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EVALUATION OF THE EFFICACY OF TAKRADHARA IN KITIBHA KUSHTA(PSORIASIS), CHANDRAMOULESWARAN.P. Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103.
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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