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Introduction

Skin that is ‘twak’ considered among panchajnanedriyas. In Sushrut Samhita twak is described as ‘Kshirasya Santanika’ that is cream part of the milk.[1] As the largest organ, skin diseases contribute higher group of health problems in general clinical practice. In classic Ayurveda literature, all skin diseases are broadly mentioned under heading Kushtha. [1,2] A simple discolouration (twak vaivarnyata) to the process of irreversible cell death is included under spectrum of Kushtha. [1] Acharya Charaka specifically mentions involvement of all seven dhatu (vitiation) that are mentioned as Saptadravya sangraha for Kushtha.3,4 According to Ayurveda, kushtha is categorized into mahakushtha and kshudrakushtha. Kitibha kushtha is one of the kshudra kushtha. [3,4] In recent medical terminologies Kushtha is correlated with psoriasis as manifestations of both shows similar symptoms and signs. The causative entities of this tridosha and krimija kushtha roga includes shitoshna krama parivartan (not following norms for hot and cold in terms of ahar and vihar), vega dharan (retention of urges), atimatra of drava (liquid), snigdha (unctuous), guru (heavy) annapana. Atisevan of vyayam (over exercise), dadhi (yogurt), lavan and amla rasa (salty and sour foods), masha (black gram), immediate use of cold after heat related work.[5] Mental factors like bhaya (fear), santap (anger), upahatachetasa (depressing thoughts) also contributes immensely. Further, mithya aahar and achar (abnormal food and regimen), vyayam (excessive exercise), gramya-anup-audaka mamsa (meat), chhardi vega dharana (suppression of vomitus), gramyadharma sevan (excessive sexual activity), payas (excessive milk and milk products) also play a very important role.[6] Scalp psoriasis can make one worry about how others look at them as discolored patches on skin (plaques) or scalp and other areas around scalp are developed. It can also affect ones’ behavior and how person think about themselves. Person may further become self-conscious or experience stress, anxiety and depression.

CASE DETAILS:

Presenting complaints – A 43-year-old male came to OPD with complains of Shiro Kandu (itching on scalp), Kesha Patan (Hair falling), Darunaka (Dandruff) for about a year.  There was black skin lesion developed on frontal region of scalp with severe itching and roughness at same place. Patient was also having burning sensation after sweating. These patients’ lakshana are same as kithibha kushtha such as shyava, keenasparsha, parusha. Patient had taken allopathic treatment for 7 months but did not get any much relief. Routine blood investigation was done to rule out any possible associated disorder. There was a history of occasional alcohol consumption. Patient worked in an industry where he faces stressed environment and needs to sit for long time in air conditioning (AC), which are main triggering elements in the disease exacerbation is stressed out psychologically.

MATERIALS AND METHODS:

Lab investigations: CBC, ESR, Urine routine and microscopy, Lipid profile, Blood glucose levels were tested.

GENERAL EXAMINATION:

Personal history -Ahar & vihar included Excessive guru ahara/heavy food (fish, rice), mamsa sevan (meat), viruddha ahar/incompatible food (milk shakes, biryani). Long time sitting type of work provided with AC exposure. Patient faced less appetite, disturbed sleep. Patient was having hypertension and was on medication of Telmisartan (5 mg once a day). 

SYSTEMIC EXAMINATION:

Asthavidha Pariksha: Nadi(pulse) – 74/min; Mala (stools) – once/day samadhankaraka, kwachit baddha mala; Mootra (urine) – 4-5 times/day; Jiwha (tounge) – Sama, Upalipta; Shabda (speech) – Samyak (proper); Sparsha (touch) – Alpa ruksha (little rough); Druk (eyes) – Doosar varnya; Akruti (built) – moderate; Nidra (sleep)- khandita; sweda (sweat)-alpa.

Samprapti ghataka: Dosha – Vata Kapha Pradhan tridoshaja; Dushya – Rasa, rakta, mamsa; Upadhatu – Sira, Twak, Snayu; Ama – Agnimandyajanya; Agni – Jatharagni, dhatwagni; Srotas – Rasavaha, Raktavaha, Mansavaha, Swedavaha; Vyakta sthana – twacha; Udbhava sthana – Amashaya; Roga swabhava – Chirakari; Sadhyasathyatwa – krichrasadhya.

Clinical findings: Patient was having lesion on scalp with discoloration of skin around lesion and loss of hairs around it were observed. Lesion was associated with blackish red in colour, severe itching, and burning sensation after sweating. The affected skin was very dry and course on touch. These lakshana are vata pitta Pradhan, and thus the patient was diagnosed with kitibha kushtha (psoriasis).

Line of treatment: Kushtha is one of the chronic diseases and takes longer period to cure. It is one of dushta karma and doshajanya vyadhi so the treatment should be also karmakshayakara and doshshayakara. In the treatment of kushtha where vata is predominat, ghee should be administered, when kapha is predominant vaman procedure should be done and where pitta is predominant, blood-letting should be done after purgation is given to the patient.[7] Upon examining the patient, it was known that the patient had unusual work hours (night shifts) and was identified with a case of hypertension. It is well known that rise in systolic pressure occurs during Vaman procedure.[8] Due to these patients’ medical conditions, Vaman was not indicated, and therefore, Shamana and Shodhana treatment was administered to the patient. Jalaukaavcharan, mrudu nitya virechana and shaman aushadhi was advised.

MANAGEMENT:

 (A)  Medicinal Treatment

The patient was advised to take the medicine course for 75 days as shown in table 1. Jalaukaavacharan was given for two sittings, one on 30th day and second was given on 45th day.

(B) Dietary management and lifestyle modification

Chikitsa is not only about medications but diet and lifestyle modifications also play important role in curing diseases. The patient was advised to follow the dietary plan very strictly. Patient was advised to avoid Amlarasa and Teekshna Dravyas (spicy) and salty foods, Pittaja Ahara-Vihara, Adhyashana, Divaswapna, Raatri Jaagarana, stress, anxiety, etc. He was also advised to avoid Maida products, meat, milk, and milk products, Kulattha, Masha, sprouts, pickles fermented food and seafood. Patient was further advised, to avoid sitting in AC as much as possible, apply oil to both the nostrils, stick to only three meals in a day, to exercise (such as walking and suryanamaskar) and do pranayam (anulomavilom), to plant trees and do dhupana (fumigation) with nimba patra in the house.

Observation and results:

CBC, ESR, Urine routine and microscopy were within normal limits, Lipid profile, Blood glucose levels were within normal limits. As per the schedule, the patient was given medication for 2.5 months and was asked to follow the diet after two months of treatment; itching and burning were reduced.  After 2.5 months of months of treatment, remarkable changes were seen in patches; itching and burning sensation were absent. Patches on scalp disappeared after 30 days of treatment (Fig. 1). Significant improvement in all signs and symptoms was seen (table 2). Hypertension was reduced to normal, abdominal distention disappeared, problem of constipation was also reduced, and patient felt fresh after waking up from bed with sound sleep.  No recurrence of black patches on the scalp were found up to two months after treatment. No relapse was found in any sign and symptoms of Kitibha Kushtha.

Discussion

In this case study, the disease was manifested due to improper lifestyle adaptations and some of stressed out psychologically. Kapha & pitta dosh involvement is seen with the dushti of swedavaha srotas pervading twacha. Nidana Parivarjana is first line of treatment in any disease. In this case, sitting in AC for long time was the main factor to be considered and patient was told to minimize the period as per his convenience.

Udwartana was done with lodhra and amlaki churna as lodhra acts as sandhaneeya / wound healing, amlaki acts as rasayana and helps for strotoshuddhi of twacha. Kanchana rasayana is specially used for kleda dushti in sharir as it contains haridra, daruharidra, amragandhi haridra, yashada bhasma. It acts as vranaropaka and heals the wound. Pachaka churna contains vara, raktapachak, dhamasa, sajjikshar it acts as Deepana, Pachana, Anulomaka and Raktaprasadaka, Bhringaraja chuna reduces the vitiated Pitta Dosha and Rasagata Pitta which improves Rakta Dhatu Pushti. Arogyavardhini vati contains Tikta Rasa Pradhana Dravyas, so it does Kaphapitta Shamana. It has action on Rasa, Rakta, Mamsa and Meda Dhatu. It acts as Agnideepana, Raktapachak and has Sukshma Srotogami property. Abhraka and Gandhaka present in this act on Rasa and Rakta Dhatu. Kutaki does Pitta Bhedhana and removes obstruction for the action of Bhrajaka Pitta. Being Tikta Rasatmaka acts on skin, removes Kleda. It improves digestion and metabolism and expels waste products from the body due to its Shodhana nature.[9] Gandhaka rasayana, is one of the best drugs of choceas it is Raktashodhak, Vranaropak, Twachya, Krumighna. Gandhaka Rasayana as able to keep the Vata, Pitta, Kapha, Dosha balanced.[10]  Krimikuthar Ras is an important formulation which contains Karpura, Kutaja, Trayamana, Ajamoda, Vidanga, Hingula Bhasma, Vatsanabha, Palasha Beeja, it is specially indicated in Krimi Janya Tvak Vikara It has agents which enhance strength as well as cardiac output.[11] Fungiwin cream contains Shuddha Gandhaka, Shudhha hingu, Karanja taila, Shatavari and is beneficial in case of itching, irritation, dryness, scratching. Its contents are having anti-inflammatory, anti-oxidant properties given for local application. Panchtiktaka ghruta guggulu were predominantly of Tikta Rasa, Ruksha and Laghu Guna. It acts mainly on Kleda, Meda, Lasika, Rakta, Pitta and Kapha. It subsides the symptoms like Rukshata, Daha, etc., it has properties like Deepana, Pachana, Strotoshodhak, Raktashodhak, Raktaprasadak, Kushthaghna, Kandughna and Varnya. The Ghrita has lipophilic action which helps to carry drugs to the target organs, it enters to its cellular level and delivers to mitochondria and nuclear membrane. It maintains the normal texture of skin.[12] Marichyadi taila, most of Dravyas are having properties like Katu, Tikta, Kashaya Rasa and Ushna Virya which does the Shamana of Kapha and Vata Dosha. Its Snighdha Guna reduces the Rukshatva, Kharatva and Parushata. It has properties like Raktashodhana, Kushthaghna and Kandughna. The nature of Taila is Sukshmagamitva means it helps drugs to go into the minute channels and does the proper absorption.[13] Jalaukavacharan - As per the Chikitsasutraof Kushtha, one should perform Shodhana Karma according to Dosha dominance.[10] Also, in Raktamokshana Chikitsa, Alpa Kushtha needs Prachhan or Jalaukaavacharana.  Considering Raktadushti and local Raktamokshana    Chikitsa, Jalaukaavacharana proves very effective in reducing raktadusti on scalp. As sitting in AC for longer duration is part of patient’s occupation which can be modified by applying oil to both nostrils while sitting in AC as it will restrict pranavaha sroto dushti (vitiation of respiratory route). Diet and exercise also go hand in hand with medications. Eating three-meals- a day format in which dinner taken before sunset (7 pm) leads to proper digestion of food and also reduce the chances to ajirna/kleda. Exercise like walking and suryanamaskar and pranayama such as anulomavilom, planting trees, etc. helps in relieving day to day stress and contributes towards for mental stability and overall well-being physiology. Dhupana with nimba patra in the house helps towards fumigation of the surrounding thus keeping the environment healthy.

Conclusion

Ayurvedic internal medications given act as Pachan, Deepan, Tridosha Shaman, Kleda   Nashan, Kandu-Kushtha Nashan, andrasa Rakta Prasadana along with Jalaukaavacharana. This case study showed that the patient was cured in 75 days and thus proves that Jalaukaavacharana and ayurvedic internal medicines can not only cures kitibha kushtha but also prevents recurrence of the Vyadhi. Raktamokshana and medicines along dietary and lifestyle modification was also found effective.

This is a cost-effective treatment method for Kushtha and needs no hospitalisation.