protection and maintaining homeostasis of the body.

Functions of the skin

01. Regulation of the body temperature.

02. Protection

03. Immunity

04. Sensation

05. Excretion

06. Blood reservoir

07. Synthesis of vitamin D

Keratin Maturation

The differentiation of basal cells into dead but functionally important coenocytes

is a unique feature of the skin. The horny layer is important in preventing all types of

agents from entering the skin including microorganisms, water and a particular matter.

The epidermis also prevents the body fluids from getting out.

Epidermal cells undergo the following sequence during keratinocyte maturation.

01. Undifferentiated cells in the basal layer immediately above divide

continuously. Half of these cells remain in place and half progress upwards and

differentiate.

Shareera 24

02. In the prickle cell layer cells change from being columnar to polygonal.

Differentiating keratinocytes synthesize keratin, which aggregate to form

tonofilaments. The desmosomes connecting keratinocytes are condensation of

ton filaments. Desmosomes distributes structural stresses throughout the

epidermis and maintain a distance of 20 mm between advancement cells.

03. In the granular layer enzymes induce degradation of nuclei and organelles.

Keratinohyalin granules mature the keratin and provide an amorphous protein

matrix for the tonofilaments. Membrane coating granules attach to the cell

membrane and release an impervious lipid containing cement which

contributes to cell adhesion and to the horney layer.

04. In the horney layer the dead flattened corneocytes have developed thickened

cell envelops encasing a matrix of keratin tonofibils. The disulfide bonds of the

keratin provide strength to the stratum corneum but the layer is also flexible

and can absorb up to 3 times its own weight in water however if it dries out i.e.

water content falls below 10% pliability falls.

05. The corneocytes are eventually shed from the skin surface.

Rate of Keratin maturation – Kinetic studies show that on an average the

dividing basal cells replicate every 200-400 hours and the resultant differentiating cells

take about 14 days to reach the stratum corneum and a further 14 days to be shed. The

cell turnover time is considerably shortened in keratinization disorders, such as psoriasis.

Biochemistry of the skin – The important molecules synthesized by the skin are

(a) keratin, (b) melanin (c) collagen and (d) glycosaminoglycans.

Hormones and the skin – the skin is the site of production of one hormone (vit.

d) but it is often a target organ for other hormones and is frequently affected in endocrine

diseases.

Shareera 25

Table No. 04. Showing the relation between skin and hormones.

No. Hormone Site of Production Effects

01.

Vit – D

In dermis from precursor

through the action of UV

radiation

Important for the absorption of

Ca-. and for calcification.

02.

Corticosteroids

Adrenal cortex

- Receptors on several cells in

both epidermis and dermis

- Produce vasoconstriction

- Reduce mitosis by basal cells.

- Generate anti-inflammatory

effects on leukocytes.

- Inhibit phospholipase A

03.

Androgens

Adrenal cortex and gonads

- Receptors on hair follicles and

sebaceous glands.

- Stimulate terminal hair growth

and increase output of sebum

04. MSH & ACTH Pituitary glands - Stimulate melanogenesis

05. Estrogens Adrenal cortex and ovaries - Stimulate melanogenesis

06.

Epidermal

growth factor

Skin

- Receptors found on

keratinocytes, hair follicles, and

sebaceous glands and sweat duct

cells.

- Stimulates differentiation after

Calcium metabolism.

07. Cytokines and

eicosanoids

Cell membrane

Effects on immune functions,

inflammatory and cell

proliferation.

Shareera 26

Immunology of Skin :60

The skin is an important immunological organ and normally contains nearly all

the elements of cellular immunity with the exception of B-Cells. Much of the original

research into immunology was done under the skin as a model. The immunological

component of skin can be separated into.

1. Structures

2. Cells

3. Functional systems

4. Immunogenetics.

Structure – The epidermal barrier is an important example of innate immunity

since most microorganisms that have contact with the skin don’t penetrate it. Equally the

generous blood and lymphatic supplies to the dermis are important channels through

which immune cells can pass to or from their sites of action.

Cells – Langerhans Cells : The langerhans cells of the epidermis are the

outermost sentinels of the cellular immune system. They are dendritic, bone - marrow

derived cells characterized ultra structurally by a unique cytoplasmic organelle known as

the “Birbeck granule”. Langerhans cells play an important role in antigen presentation.

Dendritic cells are also seen in the dermis these lack the birbeck granule but their other

character suggests that they too can present antigen.

T-Lymphocyte : T-Lymphocytes are now believed to circulate through normal

skin where they are thought to mature. Different types of T-Cells are recognized. i.e.

1. Helper - Facilitate immune reaction

2. Delayed hypersensitivity - Specially sensitized.

3. Cytotoxic suppressor - Regulate other lymphocytes.

Shareera 27

Surface receptors detectable by the use of monoclonal antibodies on tissue

sections help to categorize the subgroups. Helper T- Cells often show the CD-4 receptors

and suppressor T- Cells shows the CD-9. B-lymphocytes are not found in normal skin but

are seen in some diseases.

Mast cell : These are normal residents of the dermis as are macrophages, both

may be recruited to the site during inflammatory reactions.

Keratinocyte : It has recently been recognized to have an immunological

function. They can produce pro-inflammatory cytokines (specially interteukin-1) and can

express on their surface immune reactive molecules such as MHC Class II antigens e.g.

HLA – DR and Inter cellular Adhesion molecules ( ICAM-I)

Functional Systems

01. Skin associated lymphoid tissue : The skin with its atternt blood supply

lymphatic drainage, regional lymph nodes, circulating lymphocytes and resident immune

cells can be viewed as forming a regulatory immunological unit.

02. Cytokines are soluble molecules that mediate actions between cells. they are

produced by t-lymphoctyes and sometimes by other skin cells including langerhans cells,

keratinocytes, fibroblasts, endothelial cells and macrophages. Eicosanoids are nonspecific

inflammatory mediators (e.g. Prostaglandis, Thromboxanes and Leukotrienes) and are produced

from Arachidonic acid by most cells, macrophages and keratinocytes.

03. Adhesion Molecules : The Adhesion molecules particularly ICAM-1 are cell

surface molecules found on lymphocytes and some times on endothelial cells and

keratinocytes. By interacting with leukocyte functional antigens they help to bind t-cells and

increase cell trafficking to the area.

Shareera 28

04. Immunogenetics : The tissue type antigens of an individual are found in the

Major Histocompatibility Complex (MHC) located in man on the HLA gene cluster on

chromosome 6. The MHC Class-II antigens of which the commonest is HLA-DR are

expressed on B-lymphocytes, Langerhans cells, sometimes T-cells, Marophages,

Epithelical cells and Keratinocytes. They are vital for immunological recognition but also

are involved in transplant rejection.

In addition the appearance of specific HLA genes is associated, with an increase

likelihood of certain diseases, some of which are Autoimmune in nature.

Shareera 29

DHARAKARMA61a

Shira seka is one of the many special types of treatments widely practiced in

Kerala for diseases of head. In classical medical literature one meets with the causal

references for this as well, but details are not available from any of them.

Shiraseka otherwise called as Dhara is the process in which medicated oil, milk or

buttermilk, is poured in a continuous stream on the head especially on the forehead in a

specific manner.

Dhara is a method of the Kerala special treatment evolved from the genius of the

medical tradition there. Many such distinctive and excellent forms of treatments not

practiced in other parts of India, are conducted by the Kerala physicians. Dhara is one

amongst them and the most important. Although there are many physicians conducting

this treatment, only a few manage it with a thorough understanding of its principles. To

conduct a dhara in a proper manner order is very difficult and expensive too. To manage

it properly without any omission or mishaps, the physician should be well studied and

experienced. Besides, to select the suitable cases for dhara, he must have good

discretionary ability.

To speak the truth, dhara is good for all diseases. Changing the liquid as per the

dosha condition with necessary alteration in its process is useful to alleviate any dosha.

For instance, oils medicated with appropriate medicines in vata, ghee prepared with pitta

healing medicines in pitta and mere oils in kapha can be used. For a healthy man,

Yamaka (mixture of oil and ghee) is preferred as per tradition. According to another

version, the suitable liquid medium for vata is unctuous liquids (as oils, ghee, etc.) for

pitta milk and for kapha buttermilk. Sometimes in pitta diseases as per the conditions,

Takradhara 30

dhara with tender coconut water, or breast milk or cold water is performed. Similarly for

kapha, dhara with some decoctions and in vata with Dhanyamla (a vinegar prepared with

cereals, citrus fruits, etc.) is also conducted. This can be carried on with other liquids also

as per our discretion looking into the details of the doshas, diseases and their seats.

There are varieties of dhara. They are mainly grouped as Moordhanya (on the

head), Sarvanga (all over the body) and Pradeshika (local). The most important of these is

Moordhyanya. It is employed in diseases like insanity, diseases of the head and eyes,

chronic cold, sinusitis (peenasa), diseases of the ear, mouth, Vata diseases, etc. the

second is Sarvanga dhara. It is to be done in Sarvanga vata (Vata affecting the whole

body), Sarvangeena shopha (anasarca, swelling all over the body), etc. Pradeshika or

local in cases of rheumatoid arthritis, swelling, ascitis, abscesses, wounds, etc.

MOORDHANYA DHARA

There are many varieties of Moordhnidhara. The following are the important

among them.

a. Takra dhara

b. Ksheera dhara

c. Stanya dhara

d. Sneha dhara

Not only for Moordhanya dharas but for all dharas many arrangements are to be

made ready earlier. The following are the important once.

DHARAPATI OR DRONI

The first requirement is the proper droni. To make a proper dharapati, many

orderly steps are to be followed. The first one is the selection of the suitable wood. Many

trees as Deodar, Pine, Punnaga (Calophyllum inophyllum) Mango tree and others are

specially recommended for this.

Takradhara 31

The ideal wood universally accepted by physicians is Nuxvomica. But the wood

of jack and Asana (Madras Kino wood) are also good. An average Dharapatti must be 55

to 80 cm in breadth and 2.5 to 3 meters in length. On the head side the part that comes

under the neck of the patient when lying, is elevated. Behind it there is a pit to which

liquid flows when dhara is conducted. There is a hole to the pit to allow the liquid to flow

out, so that the flow of the liquid to the part of the Droni where the body rests is

prevented. The part of the droni where the head rests should be low by 9 to 12 cm. There

should be an outlet on the foot side also to allow the fluid to go out. Besides, there should

be handles on all the four corners 12 to 24 cm long. It is to help carry the patients

conveniently from each of the four extremes to keep the droni up from the floor. The

height of the support is to be 24 to 36 cm. The droni for Sarvanga dhara is to have its

borders higher than other ones. Here the heights of the supports also are to be altered. On

the head side they should be higher and on the foot side lower.

DHARACHATTI (The vessel for Dhara)

Amongst the apparatus required for a dhara, one very essential is the dhara vessel.

It is to be made with the utmost care. It can be made with metals like Gold, Silver, etc.

but some liquids used for dhara may not agree with some metal containers. So these

vessels are usually made of clay, which is best and congenial to, all alike. This vessel

should contain at least 5.5 liters of liquid and so formed that the liquid is drawn to the

bottom from all sides evenly. Otherwise, when the vessel is moved to and fro, the liquid

may overflow and the steady downward flow is hindered. There is no need for

emphasizing that the vessel should be made of pure clay, well baked and made durable.

The edges of the vessel is to be thick a turned outwards, so that it is easy to tie a rope

Takradhara 32

around it for hanging. A hole is bored in the very center of this vessel. The circumference

of this hole should be large enough to allow the insertion of the finger of the patient or

anybody else. A wick of thread is pushed down through this hole along which the liquid

is allowed to flow down. This wick should be of well spun thread soft and even. This is to

be tied (in the form of a ring) in the middle of a strong stick, about 12 cm in length. The

stick is then placed inside the vessel and the wick is let down through the hole. To place a

coconut shell, bored in the center between the stick and the hole, is a practice among

physicians. A coconut shell with regular slope is selected avoiding soft spots and is made

smooth. The edge of this shell is serrated. The shell is placed mouth downwards at the

very center of the vessel. The stick is fixed above the shell and the wick of the thread is

allowed to pass down through the holes of the shell and the vessel. The benefits of this

device are that, when the vessel, is moved to and fro, the range of movements of the roll

is controlled. If the stick is placed just inside the vessel above the hole with no coconut

shell between them. The whole thread hanging down swings uncontrollably. Since there

is space between the teeth of the coconut shell, there is no chance of any hindrance to the

flow of the liquid. Along with this, another trick is also done. Between the shell and the

vessel round piece of plantain leaf (made out by heating) is put. This leaf is bored here

and there at various spots. This helps regulates the speed and girth of the flow, in its

absence, there is probability of forceful rush of the liquid down when refilling the vessel

repeatedly. Fall of the liquid on the head, sometimes feebly, may create troubles. The

edge of the vessel is to be wound with strong ropes and made ready for suspending from

above.

Takradhara 33

DHARADRAVAM (The liquid for Dhara)

How to prepare the liquid for Dhara is our next concern. This is the most

important item in dhara. Dharas are named after the liquids employed for them. The

effect of a dhara mainly depends upon the quality of the fluid selected. So we have to

separately deal with the liquids commonly used and with the differences in naming their

varieties etc. Whatever be the fluid for the dhara on the head, its quantity is to be not less

than 1800 ml or more than 3600 ml. Usually an average of 2700 ml is taken. Dhara, the

most important among them in vague is Takradhara. This is not simply with raw

buttermilk as the name suggests. Dhara simply with raw buttermilk is very rare. Usually

the buttermilk is mixed with the decoction of Amalaka (Emblica myrobalans) or some

other liquids. The preparation of this buttermilk also has to be managed with special care.

The tubers of Musta (Cyprus rotundus) for which outer skin removed, are taken in the

ratio of 30 gms/450ml of buttermilk, tied in bundle and put in milk with four times of

water. Remove the water completely by boiling. The milk must be pure. When boiling a

steady and mild fire is to be maintained. Too much blazing or drying must be avoided. If

the water is not removed completely, it may be the cause of many troubles. During

boiling, the milk is to be stirred repeatedly. Even after removing the milk from the stove,

the lading is continued until it cools down. The ferment is put only when the milk is

sufficiently cooled. On the first day, ordinary buttermilk without any water is used as a

ferment, since the medicated buttermilk prepared on the above lines is not available then.

After adding the ferment it should be kept closed in a safe place and on the next day

morning the butter is removed by churning well. The bundle of the medicines put in the

milk earlier is squeezed well and removed when the boiling process is over. But some

Takradhara 34

told that the best time for its removal is only when the curd is churned. The quantity of

milk required for next day’s dhara fluid and also for preparing the ferment is to be

collected and boiled. Besides Musta, other medicinal herbs like Chandana (Sandal wood),

Usheera (Vettiver), Madhuyashti (Liquuorice) and Hribera (Coleus vettiveroides) are also

put in the milk while boiling. Such choice is left to the direction of the physician.

Whatever may be the number of medicines, the total quantity should not exceed the ratio

of 30 grams for 450 ml. Generally for all diseases, Musta enough for the intended

benefits.

ATTENDANTS

The attender is the next important requirement for dhara. There must be at least

three of them. They are to be well trained, experienced in having worked together co-

operatively, attentive, with love and attachment towards the patients so that he also likes

and feels confidence in their care and interest towards him.

THE PHYSICIAN

In all treatments, the main part belongs to the physician. Dhara can never be done

without him. The patient may have undergone many dhara treatments earlier, the

attendants may be well experienced and clever, still to start a dhara in the absence of a

physician is completely wrong. The physician, who is well versed in the medical science

and one with good experience in treatment, must have a thorough knowledge of the

nature of the patient. He must be intelligent and wise so that no mistakes are committed

and if anything goes wrong, he is able to rectify it immediately. Attention should be paid

by him not only when dhara is being done, but also in gathering the equipments and in

the daily routine of the patient.

Takradhara 35

Although not so important as the above, there are other minor things also to be

prepared earlier. A bed sheet, pillow, a roll of cloth to tie around the head, pieces of cloth,

a bath towel, a vessel to collect the dhara liquid. Coming out form the droni, two suitable

receptacles to receive liquid and pour it again into the dhara vessel, two or three small

cups made of leaves, two or three small seats for the physician and attendants, a lamp

with oil and wick, a time keeper, oil for the head and kuzhampu or Trivritasneha for the

body, herbal shampoo, water boiled with Amalaka for washing the head, powder of green

gram or hours gram for removing the oil on the body, another fresh bath towel for drying

the head, the medicine to be taken immediately after bath, the food at the proper time,

places selectively arranged for undergoing dhara, lying and sitting all these are to be set

ready before the dhara. Some of these that are to be specially attended to are pointed out

below –

Bed sheet – Must be pleasing to the patient, soft and clean, but not too warm.

Pillow – This is a temporary pillow prepared with soft cloth folded repeatedly. If

is finally covered by a plantain leaf made soft by heating. This leaf cover prevents

wetting and since it extended to the top of the droni, from where it is let out. The length,

height and thickness of the pillow are adjusted for the comfortable resting of the head

during dhara. Carelessness in this may cause many troubles. Pillows can be made of very

soft leather or oilcloth. This pillow is to be used only at the time of Dhara. At other times

the ordinary pillow is enough for use.

Varti (Roll of cloth) – This is prepared by wrapping old soft cloth. This is tied

around the head to prevent the liquid form coming down. It is to be as thick as the thumb

Takradhara 36

of the patient and long enough to be wound around the head and tied at a side. It is better

to wet the parts of the cloth that goes round the head in the dhara liquid earlier.

Oil for the head – Medicated oil for the head is to be selected to suit the

temperature of the patient and the symptoms of the disease. It should be kept safe form

cold. The quantity for immediate use is taken in another pot or cup. Take care to this cup

well before use. If wet, it may cause troubles. Generally Bhringamalaki tailam,

Manjishtadi tailam, Asanavilwadi tailam, Triphaladi tailam, Chadanadi tailam (Big),

Tungadhrumadi tailam and Balaguduchyadi tailam are taken for this purpose.

Kuzumpu for the body – These also are to be mediciated as those for the head.

Usually pinda tailam, Dhanwantaram tialam, Sudhabala, Ksheerabala, Prabhanajana

vimardhana, Lakshadi and Balashwagandhadi are applied warm on the body.

The amalaka water – This has to be made ready, boiled and cooled the previous

day. The mentioned preparation is the same as for the Paneeyas of the Ayurvedic

formulary. 10 grams of Amalaki (Emblica myrobalan) seedless are put in 1800 ml of

water (Prastha) boiled and reduced to half. Reducing only ¼ th part and leaving ¾ th for

use, is also accepted. The total quantity of Amalaka water, should not be less than six

prastha (10800 ml). For those with excess of pitta, vettiver or clearing nut (Kataka) and

for those suffering form cold, pepper leaves itself, for those with vata troubles the leaves

of bala (Sida cardifolia) and for those with excess of kapha, Haritaki, are also added

when for preparing Amalaka water as per the tradition of the physician.

Hot water – This is water was boiled with herbs healing vata such as the leaves of

castor plant or leaves of jack tree, etc. This is not to be too hot. It has to be adjusted to

suit the temperature of the patient.

Takradhara 37

The power for rubbing on the crown – Rasnadi power is the one commonly used.

But for those with an excess of Pitta, Kachoradi power is better. Manjishtadi also is

recommended. Amalaka and pepper are roasted and powdered and made use of.

The medicine to be taken in – Generally, in all treatment of dhara, Pizhichil,

Navarkizhi, etc. Gandharvahastadi kashayam is the accepted medicine is to be taken in

the morning. It’s both laxative and digestive. But sometimes in pitta predominancy, this

m ay prove unfavorable. In such conditions, for proper evacuation of the bowels

decoction of grapes and haritaki is better. This can be used in all treatments as per the

need. Drakshadi kashayam, Mridweeki kashayam, Dhanwantarm kashaya also can be

prescribed as per the condition of the patient. Here, the physician has to use his

discretion, observing the doshas, the tissues involved, etc. PROCEDURE OF TREATMENT

Karkatakam (July-August), Tulam (October-November) and Kumbham

(February-March) are considered as the best time for this treatment. In these months

when the climatic conditions are favorable, free form excess of wind, mist cold, rain etc.,

on an auspicious day, in the morning hours, the treatment is generally started. In a

spacious room protected form wind and other excesses, the Dhara droni which has been

set up, already well washed and dried on the previous day itself, is now brought in and

again wiped with a cloth and placed with its head towards the east. The head part is to be

a bit raised and leg part lowered. If the supports of the Droni are not suited for this

position, the height is to be adjusted by placing adequate pieces of wood etc., under the

Droni. The droni is to be firmly fixed. It is to be remembered that the purpose of raising

the head portion of the droni is to have space enough to place the receptacles (small

Takradhara 38

droni) for receiving Dhara liquid flowing form the Droni and also for the convenient

handling of the Dahra vessel by the physician seated on a stool. The Dhara vessel should

be suspended exactly above the head of the patient lying in the Droni. How to set up the

Dhara vessel in this way is already explained. The wick of thread hanging from the vessel

should be so adjusted as to be just 5 cm (two fingers) (according to ayurvedic treatment

of Kerala four finger) space form above the forehead of the patient, lying supine in the

Droni. Then spread the sheet in the Droni and set the pillow on its position. The

receptacle, the cups for refilling and seats are all to be placed in their respective positions.

Now make sure whether the oil for the head and Dhara liquid, the bath towel and other

necessary equipments are all ready and then light the lamp already placed on the south,

the head side. The wicks of the lamp should be laid prominently to the west and then to

the east.

Seeing that everything is ready and in order, the physician can now allow the

patient to enter. The patient in his turn should be ready by this time after having attended

to the calls of nature and cleaning the mouth, teeth, etc. When the physician calls him, he

should wash his feet once again, enter the treatment room and then stand facing the east

before the lamp. He is to submit offerings to his own deities or as directed by the

physician and having performed auspicious rituals, offer Dakshina to the physician also

according to his mite. Then with the permission of the physician, he seats himself in the

droni facing the east.

The physician now stands at the right side of the patient facing the east. Then

paying homage mentally to his teacher and the God and taking oil on his palm he applies

it on the crown of the patient. This is repeated thrice. Then the patient himself can apply

Takradhara 39

the oil. But not too much as to trickle down. If the patient has long hair, it has to be

parted and tied in the back. The next step is to tie the Varti around the head just above the

ears, eyebrows. It is not to be too tight or loose. If too tight, the blood supply may be

hindered, if too loose, it allows the Dhara liquid to pass through it to the inside of the

Droni and to the body. The knot should be only on the side of the head. If it is on the

back, it creates difficulties to lie with the head placed in order. If it is on the forehead, it

hinders Dhara. Now the patient is to lie in a supine position in the Droni. Then inspect the

position of the pillow, the thread hanging down form the vessel, its height and thickness

are all found to be in order, the liquid is poured into the dhara vessel. When pouring,

draw back the vessel form the upper part of the head with one hand, and firmly close the

hole at the bottom of the vessel with the other hand. So it is clear that another person

pours the fluid. Pouring is to be done very slowly to prevent scattering and spraying.

After the whole liquid is poured, the finger at the whole is loosened very slowly and

gradually and the liquid is let down along the wick. If the wick is too thick, some thread

is drawn out form it. If not which enough press the hole tightly to stop the flow and then

add more thread to the wick. When the wick is wet and the liquid starts to flow along it,

its edges are to be cut even, with scissors, even if they have been cut earlier. After these

precautions, the vessel is brought forward above the forehead and moved to and fro, i.e.

left and right slowly.

As per traditions, the movements of the wick to the left and right, need no be

more than 5 cm form the center of the forehead, the middle of the eyebrows. But there

could not be any objection to make some alterations so as to allow the liquid to spread all

over the head in the beginning. Massaging the scalp under the hair with the free palm of

Takradhara 40

the physician or the attender, first in the beginning and then at intervals is advised to

prevent delay in wetting the whole head with the liquid. Even if the liquid falls correctly

on the head, it is the duty of the physician to make sure that it is also flowing out through

the proper channel. If it is not followed properly, it may be either because of the hole of

the droni is blocked or the diverted liquid flows to the part of the droni where the body

lies. Whatever may be the reason; it has to be corrected immediately. So the physician

who handles the suspended dhara vessel, should be vigilant and pay concentrated

attention. If he fails in fall in this and doesn’t hold the vessel firmly, the scattered liquid

may fall in the eyes or nose of the patient, or fail to fall properly on the head, or

sometimes when refilling the vessels, may collide with each other, break and create

avoidable difficulties. So the physician, should be vigilant with a firm hold on the rope

and vessel, so that in case of collision or the breaking of the tie of the rope, the danger of

there falling down is always prevented. The attendants also should be equally careful.

The receptacles should be placed exactly where the liquid comes out. When one

receptacle is full, it is immediately replaced. The full vessel is removed carefully and

slowly without spilling and again poured inside the dhara vessel with no chance of

clashes. This goes on continuously. It is always better to take the receiving vessel before

it is full and empty it, unto the dhara vessel. Paying attention to the filling and emptying

of the vessel, one can has to adjust the speed of the refilling.

The fall of the dhara liquid from too high, or too low level is both harmful. It is

the same if it is too fast, or too slow. Both increase or decrease in the thickness of flow is

not good. As per tradition, if the wick through which the liquid flows is two fingers (5

cm) above the forehead, circumference of the hole is the size of the little finger of the

Takradhara 41

patient and if the dhara liquid is neither too thick nor too thin everything is satisfactory.

But in these matters, it will be better to consider the comfort of the patient also. For some

people, the fall form 5 cm height may be intolerable for others too low a position may be

disagreeable. Some patients like a thick flow, while others a thinner one. These

differences in reaction may be due to the difference in temperaments. Sometimes it may

also be due to the difference in doshas. For instance, in Pitta a low fall, but with more

thickness is beneficial. A patient with Kapha temperaments may like the fall form a

higher position. He also appreciates a speedy flow.

Different liquids also can create this change in reactions. We have to observe

closely and judge accurately. A fall from a higher position causes headache, fever,

burning sensation, etc. Too low a fall not only fails to alleviate the disease, but also

sometimes, even aggravates the condition. A speedy flow provokes vata and creates

headache, swoon, etc. If too slow, kapha is increased and heaviness of the head is felt.

The disturbance created by using too thick a fall is the same as due to increase in height

and slow flow. Too thin a fall fails to give any good results. On the contrary, it causes,

cold. One has to closely observe and understand these changes. Various other aspects like

viscidity are to be considered carefully.

Thus, until the scheduled time is over, all have to do their work earnestly and

carefully and the patient is to lie still. He is not to turn on his sides, but lie supine. Such

necessities as urination, etc It should not arise during this time if it is unavoidable it

should be done in lying position without any movement of the head. Sneezing, coughing,

etc in this position also create troubles. In urgency, the physician is to be informed so that

he can draw back the dhara vessel from the forehead and hold it aside until it is over. He

Takradhara 42

must be very careful to avoid any interruption in the flow by drawing back the vessel too

much. When refilling also, the best thing is to draw the vessel a little to the back and stop

the movement to avoid the troubles. If somewhat the dhara liquids happens to drop in the

eyes or the face, immediately wipe it well. It is for this purpose that storage of old clothes

is suggested.

One hour dhara on the first day is the usual practice in all common disease. Then

the duration is increased by five minutes each day, so that on seventh day it is one and a

half hour (3¾ Nazhikas). On the eight day also, the same time is taken as on seventh.

From the ninth day onwards, a reduction of five minutes is done so that on the fourteenth

day it is again one hour as on the starting day. This order is for a fourteen-day course. If it

is a twenty-one days course, the order of increasing the time is the same as given before

until the seventh day i.e. reaching to one and a half hour on the seventh day. But from the

seventh to fifteenth day, the same duration is kept. From sixteenth day, a reduction of five

minutes per day is effected, so that it is one hour again on the twenty-first day. Usually

the time for the course of dhara. Is either fourteen or twenty one day. But there is no

objection in extending or reducing the duration as per the condition of the patient. Such

discretion is the responsibility of the physician. Well-considered decisions are always

welcome. But prolongation of the dhara time to more than one and a half hours is

unnecessary, inconvenient and objected to by the shastras. In unavoidable circumstances,

competent physicians resort to extensions of the number of days. There is also a version

that the maximum time allowed is only three Nazhikas (75 minutes). The minimum time

allowed is one Nazhika or 25 minutes. The physician has to choose the time limit

considering all factors like the nature of the disease, doshas and the tolerance of the

patient.

Takradhara 43

DUTIES AFTER DHARA

At least five minutes before the compilation of Dhara all attendants should be

particularly vigilant. Everything for the next step, like bath towel, etc are to be kept

ready. Refilling the Dhara vessel is to be stopped some seconds earlier before the exact

stopping time. At the exact moment, stop Dhara by drawing the vessel back. Then wipe

the head with the towel. This is not to be done by the patient himself to avoid any

shaking. After wiping well, same oil applied himself earlier is again smeared. Then he

may take bath as usual. But Amalaka water for some people for the head and warm water

for the body are indispensable. But for some people warm water may not be agreeable.

For them cold water for the body may not be harmful. To remove the oil from the body,

pasted greengram, horsegram etc. and the head, shampoos of leaves like Vellila

(Mussaenda frondosa) which are neither too cold not too hot in potency are used. For

men of pitta temperament, the residue of the Amalaka water prepared as a paste can be

made use of. After bath wipe the head without delay. It has to be done carefully so that no

moisture is retained. After wiping well with a wet towel again wipe with a dry one also.

After wiping, part the hair and rub medicated powder. As said earlier it is Rasnadi power,

which is usually taken for this. This prevents cold better. Powers like Kachoradi also can

be used as per the disease. After bath, enter the room slowly, and then facing the east take

in the prescribed medicine. Then lie down for a while on the left. Care should be taken to

arrange the bed earlier. But, this rest is only for a while, from a minimum of five minutes

to a maximum of thirty minutes only. Then take food with the prescribed restrictions.

Takradhara 44

RESTRICTIONS DURING DHARA

Chilies, tamarind, newly harvested paddy, fish, seasum, black gram, pumpkin,

brinjal, onion, drumstick, asafetida are harmful. Natural urges should not be stopped. Day

sleep, exposure to mist, sun, dust, wind, and rain are being avoided. Walking long time

traveling in jerky vehicles, prolonged standing and sitting are harmful.

Effects of Takradhara 61b

This Dhara treatment cures premature graying of the hairs, fatigue, infirmity and

emaciation, headache, lack of vitality, pricking pains of the palm and sole, diabetes, lack

of proper functioning of the limb, joints, pain in the chest, heart diseases, disgust for

food, indigestion, dyspepsia and diseases of the eyes, nose throat and ears. This Dhara

also alleviates the derangement of the three doshas and improves the power of all sensory

organs.

Takradhara 45

KITIBHA KUSHTA –

Classification Of Kushta

The word 'Kushta' is widely used for all types of skin diseases. It is a broad term,

which covers almost all the skin diseases. Kushta is produced invariably by the vitiation

of the seven factors i.e. 3 Doshas and 4 Dushyas62. But different types of pain, colour,

shape, specific manifestation etc. are found in Kushta because of Amshamsha kalpana of

the Doshas. Accordingly Charaka Kushtas are in fact of innumerable types, but for

systemic study they are classified into two major groups 7 Maha Kushta & 11 Ksudra

Kushta63.

There is no difference of opinion between any Acharya about the total number of

Kushta, but difference of opinion in symptoms & names of some of Kushta exists.

According to Chakrapani in Kshudra kushta, the symptoms of Mahakushta are

manifested in milder form. Dalhana explained about the word 'Mahata’ that it has the

ability to penetrate to the deeper Dhatu while the Kshudra Kushta do not have the ability

to penetrate the deeper tissue64. According to commentator Gayadas there is severe and

extensive vitiation of Doshas from the very beginning, in Mahakushta, which penetrate

the deeper tissues and cause Mahakushta. But no such severe and extensive vitiation of

Doshas occurs in the Kshudra kushta from the beginning.

46

Table No. 05. Showing the difference between Maha Kushta and Kshudra kushtas.

No. Mahakustha KsudraKustha

01. Bahu Bahul Dosa Arambhata Alpa Dosa Arambhata

02. Bahulakshana Alpalakshana

03. Excessive discomfort Less discomfort

04. Penetrates into deeper Dhatus Less tendency to penetrate in deeper Dhatu

05. Mahat Chikitsa Alpa Chikitsa

06. Chronic Less Chronic

07. Loss of skin function like Supti Less functional skin deformities.

Table No. 06. Showing Classification of Kushta according to different Acharyas.

No. Types of Kustha C.S. S. S A.H K.S. B.S. M.N. B.P.

Mahakushta

01. Kapala + + + + + + +

02. Audumbara + + + + + + +

03. Mandala + + + + + +

04. Risyajivha + + + + + + +

05. Pundarika + + + + + + +

06. Sidhma + - - + + + +

07. Kakanaka + + + - + + +

08. Dadru - + + - - - -

09. Aruna - + + - - - -

Kshudra kushta

01. Ekakushta + + + + + + +

02. Kitibha + + + + + + +

03. Charmadala + + + + - + +

04. Pama + + + + + + +

05. Vicharchika + + + + + + +

06. Charmakhya + - + - + + +

47

07. Vipadika + - + + - + +

08. Alasaka + - + - - + +

09. Dadru + - - + + + +

10. Visphotaka + - + - + + +

11. Sataru + - + + + + +

12. Sidhma - + + - - - -

13. Sthularuksha - + - - - - -

14. Mahakushta - + - - - - -

15. Visarpa - + - - - - -

16. Parisarpa - + - - - - -

17. Ruksha - + - - - - -

18. Shwitra - - - - + - -

19. Vishaja - - - + + - -

Charaka did another classification on the basis of Doshic predominance in types

of Kushta. It is more useful for diagnosis and treatment of the disease, which are as

follows66.

Table No. 07. Showing relation between doshas and kushtas.

Sl. Doshic predominance

Name of Kushta

01. Vata Kapala

02. Pitta Audumbara

03. Kapha Mandala, Vicharchika

04. Vata-kapha Sidhma, Ekakushta, Alasaka, Charmakhya, Kitibha,

Vaipadika

05. Vata-pitta Rishyajivha

06. Kapha-pitta Pundarika, Dadru, Charmadala, Pama, Vispotaka, Shataru

07. Sannipatika Kakanaka

Charaka also described symptoms of predominance Dosha in Kushta. It is also

useful in the diagnosis and management of the disease67.

48

Table No. 08. Showing symptoms according to dosha predominant.

Sl. Dosha Symptoms

01. Vata Rukshata, Shosha, Toda, Shula, Sankocha, Ayama, Parushyata, Kharata,

Harsha, Shyava-Arunata.

02. Pitta Daha, Raga, Parisrava, Paka, Visragandha, Kleda, Angapatana.

03. Kapha Shaithya, Shaithilya, Kandu, Sthairya, Utsedha, Gauravata, Sneha, Kleda.

NIDANA

There is no specific description of etiological factors of the disease kitibha kushta.

Being it is being a variety of kshudra kushta. Some of the etiological factors of kushta are

to be accepted as the etiological factors of kitibha kushta. Our acharyas have described

general causative factors i.e. Samanya Nidana for all types of kushtas instead of specific

Nidana type of kushta. The etiological factors of kushta, which includes kitibha kushta,

may be classified into following groups –

A. Ahara hetu

B. Vihara hetu

C. Achara hetu like Daiva apacharaja

D. Other nidanas like Chikitsa sambandhi, Sankramika, etc.

Table No. 09. Showing Aharaja Nidana of Kitibha kushta68.

No. Aharaja Nidana C.S. S.S. A.H. B.S.

01. Viruddha ahara + + + +

02. Ajeerna, Adhyashayana + + - +

03. Matsyati sevana + + - +

04. Dugdhati sevana + + - -

05. Amlati sevana + - - -

06. Guru ahara + - - -

07. Gramyodaka with Anupamamsa sevana - + - +

49

08. Dadhi sevana + - - +

09. Snehati sevana + - - +

10. Lakucha and Kakamachi + - - +

11. Matsya with Payasa + - - +

12. Ahitashana - + - -

13. Drava, Snigdhahara sevana + - - -

14. Uddalaka, Kusumba + - - -

15. Navanna, Yavaka, Kulatha + - - -

16. Lavana, Hayanaka, Atasi + - - -

17. Moolaka, Satatamadhu sevana + - - -

18. Tilapishti, Guda + - - -

19. Chilachima matsya with milk + - - -

20. Madyamladravya with milk - - - +

21. Guda with milk - - - +

22. Matsya, Nimba with milk - - - +

23. Matsya with Madhu - - - +

24. Papodaka (Dushta jala) - - - -

25. Pippali, Haritashakha Vidangdhahara sevana - - - +

26. Guda with Moolaka - - - +

27. Haviprashana (One of the type of Ghrita) + - - -

Table No. 10. Showing the Viharaja Nidana of Kitibha68.

No. Viharaja Nidana C.S. S.S. A.H. B.S.

01. Chhardinigraha + + - -

02. Vegavarodha + + - -

03. Sheetambusnana after Atapa sevana + + - -

04. Diwaswapna + - - +

05. Ratri Jagarana - - - +

06. Mithya vihara - + + -

07. Vyayama atisantapa bhuktopa sevana + - - -

08. Shrama bhayartana sheetambu sevana + - - -

50

09. Ajeernapi vyayama + - - -

10. Senha pitasya vanatasyava vyayama - + - -

11. Vyavaya after vidahi ahara sevana - - - -

12. Gramyadharma sevana - + - -

Table No. 11. Showing Daivapacharaja Nidana of Kitibha68.

No. Daivapacharaja Nidana C.S. S.S. A.H.

01. Vipran guruna garshayatam + + -

02. Papakarma + + -

03. Poorvakrita papakarma + + -

04. Killing of female and elders - + +

05. Use of money or material aquired through theft - + -

06. Sadhuninda, Apamana and Vadha - - -

07. Gohatya - - +

Nidana of Kitibha kushta due to mithya Chikitsa (Due to improper treatment) 69

Acharyas like Charaka, Sushruta and Vagbhata considered Panchakarma mithya

apachara as a Nidana for kushta. Especially ayoga of vamana and virechana is the main

causative factor for kushta. Due to ayoga of vamana and virechana the vitiated doshas are

not eliminated properly. Hence, doshas accumulates in the srotas. Thereby causing

kushta.

Similarly, if Brimhana therapy is applied even after attainment of samyak

Brimhana lakshana would lead to aggravation of kapha dosha and rasa dhatu. There

kledatwadi vriddhi resulting in the shithilata which ultimately leads to manifestation of

kushta.

Sankramika Nidana70

Sushruta acharya has mentioned the nature of kushta i.e. the kushta may spread

from the affected by inhalation, physical contact, indulging into sexual intercourse, etc

51

though he had not mentioned the above things in the context of Nidana of kushta, it wise

to include above said things into Nidana because sankramika hetu is one of the factor

which is causing kushta.

ETIOLOGY OF PSORIASIS71

Even though extensive research has been carried out in the field of medicine to

evaluate the cause of psoriasis, but it is hard to find out the exact cause of psoriasis. Some

of the causative factors been evaluated through the extensive research are listed below –

01. Abnormal immune response – Our immune system consists of complex variety

of cells ranging form B cells to T cells (TH Cells). In psoriasis the T cells are

present more than its normal limits. The activated T cells infiltrate the skin

cells in psoriasis. T cells normally stimulates B cells to produce antibodies. In

case of psoriasis whoever they appear to direct the B cells to produce auto

antibodies by that they target self antigens in skin cells. TH cells also stimulate

the production of powerful immune factors called cytokines. In small amounts

cytokines are indispensable for healing. If over production however, they can

cause serious damage. In psoriasis cytokines known as GRO alpha, tumour

necrosis factor and interlukins–8 (IL-8), IL-11 and IL-12 are playing strong

role in the causation of disease.

02. Genetic cause of Psoriasis – A combination of genes is involved with

increasing persons susceptibility to the conditions leading to psoriasis. Mainly

4 genes are involved in the causation of psoriasis. These genes regulates the

human lucocyte antigen (HLA) system. The HLA molecules are designed to

produce foreign substances to the immune system so they can be destroyed.

52

But this process is malfunctioning in psoriasis. Psoriasis patients with specific

HLA genetic factor called HLA–CW6 have tendency to develop at an earlier

age.

03. Precipitating / Triggering factors – Psoriasis is a chronic disease marked by

periods of remissions and excerbations. Remissions may last for a few week to

many years. Triggering factors may be local or systemic.

A. Local factors – Psoriasis tend to develop at sites of injury to the skin.

“Koebner Phenomenon” also known as isomorphic response refers to the

induction of the lesion by cutaneous trauma. The trauma may be of any

kind – physical, chemical, mechanical, allergic or of any other nature.

B. Seasonal variations – Most of the patients worsening of their skin lesions

during winter, 89% of the patients studied by Farber and Nail (1978) had

worsening of the disease during cold weather. High humidity is usually

beneficial. Sunlight may worsen psoriasis in some and improves in

many.

C. Pregnancy – Remission of psoriasis may occur during pregnancy, but

there is exacerbation during the postpartum period. Rarely, generalized

postural psoriasis may be precipitated during pregnancy probably due to

raised levels of progesterone during the later half.

D. Emotional stress – Psoriasis is more stress sensitive than other skin

diseases. Many stressful events of daily life exacerbate psoriasis. The

disease itself can cause a reactive depression in the patients, which could

further exacerbate his psoriasis.

53

E. Infections – Upper respiratory tract infections and tonsillitis, especially

when caused by streptococci may cause a flare up of exciting psoriasis or

may precipitate an attack of acute guttate psoriasis.

F. Drugs – A number of drugs can worsen or induce pre-existing latent

psoriasis, including the following –

a. The anti-malarial drug chloroquine.

b. Certain drugs used for hypertension and heart problems, including

angiotensin converting enzyme (ACE) inhibitors. Beta blockers may

actually trigger the onset of psoriasis and produce flare ups in people

who already have it.

c. Progesterone used in female hormone therapies.

d. Lithium, which is used in bipolar disorder. (It may trigger the onset of

the disease and cause severe flare ups in people who already have

psoriasis).

e. Indomethacin, a non-steroidal anti-inflammatory drug (NSAID), can

cause or worsen psoriasis. (It should be noted that other NSAIDs such

as meclofenamate, might actually improve the condition.)

f. Withdrawing form oral steroid or high potency ointment that covers

wide skin areas can cause flare-ups of severe psoriasis. Because these

drugs are also used to treat psoriasis, this rebound effect is of

particular concern.

g. Agents that cause rashes, a side effect of many drugs, can trigger

psoriasis as part of the Kobner response.

54

SAMPRAPTI OF KUSHTA72

Our acharyas have not mentioned specific samprapti for each and every kushta,

but they have mentioned samanya samprapti for all kinds of kushtas. The samanaya

samprapti of kushta according to different Acharyas are given below.

Flow chart No. 01. Showing Samprapti of Kushta according to Charaka.

According to Charaka73 – Saptadravyas are palyaing as a sannikrishta hetus for Kushta.

Nidana Sevana

Vitiation of Tridoshas

Vitiated doshas

Vitiates twacha, mamasa, rakta, lasika

Combination of all these seven dravyas leads to kushta as they will be lodged in between

twcha and mamsa.

According to the site and nature of the lesion kushtas are named differently.

Flow chart No. 02. Showing Samprapti of Kushta according to Sushruta.

According to Sushruta74

Nidana sevana

Vitiates vata

Vitiated vata along with vitiated kapha and pitta enters into siras

Pitta and kapha is deposited over the skin by vitiated vata

The areas of the skin in which the morbid doshas are deposited became marked with

mandalas or skin patches (Mandalani pradurabhavanti).

55

The doshas thus lodged into the skin continue to aggravate and having been

neglected at the outset tend to enter into deeper dhauts and further vitiates the dhatus. But

this stage has to be considered for Mahakushta. Kshudra kushta is to be limited to the

stage of madalani pradurbhavati.

Flow chart No. 03. Showing Samprapti of Kushta according to Vagbhat75

Nidana sevana

Doshas gets vitiated

Spreads to tiryaga siras

Vitiates twacha, lasika and asruk and produces shaithilyata, vaivarnya of bahirtwacha

The disease kushta manifests wherever the morbid doshas gets lodged.

Madhavakara76 Madhavakara followed Charakas description, however in place of lasika he used

the term ambu among the sapta dravyas. Bhavaprakasha77 and Yogaratnakara78 followed Madhavakara.

Flow chart No. 04. Showing Samprapti of Kushta according to Bhela Samhita79

Mandagni

Vitiation of vata

Vitiated vata vitiates other doshas in their sanchayavastha

Depending on the rutus.

The doshas gets lodged in rudhira and vitiates rudhira followed by mamsa

The combination of these doshas along with rakta and mamsa gives rise to 18 types of

kushtas depending upon the etiological factors.

56

From the above samprapti it is clear that acharya Charaka has stresses to the role

of vata and kapha in kitibha kushta

On the other hand Sushruta has stressed the role of pitta in the pathogenesis of

kitibha kushta.

Samprapti of Kitibha kushta

Flow chart No. 05. Showing Samprapti of Kitibha Kushta.

Nidana sevana

Vitiates pitta and shleshma

Leads to margavarodha of vata

This margavarodha leads to vata vriddhi.

This vitiated vata carries vitiated pitta, shleshma and lasika in tiryaga siras and lodge

them in the udakadhara, raktadhara and mamsadhara twak.

Along with tridoshas kleda playas an important role in the pathogenesis of

Kitibha kushta.

Both pitta and shleshma being drava dhatus are considered as kledakaraka

sannikrishta Nidana. The accumulation of kleda results in srotorodha leading to vata

vriddhi, because of the combined effect of vata vriddhi and srotavarodha, the rasa dhatu

doesnot enter in the srotas. Twcha being dependent on rasa dhatu, because of improper

circulation of rasadhatu shithilata of twacha taking place along with shyava varna

because of vata vriddhi. At the same time due to ushna guna of pitta. The dravamsha of

kleda escapes through sweda. Due to loss of this dravamsha the kleda that remains in

twacha will be ghanibhuta kleda. This effects in parushata and khara sparsha of twacha in

kitibha kushta.

57

PATHOLOGY OF PSORIASIS80

Psoriasis appears to be largely a disorder of keratinization. The basic defect is

rapid replacement of epidermis in psoriatic lesion (3 to 4 days instead of 28 days in

normal skin.) In addition, there are marked vascular changes in upper dermis in the form

of tortuosity and dilatation. Recently, the presence of abnormal neural cells has been

demonstrated in psoriatic plaques.

Histochemical studies have revealed an increase in both oxidative and anaerobic

metabolism with increase pentose, glycogen, purines, sulphydral groups and soluble

proteins and a decrease in activity of dipeptidases.

It has been discovered that apparently normal skin of both the psoriatics and their

relations show these changes in miniature 'Latent psoriasis.

Histology is characteristic and consists of –

i) Parakeratosis

ii) Thinning of Supra-papillary portion of the stratum malpighi

iii) Elongation of ridges

iv) Oedema and clubbing of papillae

v) Micro-abscesses of Munro

vi) Dilated and tortuous capillaries in upper dermis

vii) Oedema and round cell infiltration in the papillae and upper dermis.

58

Figure No. 01. Showing Histology of psoriasis.

Parakeratosis Micro abscesses Dilated and tortuous capillary loops Irregular thickening of epidermis

Normal Psoriasis

Upper dermal T lymphocytes infiltrate

Two 'molecule-specific' histological reagents have recently become popular; these

are antibodies and laetins. Immunochemical staining shows a number of abnormal

macromolecules in the epidermis, possibly as a result of increased permeability of the

vessels. Cell surface antigens on infiltrating lymphocytes show that these are mainly T

cells; the helper: suppressor ratio is normal in quiescent lesions but may increase during

exacerbation. Lectin studies suggest a disturbance of glycoprotein synthesis, much of the

material remaining in the cytoplasm rather than appearing at the plasma membrane.

POORVA ROOPA81

Poorvaroopa is the stage where premonitory symptoms appear immediately after

sthana samsraya. Clinical manifestation of the disease starts during this stage. As there is

no specific poorvaroopa mentioned for kitibha, we have to consider samanya

poorvaroopa of kushta.

59

Table No. 12 Showing poorvaroopa mentioned by different Acharyas.

Purvarupa Ca. S. Su. S. A.S. A.H. B. S. M.N. B.P. Aswedanam + + + + + + - Atiswedanam + + + + + + + Parusyam + + - - - - - Atislaksnata + - + + - + + Vaivarnyam + - + + + + + Kandu + + + + - + +

Nistoda + - + + - + + Suptata + + + + + + + Pariharsa + - + + + + +

Lomaharsa + + + + + + + Kharatvam + - + + - + + Usmayanam + - - - + - - Gauravam + - - + + - - Svayathu + - - - - - -

Kothonnati + - + + - + + Srama + - + + - - - Klama + - - - - - - Visarpagamanam + + - - - - - Kayachidresu Upadehana + - - - - - - Pakva-Dagdha- Dasta Bhanga-Ksata-Upaskalitesu. Atimatram Vedana

+ - + + - - -

Svalpamapi Vrananam Dusti

+ - + + - - -

Svalpamapi Vrananam as amrohananm

- - + + - - -

Asrujah Krisnata - + + + - - -

Vrananam Shighrah Utpatti Cirah Sthiti

- - + + - - -

60

LAKSHANAS OF KITIBHA KUSHTA82

Different acharyas have mentioned different symptoms (lakshana) of kitibha

kushta. Majority of acharyas opine that kitibha kushta vata kaphatmaka. While some

acharyas considered it as pittatmaka.

Table No. 13. Showing the lakshanas of Kitibha kushta.

Sl.

No.

Roopa C.S., B.P.,

Y.R.,M.N.

S.S. A.H. B.S. K.S.

01. Shyava + - + + -

02. Kinakhara sparsha + - + + -

03. Parusha + - + + -

04. Khara sparsha + - + + -

05. Kandu - + + + -

06. Ahitam - - + + -

07. Stravi - + - - -

08. Vrittam - + - - -

09. Ghanam - + - - -

10. Snigdham - + - - -

11. Krishnam - + - - -

12. Drudhama - - - - -

13. Punaha Prasravati - - - + -

14. Rudhanvitam cha - - - + -

15. Vardatecha samutpannam - - - + +

16. Aruna - - - - +

17. Vriddhimati - - - - +

18. Garuni - - - - +

19. Prashanth nicha

Punarutpadyante

- - - - +

61

CLINICAL FEATURES OF PSORIASIS83

Clinically psoriasis exhibits itself as a dry well defined macules, papules and

plaques of erythma with layer of silvery scales. The appearance of a typical lesion is

characteristic of psoriasis. The typical lesion or coin shaped by confluence, big plaques of

the size of the palm of a hand or figurate areas may not all be present at the same time or

in every case and are sometimes obscured. However, in a disease of so many variations

their future remains linchpin of diagnosis when other criteria are absent.

Types of psoriasis

01. Plaque psoriasis – Plaque (Plak) is the most prevalent form of the disease.

About 80% of all those who have psoriasis have this form. Scientifically it is

called as Psoriasis vulgaris.

A. Character of lesion – Raised inflamed red lesion covered by a silvery

white scale.

B. Site of lesion – Elbows, Kees, Scalp and lower back although it can occur

on any area of the skin.

02. Guttated psoriasis – The guttate means in latin “a drop”. It often comes on quite

suddenly. Infections such as upper respiratory infection, streptococcal infection,

tonsillitis, stress, injury to the skin and the Administration of certain drugs like

anti malerials and beta clockers.

A. Character of the lesion – Red individual spots on the skin. These spots are

normally as thick or as crusty as lesion of plaque psoriasis.

B. Site of lesion – Usually trunk and limbs.

62

03. Inverse psoriasis – It is found in the armpits, groins under the breasts and in

other skin folds, around the genitals and buttocks. This type of psoriasis first

shows up as lesions that are very red and usually lack the scale associated with

plaque psoriasis. It may appear smooth and shiny. Inverse psoriasis is

particularly subject to irritation form rubbing and sweating because of its

location in skin folds and tender areas. It is more common and troublesome in

overweight people.

04. Erythrodermic psoriasis – It is a particularly inflammatory form of psoriasis

that often affects most of the body surface. It may occur in association with

Von Zumbush Pustular psoriasis. It generally appears on people who have

unstable plaque psoriasis where lesions are not clearly defined.

A. Character of the lesion – It is characterized by periodic widespread, fiery

redness of the skin. The erythema and exfoliation of the skin or often accompanied by

sever itching and pain.

05. Pustular psoriasis – This form of psoriasis is primarily seen in adults. Pustular

psoriasis is characterized by white pustules (blisters of non infectious pus)

surrounded by red skin. The pus consists of white blood cells. It is not an

infection nor is it contagious. This is relatively unusual form of psoriasis. It

may be localized to certain areas of the body for example the hand and feet.

Pustular psoriasis also can be generalized. Pustular psoriasis can appear

suddenly as the first sign of psoriasis or plaque psoriasis can turn into pustular

psoriasis. It is triggered by UV light, pregnancy, systemic steroids, infection,

emotional stress, etc.

63

Types of Pustular psoriasis

01. Von zumbusch – The onset of this psoriasis can be abduct wide spread areas of

reddened skin develop and the skin becomes actually painful and tender within

as little as a few hours the pustule appears. The pustule then dry and peel over

the next 24 to 48 hours. Leaving the skin glazed, smooth appearance. It can be

triggered by an infection sudden withdrawal of tropical or systemic steroids.

This form is associated with fever, chills, severe itching, dehydration, a rapid

pulse rate, exhaustion, anaemia, weight loss and muscular weakness.

02. Palmoplantar pustulosis – Pamoplantar pustulosis (PPP) is a type of pustular

psoriasis that generally affects people between the ages of 20 and 60 years and

causes pustules on the palms of the hand and soles of the feet. It is triggered by

infection or stress. PPP is characterized by multiple pencil eraser sized pustules

in fleshy areas of the hands and feet such as base of the thumb and the sites of

the heals. The postules appears in a studded pattern through reddened plaques

of the skin, then turns brown peel and become crusted.

03. Acro pustulosis – This is a rare type of psoriasis characterized by skin lesion

on the ends of the fingers and sometimes on the toes. The eruption occasionally

starts after an injury to the skin or infection. Often the lesions are painful and

disabling producing deformity of the nails. Occasionally bone changes make

occur in severe cases.

Psoriasis on specific skin sites

Psoriasis can occur at any part of body. Psoriasis sometimes appears on the

eyelids, ears, mouth and lips as well as arm, skin folds, the hands, feet and nails.

64

Genital psoriasis

Psoriasis can occur in genital area at the same time it occurs elsewhere on the

body or it can appear in genital area only. People with genital psoriasis may have affected

areas that range form small, red spots to large patches.

The most common type of psoriasis in genital region is inverse psoriasis.

Scalp psoriasis – It is very common in fact at least half of all people who have psoriasis

have it on their scalp. As with psoriasis elsewhere on the body, skin cells grow too

quickly on the scalp and causes red lesions covered with scale to appear.

Scalp psoriasis can be very mild, with slight, fine scaling. It can also be very

severe with thick, crusted plaques covering the entire scalp, which commonly can cause

hair loss. Psoriasis can extend beyond the hairline onto the forehead, the back of the neck

and around the ears (a common area). Most of the time people with scalp psoriasis have

psoriasis on other parts of their body as well. But, for some, the scalp is the only affected

area.

Conception, Pregnancy & Psoriasis

Psoriasis go through the child bearing phase of the lives just like other people.

Psoriasis in and off itself doesn’t affect the reproductive system of a woman or man.

Although some women reported their psoriasis improves or worsens during pregnancy.

Psoriatic Arthritis

About 10% to 30% of people with psoriasis also develop psoriatic arthritis, which

causes pain stiffness and swelling in and around joints.

65

Table No. 14. Showing the comparison between the kitibha kushta lakshana and

psoriasis.

Sl. Kitibha lakshana Psoriasis

01. Rooksha Dry

02. Kina Ruda vrana-granulation site of healing wound

03. Khara Rough

04. Kandu Itching

05. Parusha Hard

06. Prashantanicha Punar Utpadyante Subsides and relapses

07. Vriddhimanthi Spreading in nature

08. Vrittam Round or coin shape lesion

09. Ghanam Thickness of lesion

10. Snigdham Sticky, Unctuous

11. Krisham Black

12. Shyava Bluish black

13. Aruna Reddish black

66

VYAVACCHEDAKA NIDANA

Before confirming the vyadhi vinischyaya i.e. Kitibha kushta it has to be

differentiated form the other diseases, which mimic kitibha kushta. For the differentiation

purpose we can consider the following table –

Table No. 15. Showing differential diagnosis of Kitibha kushta.

Symptom of psoriasis

Dadru kushta

Kitibha kushta

Ekakushta Sidhma kushta

Charmada kushta

Itiching Kandu (All texts)

Kandu (S.S.& A.H.)

- Kandu (S.S.)

Kandu (S.S.&C.S.)

Erythematous papules or plaques

Manadala (A.H.)

(S.S.)

Silvery scaling - - Matsyashakalo pamam (A.H.)

Rajah Ghrishtam (C.S.)

Dalita (C.S.)

Thickening - - - - Hasticharmavat (A.H.)

Dryness Ruksha (Bhela)

Ruksha - Ruksha (A.H.)

-

Pin point Bleeding

Raga Pidaka (C.S.)

-

-

-

Raktadala (A.H.)

Kobner’s Phenomenon

Deergha Pratanavat (A.H.)

- - - -

Chronic in Natureorhistory of previous attack

Anushank hini (A.H.)

- - - -

67

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF PSORIASIS84

Physical examination : Psoriasis may appears anywhere on the body though

some areas are favored. Careful examination must be done on scalp fingernails and

tonsils for reddening and scaling skin that is characterized by erythematous, sharply

demarcated papules and round plaques, covered with silvery micaceous scales, which is

easily removed and may accumulate in the patients clothing of bed in folded areas of

skin, sometime the scales do not form, but the lesion remain red and sharply defined. The

distribution, coulour, and typical silvery scaling of lesion in chronic plaque psoriasis are

characristic. Classically the lesions are distributed symmetrically over the areas of bony

prominence such as elbows and knees.

The lesions are also commonly occur on the trunk and scalp and in the intergluetal

cleft sometimes scalp lesions may be mistaken for seborrhoeic dermatitis. Palms and

soles may be involved with defuse redness and scaly. The skin lesions of psoriasis are

variably pruritic. Nail involvement occurs in up to 50% of patients. Small pits, lifting on

the end of the nail plate and debris under the nail plate on the figures and toenails are

signs of psoriasis.

Colour : A full, rich red (salmon pink) with a particular depth of hue and opacity.

This quality of colour is at special diagnostic value in lesion on the palm, soles and scalp.

Scaling : The amount of scaling is variable. It may, as in Rupoid forms, be waxy

yellow or orange brown. A similar colour occurs in nails (oil drop sign). In Guttate

lesion, a single waxy scale may be present, inviting confusion with Pityriasis lichenoides

chronica, but most psoriatic lesions are surmounted by the very characteristic silvery

white scaling which may exceed in thickness the erythematous lesion beneath it.

68

Auspitz sign : This sign occurs only in psoriasis. Psoriasis can be diagnosed

when there is a classical silvery white scaling and the Auspitz sign.

When hyperkeratotic scales are mechanically removed from a psoriatic plaque by

scratching, within few minutes, small blood droplets appear on erythamatous surface.

This phenomenon is called Auspitz sign.

Koebner's Phenomenon : Psoriatic lesions may develop along with the scratch

lines in the active phase. This is called Koebner phenomenon. This phenomenon is called

the artificial production of the psoriatic lesion. It is better known as the 'isomorphic' or

Koebner phenomenon.

Candle grease sign : When a psoriatic lesion is scratched with the point of a dis-

secting forceps, a candle grease like scale can be repeatedly produced even from the non-

scaling lesions. This is called the candle grease sign (Tache de bougie).

Differential diagnosis85/

Some of the conditions that can be confused with the psoriasis Reiter’s syndrome,

Pityrasis rosea, Secondary syphilis, lichen planus, eczema. Seborrheic dermatitis, Tinea

versicolor, basal cell carcinoma, squamous cell carcinoma or a drug reaction.

1) Reiter’s syndrome – This syndrome is characterized by erythematous silvery

scaled plaques, hyperkeratotic papules of palms and soles distribution is similar to

psoriasis. Frequent in mouth or genital. Other features include nail involvement

arthritis, urethritis, conjunctivitis, iritis.

2) Pityrasis rosea – Tannish, pink, oval, papules and plaques with delicate collarette

scale, may or may not be prutitic.

69

Distribution – Rash preceded by herald patch, Christmas tree pattern on trunk,

sparea face, extremities. No mucus membrane involvement. May be associated

with upper respiratory infection.

3) Secondary syphilis – Harm red or copper coloured scaly papules and plaques and

sometimes annular. Generalized distribution, with palms and soles often

involved. Mucus membrane involvement may be there. Condyloma warts of

Anala area, condylomata in genital area; serological test for syphilis positive.

4) Lichen planus – Violaceous polygonal flat – topped papules with white scale or

wickman’s triae. May be hyperkeratotic, annular or bulbous lesions; pruritic.

Distribution often on wrists and ankles, but can be generalized. Kobner reaction,

frequent reticulated white patches or erosive lesions in mouth or genital areas.

Occasionally involves nails. Drugs can cause similar reaction.

5) Eczema – Vesiculobullous lesions on red place often form unusual patterns of

contact with substances.

6) Seborrheic dermatitis – Inflammatory, yellow, greasy, scaling patches overlying

erythematous patches or plaques on scalp, retro auricular areas, eye brows,

nasolebial folds, axilla, groin, submammary folds and gluteal cleft occurs in areas

of high concentration of sebaceous glands; may be related to intrinsic yeast in

skin.

7) Tinea versicolor – Oval scaly mucus, papules and patches concentrated on the

chest, shoulders, and back but only rarely on the face or distal extremities. On

dark skin they often appears as hypo pigmented areas. While on light they are

slightly hyperpigmented.

70

SADHYASADHYATA (PROGNOSIS)

If treatment is not given properly at early stage then it will become asadhya. Even

if the treatment is given properly at time, the patient is not following pathya then also it

will become asadhya.

When the treatment is not started in proper time and if it is neglected the sadhya

kushtas including kitibha becomes asadhya. Because krimi invade the twak mamsa, rakta,

lasika and cause kotha, kleda (exudates) and sweda. (Sweat) and eat away the dhatus and

derange the doshas and dhatus further resulting in complication.

In kushta if the patient develops prasrava, vrinas in lesions, trishna, jwara atisara,

dourbalya, arochaka and avipaka, then this disease should considered as asadhya.

According to Charaka a weak patient of kushta with all the lakshanas along with

complication like trishna, daha, agnimandya, is to be avoided by the wise physician86.

Vata kapahaja kushta can be cured easily, kapha-pittaja and vata pittaja is difficult

to cure.

According to Sushruta a patient who has full control over his gyanendriya as and

the kushta is confined to twak, rakta and mamsa dhatu it is sukha sadhya. If the disease

reaches meda dhatu it becomed yapya. If kushta spreads to deeper dhatus it becomes

asadhya87.

According to Vagbhata kushta is said to be asadhya if all the three doshas are

involved, appearance of arishta lakshanas and when the disease spreads to asthi, majja,

shukra dhatu. Kushta becomes yapya when it reaches meda dhatu involving pitta dosha.

If kushta is due to vata and kapha it is said to be sadhya88.

Form the above statements of various acharyas it is clear that vata kaphaja kushtas

are sadhya in nature.

71

PROGNOSIS OF PSORIASIS89

It is impossible to say in any particular case how long the disease will last

whether a relapse will occur or for what period of time the patient will remain free from

Psoriasis. Psoriasis is at all time and under all forms a very troublesome and often an

intractable disease, but it is rarely dangerous to life.

Remissions and exacerbations are the rule in most of the psoriatic cases but some

patient remains relatively unchanged for years after the onset of the disease. With

available therapy satisfactory control of the disease is possible in the majority of patients.

The prognosis of psoriasis also depends upon the type of psoriasis and presence or

absence of associated diseases. Guttate attacks carry a better prognosis then those of a

slower and more diffuse onset and have longer remissions after treatment. At the other

extreme, erythrodermic and pustualr forms carry an appreciable mortality and arthropathic forms a

considerable morbidity. An early onset and a family history of the disease appear to worsen the

prognosis.

72

UPADRAVA 90

The common upadravas possible in kushta are as follows –

01. Prasravanam – Excessive exudation.

02. Angabheda – Ulceration of organs.

03. Patanaani angavayavanam – Sequenstration of the organs of the body.

04. Trishna – Thirst.

05. Jwara – Fever.

06. Atisara – Diarrhoea.

07. Daha – Burnng senstion.

08. Dourbalya – Weakness.

09. Arochaka – Anorexia.

10. Avipaka – Indigestion.

Complications of Psoriasis91

The common complications of psoriasis explained in modern medical literatures

are as follows –

01. Pruritus : It is very variable in psoriasis, ranging form complete absence to severe

pruritus; pustular and erythematous forms are usually accompanied by sensations

of burning or itching.

02. Pustulation : A sudden withdrwal of cortico-steroids in treatment of psoriasis of a

relapse of exfoliative psoriasis lead to postulation associated with high fever and

severe systemic upsets. The pustules, which are sterile, appear in crops or waves,

relapses are frequent and prognosis in poor.

03. Psoriatic arthritis : Joint involvement is the most disabling complications of

psoriasis, limb joints are commonly involved, and distal arthritis involving distal

interphalageal and other small joints is the commonest presentation.

73

CHIKITSA

Treatment of a disease in Ayurveda starts with Nidana parivarjana. This should be

the first line of treatment for all diseases. The general management of kushta includes

daivavyapashraya Chikitsa, yuktivyapashraya chikitsa and satwavajaya Chikitsa through

present is minimum. The planning of treatment depends on the vitiated doshas. In vataja

kushta snehana, pittaja kushta virechana and rakta mokshana, vamana karma in kaphaja

kushta should be carried out92.

Ashatanga Hridaya prescribes snehapana for all varieties of kushta, for the

purpose of Shareera dushti. Dosha shodhana is followed by snehapana93.

Sushruta mentioned periodic shodhana karma for kushta, which is supported by

most of the other classical authors.

Vamana once inforth night, virechana once in a month, nasya once in three days if

the pathology is located above the neck. Raktamokshana is advised once in six months94.

After preliminary shodhana the following treatments are to be carried out.

Lepana – if disease is there in twak.

If raktadhatu involved – shodhana and anulepana.

If rakta and mamsa are involved – then also shodhana and lepana must be carried

out. Along with this special medicine remedies prepared form Bhallataka, Shilajatu,

Guggulu, Agaru, Tuvaraka, Khadira, Asana should be used according to rules. Kushta

invading deeper dhatus such as asthi and majja should be given up, as they’re incurable.

The general line of treatment should consider for Kitibha kushta as there is no

specific line of treatment available. In kitibha because of the involvement of tawak or

rasa, rakta, mamsa, the line of treatment should be shodhsna, alepana with internal

medication.

84

However the general measures of management mentioned in the context of kushta

seems to be most practical, the doshic predominance has to be taken into account and

respective therapies should be administered.

For snehapana purpose formulation based on ghee such as Tikta shatpala ghrita,

maha tiktaka ghrita, mahakhadira ghrita, panchatikta ghrita are vary beneficial95.

Vamana (Emesis) – May be induced after snehapana, with decoction of Kutaja,

Madanaphala, Yastimadhu, Patola, Nimba.

Virechana (Purgation) – Virechana may be induced with drugs like Trivritta,

Danti moola, Triphala, Manibhadra gula, etc.

Vasti (Medicated Enema) – Charaka advocates a number of medicated enemas for

the treatment of kushtas. Among them Panchatikta, panchaprastika vastis, specially

indicated in kushta. A decoction of Patola, Nimba, Bhoonimba, Rasna and Saptaparna –

each 4 prasthas – is to be mixed one prastha of ghee and to which a paste made out of

mustard should be added. This panchatikta nirooha basti will alleviate prameha,

abhishandya and kushta96.

Some vata-kaphaja kushtaghna yogas – paste of the following dravyas prepared

by adding dadhi manda (thin butter milk) cures kushta caused by vata and kapha97.

01. Chitraka, Shobhanjana, Guduchi, Apamarga, Devadaru, Khadira.

02. Dhava, Shyama, Danti, Dravanti, laksha, Rasanjana, Ela and Punarnava.

03. In charmadala which is one of the vatakaphaja kushta, charaka advised seka

and pradeha.

04. While giving importance to Vidanaga in Kushta Chikitsa Charaka explained,

it can be used for sechana, pana and dhoopana purpose.

85

Sushruta advised lepana should be prepared out of Kushta, Sarshapa, Sriniketana,

Vyosha, Chakramarda beeja by mixing with takra is useful in charmadala, kitibha, etc98.

Ashtanaga Hirdaya99 – Powders of Vidanga, Khadira is mixed with honey and

ghee and consumed by the person who part takes little quantities of healthy foods only

gets cure of Kitibha, Shwitra and Dadru. Equal quantities of each of Nimba, Daruharidra,

Suras, Patola, Kushta, Ashwagandha, Suradaru, Shigru, Sarshapa, Tumburu dhanya,

Vanya and Chandana are converted into powder, macerated in the butter milk and kept

ready. The body of the patient is first anointed with mediated oil and then massaged with

this paste. It cures Dadru (eczema) with itching, Kitibha (Psoriasis), Pama (Scabies) and

Vicharchika.

Paste of Chitraka, Shobhanjana, Guduchi, Apamarga, Devadaru, Khadira, Dhava,

Shyama, Danti, Dravanti, Laksha, Rasanjana, Ela, Punarnava mixed with Dadhi manda

when applied over the body cures Kushta arising form vata and kapha.

Ashtanaga Samgraha100 – Powder of Khadira shaka (bark of Khadira) mixed

with Shilajatu, Vidanga and consumed along with the honey and ghee in proper dose by a

person who takes which is easily digested, less in quantity, who maintain celibacy and

keeps control of himself cures Dropsy, Kitibha, Kotha, Shwitra and Leprosy.

Katu taila medicated with Sikta (Bee’s wax) Tuttaka, Guggulu, Sindura and

Rasanjana is best for anointing the body in case of Pama, Kitibha, Vicharchika.

Yogaratnakara101 –

01. Chakramardadi lepa –Chakramarda beeja, Twak, to be grounded in dugdha and

later mixed in Gomutra can used as lepa to pacify kushta.

86

02. Pippalyadi lepa – Pippali, Karanaja, Haritaki, Kushta, Gorochana, and

Chitraka to be taken in equal quantity and grinded into fine powder and used

for external application.

03. A lepa should be prepared out of Karpasa patra, Kaka jangha and Moolaka

beeja mixed with takra should applied on the skin of the patient who is

suffering form Sidhma kushta having the predominance of Vata and kapha.

Bhaishajya Ratnavali102 –

01. Patra of Aragwadha, pasted with butter milk and should be applied to the

patient who has already undergone abhyanga cures Kitibha, Dadru, etc.

Gada nigraha also mentioned the above prayoga.

TREATMENT OF PSORIASIS103

Agents appalled to the skin are usually the first line of defense in treating

psoriasis. Researchers believes psoriasis occurs when faulty signals in the immune

system cause skin cells to grow too rapidly, creating dry, red scaly patches called lesions.

Topicals slow down or normalize the excessive cell reproduction and reduce redness

associated with psoriasis.

The treatment starts usually with these topical agents or phototherapy for mild to

moderate psoriasis, because they may be more appropriate than other treatments.

Anthralin – This prescription topical can be very effective in treating plaque

psoriasis. It does not work as quickly or as super potent topical steroids, but unlike

steroids, it has no known long-term side effects.

Dovonex – A form of synthetic vitamin D3 approved for treating psoriasis,

available by prescription. It slows down the rate of skin cell growth, flattens psoriasis

lesions and removes scale. Donovex also can be used on the scalp and for nail psoriasis.

87

Salicylic acid – Also known as “Sal acid” salicyclic acid helps remove scales and

is often combined with topical steroids, anthralin or tar to enhance effectiveness.

Availability in both OTC and prescription forms.

Tar – Coal tar is available over the counter in crude and refined forms to treat

mild, moderate and severe psoriasis. For decades, tar was viewed as the “traditional”

treatment for psoriasis, and it remains a safe, effective and readily available treatment

option for many people.

Tazorac – Tazorac topical gel and cream (also known by its genetic name

tazarotene) are FDA approved for treating plaque psoriasis. Tazorac is a vitamin A

derivative and is also as a topical retinoid. It is available by prescription.

Topical steroids – Corticosteroids, ordinarily called “Steroids”, are routinely used to treat

psoriasis. Topical steroid medications can be very effective in controlling mild to

moderate psoriasis lesions. They are easy and work relatively quickly.

Other OTC topical – Information about bath solutions, moisturizers and

nonprescription medications that can be used to moisturize, soothe, remove scale or

relative itching.

Phototherapy – Topical treatments (treatments that are applied to the skin’s

surface) are usually the first line of defense against psoriasis, but if the psoriasis is

extensive, ultraviolet light treatment (photo therapy) can be used.

Photo therapy involves exposing the skin to wavelengths of ultraviolet light under

medical supervision.

UVB photo therapy – UVB treatment involves exposing the skin to an artificial

UVB light source for a set length of time on a regular schedule, either under a doctor’s

direction in a medical setting or with a home unit purchased with a doctor’s prescription.

88

PUVA – PUVA is an acronym for psoralen (a light sensitizing medication)

combined with exposure to ultraviolet light A, UVA, like UVB, is found in sunlight. By

itself, however, UVA is not normally used to clear psoriasis. It is relatively ineffective

unless used with a light sensitizing medication such as psoraten.

Laser – Targeted UVB treatment and pulsed dye lasers can be used to treat

chronic localized plaque lesions.

PSORIASIS SYSTEMIC TREATMENT

Systemic medications are prescription medications that affect the entire body, and

are usually reserved for patients with moderate to severe psoriasis to or eligible for

conventional topical medications or ultraviolet (UV) light treatment.

Sun and Water Therapy – Sunlight and water are natural therapies that can help

improve psoriasis and or psoriatic arthritis for many people. Eighty percent of the people

who use regular daily doses of sunlight enjoy improvement or cleaning of their plaques

psoriasis. Water can help soften psoriasis lesions.

Biologics – These medications are developed form living sources, such as cells,

rather then combinations of chemicals like traditional drugs. Generally, they are designed

to block or eliminate various immune system cells involved in psoriasis and psoriatic

arthritis. Other systemic medications for these diseases can also impact the immune

system, but usually in a broader, less specific way.

Cyclosporine – Cyclosporine is a prescription systemic medication used to treat

psoriasis. Cyclosporin has been available since 1995 to help prevent organ rejection in

transplant patients. In 1997, the FDA approved Neoral (one band name of cyclosporine)

as a psoriasis treatment.

Methotrexate – Methotrexate is a systemic medication usually sold as a generic.

Initially used to treat cancer, methotexate was discovered to be effective in cleaning

psoriasis in the 1950’s and was eventually approved for this use by the FDA in the

1970’s.

89

Soriatane – Soriatane (also known by its genetic name acitretin) is a prescription

medication called an oral retinoid, which is a synthetic form of vitamin A. synthetic

retinoids were introduced as experimental drugs in the mild 1970’s and were approved in

the United States in the 1980’s. Soriatane is currently the oral retinoid approved by the

FDA specially for treating psoriasis.

Other systemic – Accutanem Hydrea, Mycophenolate mofetil, Sulfasalazine, 6-

Thioguanine.

PATHYAPATHYA

The diet regimen explained in the context of management of kushta is as follows

Pathya

01. Anna varga – Puranashali, Shashtika shlai, Godhuma, Kora, Shyamaka,

Uddataka, Yava.

02. Yusha varga – Mugda.

03. Shaka – Tikta patola, Nimba, Triphala, etc.

04. Sneha varga – Samskaritha ghrita, Sarshapa, Taila, etc.

05. Mamsa varga – Jangala, Amedaska.

06. Jala varga – Khadirodaka.

07. Rasa – Vratha, Dana, Seva, Thyaga, Dwija, Guru, Surapuja, Bhaskara,

Aradhana, Maithrie.

Apathya

Kulattha, Masha, Nispava, Snigdha, Abhishyandhi, Guru, Ushan, Amla, Lavana,

Vidahi dracyas, Anupamamsa, Vasa, Majja, Tila, Guda, Dugdha, Dadhi, Taila,

Ikshuviakra, Pishtavikara, Sura, Viruddhashana, Adhyashayana, Ajirnashaka

Divaswapna, Vyayama, etc.

90

DRUG REVIEW Table No. Showing the Pharmacodynamics of drugs of Aragwadadi Gana104.

Properties Sl. Name Botanical name

Family Part used

Chemical composition

Rasa Guna Veerya Viapaka

Dosha Karma

01. Aragwada Cassia fistula Caesalpiniodeae Bark and heart wood

Barbalion, Fistucacidin, etc.

Madhura Mridu, Guru, Snigdha

Sheeta, Ushna (DN)

Madhura Kapha-pittahara

02. Indrayava Holarrhena antidycentrica

Appocyanacea Seeds Conessidine, Conessimine, etc

Tikta, Kashaya

Laghu, Ruksha

Sheeta Katu Kapha-pittahara

03. Pathali Stereosprmum sauvealens

Bignonaceae Stem bark.

Bark contains crystalline bitter substance

Tikta kashaya

Lahgu, Ruksha

Anushna Katu Tridoshahara

04. Kakamachi (Kakatikta)

Solanum nigrum

Solanaceae Whole plant

Solasonine, Solamargin, etc

Tikta Laghu, Snigdha

Anushna Katu Tridoshahara

05. Nimba Azadiractta indica

Meliaceae Stem bark

Nimbin, Nimbidin, etc

Tikta, Kashaya

Laghu, Ruksha

Sheeta Katu Kapha-pittahara

06. Amruta Tinospora cardifolia

Menispermaceae Stem Tinosporin, Tinsporidinene

Tikta, kashaya

Guru, Snighda

Ushna Madhura Tridosha shamaka

07. Moorva (madhurasa)

Marsdenia tenacissima

Asclepiadaceae Root Marsdenin, Asclepobiose

Tiktam Kashaya

Guru, Ruksha

Ushna Katu Kapha-vatahara

08. Vikhangata (Sruvavriksha)

Flacourita ramontchi

Flacourtiaceae Bark Tannin, Flacourtin Amla, Madhura

Laghu Sheeta Madhura Vata-pittahara

09. Patha Cissampelos pariera

Menispermaceae Bark & Root

Hayatin, Hayatinin Tikta Laghu, Tikshna

Ushna Katu Vata-kaphahara

10. Bhunimba Pwerita chirata

Gentianaceae Whole plant

Amarogentin, Chiratol, etc

Tikta Laghu, Ruksha

Sheeta Katu Kapha-pittahara

11. Sahachara Barleria prionitis

Acanthaceae Root Tikta, Madhura

Laghu Ushna Katu Khpaha-vata shamaka

12. Patola Tricosanthes diocia

Cucurbaitaceae Whole part

Cucurbita-5-24-dienol, etc

Tikta, Katu

Laghu, Ruksha

Ushna Katu Kapha-pittahara

13. Karanja Pongimia pinnata

Fabaceae Stem bark

Karanjin, Pongipin, etc

Tikta, Katu, Kashaya

Laghu, Teekshna

Ushna Katu Kapha-vatahara

14. Latakaranja Caesalpina crista

Caesalpiniaceae Stem Bark

L.r-ethylideneglutamic acid, Amino acids, etc

Tikta, Kashaya

Laghu, Rukha

Ushna Vipaka `tridoshahara

15. Saptachhada Aistonia scolaris

Apocynaceae Stem bark

Akuamidine, Picrinine, etc

Tikta, Kashaya

Laghu, Snigdha

Ushna Katu Tridoshahara

16. Agni Plumbago zeylanica

Plumbaginacea Root bark

Chitranone, Plumbagin, etc

Katu Laghu, Ruksha

Ushana Katu Vata-kaphahara

17. Karavellaka Momordica charantia

Cucurbibitaceae Whole plant

Charantin, Polypeptides, etc

Tikta, Katu

Laghu, Ruksha

Sheeta, Ushna (KN)

Katu Kapaha-pittahara

18. Madanaphala Randia dumetorum

Rubiaceae Fruit Citric acid, Tannic acid, etc.

Madhura, Tikta

Laghu, Ruksha

Ushna Katu Kapha-vatahara

19. Sahachara Barleria prionitis

Acanthaceae Root Tikta, Madhura

Laghu Ushna Katu Khpaha-vata shamaka

20. Badara Ziziphus mauritiana

Rhamnaceae Bark Leucocyanidine, etc.

Madhura, Amla

Guru, Snigdha

Sheeta Madhura Vata-pittahara

Note : In original sutra instead of Kakamachi (4) Kakajangha is mentioned on this Dalhana commented and said Kakajangha means Kakamachi. Note : Sushavi – Karavellaka – By – Dalhana on Aragwadadhi gana. Abbreviations : D.N. – Dhanwatari Nighatu, K. N. – Kaiayadeva Nighantu.

Table No. 17 Showing Pharmacodynamics of Drugs Used For Moorchana of Tilataila105. Sl.

Drug Family Name Latin Name Rasa Guna Virya Vipaka Dhoshagnatha Karma Useful

part

01. Manjistha Rubiaceae Rubia

Cordifolia

Madhura

Kashaya

Guru Ushna Madhura Kaphanashaka Rakth prasadaka Kanda

02. Haritaki Combretaceae Terminalia

chebula

Lavana Varjita

Kashayapradhana

Pancha Rasa

Laghu

Ruksha

Ushna Madhura Triadoshahara Deepana,

Pachana,

Anulomana,

Rechana

Phala

03. Vibhitaki Combretaceae Terminalia

bellirica

Kashaya Laghu

Ruksha

Ushna Madhura Tridoshanara,

Especially

Kaphahara

Deepana,

Anulomana

Phala

04. Amalaki Euphorbiaceae Emblica

Officinalis

Lavana Varjita

Amlapradhana

Pancha Rasa

Guru

Ruksha,

Sheeta

Sheeta Madhura Tridoshahara Deepana,

Pachana,

Anulomana,

Rasayana

Phala

05. Mustha Cyperaceae Cyperus

rotundus

Tikta, Katu

Kashaya

Sheeta Sheeta Katu Kaphapitta

Shamaka

Deepana,

Pachana, Grahi,

Mutrala

Kanda

06. Hardira Zingiberaceae Curcuma

longa

Titka, katu Ruksha,

Laghu

Ushna Katu Tridoshahara Ruchya,

Anulomana, Pitta

Rechaka.

Kanda

07. Lodra Symplocaceae Symplocos

recemosa

Kashaya Laghu,

Ruksha

Sheeta Amla Kaphapitta

shamaka

Shothahara,

Kustagni,

Raktastambana,

Vrunaropana,

Stambana

Twak

08. Vatankura Moraceae Ficus

bangalensis

Kashaya Guru

Ruksha,

Sheeta Katu Kaphapitta

shamaka

Shothahara,

Raktashodhaka,

Vrunaropana,

Chakshushya

Twak,

kshira,

patra,

phala

09. Ketakipushpa Pandanaceae Pandanus

odorotissimus

Tikta, Madhura,

katu

Lagu

Snigdha

Ushna Katu Kaphapitta

shamaka

Varnya,

Vedanastapaka,

Vrunaropana,

Keshya ,

Dourgandhyahara

Pushpa,

Mula

10. Hrivera*

(Rasna)

Compositae Pluchea

lanceolata

Tikta Guru Ushana Katu Kaphapitta

shamaka

Shotahara,

Vedanashaymak,

Raktashodhaka,

Rasayana

Patra

11. Nalika**

(Tamala

patra)

Lauraceae Cinnamomnm

tamala

Katu Tikta

madhura

Laghu,

Ruksha,

Teekshana

Ushana Katu Kaphapitta

shamaka

Lekhana,

Raktashodhaka,

Sleshmahara

Twak,

Taila,

patra

Table 18. Showing the Chemical composition of the drugs used in Tilataila moorchhana105. Sl. Drugs Chemical composition

01. Manjistha Anthraquinones manjistin, purpuroxanthin, rubiatriol, rubi coumaric acid, rubifolic acid, rubiadin, rubimallin,

purprin,

02. Haritaki Chebulinic acid, tannic acid, terchebin, vit C, behenic, lindeic, oleic, palmitic and stearic acids, chebulin.

03. Vibhitaki Fructose, galactose, glucose, mannitol, edible oil, gallic acid, chebulagic acid, ellagic acid.

04. Amalaki Ellagic acid, oleanolic, aldehyde, tannin vit C, phyllemblin, linolic acid, acetic acid, ellagic acid, phyllemblic

acid and salts.

05. Mustha Cyperenone, Cyperen, Cypertundone, cyperol, cyperolone, isocyperol, mustakone, rotundone, sugenol, β-

sitosterol.

06. Hardira Curcumene, curcumenone, curcone, curdione, cineole, curzorenone, eugenol, comphene, camphor, curcumins.

07. Lodra Symposide, loturine, loturidie, colloturine

08. Vatankura Leucoanthocyanin, tiglic acid, β - sisterol – a – d - glucoside

09. Hrivera Kwarsitin, isoramnitin, pluchin.

10. Nalika Cinnamaldehyde, Eugenol, Yuginal, fixed oil.

11. Ketakipushpa Sughandita taila.

Note : Hrivera* The Synonyms of Rasna mentioned in Nigantus are Hrivera, Nakuli, Gandhanakuli, Ishwarimoola, Note : Nalika** Indian Taj = Cinnamomum Tamala (Lauraceae) is known is Bengal as Naluka its leaves are known as Teja patra or Tamala Patra. Brihatrayi have mentioned as only Nalika.

Table No 19. Showing the Pharmacaodynamics of drugs of Gandharva Hastadi Kashaya106. Properties Sl. Name Botanical

name Family Part

used Chemical composition

Rasa Guna Veerya Viapaka

Dosha Karma

01. Earanda Racinus communas

Euphorbiaceae Moola Stable oils, Slimy substance, Sugar, etc

Madhura, Katu, Kashaya

Snigdham Teeskshna, Sukshma

Ushna Madhura Kapha-vatahara

02. Chirubilwa Holoptela integrifolia

Ulmaceae Bark Friedelin, Beta-sitosterol

Tikta, Kashaya

Laghu, Ruksha

Ushna Katu Kapha-pittahara

03. Chitraka Plumbago zeylanica

Plumbaginacea Root bark

Chitranone, Plumbagin, etc

Katu Laghu, Ruksha

Ushana Katu Vata-kaphahara

04. Shunti Zingiber officinale

Scataminae Rhizome Alph-curcumene, Beta-D-Curcumene, etc

Katu Guru, Ruksha, Teekshna

Ushna Madhura Vata-kaphahara

05. Haritaki Terminalia chebula

Coberetaceae Fruit Chiulinic acid, Tannic acid, etc.

Pancharasa Laghu, Ruksha

Ushna Madhura Tridoshahara

06. Punarnava Boerrhavia diffuse

Nyctaginaceae Whole plant

Hertriacontane, Oxalic acid, etc.

Madhura, Tikta, Kashaya

Laghu, Ruksha

Ushna Katu Kapha-vatahara

07. Yavasa Alhagia canelorum

Fabacei Whole plant

Catechin, Galactocatechin

Madhura, Tikta, Kashaya

Laghu Sheeta Katu Kaphahara

08. Musali Asparagus adsenden

Liliaceae Tuberous root

Saponins, Sarsa pogenin, etc

Madhura Guru, Snighda

Sheeta Madhura Vata-pittahara

Table No. 20. Showing the Drugs used for preparing of Medicated Milk107. Properties Sl. Name Botanical

name Family Part

used Chemical

composition Rasa Guna Veerya Viapaka

Dosha Karma

01. Musta Cyperus rotundus

Cyperaceae Tuber Cyperenone, cyperol, etc

Tikta,l Katu, Kashaya

Laghu, Ruksha

Sheeta Katu Kapha- Pitta shamaka

02. Yashtimadhu Glycyrrhiza glabra

Leguminosae Root Glycyrrhizin, Liquiritin, etc.

Madhura Guru, Snigdha

Sheeta Madura Kapha-pittahara

Table No, 21. Showing the qualities of Takra108. English name Varga Synonym Rasa Guna Veerya Vipaka Doshakarma Butter milk Dadhi varga Amrut Madhura, Kashya, Amla Laghu, Ruksha Ushna Madhura Kapaha-

vatahara Buttermilk contents per 100 gms109 –

Calories – 36 Kcl. Protein – 1.8 Gms. Fat – 2 Gms. Carbohydrates – 2.89 Gms. Calcium – 0.07 Gms. Iron – 0.02 Mg. Phosphorus – 0.07 Gms Vitamin A – 102 IU. Thyamine – 0.03 Mg. Nicotinic acid – 0.01 Mg. Riboflavin – 0.1 Mg. Vitamin C – 0.9 Mg.

Clinical study

For each and every research, there should be a methodology. Experimenting the

drug or therapy or both on a population makes clinical research and recordings are made

on the efficacy of the drug or therapy or both in the particular disease. Hence, in this

section, the researcher put forward the systemic procedure which are followed by him

right form the identification of the problem to the final conclusion.

Research approach

In the present study the investigators objective was to evaluate the efficacy of

Takradhara in Kitibha kushta (Psoriasia). The efficacy was determined by finding out the

difference between the baseline data of the parameters to the after treatment data.

Study design

The study design selected for the present clinical trail, was an observational study.

Reason for the selection of the study design.

The results and conclusion of a clinical trail depends on the study design. The

main aim of the study was to observe the effect of takradhara in Kitibha Kushta

(Psoriasis) and also it’s effect on the samprapti of Kitibha kushta.

Source Of Data

Patients suffering from Kitibha kushta (Psoriasis) were selected from the P.G.S &

R (Panchakarma) OPD & IPD of Shri D G Melmalgi Ayurvedic College Hospital.

Sample Size & Grouping

The sample size for the present study was thirty patients suffering from Kitibha

Kushta (Psoriasis) as per the selection criteria. Patients were randomly selected in a

single group.

Methodology 98

Selection criteria

The cases were selected strictly as per the pre-set inclusion and exclusion criteria.

A. Inclusion criteria

1. Patients with classical symptoms of kitibha kushta (Psoriasis).

2. Patients of both sexes above the age of 12 years and below the age of 70 years.

3. Patients suitable for Takradhara.

B. Exclusion criteria

1. Patents suffering form other systemic disorders

2. Pregnant women and lactating mother.

3. Patients below the age of 12 and above the age of 70.

Duration of the study

7 days treatment and 30 days follow up.

Data collection

Patients were thoroughly examined both subjectively and objectively. Detailed

history pertaining to the mode of onset of previous aliment, previous treatment history,

family history, habits, Ashtavidha pareeksha, Dashavidha pareeksha and physical

examination findings were noted. Confirmation tests to confirm the disease, and also the

previous diagnosis made on the disease were considered. Routine investigations were

done to exclude the other pathologies.

Methodology 99

Treatment Schedule

Poorvakarma

Poorvakarma of the Takra dhara involves the preparation of the Takra,

preparation of the Argwadadi gana kashaya, preparation of the patients and arranging the

other requirements.

Requirements for preparing medicated Milk –

Musta (Outer skin removed) – 60 gms.

Yashtimadhu – 60 gms.

Ksheera – 1 liter

Water – 4 liters.

Requirements for preparing Aragwadadi gana kashaya –

Aragwadi gana – 500 gms.

Water – 4 Liters.

Other requirements –

Moorchita tila taila – 50 to 100 ml.

Gandharwahastadi Kwatha – 15 ml.

Rasnadi Churna – 5 gms.

Amalaki Jala – 500 ml.

Gauze – 1 roll.

Cotton – Q. S.

Attenders – 2.

Methodology 100

Preparation of Buttermilk

One liter of ksheera was taken in a clean vessel and added with 4 liters of water.

In this mixture, a pottali containing Yashtimadhu and Musta (Outer skin removed). 60

gms each was kept immersed. The mixture was boiled till the attainment of original

quantity of milk.

The curd or buttermilk was added to milk as a fermenting agent after attainment

of swasngasheetala. First day pure curd or buttermilk was added and on the successive

days medicated buttermilk was used for fermentation. Then the vessel is well covered and

kept untouched. This was done the previous day to the performance of karma.

Next day, the fermented curd, was churned by adding little by little quantity of

Aragwadadi gana kashaya. The churning was continued till the sneha part is removed

completely. Thus the medicated buttermilk is prepared.

Preparation of Argwadadi Gana kashaya

500 gms Yavakuta churna of Aragwadadigana dravyas was boiled in 4000 ml of

water and reduced to 1000 ml. When it attained luck warm state it was added little by

little to the medicated curd and churning was done.

After proper churning, the medicated buttermilk, which was 2000 ml

approximately, is ready for the dhara karma.

Preparation of the Patient

The patient was asked to pass his natural urges prior to his entry in to the

Panchakarma theatre. The procedure was done in between 09.30 to 11.00 am. After

entering in to the Panchakarma theatre, the patient was asked to sit on the dharapati or

droni, he was then administered 15 ml of Gandharwahastadi kwatha mixed with 60 ml of

luke warm water. Then the moorchhita tila taila was applied all over the body and head

for approximately 15 minutes.

Methodology 101

Pradhana karma

After the proper oil application to the patient the varti which is made up of gauze

was tied around his forehead. Precaution was taken while trying, that the knot of varti

remains in the temporal region of the head. Then the patient was asked to close his eyes

and a piece of cotton was placed on each eye respectively. After placing the cotton

properly the eyes was tied with the help of the gauze. The medicated takra, was made into

luck warn by keeping it in the hot water and was poured into the Dharachati. Before

pouring the Takra the opening in the bottom of the vessel was closed with the help of

finger, in order to prevent the flow. After filling dhara vessel up to its brim, the finger

was released in order to make the flow on the forehead. The remaining takra was kept in

the hot water to maintain its luck warm temperature.

When the flow was started a gentle oscillatory movement was given to the vessel

to ensure the falling of the drava on forehead in a single stream. The oscillatory

movement was carried out with right hand and simultaneously by the left hand the

physician should be head message.

When the drava looses its temperature it was replaced by the warn one. Silence

and dim light was maintained throughout the procedure. In this manner the procedure was

continued up to 45 minutes.

Paschat karma

After the procedure the dharachati, Varti, the gauze and cotton was removed and

the patient was asked to open his eyes slowly. The head was washed with Amalaki jala

thoroughly. After proper washing the head was whipped with clean dry cloth and Rasnadi

churna was applied on the crown inorder to avoid cold or fever.

Methodology 102

Pathyapathya

The patients were advised to follow the below listed things –

01. Not to go out in cold weather.

02. Advised to use only hot water for bathing, drinking.

03. Advised to avoid Pungent, Sour items.

04. Advised to avoid sexual intercourse, day sleep, vyayama.

05. Advised to not to take newly harvested paddy, fish, tila, masha, madya, dadhi,

vartaka, pumpkin.

06. Advice to avoid vega dharana, adhyashana, krodha, shoka, loud speech, excessive

reading.

07. Not to expose to dust, hot sun, wind, smoke.

Methods of assessment of clinical response

PASI score was considered as both subjective and objective parameters. Because

it covers both subjective (Itching, Scaling, Erythema, and Thickness) and objective

parameters (Area).

Along with this triggering factors like Krodha, Bhaya, Chittodwega, Shoka are

also studied and results were obtained. But, they were not considered for the overall

assessment of clinical response.

Methodology 103

Objective Parameters

Table No. 22. Showing the method to assess the total PASI score.

Skin sections*

Itching

⊗

Erythema

⊗

Scaling

⊗

Thickness

of lesion

⊗

Coverag

e Area*

% of

B,S,A

Total

PASI

HEAD10%B.t + + + X X 0.1 =

After treatment + + + X X 0.1 =

ARMS20%B.t + + + X X 0.2 =

After treatment + + + X X 0.2 =

BODY30%B.t + + + X X 0.3 =

After treatment + + + X X 0.3 =

LEGS40%B.T

+ + + X X 0.4 =

After treatment + + + X X 0.4 =

Total PASI Before Treatment

Total PASI After treatment

* Coverage area Score 0 % 0 <10% 1 10-29% 2 30 -69% 4 70-89% 5 90-100% 6

⊗ Severity Score None 0

Mild 1

Moderate 2

Severe 3

Maximum 4

Skin sections

For the PASI, the body is divided into four sections. Each section of these areas is

scored by itself and then the four scores are combined into the final PASI. The four areas

are – The legs, which have 40% of a person’s skin, the body (Trunk area – chest,

abdomen, etc) at 30%, the arms (20%) and the head (10%).

Methodology 104

Area

For each skin sections, measure the amount of skin involved as a percentage of

the skin just in that part of the body (not the whole body), and then assign it a score form

0 to 6.

Severity

The severity is measured by four different parameters – Itching, Erythema,

Scaling and Thickness. Again each of these is measured separately for each skin section.

These are measured on a scale of 0 to 4 from none to maximum.

Totaling up the index

For each skin section, add up the four severity scores multiply the total by the area

score, and then multiply that result by the percentage of the skin in that section.

The severity of itching, scaling, Erythema and thickness was assessed in the

following manner

A. Itching

01. None – No itching.

02. Mild – Itching subsides when he / she scratches.

03. Moderate – Reduction in itching by internal medicaments.

04. Severe – Reduction in itching by internal and external medications.

05. Maximum – After medicaments also the patient gets itching sometimes.

B. Erythema

01. None – No Erythema.

02. Mild – Patch with reddish tinge.

03. Moderate – Patch with dull red colour.

04. Maximum – When it is bright red in colour with severe itching.

Methodology 105

C. Scaling

01. None – No scaling.

02. Mild – On scratching if the scales settle in pits on nails.

03. Moderate – If the scales fall on around where he scratches.

04. Severe – Scales found in his/her cloths without scratching.

05. Maximum – Scaling found on bed etc without scratching.

D. Thickness – Purely subjective.

The severity of krodha, bhaya, etc were assessed in following manner –

OVERALL ASSESSMENT OF CLINICAL RESPONSE

A. Krodha

01. None – No Krodha.

02. Mild – Gets anger but not showing outside.

03. Moderate – Shouting loudly, throughing the articles occationally.

04. Severe – Shouting loudly and making harm to others occationally.

B. Shoka

01. None – No Shoka.

02. Mild – Disturbance in concentration, occational thinking of his/her problem.

03. Moderate – Always thinking about his problem with mild disturbance in sleep.

04. Severe – Not responding to others properly with complete disturbance of sleep.

C. Bhaya

01. None – No Bhaya.

02. Mild – Gets occational fear by thinking about the illness.

03. Moderate – Fear causing occational disturbance in day to day activity.

04. Severe – Fear causing occational disturbance in day to day activity, sudden

disturbance in sleep.

Methodology 106

D. Chittodvega

01. None – Zero.

02. Mild – Patient not anxious about the disease.

03. Moderate – Will be anxious, but having the belief that the disease will be cured.

04. Severe – Doesn’t have belief in any therapy and worried that the disease will

not be cured.

OVERALL ASSESSMENT OF CLINICAL RESPONCE

01. Complete Remission – PASI score 0 after treatment.

02. Marked improvement – Reduction in PASI score >75%.

03. Moderate improvement – Reduction in PASI score between 75% and 50%.

04. Minimal improvment – Reduction in PASI score <50%.

05. Unchanged – No reduction in PASI score.

Statistical Analysis

Only net affect that is baseline data i.e. before commencement of treatment i.e. on

first day and at the end of 7 day were considered for statistical analysis. The net effect

was calculated by using paired “t” test.

Methodology 107

34 patients were registered for the present study. Out of this, 4 patients were

excluded. Due to the non-fulfillment of the objective criteria. The remaining 30 patients

of Kitibha Kushta fulfilling the subjective and objective criteria were treated.

All the patients were examined before and after the treatment according to the

case sheet format given in the appendix. Both the subjective and objective changes were

recorded. The data recorded are presented under the following headings –

I. Demographic data

II. Data related to the disease

III. Data related to over all response to the treatment

IV. Statistical analysis of the clinical study.

I. DEMOGRAPHIC DATA

01. Distribution of Patients by Age groups

Table No.23. Showing Distribution of patients by age.

Age group No. Of Patients %

10-20 3 10

21-30 10 33.33

31-40 4 20

41-50 9 30

51-60 4 20

Among the 30 patients, maximum number of patients i.e. 10 patients (33.33%)

fell in between the age group of 21-30, 9 patients (30%) fell in between the age group of

41-50, 4 patients fell in between age group of 31-40 & 51-60 respectively and 3 patient

(10%) fell in between the age group of 10-20.

Observation & Results 108

02. Distribution of patients by Sex

Table No. 24. Showing the distribution of patients by sex.

Sex No. Of Patients %

Male 21 70.00

Female 9 30.00

In the study it was observed that 21 patients were males (70%) and 9 patients

were females (30%), out of 30 patients.

03. Distribution of patients by Occupation

Table No. 25. Showing the distribution of Patients by Occupation.

Occupation No. Of Patients %

Sedentary 11 36.6

Student 4 20

Labour 10 33

Executive 5 16.66

Among the 30 patients, 11 patients (36.66%) were of sedentary, 10 patients (33%)

were of labours, 5 patients (16.66%) were of executive and 4 patients (20%) were of

students.

04. Distribution of patients by Economical Status

Table No. 26. Showing the distribution of patients by Economical status.

Economical status No. Of Patients %

Poor 4 20

Upper Middle class 8 26.66

Lower middle class 15 50

High class 3 10

Among the 30 patients, 15 patients were from lower middle class (50%), 8

patients were from the upper middle class (26.66%) and 4 patients (20%) were from poor

economical status and 3 patients (10%) were from high-class society.

Observation & Results 109

05. Distribution of patients by Religion

Table No. 27. Showing the distribution of patients by Religion.

Religion No. Of Patients %

Hindu 28 93.33

Muslim 2 6.66

Christian 0 0

Others 0 0

Among the 30 patients, 28 patients were Hindus (93.33%), 2 patients were

Muslims (6.66%) and no patient were form other religions.

06. Distribution of patients by Marital Status

Table No. 28. Showing the distribution of patients by Marital Status.

Marital Status No. of Patients %

Married 18 60

Unmarried 12 40

The maximum numbers of individual i.e. 18 patients (60%) were married and

remaining 12 patients (i.e. 40%) were unmarried.

07. Distribution of patients by Dietary habits

Table No. 29. Showing the distribution of Patients by Dietary habits.

Dietary habit No. Of Patients %

Vegetarian 15 40

Mixed 15 60

Among the 30 patients, it was found that the incidence of the vegetarians and

mixed dietary habits was equal i.e. 50%.

Observation & Results 110

08. Distribution of patients by Addiction

Table No. 30. Showing distribution of patients by Addiction.

Addiction No. Of Patients %

Smoking 11 36.66

Pan chewing 6 20

Alcohol 10 33.33

Tobacco 3 10

Among the 30 patients, 11 patients were addicted to smoking (36.66%), 10

patients were addicted for alcohol (33.33%) and 6 patients were addicted to pan chewing

(i.e. 20%) and 3 patients (i.e.10%) were addicted to tobacco chewing.

09. Distribution of patients by Agni

Table No. 31. Showing the distribution of Patients by Agni.

Agni No. Of Patients %

Manda 10 33.33

Teekshna 7 23.33

Vishama 13 43.33

Sama 0 0

Among the 30 patients, 13 patients were having Vishama agni (43.33%), 10

patients were having Manda agni (33.33%) and 7 patients were having Teekshna agni

(23.33%) and interestingly no patient was with sama agni.

10. Distribution of patients by Koshta

Table No. 32. Showing the distribution of patients by Koshta.

Koshta No. Of Patients %

Madhya 12 40.00

Mridu 8 26.66

Krura 10 33.33

Among the 30 patients, 12 patients were having Madhya koshta (40%), 8 patients

(i.e. 26.66%) were having Mridu koshta & 10 patients (i.e. 33.33%) were having Krura

koshta.

Observation & Results 111

11. Distribution of patients by Nidra

Table No. 33. Showing the distribution of Patients by Nidra.

Nidra No. Of Patients %

Sound 7 25.99

Disturbed 23 76.66

Among the 30 patients, 23 patients had sound sleep (76.66%) and 7 patients had

disturbed sleep (25.99%).

12. Distribution of patients by Deha Prakriti

Table No. 34. Showing the distribution of Patients by Deha prakrithi.

Deha prakriti No. Of Patients %

Vata-pitta 12 40

Vata-kapha 15 50

Pitta-kapha 3 10

Among the 30 patients, 12 patients were of Vata-pitta prakriti (40%), 15 patient

were of vata - kapha prakriti (50 %) and 3 patients were of pitta-kapha prakriti (10%).

13. Distribution of patients by Satmya

Table No. 35. Showing the distribution of patients by Satmya.

Satmya No. Of Patients %

Rooksha 23 76.66

Snigdha 7 25.99

Among the 30 patients, majority of patients were having rooksha satmya i.e. 23

(76.66%) and 7 patients were of snigdha satmya (25.99%).

Observation & Results 112

14. Distribution of patients by Sara

Table No. 36. Showing distribution of patients by Sara.

Sara No. of patients %

Pravara 2 6.66

Madhyama 26 86.66

Avara 2 6.66

It can be observed from the above table that no patient is of Pravara Sara. 26

patients i.e. 86.66% were having Madhyama Sara and 2 patients (i.e. 6.66%) were having

Avara Sara.

15. Distribution of patients by Sahanana

Table No. 37. Showing distribution of patients by Samhanana.

Samhanana No. of patients %

Pravara 2 6.66

Madhyama 26 86.66

Avara 2 6.66

Above table shows that 26 patients (i.e. 86.66%) were having Madhyama

Samhanana and 2 patients (i.e.6.66%) were of Pravara and Avara Samhanana

respectively.

16. Distribution of patients by Sattva

Table No. 38. Showing distribution of patients by Sattva.

Sattva NO. of Patients %

Pravara 3 10.33

Madhyama 20 66.66

Avara 7 23.33

Above table reveals that maximum of patients i.e. 20 (66.66%) were having

Madhyama Satva followed by 7 patients of Avara satwa (i.e.23.33%) and 3 patients i.e.

10.33% of Pravara Satva respectively.

Observation & Results 113

17. Distribution of patients by Ahara shakti

Table No. 39. Showing distribution of patients by Ahara Shakti.

Ahara Shakti No. of Patients %

Pravara 4 13.33

Madhyama 10 33.33

Avara 16 53.33

Maximum numbers of patients i.e. 16 (53.33%) were having Avara Jarana Sakti,

followed by Madhyama jarana shakti i.e. 10 patients (33.33%) and pravara jarana shakti

i.e. 4 patients (13.33%) respectively.

18. Distribution of patients by Vyama Shakti

Table No. 40. Showing distribution of patients by Vyayama Sakti.

Vyayama Shakti No. of Patients %

Pravara 9 30

Madhyama 4 13.33

Avara 17 56.77

Above table shows that 17 patients i.e. 56.77% were having avara vyayama sakti

followed by 9 patients (30%) were of pravara and 4 patients (13.33%) were of madhyama

vyayama sakti respectively.

19. Distribution of patients by Onset of Diseases

Table No. 41. Showing distribution of patients by Onset of the disease.

Onset No. of Patients %

Sudden 1 03.33

Gradual 29 96.66

Insidious 0 0

Maximum numbers of patients i.e. 29 (96.66%) were had gradual onset and 1

patient 3.33% had sudden onset.

Observation & Results 114

20. Distribution of patients by Dominant rasa

Table No. 42. Showing distribution of patients by Dominant Rasa.

Dominant Rasa No. of patients %

Madhura 10 33.33

Amla 11 36.66

Lavana 1 3.33

Katu 8 26.66

Tikta 0 0

Kashaya 0 0

As shown in above table the dominant usage of Rasa in the diet of the patients

was found to be Amla (i.e. 36.66%), followed by Madhura (i.e.33.33%) and Katu (i.e.

26.66%) and only 1 patient was found to have Lavana rasa satmya. (i.e. 3.33%)

21. Distribution of patients by Nidana

Table No. 43. Showing distribution of patients by Nidana (etiological factor).

Nidana No. of patients %

Viruddha Ahara 5 16.6

Mithya Ahara 12 40

Mithya Vihara 6 20

Manasika Nidana 7 25.99

In the study it was observation 12 patients i.e. 40% were taking Mithya Ahara, 7

patients i.e. 25.99% were having Manasika karanas as the causative effect. 6 patients i.e.

20% had Mithya vihara as the causative factor and 5 patients i.e.16.6% had Viruddha

Ahara as the causative factor.

Observation & Results 115

22. Distribution of patients by Viruddha ahara

Table No. 44. Showing distribution of patients by Viruddha Ahara.

Viruddha Ahara No. of patients %

Milk + Honey 5 16.66

Milk + Fish 0 0

Milk + Onion 0 0

Milk + Rice 22 73.33

Milk + Khichadi 3 10

Out of 30 patients it was observed that, 22 patients i.e. 73.33% were taking milk

with rice, 5 patients i.e. 16.66% were using Honey with milk and 3 patients i.e. 10% were

taking milk with Khichadi.

23. Distribution of patients by Mithya ahara

Table No. 45. Showing distribution of patients by Mithya Ahara.

Mithya Ahara No. of patients %

Masha 10 33.33

Mulaka 18 60

Ati Dadhi 18 60

Meat 15 50

Sour food 5 16.66

Tila taila 2 6.66

Kullatha 22 73.33

Guda 20 66.66

Ushna & Tikshna 5 16.66

Guru 3 10

Vidahi 2 6.66

Ati Snigdha 4 13.33

Observation & Results 116

In Mithya Ahara maximum number of patients i.e. 22 (73.33%) patients were

taking Kullatha and 20 i.e. 66.66% patients were consuming more Guda. The excess use

of Mulaka and Ati dadhi sevana was found in 18 patients i.e. 60%. 15 patients i.e. 50%

patients were habituated to meat consumption and 10 patients i.e. 33.33% reported with

Masha atisevana. Ushna & Tikshana & Sour foods habituation was found in 5 patients

i.e. 16.66% respectively. 4 patients i.e. 13.33% were accustomed to ati snigdha ahara and

3 patients i.e. 10% patients were accustomed to Ati guru ahara. Usage of Vidahi Ahara

and Tila taila was found in 2 patients i.e. 6.66% respectively.

24. Distribution of patients by Mithya vihara

Table No. 46. Showing distribution of patients by Mithya Vihara.

Mithya Vihara No. of patients %

Vegadharana 10 33.33

Divasvapa 12 40

Ratri Jagarana 8 26.6

Excessive physical works 18 60

Sheetoshna Viprayaya 4 29.66

Most common mithya vihara was found to be excessive physical work. 18

patients (60%) reported with excessive physical work followed by Divasvapa 12 patients

(40%), Vegadharana in 10 patients (33.33%) and Ratri Jagarana in 8 patients (26.6%). 4

patients (i.e. 29.66%) were reported with Sheetoshna Viparyaya.

25. Distribution of patients by Manasika Nidana

Table No. 47. Showing distribution of patients by Manasika Nidana.

Manasika Nidana No. of patients %

Chittodwega 13 43.33

Bhaya 17 56.66

Krodha 4 13.33

Shoka 18 60

Observation & Results 117

The manasika Nidana Krodha was found in 18 patients i.e. 60%, Bhaya was found

in 17 patients i.e. 56.66% and Chittodvega was found in 13 patients i.e. 43.33%. 4

patients i.e. 13.33% reported Shoka as a manasika Nidana.

26. Distribution of patients by Family history

Table No. 48. Showing distribution of patients by Family History.

Family History No. of patients %

Positive 2 6.66

Negative 28 93.33

Majority of the patients i.e. 28 (93.33%) were not having family history of

psoriasis and only 2 patients (i.e. 6.66%) reported with positive family history of

psoriasis.

27. Distribution of patients by Chronicity

Table No. 49. Showing distribution of patients by Chronicity.

Chronicity No. of patients %

< 1 year 5 16.66

1 – 5 years 16 53.33

6 – 10 years 7 23.33

>10 years 2 6.66

The maximum number of patients i.e. 16 (53.33%) were having 1to 5 years

chronicity of the disease, followed by 7 patients i.e. 23.33% and 5 patients i.e. 16.66%

were having the chronicity of 6-10 years and less than 1 year respectively. Only 2

patients i.e. 6.66% reported with the chronicity of more than 10 years.

Observation & Results 118

28. Distribution of patients by Medication

Table No. 50. Showing distribution of patients by Medication.

Medication No. of patients %

Allopathy 28 93.33

Ayurveda 2 6.66

Other 0 0

In this study, majority of the patients i.e. 29 (93.33%) had previously undergone

allopathic treatment, and only 2 patients had the Ayurvedic treatment. None of the

patients was approached with the treatment history of other systems of medicines.

29. Distribution of patients by Aggravating Season

Table No. 51. Showing distribution of patients by Aggravating Season.

Aggravating season No. of patients %

Winter 23 76.6

Summer 2 6.66

Monsoon 1 3.3

None 4 13.3

The symptoms aggravating season of the maximum 23 patients i.e. 76.6% was

winter followed by summer 2 patients i.e. 6.66% and monsoon 1 patient i.e. 3.33% 4

patients i.e. 13.33% had no experience of seasonal variation.

30. Distribution of patients by types of Psorasis

Table No. 52. Showing distribution of patients by Types of Psoriasis.

Types No. of patients %

Plaque 27 90

Guttate 2 6.6

Erythrodermic 1 3.33

Pustular 0 0

Maximum numbers of patients i.e. 27 (90%) reported with plaque psoriasis 2

patients i.e. 7.4% reported with Guttate psoriasis and in only 1 patient i.e. 3.33% reported

with Erythrodermic psoriasis. No patient was reported with Pustular psoriasis.

Observation & Results 119

31. Distribution of patients by Chief complaints

Table No. 53. Showing distribution of patients by Chief Complaints.

Chief Complaints No. of patients %

Shyava or Krishna varna 30 100

Kina khara sparasha 29 96.66

Parusha 29 96.66

Kandu 30 100

Srava 2 6.66

Ghana 30 100

All 30 patients (i.e. 100%) of this study were having shyava or Krishna varnata,

kandu, Ghana as a chief complaint, where as 29 patients (i.e. 96.66%) were reported with

Kina khara sparsha and Parushata. Only 2 patients (i.e. 6.66%) were reported with srava.

32. Distribution of patients by Associated complaints

Table No. 54. Showing distribution of patients by Associated Symptoms.

Associated symptoms No. of patients %

Agnimandya 6 20

Malabaddhata 6 20

Aswedana 4 13.33

Atiswedana 4 13.33

Shareera Guruta 3 10

Suptata 3 10

Chimchimayana 1 3.33

Toda 3 10

The associated complaints like Agni madya and Malabaddhata was found in 6

patients (i.e. 20%) each. Aswedanam, Atiswedanam was found in 4 patients (i.e.13.33%)

each. Shareera Guruta, Suptata and Toda was noted in 3 patients (i.e.10%) each. Only 1

patient (i.e. 3.33%) reported with Chimachimayana.

Observation & Results 120

33. Distribution of patients by Confirmation tests of Psoriasis

Table No. 55. Showing distribution of patients by confirmation tests of Psoriasis.

Signs No. of Patients %

Auspitz sign 15 50

Candle grease sign 12 40

Koebner Phenomena 3 10

The Auspitz sign was positive in 15 patients (i.e. 50%) and Candle greaes sign

was positive in 12 patients (i.e. 40%). Positive Koebner Phenomena was present in 3

patients (i.e. 10%).

34. Distribution of patients by Precipitating factors

Table No. 56. Showing distribution of patients by Precipitating factors.

Precipitating Factor No. of Patients %

Trauma 3 10

Sunlight 10 33.33

Emotional stress 8 26.66

Drug 1 3.33

10 patents (i.e. 33.33%) were having sunlight as a precipitating factor, 8 patients

(i.e. 26.66%) were having emotional stress as the triggering factor and 3 patients (i.e.

10%) had trauma as the precipitating factor and only 1 patient (i.e. 3.33%) was reported

drug as a triggering factor.

35. Distribution of patients by Site of involvement

Table No. 57. Showing distribution of patients with different Site of involvement.

Site of involvement No. of Patients %

Head 16 53.33

Arms 19 63.33

Legs 19 63.33

Body 14 46.66

Observation & Results 121

Out of 30% 19 patients each i.e. 63.33% were reported with the arms and legs

involvement respectively, 16 patients (i.e. 53.33%) were reported with head involvement

and 14 patients (i.e. 46.66%) reported with body involvement.

36. Distribution of patients by particular site involvement

Table No. 58. Showing distribution of patients with Particular site involvement.

Site of involvement No. of Patients %

Only scalp 7 23.33

Only palms & soles 5 16.66

Genital 1 3.33

Out of 30 patients, 7 patients i.e. 23.33% were having only scalp involvement

(Scalp Psoriasis), 5 patients i.e. 16.66% were having only palms and soles involvement

(Palmo-plantar Psoriasis). Only 1 patient (i.e. 3.33%) was found with the involvement of

genitals.

Overall response of the treatment

Table No. 59. Showing Overall response of the treatment.

Overall results No. of Patients %

Complete remission 8 26.66

Marked improvement 7 25.90

Moderate improvement 4 13.33

Mild improvement 9 30

No response 5 16.66

After treatment, 8 patients (i.e. 26.66%) showed complete remission, 7 patients

(i.e.25.90%) showed marked improvement, 4 patients (i.e. 13.33%) showed moderate

improvement and 9 patients (i.e.30%) showed mild improvement and no response was

found in 5 patients (i.e.16.66%).

Observation & Results 122

Graph No. 01. Showing Distribution of patients by Age groups.

Distribution of Pt.'s by Age

3

10

4

9

4

0

2

4

6

8

10

12

10. - 20 21-30 31-40 41-50 51-60

Age groups

No

of P

t.'s

No. Of Patients

Graph No. 02. Showing the distribution of patients by Deha prakriti.

12 15

30

5

10

15

V-P V-K P-K

Deha Prakriti

Distribution of Pt.'s by Deha Prakriti

No. Of Patients

Graph No. 03. Showing the distribution of patients by onset.

1

29

00

5

10

15

20

25

30

Sudden Gradual Insidious

Nature of Onset

Distribution of Pt.'s by Onset

No. of Patients

Graph No. 04. Showing distribution of the patients by Nidana.

Distribution of Pt.'s by Nidana

5

126

7

VA MA MV MN

Graph No. 05. Showing the distribution of patients by Manasika nidana. Distribution of Pt.'s by Manasika Nidana

13

17

4

18

0 5 10 15 20

Cv

Bh

Kr

Sh

Man

asik

a N

idan

a

No. of Pt.'sNo. of patients

Graph No. 06. Showing the distribution of the patients by family history.

Distribution of Pt.'s by Family History

2

28

Positive Negative

Graph No. 07. Showing the distribution of patients by Chronicity.

Distribution of Pt.'s by Chronicity

5

16

7

2

0

5

10

15

20

< 1 yr 1 – 5 yrs 6 – 10 yrs >10 yrs

Chronicity in YearsNo. of patients

Graph No. 08. Showing the distribution of patients by aggravating season Distribution of Pt.'s by Aggravating season

23

2 14

0

5

10

15

20

25

Winter Summer Monsoon None

Aggravating season

No.

of P

t.'s

No. of patients

Graph No. 09. Showing the distribution of patients by types of psoriasis.

Distribution of Pt.'s by types of Psoriasis

27

2 1 00

5

10

15

20

25

30

Plaque Guttate Eryth. Pustular

Type of Psoraisis

No.

of P

t.'s

No. of patients

Graph No. 10. Showing the distribution of patients by chief complaints.

Distribution of Pt.'s By chief compliants

30 29 29 30

2

30

0

10

20

30

40

S/K Vr. KK Sp Pr Kd Sr Gh

Chief complaints

No.

of P

t.'s

No. of patients

Graph No. 11. Showing the distribution of patients by associated complaints.

Distribution of Pt.'s by Associated Symptoms

6 6

4 43 3

1

3

01234567

A B C D E F G H

Associated complaints

No.

of P

t.'s

No. of patients

Graph No. 12. Showing the distribution of patients by confirmatory tests. Distribution of Pt.'s by confirmatory tests

1512

3

A B C

Graph No. 13. Showing distribution of patients by involvement of body

Distribution of Pt.'s by involvement of body parts

1619 19

14

0

5

10

15

20

Head Arms Legs Body

Body Parts

No.

of P

t.'s

No. of Patients

Graph No. 14. Showing the Overall results.

Overall results

87

4

9

5

0

2

4

6

8

10

CR Mr.I Mo.I Mi.I NR Response to treatment

No.

of P

t.'s

No. of Patients

RESULTS

HEAD

Out of 30 patients, 16 patients i.e. 53.33% reported with psoriasis on head. Out of

these 16 those who reported with psoriasis only head (scalp psoriasis) was 7 (i.e.23.33%)

means only 7 patients had scalp psoriasis, others i.e. 9 patients (i.e.56.25%) had the

involvement of scalp along with other parts. Here, in the following tables only data

related to head affliction is given in forth coming pages data related to other parts if

affected will be given.

Table No. 60. Showing the distribution of patients with different severity scorings.

Sl. Symptom Mild Moderate Severe Maximum Total % 01. Itching 3 4 3 6 16 100 02. Erythema 7 3 1 3 14 87.50 03. Scaling 5 2 6 3 16 100 04. Thickness 7 6 2 1 16 100 Itching

Table No. 61. Showing the distribution of patients with itching head.

Sl. OPD BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 0 100 C.R. 09. 3889 4 0 100 C.R. 02. 1455 3 0 100 C.R. 10. 3581 1 0 100 C.R. 03. 2548 2 0 100 C.R. 11. 1486 1 0 100 C.R. 04. 2924 4 0 100 C.R. 12. 267 2 2 0 N.I. 05. 2173 3 1 66 Mo.I. 13. 1995 4 0 100 C.R. 06. 1470 1 0 100 C.R. 14. 986 4 0 100 C.R. 07. 3700 4 0 100 C.R. 15. 322 3 0 100 C.R. 08. 2388 4 0 100 C.R. 16. 1467 2 0 100 C.R. Scaling

Table No. 62. Showing the distribution of patients with scaling head.

Sl. OPD BT AT % Remarks Sl. OPD No. BT AT % Remarks 01. 3569 3 0 100 C.R. 09. 2388 3 0 100 C.R. 02. 1455 2 0 100 C.R. 10. 3581 1 0 100 C.R. 03. 1467 3 0 100 C.R. 11. 1486 1 0 100 C.R. 04. 2548 1 0 100 C.R. 12. 267 3 3 0 N.I. 05. 2924 4 0 100 C.R. 13. 1995 3 0 100 C.R. 06. 2173 4 4 0 N.I. 14. 986 4 0 100 C.R. 07. 1470 1 0 100 C.R. 15. 322 3 0 100 C.R. 08. 3700 3 0 100 C.R. 16. 3889 1 0 100 C.R.

Results 123

Erythema

Table No. 63. Showing the distribution of patients with Erythema head.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 0 100 C.R. 08. 3700 3 0 100 C.R. 02. 1455 2 0 100 C.R. 09. 2388 2 0 100 C.R. 03. 1467 1 0 100 C.R. 10. 267 4 4 0 N.I. 04. 2548 1 0 100 C.R. 11. 1986 1 0 100 C.R. 05. 2924 1 0 100 C.R. 12. 322 1 0 100 C.R. 06. 2173 4 4 0 N.I. 13. 3889 4 0 100 C.R. 07. 1470 2 2 0 N.I. 14. 1995 1 0 100 C.R. Thickness

Table No. 64. Showing the distribution of patients with thickness head.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 0 100 C.R. 09. 3581 1 0 100 C.R. 02. 1455 2 0 100 C.R. 10. 1486 1 0 100 C.R. 03. 1467 1 0 100 C.R. 11. 322 2 0 100 C.R. 04. 2548 1 0 100 C.R. 12. 267 2 2 0 N.I. 05. 2924 2 0 100 C.R. 13. 1995 1 0 0 N.I. 06. 2173 4 4 0 N.I. 14. 986 3 0 100 C.R. 07. 3700 3 0 100 C.R. 15. 3889 2 0 100 C.R. 08. 2388 1 0 100 C.R. 16. 1470 2 2 0 N.I. Area

Table No. 65. Showing the distribution of patients presented with area head.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 0 100 C.R. 09. 3581 1 0 100 C.R. 02. 1455 1 0 100 C.R. 10. 1486 1 0 100 C.R. 03. 1467 2 0 100 C.R. 11. 3700 3 0 100 C.R. 04. 2548 1 0 100 C.R. 12. 267 2 2 0 N.I. 05. 2924 2 0 100 C.R. 13. 1995 2 0 100 C.R. 06. 2173 3 3 0 N.I. 14. 986 4 3 66 Mo.I. 07. 1470 1 1 0 N.R. 15. 322 1 0 100 C.R. 08. 2388 3 0 100 C.R. 16. 3889 4 0 100 C.R.

Results 124

Table No. 66. Showing the distribution of patients with Coverage area in head.

Sl. Coverage area No. of patients % 01. <10% 7 43.75 02. 10-29% 4 25 03. 30-49% 3 18.75 04. 50-69% 2 12.5 05. 70-89% 0 0 06. 90-100% 0 0

Total PASI score of Head

Table No. 67. Showing the distribution of patients with total PASI score of Head.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3561 0.7 0 100 C.R. 09. 3700 3.9 0 100 C.R. 02. 3889 4.4 0 100 C.R. 10. 2388 3.0 0 100 C.R. 03. 1455 0.9 0 100 C.R. 11. 3681 0.3 0 100 C.R. 04. 1467 1.4 0 100 C.R. 12. 1486 0.3 0 100 C.R. 05. 2548 0.5 0 100 C.R. 13. 267 2.2 2.2 0 N.I. 06. 2924 2.2 0 100 C.R. 14. 1995 1.8 0 100 C.R. 07. 2173 4.9 3.9 13.3 Mi.I. 15. 986 4.8 0 100 C.R. 08. 1470 0.6 0.4 33.3 Mi.I. 16. 322 0.9 0 100 C.R. ARMS

Out of 30 patients, 19 patients (i.e.41.17%) reported with psoriasis on arms. Out

of these 19 those who reported with psoriasis only on arms was only 1 (i.e.5.26%).

Others i.e. 18 patients (i.e.94.73%) had the involvement of arms along with other parts.

Here, in the following tables only data related to arms affliction is given in forth coming

pages data related to other parts if affected will be given.

Table No. 68. Showing the number of patient with different severity scorings.

Sl. Symptom Mild Moderate Severe Maximum Total % 01. Itching 5 3 10 1 19 100 02. Erythema 4 3 3 4 14 73.68 03. Scaling 6 4 6 3 19 100 04. Thickness 5 6 5 3 19 100

Results 125

Itching

Table No. 69. Showing the distribution of patients with itching arms.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 0 100 C.R. 11. 1486 3 1 66.6 Mo.I. 02. 1455 2 1 50 Mo.I. 12. 2897 3 0 100 C.R. 03. 2548 3 1 66.6 Mo.I. 13. 1647 1 1 0 N.I. 04. 3118 3 3 0 N.I. 14. 267 2 2 0 N.I. 05. 2924 4 0 100 C.R. 15. 5574 3 0 100 C.R. 06. 3755 1 0 100 C.R. 16. 5609 3 0 100 C.R. 07. 2173 3 1 66.6 Mo.I. 17. 2308 3 0 100 C.R. 08. 1470 1 0 100 C.R. 18. 5323 2 0 100 C.R. 09. 282 3 1 66.6 Mo.I. 19. 2160 1 0 100 C.R. 10. 3581 3 1 66.6 Mo.I. Erythema Table No. 70. Showing the distribution of patients with Erythema arms.

Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 1 1 0 N.I. 08. 1470 2 2 0 N.I. 02. 1455 2 2 0 N.I. 09. 282 3 3 0 N.I. 03. 2548 4 4 0 N.I. 10. 1647 3 3 0 N.I. 04. 3118 3 3 0 N.I. 11. 267 4 4 0 N.I. 05. 2924 4 4 0 N.I. 12. 5574 1 0 100 C.R. 06. 3755 1 1 0 N.I. 13. 2308 2 1 50 Mo.I. 07. 2173 4 4 0 N.I. 14. 2160 1 1 0 N.I.

Scaling

Table No. 71. Showing the distribution of patients with scaling arms.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 3 2 33.3 Mi.I. 11. 1486 3 2 33.3 Mi.I. 02. 1455 2 2 0 N.I. 12. 2897 3 0 100 C.R. 03. 2548 4 3 25 Mi.I. 13. 1647 1 1 0 N.I. 04. 3118 3 3 0 N.I. 14. 267 3 3 0 N.I. 05. 2924 4 3 25 Mi.I. 15. 5574 2 0 100 C.R. 06. 3755 1 0 100 C.R. 16. 5609 3 1 66.6 Mo.I. 07. 2173 4 4 0 N.I. 17. 2308 2 0 100 C.R. 08. 1470 1 1 0 N.I. 18. 5323 1 0 100 C.R. 09. 282 2 1 50 Mo.I. 19. 2160 1 0 100 C.R. 10. 3581 1 1 0 N.I.

Results 126

Thickness

Table No. 72. Showing the distribution of patients with thickness arms.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 1 0 N.I. 11. 1486 3 3 100 C.R. 02. 1455 2 2 0 N.I. 12. 2897 3 0 100 C.R. 03. 2548 4 4 0 N.I. 13. 1647 2 2 0 N.I. 04. 3118 3 3 0 N.I. 14. 267 2 2 0 N.I. 05. 2924 4 0 100 C.R. 15. 5574 2 0 100 C.R. 06. 3755 1 1 0 N.I. 16. 5609 2 1 50 Mo.I. 07. 2173 4 4 0 N.I. 17. 2308 2 1 50 Mo.I. 08. 1470 2 2 0 N.I. 18. 5323 1 0 100 C.R. 09. 282 3 3 0 N.I. 19. 2160 1 1 0 N.I. 10. 3581 1 1 0 N.I.

Area

Table No. 73. Showing the distribution of patients with area arms.

Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 2 0 N.I. 11. 1486 3 3 0 N.I. 02. 1455 1 1 0 N.I. 12. 2897 3 0 100 C.R. 03. 2548 2 2 0 N.I. 13. 1647 3 3 0 N.I. 04. 3118 1 1 0 N.I. 14. 267 4 4 0 N.I. 05. 2924 2 2 0 N.I. 15. 5574 2 0 100 C.R. 06. 3755 1 1 0 N.I. 16. 5609 1 1 0 N.I. 07. 2173 3 3 0 N.I. 17. 2308 2 1 50 Mo.I. 08. 1470 1 1 0 N.I. 18. 5323 1 0 100 C.R. 09. 282 3 3 0 N.I. 19. 2160 1 1 0 N.I. 10. 3581 2 2 0 N.I.

Table No.74. Showing distribution of patients with Coverage area of arms.

Sl. Coverage area No. of patients % 01. <10% 7 41.70 02. 10-29% 6 35.29 03. 30-49% 5 29.41 04. 50-69% 1 5.26 05. 70-89% 0 0 06. 90-100% 0 0

Results 127

Total PASI score of Arms Table No. 75. Showing the total PASI score of Arms. Sl. OPD

No. BT AT % Remarks Sl. OPD

No. BT AT % Remarks

01. 3569 2.4 1.6 33.33 Mi.I. 11. 1486 5.4 3.6 33.33 Mi.I. 02. 1455 1.6 1.4 12.5 Mi.I. 12. 2897 5.4 0 100 C.R. 03. 2548 6.0 4.8 20 Mi.I. 13. 1647 4.2 4.2 0 N.I. 04. 3118 2.4 2.4 0 N.I. 14. 267 8.8 8.8 0 N.I. 05. 2924 6.4 2.8 56.25 Mo.I. 15. 5574 3.2 0 100 C.R. 06. 3755 0.8 0.4 50 Mo.I. 16. 5609 1.8 0.4 77.78 Mo.I. 07. 2173 9.0 7.8 13.33 Mi.I. 17. 2308 3.6 0.4 88.89 Mo.I. 08. 1470 1.2 1.0 16.67 Mi.I. 18. 5323 0.8 0 100 C.R. 09. 282 6.6 4.8 27.27 Mi.I. 19. 2160 0.8 0.4 50 Mo.I. 10. 3581 2.0 1.2 40 Mi.I. Body

Out of 30 patients, 15 patients i.e. 50% reported with psoriasis on body surface,

which include chest, abdomen, back and genitals. Out of these 15 those who reported

with psoriasis only on body was only 2 (i.e.13.33%). Others i.e. 13 patients (i.e. 86.66%)

had the involvement of body along with other parts. Here, in the following tables only

data related to body affliction is given. In forth coming pages data related to other parts if

affected will be given.

Table No. 76. Showing the number of patient with different severity scorings.

Sl. Symptom Mild Moderate Severe Maximum Total % 01. Itching 5 6 3 1 15 100 02. Erythema 3 4 2 3 12 80 03. Scaling 6 4 3 2 15 100 04. Thickness 4 7 2 2 15 100 Itching

Table No. 77. Showing the distribution of patients with itching body.

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 2 1 50 Mo.I. 09. 3547 1 0 100 C.R. 02. 1455 3 1 66.66 Mo.I. 10. 2388 2 1 50 Mo.I. 03. 2548 2 1 50 Mo.I. 11. 2368 3 1 66.6 Mo.I. 04. 3118 4 4 0 N.I. 12. 2897 2 1 50 Mo.I. 05. 2924 1 0 100 C.R. 13. 267 2 2 0 N.I. 06. 2210 1 1 0 N.I. 14. 1995 2 2 0 N.I. 07. 1470 3 1 66.66 Mo.I. 15. 2160 1 0 100 C.R. 08. 3700 1 0 100 C.R.

Results 128

Erythema Table No. 78. Showing the distribution of patients with Erythema body. Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 2 0 N.I. 07. 2173 4 4 0 N.I. 02. 1455 2 2 0 N.I. 08. 1470 2 2 0 N.I. 03. 2548 3 3 0 N.I. 09. 282 1 1 0 N.I. 04. 3118 4 4 0 N.I. 10. 3547 2 2 0 N.I. 05. 2924 1 1 0 N.I. 11. 1647 3 3 0 N.I. 06. 3756 1 1 0 N.I. 12. 267 4 4 0 N.I. Scaling Table No. 79. Showing the distribution of patients with scaling body. Sl. OPD

No. BT AT % Remarks Sl. OPD

No. BT AT % Remarks

01. 3569 3 2 33.3 Mi.I. 09. 282 1 0 100 C.R. 02. 1455 2 2 0 N.I. 10. 3457 2 2 0 N.I. 03. 2548 3 3 0 N.I. 11. 3581 1 1 0 N.I. 04. 3118 4 4 0 N.I. 12. 1486 2 1 50 Mo.I. 05. 2924 1 1 0 N.I. 13. 1647 1 1 0 N.I. 06. 3756 1 1 0 N.I. 14. 267 3 3 0 N.I. 07. 2173 4 4 0 N.I. 15. 5323 1 0 100 C.R. 08. 1470 1 1 0 N.I. Thickness Table No. 80. Showing the distribution of patients with thickness body. Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks 01. 3569 3 3 0 N.I. 09. 282 2 2 0 N.I. 02. 1455 2 2 0 N.I. 10. 3547 2 2 0 N.I. 03. 2548 3 3 0 N.I. 11. 3581 1 1 0 N.I. 04. 3118 4 4 0 N.I. 12. 1486 2 2 0 N.I. 05. 2924 1 1 0 N.I. 13. 1647 2 2 0 N.I. 06. 3756 1 1 0 N.I. 14. 267 2 2 0 N.I. 07. 2173 4 4 0 N.I. 15. 5323 1 1 0 N.I. 08. 1470 2 2 0 N.I. Area

Table No. 81. Showing the distribution of patients with area Body.

Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 3 3 0 N.I. 09. 282 1 1 0 N.I. 02. 1455 2 2 0 N.I. 10. 3547 2 2 0 N.I. 03. 2548 1 1 0 N.I. 11. 3581 2 2 0 N.I. 04. 3118 3 3 0 N.I. 12. 1486 3 3 0 N.I. 05. 2924 1 1 0 N.I. 13. 1647 2 2 0 N.I. 06. 3756 1 1 0 N.I. 14. 267 5 5 0 N.I. 07. 2173 4 4 0 N.I. 15. 5323 1 1 0 N.I. 08. 1470 1 1 0 N.I.

Results 129

Table No. 82. Showing the coverage area of the body.

Sl. Coverage area No. of patients % 01. <10% 6 40 02. 10-29% 4 26.66 03. 30-49% 3 20 04. 50-69% 1 6.66 05. 70-89% 1 6.66 06. 90-100% 0 0

Total PASI score

Table No. 83. Showing the total PASI score of Body.

Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks01. 3569 9.0 7.2 20 Mi.I. 09. 282 1.5 0.9 40 Mi.I. 02. 1455 5.6 4.2 25 Mi.I. 10. 3547 4.8 4.2 12.5 Mi.I. 03. 2548 3.3 3.0 9.09 Mi.I. 11. 3581 3.0 1.8 40 Mi.I. 04. 3118 14.4 14.4 0 N.I. 12. 1486 5.4 3.6 33.33 Mi.I. 05. 2924 1.2 0.9 25 Mi.I. 13. 1647 4.8 4.8 0 N.I. 06. 3756 1.2 1.2 0 N.I. 14. 267 16.5 16.5 0 N.I. 07. 2173 18.0 15.6 13.33 Mi.I. 15. 5323 0.9 0.3 66.66 Mo.I. 08. 1470 1.8 1.5 16.65 Mi.I.

LEGS

Out of 30 patients, 15 patients i.e. 50% reported with psoriasis on body surface,

which include chest, abdomen, back and genitals. Out of these 15 those who reported

with psoriasis only on body was only 2 (i.e.13.33%). Others i.e. 13 patients (i.e. 86.66%)

had the involvement of body along with other parts. Here, in the following tables only

data related to body affliction is given.

Table No. 84. Showing the distribution of patients with different severity scorings

Sl. Symptom Mild Moderate Severe Maximum 01. Itching 9 4 6 1 02. Erythema 9 2 2 2 03. Scaling 12 2 5 1 04. Thickness 9 6 4 1

Results 130

Itching

Table No. 85. Showing the distribution of patient with itching legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 1455 1 0 100 C.R. 11. 2368 3 3 100 C.R. 02. 2548 1 0 100 C.R. 12. 1486 1 0 100 C.R. 03. 3118 1 1 0 N.I. 13. 2897 3 0 100 C.R. 04. 2924 1 0 100 C.R. 14. 1647 2 2 0 N.I. 05. 3755 1 0 100 C.R. 15. 267 2 2 0 N.I. 06. 2210 2 0 100 C.R. 16. 5609 3 0 100 C.R. 07. 2173 3 1 66.66 Mo.I. 17. 2388 3 0 100 C.R. 08. 1470 1 0 100 C.R. 18. 5323 2 0 100 C.R. 09. 282 1 0 100 C.R. 19. 2160 1 0 100 C.R. 10. 3581 3 1 66.66 Mo.I. Erythema

Table No. 86. Showing the distribution of patients with Erythema legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 1 0 N.I. 09. 1470 2 2 0 N.I. 02. 1455 1 1 0 N.I. 10. 282 1 1 0 N.I. 03. 2548 1 1 0 N.I. 11. 2368 1 1 0 N.I. 04. 3118 1 1 0 N.I. 12. 1647 3 3 0 N.I. 05. 2924 1 1 0 N.I. 13. 267 4 4 0 N.I. 06. 3756 1 1 0 N.I. 14. 2308 3 1 66.66 Mo.I. 07. 2210 2 1 50 Mo.I. 15. 2160 1 1 0 N.I. 08. 2173 4 4 0 N.I. Scaling

Table No. 87. Showing the distribution of patients with scaling legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 3 2 33.33 Mi.I. 11. 3700 3 3 0 N.I. 02. 1455 1 1 0 N.I. 12. 282 1 0 100 C.R. 03. 2160 1 0 100 C.R. 13. 2160 1 0 100 C.R. 04. 2548 1 0 100 C.R. 14. 3581 1 1 0 N.I. 05. 3118 1 1 0 N.I. 15. 2368 3 3 0 N.I. 06. 2924 1 1 0 N.I. 16. 1486 1 0 100 C.R. 07. 5323 1 0 100 C.R. 17. 2897 3 1 66.66 Mo.I. 08. 2210 2 1 50 Mo.I. 18. 1647 1 1 0 N.I. 09. 2173 4 4 0 N.I. 19. 267 3 2 33.33 Mi.I. 10. 1470 1 1 0 N.I. 20. 5609 3 1 66.66 Mo.I.

Results 131

Thickness

Table No. 88. Showing the distribution of patients with thickness legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 1 0 N.I. 11. 3581 1 1 0 N.I. 02. 1455 1 1 0 N.I. 12. 1486 2 2 0 N.I. 03. 2548 1 1 0 N.I. 13. 2388 1 1 0 N.I. 04. 3118 1 1 0 N.I. 14. 2368 3 3 0 N.I. 05. 2924 1 1 0 N.I. 15. 2897 3 2 33.33 Mo.I. 06. 3755 1 1 0 N.I. 16. 1647 2 2 0 N.I. 07. 2210 2 2 0 N.I. 17. 2308 1 0 100 C.R. 08. 2173 4 4 0 N.I. 18. 5323 1 0 100 C.R. 09. 1470 2 2 0 N.I. 19. 986 3 1 66.66 Mo.I. 10. 282 2 2 0 N.I. 20. 322 3 1 66.66 Mo.I. Area in body

Table No. 89. Showing the distribution of patients with area legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 1 1 0 N.I. 11. 3581 2 2 0 N.I. 02. 1455 1 1 0 N.I. 12. 1486 2 2 0 N.I. 03. 2548 1 1 0 N.I. 13. 2160 1 1 0 N.I. 04. 3118 1 1 0 N.I. 14. 2368 1 1 0 N.I. 05. 2924 2 2 0 N.I. 15. 2897 3 3 0 Mo.I. 06. 3755 1 1 0 N.I. 16. 1647 3 3 0 N.I. 07. 2210 2 2 0 N.I. 17. 267 4 4 0 N.I. 08. 2173 3 3 0 N.I. 18. 5609 3 1 66.66 Mo.I. 09. 1470 1 1 0 N.I. 19. 2308 3 1 66.66 Mo.I. 10. 282 1 1 0 N.I. 20. 5323 2 1 50 Mo.I. Coverage area

Table No. 90. Showing Coverage area of legs.

Sl. Coverage area No. of patients % 01. <10% 8 40 02. 10-29% 5 25 03. 30-49% 6 30 04. 50-69% 1 5 05. 70-89% 0 0 06. 90-100% 0 0

Results 132

Total PASI score

Table No. 91. Showing the total PASI scoring of legs

Sl. OPD No.

BT AT % Remarks Sl. OPD No.

BT AT % Remarks

01. 3569 2.0 1.6 20 Mi.I. 11. 3581 4.0 2.4 40 Mi.I. 02. 1455 1.6 1.2 25 Mi.I. 12. 1486 3.2 1.6 50 Mo.I. 03. 2548 1.6 0.8 50 Mo.I. 13. 2160 1.6 0.8 50 Mo.I. 04. 3118 1.6 1.6 0 N.I. 14. 2368 12.0 12.0 0 N.I. 05. 2924 3.2 2.4 25 Mi.I. 15. 2897 6.8 3.6 47.06 Mi.I. 06. 3755 1.6 0.8 50 Mo.I. 16. 1647 9.6 9.6 0 N.I. 07. 2210 6.4 3.2 50 Mo.I. 17. 267 17.6 17.6 0 N.I. 08. 2173 18.0 15.6 13.33 Mi.I. 18. 5609 9.8 0.8 91.8 B.R. 09. 1470 2.4 2.0 16.6 Mi.I. 19. 2308 13.2 0.8 93.94 B.R. 10. 282 2.0 1.2 40 Mi.I. 20. 5328 3.2 0 100 C.R.

Master chart

Table No. 92. Showing total PASI scoring of the all 30 patients.

Sl. OPD Total PASI BT Total PASI AT % Reduction Remarks 01. 3569 14.1 10.4 26.24 Minimal 02. 1455 9.7 7.2 25.77 Minimal 03. 1467 1.4 0 100 Completer remission04. 2548 11.7 8.6 26.50 Minimal 05. 3118 18.4 18.4 0 Unchanged 06. 2924 13.0 6.1 53.08 Moderate 07. 3755 2.4 1.2 50 Moderate 08. 3756 1.2 1.2 0 Unchanged 09. 2210 6.4 3.2 50 Moderate 10. 2173 49.5 42.5 14.14 Minimal 11. 1470 6.0 4.9 18.33 Minimal 12. 3700 3.9 0 100 Completer remission13. 282 10.1 6.9 31.68 Minimal 14. 3547 4.8 4.2 12.5 Minimal 15. 2388 3.0 0 100 Completer remission

Results 133

Table No. 92. Showing total PASI scoring of the all 30 patients.

Sl. OPD Total PASI BT Total PASI AT % Reduction Remarks 16. 3581 9.3 5.6 39.79 Minimal 17. 2368 12.0 12.0 0 Unchanged 18. 1486 14.3 8.8 38.46 Minimal 19. 2897 13.2 3.6 72.73 Moderate 20. 1647 18.6 18.6 0 Unchanged 21. 267 45.1 45.1 0 Unchanged 22. 1995 1.8 0 100 Completer remission 23. 5574 3.2 0 100 Completer remission 24. 986 4.8 0 100 Completer remission 25. 5609 11.6 1.2 89.66 Marked improvement26. 322 0.9 0 100 Completer remission 27. 2308 16.8 1.2 92.86 Marked improvement28. 5323 4.5 0.3 93.88 Marked improvement29. 2160 5.4 1.2 79.63 Marked improvement30. 3889 4.4 0 100 Completer remission

STATISTICAL RESULTS

Table No. 93. Showing the after treatment statistical results of total PASI score of

different areas.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Head total PASI 0.863 0.863 1.404 0.256 <0.001 H.S.

02. Arms total PASI 0.88 0.88 1.351 0.246 <0.01 H.S.

03. Body total PASI 0.376 0.376 0.662 0.120 <0.01 H.S.

04. Leg total PASI 1.393 1.393 2.765 0.504 <0.01 H.S.

Form the above table one can say that statistical analysis holds good for each parts

of the body. Namely head, arms, body and legs. But it is more significant in head arms

and legs as compare to the body. Among the significant parameters (i.e. head, arms and

legs) head and legs showed highly significant when comparing to the arms, (p <0.01.)

Results 134

Table No. 94. Showing the after treatment statistical results of different symptoms of

head.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Scaling (Head) 1.1 1.422 0.259 4.247 <0.001 H.S.

02. Itching (Head) 1.366 1.629 0.297 3.364 <0.01 H.S.

03. Erythema (Head) 0.333 0.884 0.161 2.068 <0.01 H.S.

04. Thickness (Head) 0.286 0.469 0.125 2.288 <0.01 H.S.

The above table one can say that the parameters scaling head, itching head, have

shown significant difference as compared to the remaining parameters namely Erythema

and thickness.

Table No. 95. Showing the after treatment statistical results of different symptoms of

arms.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Scaling (Arm) 1.066 1.436 0.262 4.068 <0.001 H.S.

02. Itching (Arm) 1.166 1.234 0.225 5.068 <0.01 H.S.

03. Erythema (Arm) 0.066 0.253 0.046 1.434 >0.05 N.S.

04. Thickness (Arm) 1.066 1.362 0.248 4.298 <0.001 H.S.

The above table shows highest significant was observed in itching compare to the

scaling. But it is of no less significant in case of thickness when compared to the above

parameters. But it is of no significance in case of Erythema. (p >0.05)

Table No. 96. Showing the after treatment statistical results of different symptoms of

body.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Scaling (Body) 0.133 0.345 0.063 2.11 >0.05 N.S.

02. Itching (Body) 0.466 0.681 0.124 375 <0.01 H.S.

03. Erythema (Body) - - - - -

04. Thickness (Body) - - - - -

Results 135

Form the above table one can say that, according to the analysis; there is high

significance in itching and no significant in the case of scaling (p >0.05). But in case of

other parameters like Erythema and thickness. 0 significance was observed as the before

and after treatment values remained the same.

Table No. 97. Showing the after treatment statistical results of different symptoms of

Legs.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Scaling (Legs) 0.766 0.817 0.149 5.14 <0.001 H.S.

02. Itching (Legs) 0.833 1.019 0.186 4.478 <0.001 H.S.

03. Erythema (Legs) 0.1 0.395 0.072 1.388 >0.05 N.S.

04. Thickness (Legs) 0.13 0.343 0.062 2.11 >0.05 N.S.

Form the above table one can say that, there is high significance in the parameters

like itching and scaling as compared to the remaining parameters like Erythema and

thickness, which are of no significant.

Table No. 98. Showing the a after treatment statistical results of total PASI of all the

parts.

Sl. Parameter Mean S.D. S.E. t-value p-value Remarks

01. Total PASI of all the parts 3.65 3.519 0.642 5.685 <0.001 H.S.

Total PASI includes (head total PASI + arms total PASI + body total PASI + legs

total PASI).

After treatment the total PASI score of all the parts showed highly significant

results as compare to the before treatment. (p <0.01).

Table No. 99. Showing the after treatment statistical results of Manasika bhavas.

Sl. Parameters Mean S.D. S.E. t-value p-value Remarks

01. Krodha 0.333 0.884 0.161 2.068 <0.05 H.S.

02. Bhaya 1.1 1.322 0.241 4.564 <0.001 H.S.

03. Shoka 1.2 1.063 0.194 6.185 <0.001 H.S.

04. Chittodvega 0.733 1.048 0.194 3.77 <0.001 H.S.

Results 136

Form the above table one can say that, significant results are obtained in the

parameters like shoka and bhaya as compared to the chittodvega and krodha, which

shows less significant than the above said parameters.

OVERALL CONCLUSION

All the parameters except Erythema arms, scaling body, Erythema legs, shows

highly significant (p <0.05). 0 significance was observed in Erythema body and thickness

body.

Among the highly significance parameters total PASI, shoka, thickness head,

itching arms and scaling legs shows highly significant than others. (By comparing t

values).

The net mean effect of PASI is more with more variations. But the parameters

Erythema legs, the net mean effect is less with less variation. (By comparing means and

S.D.)

Results 137

Acharya charaka explained long back any hypothesis / principals if to be proved

must be discussed thoroughly form all angles.

If the hypothesis is formed properly it has to be tested and observed by various

methods and eventually the results are obtained. A hypothesis gets established as a

principle if the reasoning given is satisfactory otherwise it remains as it is.

Discussion improves the knowledge and discussion with shastra becomes basic

establishment of the concept. Thus, the discussion is the most essential phase of any

research work. Keeping this as a view the discussion will be made on the following

headings –

01. Discussion on Disease entity.

02. Discussion on Therapeutic regimen.

03. Discussion on Plan of study.

04. Discussion on Observations.

05. Discussion on Clinical response to the treatment.

06. Discussion on Probable mode of action of the therapy.

DISEASE

Kitbha kushta of Ayurevda closely resembles the clinical symptoms of psoriasis.

As per the nature of the disease, this is a chronic recurrent dermatosis. The primary lesion

is a epidermal papule and the papule is pink in colour of various intensity. The fresh

lesions are brighter and older ones are darker. The papules are flat and have rough surface

covered with silvery white, microlamular scales, which scrap off easily. At first the

papules have a regular round countour and a diameter of 1-2 mm of each, latter they

spread peripheral after attaining a size with an intensive itching sensation of the skin. If

we consider the above symptoms, they closely resembles the symptoms of Kitibha kushta

and also the researchers those worked on skin disorders have co-related Kitibha kushta

with psoriasis.

Discussion 138

It is one among the most important skin disorder, because of its frequent

persistent and or recurrence and tendency to disable in proportion of those it affects. The

estimated prevalence in India is 1.5 to 3.5 % in the general population. It may occur on

both sexes. More common in third and fourth decade of life. It usually follows an

irregular chronic course marked by remission and exacerbation of unpredictable onset

and duration. Factors that may leads to more lesions include drug reactions, respiratory

infections, cold weather, emotional stress, surgery and viral infections.

Psoriasis (Kitibha kushta) is not only a somatic but also a disease of psychological

importance since stress, tension and anxiety aggravate the course of the disease.

Regarding the prognosis of the disease, Madhavakara said, if the kushta is due to

dwidoshaja, then it is yapya. It is true till today in spite of rapid advancement in modern

science like physiology, molecular biology, genetic immunology and clinical medicine

the disease still remains recurrent oriented.

Keeping the above facts and also the extensive research works, which is going on

in our science in this particular disease, it was decided to study, the effect of takradhara

karma in Kitibha Kushta (Psorasis). Enormous research works had been carried out in the

field of Panchakarma in order to prove the efficacy of therapies such as vamana,

virechana, basti, etc and even they are proved to be effective. Since Psoriasis involves

both mind and body, Aragwadadi gana kashaya takra dhara was selected for the research

purpose and also there was no research work was done previously on this particular

karma and on this particular disease. Hence, an attempt was made to know the efficacy of

the particular treatment modality in the disease Kitibha kushta (psoriasis).

Discussion 139

SHAREERA

When we look in to the Shareera (Anatomy) of twak, it was observed that Kitibha

kushta (Psoriasis) is a disease caused by abnormal keranitinization. As twak is said to be

one of the main seat of vata dosha, its abnormal clinical manifestation can be observed on

the twak in the form of different clinical manifestations like Vaivarya, Rukshata, etc.

NIDANA

As there is no specific Nidana mentioned in the texts for kitibha we had

considered the samanya Nidana mentioned for kushta under –

a. Aharaja

b. Viharaja

c. Achara &

d. Other nidanas like Chikitsasambandhi sankramika, etc.

Rasa sambandhi

Excessive and regular intake of food articles which are predominance of Amla

and lavana rasa act in two ways –

a. They cause dosha dushti.

b. They cause rakta dushti.

The resultant kushta is a combined effect of both. It is evident form the statement

of the Charakacharya that excessive intake of Amla rasa causes vilayana and pitta vriddhi

and also acts as ubhaya hetu. The same is true with lavana rasa also.

Viruddha ahara sambandhi

According to Acharya Charaka viruddha ahara influences on the equilibrium

status of dosha, dushya, mala and srotas. These may become responsible factors for the

manifestation of the disease.

Discussion 140

The exact role of some of the nidanas mentioned such as papakarmas, gohatya,

etc in the causation of kushta is difficult to understand and analyse. Vagbhata considered

these nidanas as Adrushta karmaja vyadhi hetus.

Manasika karanas like adhika chinta shoka, bhaya and krodha, etc acts as a

vyanjaka (precipitating) hetu because of papa karma. This view is also supported by the

contemporary sciences as the intense stress of the life in concentration camps may

temporarily suppress some psychosomatic skin disorders, which may later recur in severe

form. This psychosomatic mechanism may be implicated in delayed reactions to

prolonged stress.

Because of repeated papa karma (Kaya, Vak, Manasa) which inturn leads to

Manovaishamya i.e. altering the normal functions of manas. These altered functions of

manas like chinta, shoka, bhaya, etc leads to vataprakopa thereby precipitating the

disease condition.

SAMPRAPTI, SADHYASADHYATA & CHIKITSA

While describing the samprapti, it was said that the pathophysiology of kitbha

kushta could be discussed according to the Nidana. By the above-mentioned Nidana,

prakupita vata due to margavarodha carry vitiated pitta, kapha, and lasika in tiryaga siras

and loading them in udakadhara, raktadhara and mamsadhara twachas. If vitiated

shleshma is predominant with sneha, sheeta and picchhila gunas they intern vitiate kleda.

On the other hand, if pitta is predominant with its gunas like sneha and drava, then also

kleda gets accumulated. The accumulated kleda results in srotavarodha leading to vata

vriddhi. Due to this, twacha becomes shyava varna at the same time, due to the ushna

guna of pitta, the dravamsha of kleda escapes through sweda which inturn leads to

ghanibhuta kleda in twacha. This affects in parushata, kharasparsha of twacha, which are

the chief complaints of kitibha kushta.

Discussion 141

In Ayurveda, the prognosis depends on age, sex, immuno status and mental status.

Madhavakara stated that, the kushta which are dwidoshaja are yapya. So as kitibha kushta

is vata kaphaj it is yapya. On the contrary modern science explains above fact that

because of its recurrence it requires persistent treatment and after that also the remission

cannot be denied.

The course of Kitibha kushta is not uniform with periods of excerbations and

recurrences, which varies form days to week, to months to year. Therefore, the

management requires a continuous care approach to control the symptoms, to prevent

exacerbations, relapses and avoiding triggering factors. Again the course and severity of

kitibha kushta varies form patient-to-patient, season-to-season over the years. The

number of guidelines has been developed, but no specific therapy to fulfill the need of the

patient in modern medical care exists.

Ayuredic approach to a disease is definitely psychosomatic in nature. For example

– Kushta is due to disrespect given to the guru, bramhana, doing papa karmas, etc and the

treatment approach of all these diseases includes –

a. Daiva vyapashraya

b. Yukti vyapashraya

c. Satwavajaya

It shows the integrated approach i.e. psychosomatic approach of our acharyas

towards the diseases.

Ayurveda emphasized more medical care than symptomatic cure, for the radical

cure shodhana is indicated in kitibha kushta. Specifically in vata pradhana kushta there is

an indication of Virechana, niruha and anuvasana basti. In kapha pradhana kushta

vamana can be given.

Discussion 142

Takra Dhara, which is proven therapy in may psychological as well as many

somatic problems, had a definite role in kitibha kushta (Psoriasis), which is

psychosomatic in nature.

Acharya sushruta emphasized that Nidana parivarjana is must in the management

of disease. That is to say “Prevention is Better than Cure”. Thus, it is essential to avoid all

physical, psychological and triggering factors.

DISCUSSION ON THERAPEUTIC REGIMEN

Takra dhara karma is delt in detail in dhara kalpam a book in Malyalam literature.

Great Ayurvedic scholars such as Vaidyaratnam P. S. Warier, Ashtavaidyan Vayaskara

N. S. Moos, etc have translated it into English long back. After thorough insight of these

books Argwadadi gana takra dhara karma was selected.

Though, there is no direct indication of Takradhara karma in Kitibha kushta

(psoriasis), considering its utility in dhatu shaithilyata and all kinds of Dosha kopa, it was

selected as a therapeutic regimen. Because dhatu shaithilya and dosha kopa is normally

seen in all kinds of kushtas and also our ancient acharyas like Charaka, Sushruta,

Vagbhata, Bhavamishra, etc had explained the utility of takra lepana and kashaya seka in

different kushtas. Considering this one as a guideline (Shastram Jyotir Prakasharthm…|)

the expanded version of takralepa and kashaya seka was studied as takradhara.

Bhavamishra explained seka as sukshma dhara. (Sekastu Sukshma dharabhi: . . .)

Hence, one cannot deny that there is no reference of the word Dhana in our classics.

Textbooks such as Dharakalpam, Ayurvedic treatments of Kerala, Chikitsa

sangraham, etc have explained Dhatritakrotthadhara in detail. In this present study

Aragwadadi gana was used in the place of Amalaki considering the reference in Chikitsa

samgraha and Ayurvedic treatments of Kerala that according to the disease condition the

kashaya can be changed and used for the Dhara purpose. So Aragwadadi gana kashaya

was selected and used for dharakarma which is indicated in all kinds of kushta.

Discussion 143

Many of the drugs in Aragwadadi gana are having vata kapha nashaka, krimighna,

kandughna action and some of the drugs are having kaphapitta shamaka and vishaghna

action. Both kapha pitta shamaka and vata kapha shamaka actions are justified in terms of

Kitibha kushta, because according to Charaka Kitibha kushta is due to the vitiation of

vata and kapha and according to Sushruta it is due to vitiation of vata pitta.

While purchasing the drugs in the place of Kakajangha, Kakamachi was used.

Instead of black variety of Sahachara white variety was taken and in the place of big

variety of Badara small variety was taken due to their non-availability.

Daily before to Dhara, Gandharvahastadi kwatha 60 ml with luke warm water was

given in order to eliminate the dosha utklesha which usually occurs during the course of

dhara. Though it is having slight anulomana action, it was selected because the drugs

which are their in the kashaya are not having kushtahara properties. This justifies that it

may not have contributed in the reduction of symptoms. But it action on the symptoms

cannot be denied completely.

For Abhyanga (Oil application) purpose on head and body moorchhita tila taila

was selected. Though the text advices taila which is good for the particular disease, it was

decided to use moorcchita tila taila in order to prove the particular effect of dhara in

Kitibha kushta. The moorchhita tila taila dose contain some of the kushtahara drugs like

Manjishta, Yashtimadhu, etc, but their concentration in taila are minimal. Hence, they

cannot exhibit any action over the disease.

In the text it is mentioned that the minimum time duration for performing dhara

karma is 25 minutes and the maximum time duration is 75 minutes. In the present study

45 minutes was fixed for the dhara purpose. Though it is mentioned in text that the time

duration for performing dhara karma is to be started from least and ended at the

maximum time. In the present study standard 45 minutes time duration was followed and

no complications were observed.

Discussion 144

The following Observations were made during the Therapeutic regimen –

If the fine powder is used i.e. fine powder of Yasti and Musta for preparing medicated

milk, it was observed that the fine powder was hampering the curd formation. It may

be due to the interference of fine power with the fermentation process. Hence,

Yavakuta churna was used for preparing the medicated milk.

It was observed that if the fermenting agent (curd or buttermilk) was added to cold

milk the curd was not formed properly. Hence, the fermenting agent was added

always when the milk was in lukewarm state. It may be due to cold environment or

the hampered growth of lactic acid bacillus in cold milk.

During the course of treatment brightness of face, complete remission of hair fall was

noticed on some patients. By this it is proved that dhara is useful in Keshadinam

Shauklyam & Oja kshayam which are the conditions indicated for Takradhara.

Sound sleep was observed on majority of the patients during the dhara procedure. It

may be due to sedative effect of dhara means we are making the patient to

concentrate on one point, closing the eyes with guaze and the calm environment of

dharagraha.

During the course of treatment some patients developed cold. For them the treatment

was stopped for 2 to 3 days and started once again. At that time the precaution was

taken and lukewarmness of buttermilk was maintained properly throughout the

procedure.

Discussion 145

Discussion on plan of the study

A. Selection of the patients –

The patients of both sexes were selected for the clinical trial between the age

group of 14-60 years. The patients were selected irrespective of duration of the disease.

Total 34 patients were reported, but only 30 patients who had fulfilled the inclusion

criteria were taken for the study.

B. Laboratory investigations –

The selected patients were subjected to laboratory investigations like Hb, TC, DC,

AEC, ESR, Urine for albumin and sugar.

C. Diagnosis and confirmation –

The disease was diagnosed as Kitibha kushta based on symptomatology described

in Charaka samhita, Sushruta samhita, Ashtanga hridaya etc, it is added by previous

diagnosis made by the contemporary practitioners, as most of the patients come after

undergoing contemporary treatment. Confirmation was made by Auzpit sign, Candle

grease sign and Kobners phenomenon.

D. Availability –

Patients were availed form different sources such as medical camps, through

advertisement and OPD and IPD of D.G.M.A.M.C.H. & R.C., Gadag.

E. Grouping –

The selected patients were placed in the single group irrespective of age, sex and

chronicity of the disease.

Discussion 146

Discussion on Observations

Age

It was observed from the clinical study, that the age incidence of the disease was

maximum in the patients of age group 20-40 years. It holds well the explanation given in

contemporary science that onset of psoriasis is most common in the second to fourth

decades of life.

Sex

In this clinical study, among 30 patients 22 patients i.e. 73.33% were males,

which is supporting the observation of modern science i.e. prevalence rate is more in

males than in females. The probable reason may be that the males are more exposed to

different types of contacts and environments. So they may be more affected by viruddha

ahara and vihara due to conditions i.e. hostel, business, etc which are the main causative

factor of Kushta.

Religion

A distributed incidence among Hindus and Muslims was seen in this study shows

a greater prevalence was in Hindus 28 patients i.e. 93.33% and 2 patients i.e. 6.66% from

Muslim community. The greater incidence may be due to more population of Hindus in

and around this area.

Diet

It was observed that equal incidence of diet (i.e. vegetarian and mixed) was found.

The study showed there is no specific relation between diet and disease. It may be due to

the random selection of the patients.

Discussion 147

Economical status

Socio-economical status showed 23 cases i.e. 76.66% were form middle class

society. As number of cases included in the study was limited. Hence, It is not worthy to

give conclusion and it also may be due to the random selection of the patients.

Occupation

The incidence of Kitibha kushta was more in the people who were habituated to

sedentary life style. The high percentage ratio (36.6%)was found in above said life style.

It may be due to the excessive concentration over the disease by the sedentary people and

intern develops shoka, chinta, etc which are the triggering factors of psoriasis.

Marital Status

Maximum number of individuals (60%) were married. In this particular

geographical sect, as soon as the age of 18/21 years is crossed the individuals gets

married. As the study is based on based on age of 14 years, it is quite natural to have

more number of patients who were married.

Koshta

The result of the present study showed that the most of the patients were having

Krura and Mridu koshta. It may be due to the desha. The geographical area of the study

was being Jnagala desha, naturally the people will be having dominancy of vata and pitta

dosha. Krura and mridu koshta are having dominancy of vata and pitta dosha

respectively.

Onset

Majority of the patients were having gradual onset of Kitibha kushta (96.66%).

Because the causative factors like Viruddha and mithya ahara vihara are just like gara

visha (slow poison) it is obvious that it acts slowly.

Discussion 148

Addiction

Smoking, Alcohol, Pan chewing, Tobacco, was found in almost all the patients.

Here, alcohol intake and smoking precipitate the disease. This view supports the

contemporary science view.

Prakriti

In the present study, it was observed that vata pitta prakriti (40%) as well as vata

kapha prakriti (50%) patients were dominant. This is possible because Kitibha kushta is a

vata kapha dominant disorder and this particular geographical sect (Jnagala desha) is also

vata pitta dominant in nature. Sara

(86.66%) of patients were having madhyama Sara. Acharya Charaka explained

sara with a view to determine the measurement of the strength of an individual. In the

classics it has been said that madhyama and avara sara are more prone to diseases. It is

also remarkable that no patient was observed having pravara sara.

Samhana

Most of the patients (86.66%) were of madhyama samhana. Madhyama samhana

indicates moderate body compactness and strength. If the person is strong enough then

the viruddha, mithya, ahara, viharas can not affect him. Madhyama samhana and avara

samhana people are usually affected by the above said things.

Satva

Majority of patients were of madhyama satva (66.66%) followed by (23.33%) of

avara satva. Satwa bala decides the severity and the prognosis of disorder. Acharya

charaka has stated that the people with madhyama and avara satva are more vulnerable to

diseases, which is supported by present study.

Discussion 149

Satmya

Most of the patients (76.66%) were belonged to ruksha satmya and most of the

patients were having madhura, amla rasa satmya which is reflective of the nature of the

diet.

Jarana shakti

The study showed that (53.33%) patients were having avara jarana shakti. It is

due to agni mandya which is the prime cause for almost all the diseases. Causative factors

such as viruddha, mithya ahara, etc doesn’t affect if digestive power (agni) is good.

Vyayama shakti

Majority of the patients were having avara vyayama shakti (56.77%) followed by

pravara vyayama shakti (30%). Vyayama shakti is determined on the basis of an

individual ability to perform work. Charaka has very rightly stated that one who does

exercise daily remains unaffected by the diseases.

Nidana

Ahara

Masha and mamsa atisevana, sour food, kulattha, guda, dadhi atisevana

were noted in one or other patients. They may be the cause for vitiating the vata and

kapha which are the prime causitive factors of kitibha kushta.

Vihara

Vega dharana, divaswapna, ratri jagarana, adhika atapa sevana, sedentary

habits were observed in one or other patients and in turn viharas tends to vitiate vata and

kapha. Then intern causes kitibha kushta.

Discussion 150

Mansika Hetu

Emotional disturbances were found in all patients in one or other form like

krodha, bhaya, shoka or chittodvega. It may be due to the self-detachment from the

family and the society, which is resultant of the disease.

Triggering factors

Physical trauma, exposure to hot sun light, withdrawal of cortico steroids have

been observed as triggering factors in most of the patients. The above findings suggests

the hyper responsiveness of the skin.

Poorva roopa

It was observed that most of the patients were having kandu, vedana, rukshata,

daha, raga, vaivarnya, tandra, aswadana, etc. All the poorva roopas explained in the

classics were found in one or the other patients.

Roopa

It was observed from that chief complaints like kandu, shyava or Krishna varna,

khina khara sparsha, parusha, ghanatwa were found in 96.66% cases in various grades

and associated complaints like agnimandya, malabaddhata, toda, chimachimayana,

gourava were found in many patients.

Family history

Out of 30 only two patients (6.66%) has the family history of psoriasis. It may be due to

the small sample size and random selection.

Sleep

Most of the patients (76.66%) complained of disturbed sleep. This may be due to

their complaints and psychological disturbances.

Discussion 151

DISCUSSION ON CLINICAL RESPONSE TO TREATMENT

01. Overall PASI (Psoriasis Area severity Index) score –

Overall PASI score was calculated in the following manner. Before treatment

response of each patients was calculated first, then after treatment response of each of

them was calculated with the help of statistics. (Paired t-test).

The total PASI score of each individual was calculated in the following manner.

a) Head (Ihead + Ehead + Shead + Thead) X Ahead X 0.1 = Total head.

b) Arms (Iarms + Earms + Sarms + Tarms) X Aarms X 0.2 = Total Arms.

c) Body (Ibody + Ebody + Sbody + Tbody) X Abody X 0.3 = Total body.

d) Legs (Ilegs + Elegs + Slegs + Tlegs) X Alegs X 0.4 = Total legs.

(I – Itching, E – Erythema, S – Scaling, T – Thickness, A – Area.)

Finally the total PASI of each patient is-

Total head + Total arms + Total body + Total legs. This PASI score will range

from 0 (No psoriasis) to 96 (covered head-to-toe, with complete itching, redness, scaling

and thickness)

After calculation the over all response was made in the following manner.

Over all effect of the treatment was assed as complete remission (PASI score 0 after

treatment). Best improvement (Reduction in PASI score >75%) Moderate improvement

(Reduction in PASI score between (75%-50%) Minimal improvement (Reduction in

PASI score<50%) and unchanged No reduction in PASI score).

Before treatment the total PASI score of 30 patients was 11.7. After treatment it

was reduced to 4.25. The net reduction rate was 7.45.

Discussion 152

DISCUSSION ON HEAD AFFECTED PATIENTS OF PSORIASIS

Out of 30 cases, 16 cases (i.e.53.33%) were reported with the psoriasis on head.

Out of these 16, those who reported psoriasis only on head (scalp psoriasis) was 7

(i.e.23.3%).

Itching head was present in all the 16 patients (i.e.100%). After treatment

complete remission of itching was observed in 14 cases (i.e.87.5%), moderate

improvement was noticed in 1 (6.25%) case and no improvement was found in 1

case(i.e.6.25%). Totally 95.6% reduction in itching was observed.

Scaling head was found in all the 16 cases (i.e.100%). After treatment complete

remission was observed in 14 (87.5%) cases and no reduction in the symptoms was

observed in 2 (12.5%) cases. Totally the therapy provided 82.5% reduction in symptom.

Erythema head was found in 14 cases (i.e.87.5%). After treatment complete

remission of Erythema of head was observed in 11 (78.57%) cases and no improvement

was observed in 3 (21.42%) cases. Totally the therapy provided 64.28% reduction in

symptom.

Thickness head was observed in all the 16 cases (i.e.100%). After treatment 13

(81.25%) patients got complete remission of symptoms and no response was found in 3

(18.75%) cases. Totally the therapy provided 61.90% reduction in symptom.

Out of 16 cases, complete reduction in area was found in 11 (68.75%) cases,

minimal reduction and no reduction was found in 1 (6.25%) and 3 (18.75%) patients

respectively. Totally 81.25% reduction in area was found in head.

After treatment the total PASI score of head showed, complete remission in 13

(81.25%) cases, minimal response in 2 (12.5%) cases and no reduction in 1 (6.25%)

patient.

Discussion 153

DISCUSSION ON ARMS AFFECTED PATIENTS OF PSORIASIS

Out of 30 patients, 19 patients were reported with psoriasis in arms i.e. 63.33%.

Itching in arms was present in all the 19 (100%) cases. After treatment complete

remission of itching was observed in 11 (57.89%) cases, moderate improvement was

noticed in 5 (26.3%) cases and no improvement was found in 3 (15.78%) cases. Totally

the therapy provided 74.46% reduction in symptom.

Scaling in arms was found in all the 19 cases i.e. (63.33%). After treatment

complete remission was observed in 6 (31.5%) cases, moderate, minimal and no

reduction in the symptom was observed in 1,5 and 7 (5.26%), (26.3%) and (36.84%)

cases respectively. Totally the therapy provided 36.63% reduction in symptom.

Erythema in arms was found in 14 cases (i.e.73.68%). After treatment complete

remission of Erythema was observed in 1 (7.14%) case, moderate improvement was

noticed in 1 (7.14%) case and rest 12 (85.7%) cases not responded to the treatment.

Totally the therapy provided 5.71% reduction in symptom, which is very minimal.

Thickness in arms was observed in all the 19 cases (i.e.100%). After treatment 3

(15.78%) patients got complete remission of symptom, 2 (10.52%) patients observed with

moderate improvement and no response was found in 14 (73.68%) cases. Totally the

therapy provided 13.5% reduction in symptom.

Out of 19, cases complete reduction in area was found in 3 (15.78%) cases,

moderate reduction in 1 (5.26%) case, no reduction was found in 15 (74.94%) patients.

Totally 18.42% reduction in area was found in arms, which is very minimal.

After treatment the total PASI score of arms, showed complete remission in 4

(21%) cases, best improvement in 2 (10.52%) cases, moderate improvement in 3 cases

(15.78%), minimal improvement in 8 (42.18%) cases and no improvement in 2 (10.52%)

patients.

Discussion 154

DISCUSSION ON BODY AFFECTED PATIENTS OF PSORIASIS

Out of 30 patients, 15 patients i.e. 50% were reported with psoriasis on body

surface, which includes trunk area, abdomen, back, genitals, etc.

Itching in body was present in all the 15 cases (i.e.100%). After treatment

complete remission of itching was observed in 4 (26.66%) cases, moderate improvement

was noticed in 7 (46.66%) cases and no improvement was found in 4 (26.66%) cases.

Totally the therapy provided 50% reduction in symptoms.

Scaling in body was found in all the 15 cases (i.e.100%). After treatment

complete remission was observed in 2 (13.33%) cases, minimal and no reduction in the

symptoms was observed in 2 (13.33%) and 1 (6.66%) cases respectively. Totally the

therapy provided 13.33% reduction in symptom, which is very minimal.

Erythema in body was found in 12 cases i.e. 80%. There is no reduction in

Erythema of body after treatment was observed and the pretreatment & post treatment

values remained as the same.

Thickness of lesion in body was found in all the 15 cases i.e. 100%. No reduction

in Thickness of lesion in body after treatment was observed and the pretreatment & post

treatment values remained same.

After treatment there is no reduction in area of the body was observed and the

pretreatment & post treatment values remained the same.

After treatment in total PASI score of body, minimal improvement was noted in

10 (66.66%) cases, moderate improvement was observed in 1 (6.66%) case and no

reduction was found in 4 (26.66%) cases. It is due to the reduction values in itching,

scaling and total PASI calculation, which is calculated after adding the values of itching,

scaling, Erythema and thickness.

Discussion 155

DISCUSSION ON LEGS AFFECTED PATIENTS OF PSORIASIS

Out of 30 patients, 20 patients (i.e.66.66%) were reported with psoriasis in legs.

Itching in legs was present in all the 19 cases (i.e.95%). After treatment complete

remission of itching was observed in 13 (68.42%) cases, moderate improvement was

noticed in 2 (10.52%) cases and no improvement was found in 4 (21.66%) cases. Totally

the therapy provided 71.42% reduction in symptom.

Scaling in legs was found in all the 20 cases (i.e.100%). After treatment complete

remission was observed in 7 (35%) cases, moderate reduction was found in 2 cases,

minimal and no reduction in the symptom was observed in 3 (15%) and 8 (40%) cases

respectively. Totally the therapy provided 25.71% reduction in symptom.

Erythema in legs was found in 15 cases (i.e.75%). After treatment mild and

moderate reduction was observed in 1 (6.66%) case each, no reduction was found in 13

(86.66%) cases. Totally 11.11% reduction in Erythema in legs was noted, which is very

minimal.

Thickness of lesion in legs was found in all the 20 cases (i.e.100%). After

treatment complete remission was observed in 1 (5%) case, moderate reduction was

observed in 2 (10%) cases and mild reduction was noted in 1 (5%) case. No reduction

was observed in 16 (80%) cases. Totally 16.2% reduction in thickness of lesion in legs

was noted.

Out of 20 cases moderate reduction in area was found in 3 (15%) cases and no

reduction was found in 17 (85.00%) cases. Totally 12.5% reduction area was found in

legs which is very minimal.

Discussion 156

After treatment the total PASI score of legs, showed that, complete remission in 1

(5%) case, best improvement in 2 (10%) cases, moderate improvement in 5 (25%) cases,

minimal and no improvement in 4 (20%) cases.

In 7 cases (i.e.23.33%) the lesions were found in all over the body parts. (i.e.

head, arms, body, legs.) The results were not shown because, it was discussed under the

particular part affected.

Out of 30 patients, bhaya was found in 16 (53.33%) cases after treatment,

complete remission was found in 12 (40%) cases, moderate improvement was noted in 1

(3.33%) case and no reduction was found in 3 (10%) cases.

Out of 30 patients, 5 (16.66%) patients got affected with krodha, after treatment

complete reduction was found in 3 (10%) cases, moderate reduction was found in 2

(6.66%) cases. No case was remained un-responded.

Out of 30 patients Shoka was found in 18 (60%) cases, after treatment 16

(53.33%) cases got relieve completely and 2 (6.66%) patients got moderate relief.

Out of 30 patients Chittodvega was found in 14 cases (46.66%), after treatment

complete reduction was observed in 13 (43.33%) cases and 1 (3.33%) case responded

moderately.

OVERALL RESULT

Out of 30 patients complete remission was observed in 8 (26.66%) cases, marked

improvement was found in 7 (25.90%) cases, 4 (13.33%) cases were responded

moderately and 9 (30%) responded mildly. No response was found in 5 (16.66%) cases.

Discussion 157

OVERALL DISCUSSION ON RESULTS

The statistical results showed that, therapy was very effective in reducing total

PASI score. It may be due to the variation in results i.e. the patients who got affected with

psoriasis on head especially scalp psoriasis and palmo-plantar variety of psoriasis were

responded well. At the same time the patients who got affected with psoriasis on body

and other parts of arms and legs (except soles and palms) did not responded well. This is

the reason for reduction in total PASI score.

Though the overall response of treatment in body, arms and legs (except palms

and soles was not good, but the therapy provided considerable amount of reduction in

itching and scaling.

Though the results were shown according to the different sites involvement, one

should not assume that the lesions were present only on that particular site of the

particular patient. Because, some of the patients had two sites involvement viz. head and

body. Some of them had three site involvement viz. head, arms and body and some of

them had all the four sites involvement viz. head, body, arms and legs.

In order to emphasis the efficacy of the therapy in that particular site the results

were given according to the site affliction. Because the statistical analysis showed highly

significant results in all the parameters irrespective of the sites affected.

Out of all the 30 cases, some of the cases reported with the particular site

involvement viz. scalp, palm, soles, genitals, etc. They have included under the concern

part affliction for eg. Scalp affected patients were included under head affected patients

and their after treatment results were also shown according to the parts which includes

the above said sites.

Discussion 158

PROBABLE MODE OF ACTION

Ayurevdic approach to any disease is psychosomatic in nature. In Kitibha kushta

(Psoriasis) there are somatic symptoms like kandu (itching), Ghana (thickness), Parusha

(Dry) and Psychological symptoms like anxiety, stress, depression, and etc are present, so

it is considered as psychosomatic disorders in which both mind and body are affected. So

this aragwadadi gana takra dhara helps in regulating the vitiated shareerika and manasika

doshas.

For better understanding the probable mode of action of takara dhara in kitibha

kustha (psoriasis) can be discussed in the following headings.

01. Medicinal effect

02. Procedural effect

Medicinal effect

The medicines which are used in takradhara karma are having vata kapha hara

properties. Kitibha kushta being vata kapha in nature might have got responded to the

treatment, which contains exact antagonistic medicinal properties to the disease.

“Aushadham Veerya Pradhanavat |” The veerya of the different medicines used

in takra dhara might have entered through four tiryag gami dhamanis which gradually

ramify to hundred and thousands of branches. The network of this dhamanis spread all

over the body and their exterior orifices are attached to the root of hair. It is through these

orifices the veerya is absorbed into the body rather than the medicine themselves.

Through these dhamanis the veerya is circulating all over the body there by causing

samprapti vighatana of the disease.

Discussion 159

Acharya Sushruta explained, the pitta, which is located in skin, is spoken as

Bhrajakagni, in as much as it enables the digestion and utilization of substances used for

abhyanga, pariseka, avagaha, lepana, etc. Dalhana commenting on above and says

bhrajakagni is located in Avabhasini twacha (i.e. 1st layer). Commenting on Vagbhata

Sutra 12th chapter 14th shloka, Arunadutta says Bhrajakagni performs deepana and

pachana of substances used for abhyanaga, lepana, pariseka, etc. Takra dhara is a kind of

pariseka. Hence, the medicaments used in it will be absorbed in the first layer of twacha

i.e. Avabhasini and getting digested (deepana) and metabolized (pachana) by the power

of bhrajakagni. After the digestion and metabolism, the veerya of the medicaments which

are used in dhara spreads all over the body, through tiryag gami dhamanis and exhibits

their action all over the body.

The therapeutic effect is attributed to the medicaments viz. medicated buttermilk,

which exchange through the fine pores present over the scalp and forehead.

The modern physiology and biochemistry says that it is possible to produce a

certain amount of absorption by the application of substances conveyed in the fatty

vehicles (Lovatt Evan’s Physiology). Here the aragwadadi gana kashaya is employed

through the buttermilk, which also contain some amount of fat in it. It is true that for

dhara purpose the fat removed buttermilk is used, then also it may contain some amount

of fat in molecular form. With this molecules the substances may enters through the skin

pores, which is presented in the scalp and might have exhibit their action.

There are three possible roots for absorption. The pilosebaceous follicles play

some part in absorption of many compounds. The trans-follicular absorption, route of

penetration is through the follicular pores to the follicles and then to the dermis via

Discussion 160

sebaceous gland. The permeability of the cells of the sebaceous glands is greater than that

of granular layer of the epidermis. In this way the substances which are used in

takradhara karma absorbed and entered in the blood through and remove pathology.

Procedural effect

Imbalance of prana, udana and vyana vayu, sadhaka pitta and tarpaka kalpha can

produce stress and tension which are the usual triggering factors of the psoriasis.

Takradhara re-establishes the functional integrity between these three subtypes of doshas

through its mechanical effect.

Agnya chakra (the space between the two eyebrows) is the seat of pituitary and

pineal gland. As we know the pituitary gland is one of the main gland of the endocrine

system and exhibits its action on skin, etc. Takradhara stimulates it by its penetrating

effect, which decreases the brain cortisones and adrenalin level, Synchronizes the brain

wave (alpha wave) and strengthens the mind which is usually disturbed in psoriasis.

By takradhara, patient feels relaxation, both physically and mentally. Relaxation

of the frontalis muscle tends to normalize the entire body activity and achieves a decrease

activity of sympathetic nervous system with lowering of heart rate, respiration, oxygen

consumption, blood pressure, brain cortisones and adrenalin levels, muscle tension and

probably increase in alpha brain waves. It strengthens the mind and spirit and this

continues even after the relaxation. Corresponding to different levels and powers of

consciousness there are nerve plexus and glands in human organisms. Special stimulation

of different nerve plexus, glands and brain cells accompanies mental functions of

different levels. Takradhara which contain many kushtahara property drugs may

stimulate the endocrine, nervous and immune system and there by it may reduces disease

pathology.

Discussion 161

In Kushta, dhatus are involved and dhatu shaithilyata takes place due to vitiated

doshas. It is clear from our texts, that the dhatu kshaya will leads to ojo kshaya and also

the ojas is getting kshaya due to kopa, shoka, etc which are the triggering factors of

psoriasis. Reduction in chittogvega kopa, shoka are taking place due to takradhara, which

in turn over comes the oja kshaya. It is stated in the benefits of takradhara that it is best

therapy for ojokshaya. Hence, it is having definite role in samprapti vighatana of Kitibha

kushta (Psoriasis).

Discussion 162

A

SPECIAL CASE SHEET FOR KITIBHA KUSTHA (PSORIASIS) Post Graduate studies and research centre, (Panchakarma)

Shri. D.G.M Ayurvedic Medical College, Gadag Guide: - Dr G.Purushottamacharyulu

M.D.(Ayu) Scholar: P. Chandramouleeswaran

Co-Guide:- Dr S.H. Doddamani. M.D.(Ayu)

1. Name of the patient _________________________ SL. No O.P.D. No I.P.D. No 2. Father’s / Husband’s Name ___________________

3. Age ______ yrs, Place of Birth _______________

4. Sex Education __________________ M F 5. Marital Status M ( ) UM ( ) 6. Religion H. ( ) / M ( ) / C ( ) Others ( )

7. Occupation Labour ( ) Student ( ) Executive ( ) Sedentary ( )

8. Economical status P ( ) / LM ( ) / UM ( ) / R ( )

9. Address ________________________ E-mail ID _________________

_________________________ Phone No :______________

_________________________ Pin. : ___________________

D M Y D M Y 10. Date of schedule initiation Completion

11. Result

Well Responded

Moderately Responded

Mildly Responded

Not Responded

CONSENT I am fully educated with the disease and treatment there by I got satisfied. I

accept for medical trail on me happily.

Signature of Patient

B

A. Pradhana Vedana Vruttanta Avadhi Before After

Shyava or Krishna varna

Kina khara sparsha

Parusha

Kandu (Itching)

Srava (exudate)

Ghana (thickness)

B. Anubandhi vedana Vruttānta Avadhi Before After

Loss of Appetite (Agni Mandya)

Irregular bowel habits (Malabaddhata)

Over sweating (Ati Sweda)

Absence of Sweating (Asweda)

Heaviness of the body (Shareera Guruta)

Numbness (Suptata)

Formication (Chimchimayana)

Pain (Toda)

C. Adhyatana vyadhi vruttānta

a) Onset of skin lesion Sudden ( ) Gradual ( ) Insidious ( ) b) Site of onset Scalp ( ) Trunk ( ) Upper Extremity ( ) Lower Extremity ( )

D. Chikitsa vruttanta: (If any)

New Case ( ) Treated ( ) Under Treatment ( ) Previous Medication: Allopathy ( ) Ayurveda ( ) Others ( ) Response: No ( ) Mild ( ) Moderate ( ) Good ( ) Drugs used: (If any) E. Purva vyadhi Vruttanta: (If any)

F. Kula Vruttanta: History of Psoriasis in family ( )

C

G. Vayaktika vruttanta : 1 Ahāra Vegetarian ( ) Non Vegetarian ( ) 2 Vihāra Nature of work : Hard ( ) Moderate ( ) Sedentary ( ) 3 Agni Samāgni ( ) Mandāgni ( ) Teekshāgni ( ) vishamāgni ( ) 4 Kostha Mrudu ( ) Madhyama ( ) Krura ( ) 5 Nidra Prākruta ( ) Alpa ( ) Ati ( ) Diwāswapna ( ) 6 Vyasana None ( ) Tobacco ( ) Smoking ( ) Alcohol ( ) 7 Artava Regular ( ) Irregular ( ) Menopause ( )

Samanya Pareeksha A. Asta sthāna Pareeksha : B. Vital examination

1 Nadi /Min

2 Mala

3 Mootra

4 Jihwa

5 Shabda

6 Sparsha

7 Druk

8 Akruti

1 Heart Rate /min 2 Resp. rate /min 3 Blood Pressure mm of Hg4 Body Temp / F5 Body weight Kgs.

C. Dasha vidha Pareekshā :

1 Prakruti V ( ) P ( ) K ( ) VP ( ) VK ( ) PK ( ) Sama ( )

2 Sāra Pravara. ( ) Madhyama. ( ) Avara ( )

3 Samhanana Pravara ( ) Madhyama. ( ) Avara ( )

4 Pramana Pravara ( ) Madhyama. ( ) Avara ( )

5 Sātmya Ekarasa. ( ) Sarva rasa ( ) Vyamishra ( )

Rooksha satmya ( ) Snigda satmya ( )

6 Satva Pravara ( ) Madhyama ( ) Avara ( )

7 Ahara Shakti a) Abhyavaharana shakti P ( ) M ( ) A ( )

b) Jarana shakti P ( ) M ( ) A ( )

8 Vyayam Shakti Pravara ( ) Madhyama ( ) Avara ( )

9 Vaya Bala ( ) Yuva ( ) Vrudda ( )

D

D. Sroto Pareeksha : Observed Lakshanas.

1. Rasavaha srotas

2. Rakta vaha srotas

3. Mamsa vaha srotas

4. Sweda vaha srotas

5. Pranavaha srotas

6. Annavaha srotas

7. Udakavaha srotas

8. Medavaha srotas

9. Asthivaha srotas

10. Majjavaha srotas

11. Sukravaha srotas

12. Pureeshavaha srotas

13. Mutravaha srotas

14. Artavavaha srotas

15. Manovaha srotas

E. Vishesha pareeksha of twachā (Special examination of skin) Character of lesion

Area Localized ( ) Generalized ( )

Size Small ( ) Large ( )

Area of skin

affected

Scalp ( ) Elbow( ) Palms ( ) Soles ( ) Trunk ( ) Back ( ) Knee ( )

Arms ( ) Legs ( ) Generalized ( )

Colour Bright red ( ) Red ( ) Dull red( ) Pink ( ) Bluish Brown ( )

Surface Dry ( ) Moist ( ) Greasy ( ) Scaly ( )

Borders Round ( ) Polycyclic ( ) Irregular ( ) Demarcated ( )

Texture Oedamatous ( ) Rough ( ) Smooth ( )

Pattern Linear ( ) Annular ( )

Associated with Pain ( ) Itching ( ) Burning ( ) Others ( )

Shape of lesion Macule B A Papule B A Plaque B A

Hypo pigmented Scaly Erythematous

Hyper pigmented Accuminate Silvery Scale

Erythematous Dome shaped

E

I. Nidana :

A. Ahara Hetu

Honey + Milk Milk + Fish

Milk + onion Kichadi + Milk

Rice with milk Ati dadhi sevana

Tila taila ati sevana Kulattha ati sevana

Mamsa ati sevana Guda ati sevana

Moolaka ati sevana Ushna & Teekshna ahara

Guru ahara ati sevana Vidahhi ahara ati sevana

Excessive sour food intake Ati snigda sevana

B. Vihara Hetu

Vega dharana Divaswapna

Ratri jagarana Sheeta Ushna viparyaya

Excess physical work

C. Manasika Hetu

Chittodvega Krodha

Bhaya Shoka

D. Triggering factors

Trauma Sunlight

Emotional stress Drugs

II. Purva rupas : Slno Laxana Before After Sl.no Laxana Before After

1 Adhika Sweda 6 Kledata

2 Asweda 7 Shareera guruta

3 Atislakshnata 8 Aruna Varna

4 Kandu 9 Vivarnata

5 Kharata 10 Suptata

F

III. Rupas :

Lakshanas Before Treatment

After Treatment

1 Shyava / Aruna /Asita / Krishna Varna

2 Kina khara sparsha

3 Parusha

4 Sravi

5 Vruttam

6 Ghana

7 Kandu

8 Snigda / Ruksha

9 Asweda

10 Matsyashakalasannibham

11 Vruddimanti

12 Guruni

13 Druda

14 Punah:prasavati

15 Prashantate Punha punah Utpadyate

Gradings : Normal -0 Mild-1 Moderate-2 Severe-3

IV. Samprapti

V. Samprapti ghataka’s

1 Dosha 6 Srotodusti prakar

2 Dusya 7 Adhistana

3 Ama 8 Sanchar sthana

4 Agni 9 Roga marga

5 Srotas 10 Vyadhi swabhava

VI . Upashaya : Anupashaya : VII . Vyadhi vinischaya :

G

VIII. Upadrava : IX . Sadhyasadhyata : Sukha sadhya ( ) Kastha sadhya ( ) Yapya ( )

X . Laboratory Investigations :

Sl. Name of the test Values

1 ESR /1st hour

2 Hb% Gm%

RBC Per cm3 Total count

WBC Per cm

N E B M L 4 Differential count

5 AEC (Absolute Oesinophil Count) Per cm

6 Urine for albumin and sugar

XI. Chikitsa: Takradhaara Dainamadiana Neerikshana

DAY Time of performance Duration

H

XII. Objective Parameters PASI SCORING

Skin sections*

Itching Erythema Scaling Thickness of lesion

Coverage Area*

% of B,S,A

Total PASI

HEAD10%B.T + + + × x 0.1 = After treatment + + + × x 0.1 = ARMS20%B.T + + + × x 0.2 = After treatment + + + × x 0.2 = BODY30%B.T + + + × x 0.3 = After treatment + + + × x 0.3 = LEGS40%B.T + + + × x 0.4 = After treatment + + + × x 0.4 =

Total PASI Before Treatment

Total PASI After treatment

Severity⊗ Score

None 0

Mild 1

Moderate 2

Severe 3

Maximum 4

*Coverage Score

0 % 0

<10% 1

10-29% 2

30-49% 3

50-69% 4

70-89% 5

90-100% 6

Overall Assessment of Clinical Research

01. Complete Remission – PASI score 0 after treatment.

02. Marked improvement – Reduction in PASI score >75%.

03. Moderate improvement – Reduction in PASI score between 75% and 50%.

04. Minimal improvment – Reduction in PASI score <50%.

05. Unchanged – No reduction in PASI score.

Guide’s signature Investigators signature (Dr. G. Purushottamacharyulu) (P.Chandramouleeswaran)

I

The severity of itching, scaling, Erythema and thickness was assessed in the

following manner

A. Itching

01. None – No itching.

02. Mild – Itching subside; when he / she scratches.

03. Moderate – Reduction in itching by internal medicaments.

04. Severe – Reduction in itching by internal and external medications.

05. Maximum – After medicaments also the patient gets itching sometimes.

B. Erythema

01. None – No Erythema.

02. Mild – Patch with reddish tinge.

03. Moderate – Patch with dull red colour.

04. Maximum – When it is bright red in colour with severe itching.

C. Scaling

01. None – No scaling.

02. Mild – On scratching if the scales settle in pits on nails.

03. Moderate – If the scales fall on around where he scratches.

04. Severe – Scales found in his/her cloths without scratching.

05. Maximum – Scaling found on bed etc without scratching.

D. Thickness – Purely subjective.

The severity of krodha, bhaya, etc were assessed in following manner –

A. Krodha

01. None – No Krodha.

02. Mild – Gets anger but not showing outside.

03. Moderate – Shouting loudly, throughing the articles occationally.

04. Severe – Shouting loudly and making harm to others occationally.

J

B. Shoka

01. None – No Shoka.

02. Mild – Disturbance in concentration, occational thinking of his/her problem.

03. Moderate – Always thinking about his problem with mild disturbance in

sleep.

04. Severe – Not responding to others properly with complete disturbance of

sleep.

C. Bhaya

01. None – No Bhaya.

02. Mild – Gets occational fear by thinking about the illness.

03. Moderate – Fear causing occational disturbance in day to day activity.

04. Severe – Fear causing occational disturbance in day to day activity, sudden

disturbance in sleep.

D. Chittodvega

01. None – Zero.

02. Mild – Patient not anxious about the disease.

03. Moderate – Will be anxious, but having the belief that the disease will be

cured.

04. Severe – Doesn’t have belief in any therapy and worried that the disease will

not be cured.

CONCLUSION

Based on the observation made in the study the following conclusion can be

drawn –

Takradhara is a modification of the Shirahseka procedure, which comes under the

type of Moordhni taila.

The word “Dhara” is available in our classics (Sekastu Sukshma Dharabhi: | B.P.).

Considering utility of takralepana and kashaya seka in kushta, the improvised

study was conducted was conducted in the name of takradhara.

No severe side effects were observed in the study, through some of them

complained of running nose, etc.

Though statistical analysis of after treatment results of total PASI score showed

highly significant. It was observed that the procedure was highly effective in scalp

and palmo-plantar variety of psoriasis.

Reduction in symptoms like scaling and itching was found in all most all the

patients.

No reduction or mild reduction was observed in Erythema of arms, body and legs.

Maximum reduction in Erythema was found in head.

Maximum reduction in thickness of lesion was found in head comparing to arms

and legs. In body it was very minimal.

In the body the affected area was not reduced after the treatment.

Overall treatment response was good in head while comparing to other parts.

In head affected patients, the therapy provided complete remission in almost all

the cases, but in some cases it doesn’t even had a minimal impact.

Conclusion 163

Significant reduction was found in triggering factors like bhaya, krodha,

chittodvega, etc.

During follow up period the results attained seemed to wear out in body

completely, minimal in arms and legs. But results lasted throughout the follow up

period in the head affected patients.

LIMITATIONS OF THE STUDY

01. The sample size was very small to generalize the result.

SUGGESTIONS FOR FUTURE STUDIES

⇒ The study should be conducted in a large sample.

⇒ The study should be conducted for a longer duration so as to know the

lasting of the clinical effects.

⇒ The study should be conducted along with the shodhana procedures.

Conclusion 164

SUMMARY

The dissertation work entitled “Evaluation of the efficacy of the takradhara in

Kitibha Kushta (Psoriasis)” consists of seven parts. They are

1. Introduction

2. Objectives

3. Review of literature

4. Methodology

5. Results

6. Discussion

7. Conclusion.

The introduction highlights on aim of Ayurveda, importance of

Panchakarmas, psychosomatic approach to treatment of Kitibha kushta, Dharakarma,

Takradhara and Kitibha kushta. The objectives part describes the need for the study,

previous studies on Takradhara, title of the present study and the objectives of the present

study. Review of literature part covers the historical view on Takradhara karma and

Kitibha kushta, Nirukti and Paribhasha of Takra, Dhara and Kitibha Kushta, Shareera of

Twak (Rachana and Kriya), description of Takradhara procedure in particular and

description of Kitibha kushta. Methodology part contains review of the properties and

chemical composition of the drugs used, methodology of the clinical study, procedures of

Takra dhara karma and the parameter for clinical assessment. The results part contain

demographic data, data related to the disease, data related to the overall response to the

treatment, statistical analysis of the clinical parameters. Discussion part consists of the

headings Discussion on disease, therapeutic regimen, plan of the study, observations, and

clinical response to the treatment, probable mode o action. Conclusion part contains the

conclusions of the present study and suggestions for future study.

Summery 165