Kitibha kc022 gdg


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To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis), Yasmin, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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Kitibha kc022 gdg

  1. 1. 1 INTRODUCTION Skin disorders constitute one of the largest groups of health problems in generalpractice opting Ayurvedic treatment for variety of skin disorders has also increaseddramatically. Fortunately, Ayurvedic Medical Literature has bestowed substantial informationregarding the diagnosis and management of skin disorders. The term “Kusta”mentioned in ancient Ayurvedic Literature represents variety of skin manifestationsranging from a complex leprosy to a simple eczema. The different lesions are broadlyclassified and studied in two groups viz. the Mahakusta and the Kshudra Kusta1. Kitibha Kusta is a form of Kshudra Kusta. Based on the similarities of symptomsand other descriptions available in the medical literature, many of the Ayurvedicresearchers and authors of recent past who have worked on skin disorders haveequated it to psoriasis; a skin condition which involves genetic and immunologicalderangement and is classified as a keratinization disorder described in modernDermatology. It is described as a Kshudra Kusta or minor kusta, probably because; it isneither a life threatening disease nor a disabiling disorder. But that should not underratethe importance of its study, as it affects a substantial portion of population (around 2%)causing a major psychosocial and cosmetic problem. The symptoms and complaintsare serious enough to cause the patient significant emotional distress or impairment inpatient’s ability to function in social and occupational roles. Psoriasis is a chronic, recurrent, nonallergic, noncontagious, papulo-squamousdisorder of skin and is a complex phenomenon, the etiology of which is not certain,showing a wide variation in severity and distribution of skin lesions. It is one among themost important skin disorders because of its frequency, persistence and/or recurrenceand tendency to disable in a proportion of those it affects. It may occur in both sexes,To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  2. 2. 2more common in the 3rd or the 4th decades of life. It usually follows an irregular, chroniccourse, marked by remissions and exacerbations of unpredictable onset and durations.Factors that may lead to more lesions include drug reactions, respiratory infections, coldweather, emotional stress, surgery and viral infections2. Psoriasis (Kitibha) is not only a somatic, but also a disease of psychologicalimportance since stress, tension and anxiety aggravate the course of the disease. Vatais considered as one of the important factor in the psychological impairments3, where inchinta, shoka, bhaya etc., in excess leads to its aggravation. Twak is considerd, as themain ashraya for vata when this vata is vitiated the lakshnas will be manifested intwacha. Indeed, the medical faculty to counter this disease has devoted a lot of attention.But the reality is; the present health care delivery system is poorly prepared to deal withthe disease. The modalities of management of Psoriasis/ Kitibha Kusta are only palliative andrecurrence oriented. The topical applications and internal medications provide only atemporary relief to the patient. Considering the chronicity of the disease they have avery limited role to play. And also most of the drugs used for the remission of thisdisorder are known for their potent side affects. In the above situation, there is a need for an effective and multidisciplinaryapproach to attend this, so as to have long-term benefits causing minimum side effects.Checking relapses is another important factor to be taken care of. Ayurveda has got an abundant area for the treatment of such skin disease.Among them panchakarma plays a major role. Diseases of skin can be well cured withthe help of pancha karma. Generally the pancha karma like vamana and virechanaraktamokshana are best suited and result oriented in the management of kitibha kusta4.Similarly vasti plays a good role in the management of disorders caused due to vata,To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  3. 3. 3since vasti has been considered as ardha chikitsa5 i.e., vasti itself acts as half of thetreatment. Kitibha is said to be tridoshaja but it is pittanubandha vata kaphaja. Where insymptoms related to vata are more prominent than that of the other doshas (parushata,kharata) etc. Psychological factors are also said to be disturbed in kitibha kusta. Keeping all such factors the present clinical trial is an effort to make the patientfree from all the symptomatology there by minimizing the recurrence rates. Hence the present clinical trial is undertaken to evaluate the role of yoga bastiand efficacy of patoladi compound in Kitibha Kusta.Study design: - 28 Patients from out patient department of D.G.M. Ayurvedic MedicalCollege and Hospital, Gadag were scrutinized and considered for the study. Objectiveparameters like complete blood picture, random blood sugar levels were considered toexclude the patients from other disease. 28 patients were equally distributed into twogroups as shamana and shodhana groups. Shodhana group patients will undergoyogabasti for 8 days followed by parihara kala and later by shamana yoga for 60 days.Patients those who were in shamana group will have only shamana yoga i.e., patoladicapsules, in the dose of two capsules three times a day with water. Patients wereadvised to visit the hospital twice in a month to record the progress. The tretment wascontinued for two months.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  4. 4. 4 REVIEW OF LITERATURE The history and literature enables to understand the ever-changing modalities oflife, in this connection the knowledge of origin, existance and variation in the pattern ofthe diseases. The Ayurveda is the oldest system of medicine and philosophy of life.Thus all the diseases and treatment aspects concerned the medicines are available fromancient time to the present period in different manners, So literary aspects play animportant role in determining various diseases and their treatment.Derivation of Kusta (Vyutpatti)“KUSTA”: - The word Kusta is derived from the root “KUSH” which means that whichcomes out from the inner part to outer part. In the term Kusta, the word “KUSH“ is added to “HANI” to form Kusta, whichgives a meaning that it gives an ugly look to the body6. The word “Kusta” is derived from dhatu “Kush “ meaning; the morbid factorsmainly Raktha is drawn towards the region of twak so as to cause Kusta. 6Definition of Kusta (Paribhasha) According to Arunadatta, Kusta is defined as that which causes disfguerment tothe body.NIRUKTI AND PARIBHASHA OF KITIBHA KUSTA The term Kitibha is constituted by the combination of “Kiti’ and “Bha”. The wordkiti refers to a variety of insect, which is black in colour and stays in Kesha Pradesha orin hair.7 The word “Kiti” is also termed as “Akuna” by Hemadri. This indicates that it iseither a louse or some other insect, which is similar to louse.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  5. 5. 5 The term “Bha” refers to the resembalence or similarity. So the term Kitibha,which is constituted by suffixing “Bha” to “Kiti”, suggests something, which resembleslouse. The similarity, mentioned is only in colour (Krishna) as it resembles, the colour oflouse, but not refered to its shape or size So the definition of Kitibha is “A pathological skin condition where the color ofskin is black like Kiti” i.e., louse. Susruta has also given one more meaning to Kitibha; itis an Upadrava caused as a result of the bite of poisonous varities of insects8.DEFINITIONS OF PSORIASIS Psoriasis is defined as skin disorder, which have been classified and discussedunder various headings. Keratinization disorder is one group, in which there will be hyperKeratinization of the basal cells of epidermis. Kitibha Kusta in which the skin becomeshard or horny, as like Psoriasis in contemporary context. Psoriasis is one among thekeratinization disorders of the skin, which also involves either genetic or immunologicalderangements. According to various authors the psychosamatic disorder, Psoriasis is definedand characterstic features are established as under. 1) Psoriasis is characterized by the development of erythematous, well defined, dry, scaly papules and plaques of sizes ranging from a pin head to larger lesions (Pavitram K.1994). 2) A common, genetically determined disease of the skin consisting of well defined pink or dull red lesions surmounted by a characteristic silvery scaling. (Baker Harvey and Wilkinson D.S.1986) 3) A chronic disease characterized by sharply defined patches of erythema covered by silvery scales, (Kirby John D, 1986)To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  6. 6. 6 4) 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. (Behl. P.N. 1987).HISTORICAL REVIEW OF KUSTA The description of Kitibha Kusta is found in the context of Kusta in Brihatrayeesand Laghutrayees. Symptomatology of Kitibha Kusta described in the classics has lot ofvariations causing sceptisism among the disciples following the Ayurvedic principles. AsKitibha Kusta is explained under the context of Kusta, the historical review of Kustabecomes necessarily to be dealt along with Kitibha Kusta.DESCRIPTION IN VARIOUS VEDAS & PURANAS:Rigveda: - Rigveda is the earliest documentation of Kusta. There is a descriptionavailable that “Kakshavathi’s” daughter, “Gosha” was inflited by the Kusta and wasdeserted by her husband. Aswini Kumaras treated her disease (Kusta), which made herto regain her marital status. In the other context Vaivarntha, and Romastana are thesymptoms of Kusta. The daughter of “Atri – Apale” was another victim of Kusta knownfrom Atharvaveda; by Indra they restored thier health9. The other references available in Rigveda, tells about disfigurations of Kustarogam. The famous story of a sati “Sumathi gives us valuable informations about thechronic skin disease, kusta and its clinical picture. In this story it was narrated as suchthe loss of sensation, scaling disability and physical deformities are the charactarsticfeatures. It was further said to have congerration towards the patients even though it issaid as appeared because of sins done in past life.Athrvaveda: - Athrvaveda records the description of the disease Kusta with symptomsand some useful drugs like Kusta and Trivruth advised in the management of Kusta.8Direct references of Kitibha Kusta are not available from Vedic literature10.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  7. 7. 7 In “Koushika Sutra” a recipe said to be useful in Kusta roga when given alongwith Mantrajala. The recipe is composed of Rakta Kusta powder in Gomayha,Brhangaraja, Haridra, Indravaruni and Nilikapuspa. It is given with navaneeta asAnupana. This recipe when prescribed with Mantra Jala is said to have a curative effecton Kusta.Yajurveda :- In 10th Shuktha of Shukla Yajurveda, we find a quotation about Twakrogas and number of kusta roga and their list of drugs are also available.11Smruthi Purana: This explains the nidana and treatment of Kusta.Brahat devatha12 indicates that the patients of Kusta are not eligible to occupy thethrone though they are the proper heirs. Application of above role is seen inMahabharatha, wherein Vichitra Veerya, brother of King “Santana” lost the throne asKusta afflicted him. Incidentally short descriptions of Kitibha Kusta are also available in the context ofKusta.Garuda Purana: - In various chapters of Garuda purana description about Twakdisorders explained13.Panini (700 B.C): - In Asthadhya of Panini grammatical literature about the diseasesare explained. Diseases like Atisara, Arshas, and Kusta major diseases have beenexplained. The diseases caused by Anuvamshika doshaja vyadies are being explainedalong with maha kustas.Mahabharata: - The reference of twakrogas is available in Mahabharata also. TheShyantanu’s elder brother of Devaki was the victiom of Twakrogas that prevented him inbecoming the king. 14To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  8. 8. 8 Ayurvedic classics:Charaka Samhitha (400-500 B.C.) Charaka Samhita describes Kitibha Kusta as a variety of Kshudra Kusta, which,is one between the two main classifications of Kusta i.e Mahakusta and Kshudra Kusta.Even though the Nidana and Purva rupa of Kitibha Kusta are not exclusively explained.Brief description of Kitibha Kusta is available in Chikitsa sthana (7th Chapter 14th sloka.)of charaka samhita. Though Charaka has dedicated a complete chapter for Kusta inNidana sthana. He had given prominence to Mahakusta but not dealt Kitibha Kusta inthis chapter.Sushruta Samhita (800-700B.C): In Sushruta samhita also elaborative description of kusta roga has beenpresented in nidanasthana 5th chapter and chikitsasthana 9thand 10th chapterrespectively. Kusta dhatugatathwa had been mentioned in Sushruta samhita only.Sushruta explained Kitibha Kusta under Kshudra kusta.Ashtanga Hridaya (500 A.D): Description of Kitibha Kusta in Astnga Hridaya Samhita is similar to that ofCharaka Samhita with slight modification. It is described in Nidana Sthana 14th chapter20th sloka and chikitsasthana 19th chapter. A similar description is also given in AstangaSangrha, Nidana sthana, 14th chapter 20th sloka.Bhela Samhita (800-700 B.C): Bhela mentioned Kitibha Kusta as one of the Kshudra Kusta in (chikitsa sthana6th chapter 25th sloka).Madhava Nidana (800 A.D): Madhavakara had reproduced the description of Kitibha Kusta as available inCharaka Samhita. He had also accepted it as a variety of Kshudra Kusta in 49th chapter18th sloka.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  9. 9. 9Bhavaprakasha: Bhava Prakasha had also described Kitibha Kusta similar to thatof Charaka Samhita, in Madhyama Khanda, 54th chapter, and 33rd sloka.Sharangadhara samhitha: Details of Kitibha Kusta is not available in SharanghadharaSamhita; only he had named Kitibha Kusta as a disorder of skin.Yogartnakara: In Yogaratnakara uttarardha information of kusta is given. He haddescribed this disorder on similar lines of Charaka Samhita.Bhaishajyaratnavali: In Bhaishajyaratnavali 54th chapter many kustarogharayogas wereexplained in treatment aspect.Vangasena: Vangasena also explained about Kitibha Kusta in Kustadhikara chapter.Rasatarangini: In Gandhaka prakarana, Gandhaka taila was indicated in Mahakusta&other skin diseases.Rasaratna samucchaya: In third chapter while explaining Ghadhaka gunas hementioned that it is useful in Kusta vyadhis & other skin diseases. Contemporary scienceThe history of Psoriasis is interesting and at the same time puzzling. The biblical term‘lepra’ was actually applied to various cutaneous disorders including Psoriasis, Vitiligo,Eczema, Boils and Alopecia areata. The Roman sage Aurelius Cornelius Celsus iscredited with the first clinical description of Psoriasis. Galen was the first to use the termPsoriasis and Robert willan (1808) specifically distinguished and described Psoriasis asa recognizable entity. Lepra vulgaris, described by Willan, was a variety of Psoriasis. In1841, Hebra definitively distinguished the clinical picture of Psoriasis from that ofLeprosy.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  10. 10. 10 SHAREERA OF TWAK Kusta is one of the dermatological diseases. According to Acharya Charaka,Sushruta, and Vagbhata, the Maha kusta is one among the skin diseases. The othersare Visarpa and Kshudra Kusta. It is necessary to study the skin indetail to know thepathophysiology of Kitibha and its vighatana i.e. counter action through treatment.Derivation of Twacha: - The word Twach is derived from the root “Twacha- Samvarnane” means, “whichcovers”. It can be defined as the body substance that covers the internal tissues likerakta, mamsa, medas and other dhatus15.Synonyms of Twacha: Twak, Charma, Raktadhara, Asrgdhara, Sparshanendriya etc.,Embrological development of Twacha: The development of twacha follows the fertilization of streebeeja and pumbeejaand entry of the Atma into it. After joining the chetana dhatu twacha starts to developduring the fourth month of the garbha. The different layer of twacha is formed by alltridoshas particularly Pittadosha cause this formation. The formation of twacha and its layer are identical to the formation of layers ofSantanika on the surface of the boiled milk. The Santanika becomes thicker and thicker,as creamy layer multiply. Similarly the layers formed in the developmental stage of theembryo forms the twak16.Rachana of twak: Susruta has stated that twak is composed of 7 layers, each of which is measuredin terms of vrihi17. The thickness of each layer of twak is different according to the natureand function of that particular part. Therefore the above vrihipramana is applicable tothe regions where muscular tissue is abundantly covered by skin and not to the regionsTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  11. 11. 11where the skin covers the bones. Usually maximum thickness of skin is noticed in palmsand soles and is minimum in lips, eyelids etc. According to Charaka twak is one of theupadhatus, which are produce during the prasadapaka of dhatus18. According toCharaka, twak is an upadhatu of mamsa19. Therefore factors influencing the mamsadhatu in utpatti, vriddhi, kshaya invariably influence twak also. Therefore details ofmamsadhatu are also discussed here.Mamsadhatu utpatti During ahara parinama poorva dhatus are primarily transformed into uttaradhatus. In this series, rakta gives rise to mamsa. Due to rakta dhatwagni rakta dhatu isdigested to form poshya rakta and mamsa dhatu in the presence of vata, pitta, andkapha. In this process, due to ruksha guna of vata, ushna guna of pitta and tejas, raktagets solidified to become mamsa dhatu, which is red in colour. In the next stage due tomamsadhatwagni mamsa dhatu is partially digested to form poshya mamsadhatu andmedo dhatu, vasa and twak as products and byproducts20. Thus the twak is formedduring the transformation of mamsadhatu into medodhatu.Dosha pradhanyata of twak In general twak is a tridoshaja bhava. This can be explained as, wide spreadingnature; sparsha and different gandhas are due to vata. The Varna, chaya and prabhaare due to pitta and smoothness, twakgata rasa are due to kapha. Also twak is anashrayam for rasadhatu, which is in turn, resembles kapha in nature. Therefore twak isconsidered as tridoshaja.Various layers of twak In Ayurveda six or seven layers of skin are mentioned. According to Charakaand Vagbhata skin is of 6 layers and according to Susrutha it is of 7 layers. Of the sixlayers, Charaka gave names only to the first and second layers. Vagbhata coined thenames of first, second and sixth layer. No names were given to the remaining layers21.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  12. 12. 12 Table No. 1 Showing layers of skin & their measurements according to Susrutha 22 SL.No. Layers Pramana Vyadhi th 1 Avabhasini 1/18 of vrihi Sidhma, padma kanthaka 2 Lohita 1/16th of vrihi Tilakalaka, Nyaccha, Vyangam 3 Swetha 1/12th of vrihi Charmadala, Ajagallika, Masaka 4 Tamra 1/8th of vrihi Kilasadi kustas 5 Vedini 1/6th of vrihi Kusta, visarpa 6 Rohini 1 yava Granthi, apachi, arbuda, galaganda 7 Mamsadhara 2 yava Bhagandara, Vidradhi, Arshas Table No. 2 showing layers of skin according Table No. 3 showing layers of skin according to Charaka23 according to vagbhata24 Sl.No. Layers Diseases Sl.No. Layers Diseases 1 Udakadhara - 1 Udakadhara - 2 Asrigdhara - 2 Asrigdhara - 3 Triteeya Sidhma, Switra 3 Triteeya Sidhma, Kilasa 4 Chathurtha Dadru, Kusta 4 Chathurtha Kusta 5 Panchama Alaji, Vidradhi 5 Panchama Alaji, Vidradhi 6 Sashta Arshas, Bhagandara 6 Pranadhara Pidika Timira- Table No.4 Showing probable comparison of various layers of skin according to Ayurveda and modern science: 25 S.No Name of the skin layer Name of the skin layer comparable according to Ayurveda with modern anatomy of skin. 1 Avabhasini St. cornium 2 Lohita St. lucidum 3 Swetha St. granulosum 4 Tamra St. Malpighii 5 Vedini Papillary layer 6 Rohini Reticular layer 7 Mamsadhara Superficial & Deep Fascia To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  13. 13. 13 ANATOMY AND PHYSIOLOGY OF SKIN26 Psoriasis is a disease of skin, therefore a detailed anatomy and physiology ofskin is essential to study the disease in detail. The skin is composed of 1) Epidermis, 2) Dermis and 3) Subcutaneous tissue. Allthe orifices, muscles, membranes are continuous with skin. The appendages of skin arethe hair, nails, sebaceous glands and sweat glands. The epidermis is composed ofepithelial layer cells and is developed from the ectoderm of the fertilized ovum. It is thesuperficial coat which covers the dermis, and devoid of blood vessels. The dermis(corium) is derived from the mesoderm and it is some times called as canvas of thecutaneous origin. The paramount function of skin is protection.Epidermis The epidermis is a cellular, avascular tissue consisting of two main components.They are: - 1. Malphigian or Keratinising component, which forms the bulk of the epidermis. 2. Pigmentary system, which produces the pigment, Melanin, which is transferred to the keratinocytes through the dendrites of melanocytes. 3. The epidermis is composed of 5 layers. They are as follows: a) Stratum germinatum (The basal layer) b) Stratum malphigi (The prickle cell layer. c) Stratum granulosum (Granular layer) d) Stratum lucidum e) Stratum cornium (Horny layer)Dermis (corium) It is also called cutisvera and is thicker than epidermis by 15-40 times, measuringabout 1-3mm, depending upon the location. The dermis rests on the thick pad of fat.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  14. 14. 14 Embryologically, mesenchymal cells of the mesoderm give rise to the followingdermal components. 1) Cells a) Fibrocytes (fibroblasts) b) Endothelial cells 2) Fibers a) Reticular b) Collagen c) Elastic 3) Ground substance a) Hyaluronic acid b)Chondriotin sulphatec)Dermatansulphate This layer consists of bundles of collagen and elastic fibers arranged in areticular fusion. It is abundantly supplied by blood vessels. The fibrous network ofdermis is attached to the basement membrane of the epidermal cells. Underneath thismembrane, many blood vessels forming a capillary network that send up loops into thedermal papillae. These papillae are finger like projections in the epidermis. Theconnective tissue cells are spindle shaped and are more in number in superficial layer. A microscopic view of the dermis shows all the above structures and also hairfollicles, sweat glands, sebaceous glands, plain muscle fibers, sensory organs likepacinian and Meissner’s corpuscles and adipose tissue. The adipose tissue is presentin deeper parts. There are a few round cells. Occasional fibrocytes and a few pigmentcarrying histocytes called, melonophores. In the deeper layer of dermis, there is an arterio-venous anastamosis surroundedby sphincter like group of smooth muscles that are supplied by autonomic fibers. Basallayer of the epidermis consists of nerve plexus in the papillae, meisensr’s and paciniancorpuscles, Merkle’s discs and nerve endings. There are rich capillary beds in thepapillae and around the appendages and in subpapillary plexus.Subcutaneous structures: This is the third layer of the skin and is also called panniculus layer. It consists oflobules of fat cells or lipocytes separated by fibrous septa composed of collagen andlarge blood vessels. The collagen in the septa is continues with the collagen in thedermis.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  15. 15. 15Sebaceous glands: Sebaceous glands are globulated, which secrete an oily substance called sebum,through rupture of the cells. They are situated at the upper half of the corium and middlethird of a hair follicle and connected to it by a duct through which their secretion gains anaccess to the surface of the skin. Hair follicles join the sebaceous gland and their union is called pilosebaceousunit. Sebaceous glands are distributed all over the body except in palms and soles.Keratin and its formation: The insoluble cystine containing proteins of the epidermis is common with thoseof hair, horn and hoof are known as keratins, a word derived from the Greek, and theprocess by which they are formed as keratinization27. Determination of the chemical nature of keratin is controversial, since proceduresto render it soluble by breaking the disulfide links may also cleave the peptide. Asoriginally found by Rudall, it appears that two types of soluble protein fractions can beextracted from epidermis. The major one has low sulphur content and gives a so calledX- ray diffraction pattern, which reflects the process of helicaly arranged peptide chains.Where as the minor one has B-diffraction pattern, indicating a lack of such orientationand also contains more sulphur. Where the B-pattern component exists in that form inthe tissue or whether it is derived from a protein with an X-structure is uncertain28. It isnot worthy, however that Baden by hydrolysis with low concentration of trypsin for shortperiods at only 4C, successfully split fibrillar –protein from human stratum cornium intofragments of both helical and non helical structures29. The soft keratin of epidermis contains less cystine and substantially more glycinethan the hard keratin of hair. This suggests that glycine residues of soft keratin arereplaced by cystine in hard keratin, while cross-linking is a necessary feature. Variousattempts have been made to characterize chemically pure prekeratin sub unit fromTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  16. 16. 16epidermis. Maltolsy isolated a molecule with a molecular weight of 640,000 containing5534 residues with a length of 105 nm and a diameter of 3.7 nm. After enzymaticdigestion of human stratum cornium, Baden obtained three peaks in chromatogram; theprotein in the second one had an –diffraction pattern and a molecular weight of 100,000-200-00. Crounse has suggested a sub unit with a molecular weight of 50,000. Thequestion of whether epidermal keratin originates from the filamentous structures found incells of lower epidermal layer or from the keratohyalin granules in the stratumintermedium or from the both has been subjected to considerable argument which hasnot get entirely abated. Most authors however believe that both elements are involved.From basal layer to stratum cornium, there is a continuous gradual maturation of fibrillarmaterial into keratin. Brody resolves this by saying that it seems that, in the stratumintermedium, the fibrils are infiltrated with an interfilamentous material, which not onlyhas a strong affinity for the stains but also affects affinity of the filamentsAbnormalities of keratinization The intricate control of the epidermis can readily be disturbed. Excess thicknessof normal horny layer may result either from over production of keratin or by preventionof normal desquamation. Abnormalities of keratinization are common occurrance, eitheras apparently primary defects or secondary to other pathological process. In somedisorders, in which keratin is defective, parkeratosis, in which the cornified cells retaintheir nuclei or dyskeratosis, in which individual cells are prematurely keratinized, appearto be associated with rapid transit of cell through the epidermis and abnormally shortbasal-cell cycle.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  17. 17. 17Important Functions of Twacha301) The most important function of skin is to maintain an effective barrier for the loss of water, electrolytes and macromolecules, which are the functions of Udhakadhara Twacha.2) It avoids the entrance of external injuries physical, chemical and microbiological substances into the internal environment of the body, which is the function of bahya srotas.3) Skin plays the most important role in the regulation of body temperature through sweating and cutaneous vasoconstriction and vasodilatation-which is the function of Bharajaka Pitta.4) Skin is a prime sense organ for touch, temperature, pain and itch, which are the functions of Twagendriya.5) The flexibility, elasticity and roughness of skin allow motions and provide shape and form of the body.6) The skin surface has antibacterial and antifungal properties.7) Changes in its vascular bed affect the regulation of blood pressure.8) Skin is a secretory organ by virtue of its apocrine, sweat and sebaceous glands.9) Skin produces keratinized structures such as hair, nails, and stratum cornium – which are the functions of the Rohini Twacha.10) Skin is a reservoir of electrolytes, water, vitamins, fat carbohydrates, proteins, and other materials. Which are the functions of Udakadhara and Pranadhara Twacha.11) Processes in the skin (melanin function, vasodilatation, and keratinization) play an important role in determining the colour of the individual-which is the function of Avabhashini Twacha.12) Skin functions in a limited way as an excretory organ.13) Vitamin D is produced in the skin.14) Finally the appearance of skin is valuable to the physician as a mirror or indicator of internal processes.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  18. 18. 18 NIDANA Specific nidana of Kitibha Kusta are not described in Ayurvedic classics, asKitibha Kusta is one among the 18 types of kusta, some of the nidana mentioned in thecontext of kusta holds good for Kitibha Kusta also. “Kitibha Kusta” is a variety of “Kshudra Kusta” according to Charaka. There is nospecific nidana factor of Kitibha kusta. As such the causative factors attributed to kustasare to be taken as causative factors for Kitibha Kusta also. The nidana mentioned for the causation of kusta can be broadly classifiedand sudied under the following five headings: 1) Aaharaja 2) Viharaja 3) Daivapacharaja 4) Chikitsa sambandhi 5) SankramikaTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  19. 19. 19 TABLE NO 5 SHOWING AHARAJA NIDANA OF KITIBHA KUSTA31SL. NO NAME Cha. Su. A.H. B.S. Ha.S. 1 Viruddhahara + + + + + 2 Ajeerna, Adhyashana + + - + - 3 Matsyati sevana + + - + - 4 Dugdati sevana + = - - + 5 Amlati sevana + - - - + 6 Guru ahara + - - - + 7 Gramyodaka with Anupamasa sevana - + - + - 8 Dadhi sevana + - - + - 9 Snehati sevana + - - + - 10 Lakucha and kakamachi + - - + - 11 Matsya with Payasa + - - + - 12 Ahitashana - + - - - 13 Drava, Snigdhara sevana + - - - - 14 Uddalaka, Kusumba + - - - - 15 Navanna, Yavaka, Kulattha + - - - - 16 Lavana, Hayanka, Atasi + - - - - 17 Moolaka, Satata madhu sevana + - - - - 18 Tilapishta, Guda + - - - - 19 Chilichima with milk + - - - - 20 Madyamladravya with Milk - - - + - 21 Guda with Milk - - - + - 22 Matsya, Nimba with Milk - - - + - 23 Mamsa with Madhu - - - + - 24 Papodaka (dushta jala) - - - - + 25 Pippali, Haritashakha, Vidagdhahara sevana - - - + - 26 Guda with Moolaka - - - + - 27 Haviprashana (Ghrita type) + - - - - To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  20. 20. 20 TABLE NO 6 SHOWING VIHARAJA NIDANA31 Sl.No Nidana Cha Su. Vag B.S. Ha.S 1 Chardinigraha + + - + - 2 Vegaavarodha + + - + - 3 Sheetaambhu Snana after atapa sevana + + - + - 4 Diva swapna + - - + + 5 Mitya vihara - + + - - 6 Vyayamam atisantaapa bhuktopa sevanam + - - - - 7 Shrama bhayartanam Sheetambu sevanam + - - - - 8 Ratri jagarana - - - - + 9 Ajeernepi Vyayamam + - - - - 10 Sneha pitasya Vantasyeva vyayamam - + - - - 11 Vyavaya after vidahi ahara sevana - - - + - 12 Gramya Dharma sevanam - + - - - TABLE NO.7 SHOWING DAIVAPACHARAJA NIDANA31Sl.No DAIVAPACHARAJANYA KARMANI Cha Su. Vag B.S. Ha.S 1 Papakarma + + + - - 2 Vipram garshayatan + + + - - 3 Purvakruta Akarma + + + - - 4 Gohatya - - - - + 5 Use of money or material acquired through theft - + + - - 6 Sadhu ninda, apamana and vadha - + + - -To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  21. 21. 21IV) Chikitsa sambandhi nidana : The hetu listed undr chikitsa sambandhi are vyadhihetus. Panchakarmamityapachara is considered as a nidana for kusta in Brithatrayee. The vyapath ofshoodhana is a cause for kusta. That too, ayoga of vamana and virechana is a strongercause for kusta than atiyoga of these procedures. The panchakarma procedures are adopted to eliminate the aggravateddoshas,but improper application of panchakarma measures will cause adverse effects.By the ayoga of vamana and virchana, which are supposed to be eliminated from thebody will not be completely eliminated and accumulated in srotases, ultimately leading tothe manifestation of kusta by causing shithilatha in the dhatus. If snehakarma iscontinued even after samyak snehana it leads to kotha and causes kusta. Similarly the continuation of brimhana therapy even after the exhibition ofsamyak brimhana lakshsana causes increase of kapha dosha and rasadidhatu, theirkledatvadi vruddhi resulting in the shithilatha, which ultimately leads to manifestation ofdisease kusta.V) Sankramika nidana32Sushrutacharya is an only author who has mentioned the category nature of kusta, eventhough he had not mentioned these in the context of explaning the causative factors ofkusta. All the modes of communicating a contagious and infectious disease such asinhalation, physical contacts, including sexual contacts, contamination of food etc, havebeen mentioned. The diseases manifesting, due to sankramika hetu can be as bhootabhishangaja,here bhoota refers to krimi In krimi prakarana while explaning about the raktajakrimi has been told whichclearly justifies the role of krimi in kusta.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  22. 22. 22 ETIOLOGY OF PSORIASIS33 Inspite of many advanced researches in the field of psoriasis. The riddle ofpsoriasis remains unsolved. Despite intensive basic and clinical investigation allmostevery conceivable causative influence including microbiologic, metabolic andimmunologic has been indicated. But conclusive evidence is lacking of any and allthese. The etiology of Psoriasis can be considered under three sections ie,1) Genetics: Among the genetic marker systems, the major human leukocytehistocompatibility (HLA) antigens are regarded as the most important genetic andepidemiologic guideposts for psoriasis; studies at different centers have consistentlyconformed. A significant increase observed in the frequency of HLAB 13 and BW17antigens in psoriatic patients.2) Precipitating factors: Local factors Emotional stress Seasonal variations Infections Pregnancy Drugs3) Pathogentic Factors in Psoriasis Accelerated epidermopiesis Elevated cGMP; camp levels variable Increased PGE21 PFG21 HETE is psoriatic skins Elevated cutaneous and urinary polyamines Immunologic phenomena - Anti stratum cornium antibodies - Anti basal cell unclear antibodies - Circulating immune complexes - Decreased circulating T cells - Decreased suppressor cellsTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  23. 23. 23 - Normal Natural killer cells Polymorphonuclear leukocyte migration to epidermis Increased proteinases in epidermis Dermal vascular changes Viral role The above said factors are said to play a very important role in psoriasis, summarized after going through all the research works in psoriasis from the begining to 1987 and presented in Dermatology Vol.I and Iiedition of Samuel L. Moschella and Harry J. Hurley.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  24. 24. 24 SAMPRAPTI OF KUSTA All the classical textbooks of Ayurveda have elaborated common Samprapti forKusta. Even though kusta is classified into Mahakusta and Kshudra kusta, no authorhas not emphasized separate samprapti of these two types not even the samprapti ofindividual variety of Kusta also. Naturally a separate samprapti for Kitibha Kusta is notavailable in any of the Brihatrayees or in the works of later authors. The common samprapti of Kusta according to different authors is as follows:According to Charakacharya the vitiated Sapta Dravyas are considered as sannikristahetus for Kusta, the vitiated doshas vitiate twacha, mamsa, rakta and laseeka and thecombination of these sapta dravyas lead to the disease process the morbid saptadravyas will be localized in between twak and mamsa and may produce differentvarieties of lesions at different sites over the skin. They are named differently based onthe site and nature of the lesions34. The Samprapti described in Sushruta samhita is as follows. The Vataaggravated by the nidana sevana in combination with the aggravated pitta and kaphaenter into the siras, which are transversly spread over the surface of the body, thus theenraged vayu deposits the pitta and kapha on the skin through the medium of theirchannels and spreads them over the surface of the body. The areas of the skin in whichthe morbid doshas are deposited become marked with mandalas or skin patches(Mandalani Pradurbhavanthi). The doshas thus lodged in the skin continue to aggrevate, and having beenneglected at the out set, tend to enter into the deeper tissues and further vitiates thedhatus31. After going through the samanya samprapti of Kusta according to differentauthors the samprapti described by Sushrutacharya seems to be elaborated andaccurate denoting samprapti of both Mahakusta and Kshudrakusta. But KshudrakustaTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  25. 25. 25samprapti is to be limited to the stage of Mandalani Pradurbhavanthi. The further stagesof pathogenesis described by Sushrutacharya has to be restricted to Mahakusta. The samprapti explained by Vagbhatacharya is as follows: By the above saidnidana the doshas get vitiated then spread to tirygh siras. They vitiate twacha, laseekaand asruk. This produces shithilikarana and vaivarnya of bahir twacha. The diseasekusta manifests wherever the morbid doshas get lodged36. Madhavakara’s description of Kusta samprapti is similar to that ofCharakasamhita, however there are some modifications it is as below. The morbid threedoshas vitiate twacha, rakta, mamsa and ambu. These sapta dravyas are considered assannikrista hetus, which are responsible for producing seven maha kustas and elevenkshudra kustas. He had used the term Ambu in the place of laseeka among the saptadravyas37. Bhavaprakash and Yogaratnakara have followed the descriptions ofMadhavanidana38. The Samprapti described in Bhela Samhita focuses on the vitiation of the vatadosha. The state of mandagni gives rise to the provocation of vata. The provocatedvata vitiates the other doshas in their sanchayavastha. Depending on the rutus the threedoshas get lodged in Rudhira and vitiates Rudhira followed by mamsa. The combinationof three doshas along with rakta, mamsa gives rise to eighteen types of kustasdepending on the etiological factors39. Among the Sapta dravyas of Kusta the three doshas viz, Vata, Pitta,Kapha and two dushayas namely, rasa and rakta seem to play an important role in themanifestation of kitibha kusta. The role of mamsa and laseeka seems to be minimum.Among the three doshas Charaka has stressed to the role of vata and kapha byclassifying kitibha kusta, on the other hand sushruta has stressed to role of pitta in thepathogenesis of kitibha kusta.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  26. 26. 26 Classical textbooks of Ayurveda mentioned Kusta as a JanmabalaPravrutha Vyadhi, Kitibha Kusta being one among them. In the genetically predisposedpersons the intake of pitta and kapha karaka nidana result in the vitiation of Kledainitiating the process of pathogenesis. Both Mahakusta and Kshudrakusta are Sankledapradana vyadhis.SAMPRAPTI OF KITIBHA KUSTA:The nidana vitiate pitta and sleshma dosha and cause the shithilata of bahya twacha.These doshas cause marghavarodha of vata dosha inturn leading to vata vriddhi. Thisvitiated vata carries the vitiated pitta, shlesma and laseeka in tiryagha Siras and lodgethem in the udhakadhara, rakthadhara and mamsadhara twak. Along with three doshaskleda plays an important role in the pathogenesis of any of the variety of pitta includingkitibha kusta. Both pitta and sleshma being, drava dhatus are considered as kledakaraka sannikrista nidana. The siddantha explained in the classics suggest that usuallyif the vitiation of sleshma is predominant with the predominance of sneha, sheeta andpichhila gunas then the vitiation of kleda occurs, on the other hand if initially the vitiationof pitta is predominant with predominance of its gunas i.e, sneha, Drava then also kledagets accumulated. The accumulation of kleda results in Srotorodha leading to vata vriddi. Becauseof the combined effect of vata vriddi and srotorodha, the rasadhatu does not properlyenter the srotas. Twacha being entirely dependent on rasa for its manifestation becomeshina satwa resulting in Shaithilya of twacha. There will be abhava of snigdha guna ofrasa in the twacha resulting in further vata vridhi. Twacha becomes shyava Varnabecause of vata vriddhi. At the same time due to ushnaguna of pitta the dravamsha ofkleda escapes through sweda. Due to the loss of this dravamsha the kleda that remainsin the twacha will be ghanibhuta kleda. This effects in parushata, kharasparshata oftwacha in kitibha kusta.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  27. 27. 27Aetiopathogenesis of psoriasis40: - Genetic Factors Much importance has been given in recent years to the major human leucocylehistocompatibility antigens (HLA). Which are located on chromosome 6. HLA studieshave shown an increased frequency of HLA-B13, HLA-B17 and HLA-BW16 in patientswith psoriasis. A six fold increases in susceptibility to psoriasis for individuals with the BW17antigen. Many other HLA markers which are closely linked to B13 and TW17 such asCW6, BW17 are also said to have a major role patients with HLA B13 have milderclinical presentation whereas those with HLA B17 have higher familial involvement andpresent with severe clinical presentations1. The Epidermal Cell Cycle in Psoriasis The epidermis basically consists of three-cell compartment consisting of stratummalphiliigi and stratum granulosum and the germinative cell compartment. Normallyabout 10% of the germinative cells undergo mitosis. The interval between the division ofa basal cell and the next one of the daughter cell is called the cell cycle time. The fourstages in the cell cycle are: 1, mitotic phase, 2, G1 interphase, 3, synthetic phase, and 4, G2 interphase. After mitosis, the cell enters the G1 phase where biochemical preparation for thenext phase occurs. During the synthetic (S) phase the DNA doubles. During the G2phase a cell synthesizes RNA and proteins and prepares for the next mitosis. In spite ofusing modern sophisticated techniques, we do not know the exact duration of the cellcycle in psoriasis. Most values based on indirect calculations with inherent defects.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  28. 28. 28Both flash labelling and mitotic indices are increased in psoriasis. Studies, by Weinsteinand Frost, revealed that the turnover time of the cells in psoriasis was reduced to 37hours, Compared to 457 hours for noumal epidermis. Similarly early studies on thetransit time of cells from the basal cell layer to the uppermost row of squamous cellsshowed a shortening from 13 days in normal epidermis to only 2 days in psoriaticepidermis. 132 Having completed mitosis, the cells may remain in the cycle and recycleor may lose the capacity to divede. And decycle. If this occurs permanently, the cellbecomes a postmitotic maturing basal cell, which is destined for migration, differentiationand eventual death, and is lost in the horny layer. But some post-mitotic cells maytemporarily leave the cycle to enter a G0 phase where they remain quiescent andpotentially fertile, re-entering the cycle and profiferating if thereis a special stimulus.There are two categories of these non-cycling G0 cells-those blocked in the G1 phaeand those blocked in the G2 phase. Many recent report dispuite the old valures of cell cycle time and transition time.They indicate that there is only a 2-fold speeding up of the cell cycle time of germinativecells in psoriasis, and not a 12-fold speeding up as was originally believed. The presentview is that the cell cycle time of the germinative cells in psoriatic epidermis is about 100hours as compared to 200 hours in the normal epidermis.2. Cycle Nucleotides and Psoriasis It has been suggested that the cell cycle is controlled by the intracellularconcentration of cycle nucleotides. The epidermal cells are subject to a block in the G1phase, which is maintained by a high level of cycle AMP in relation to the concentrationof cycle GMP. Cell proliferation is stimulated either by a fall in camp or by an increase incGMP.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  29. 29. 293. Arachidonic Acid Metabolisms and Psoriasis Psoriasis tends to occur at the site of trauma. This may be a stimulus foractivation of the arachidonic acid cascade with subsequent release of various mediatorslike l leukotrience prostaglandins and 12-hydroxycicosteraenoics; acid (HETE) Psoriaticepidermis contains elevated levels of 12-HETE and arachidonic acid. It appears thatpsoriatic skin has an endogenous inhibitor of cyclo-oxygenase resulting in diversion ofarachidonic to the lipo-oxygenase pathway. Non-steroidal anti-inflammatory drugs likesalicylates, Indomethacin, phenylbutazone, oxyphenbutazone, ibuprofen andmeclofenamate have all been reported to exacerbate psoriasis. These drugs act mainlyby inhibiting prostaglandin synthesis, which leads to a reduction of prostaglandin andcamp production and there by precipitates the abnormal epidermal activity characteristicof psoriasis.4. Polyamines and Psorisis Polyamines are low molicular weight organic amines such as putrescine,spermidine and spermine. They are important in the regulation of cellular proliferationand are increased in the involved and uninvolved skin of activity of ornithinedecarboxlase, skin of psoriatics. The activity of ornithine decarboxylase, which is therate-limiting enzyme in the biosynthesis of polyamines, is increased during the earlystages of epidermal hyperplasia. Hence it is possible that these polyamines play a role inthe pathogenesis of psoriasis.5. Immunologic Basis of Psoriasis Another site of interest for immunologists is the basal cell layer of the epidermis.In a normal person the basal cell nuclear material is not ‘ recognised’ by theimmunological system. A clone of suppressor T-cells present such recognition. It ispostulated that a genetic defect or a virus leads to malfunctioning of such a clone ofsuppressor cells leading to the recognition of basal cell nuclear material as antigen.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  30. 30. 30Subsequenctly antibodies are formed against this antigen, leading to an immunologicalresponse, which results in the epidermal cell proliferation typical of psoriasis.Langerhans cells are activated in Psoriasis but their role in its pathogenesis is not clear.6. Contact Inhibition Theory in Psoriasis Normally, firm contact between epidermal cells especially those of the superficiallayers causes a feed – back inhibition of basal cell proliferation. Any defect in thisintercellular contact will result in uncontrolled cellular proliferation. It has been observedthat the glycoprotein – rich cell surface coat is completely absent in cells of the stratumMalpighi of psoriatic skin. This results in diminished coherence between the epidermalcells and thus there is loss of contact inhibition of growhth. This leads to acceleratedepidermopoiesis. A reduced cell surface coat also decreases the activity of various cellmembrane bound enzymes. Adenyl cyclase synthesizes AMI’ from adenosinetriphosphate. Disturbance of intracellular regulation of cAMI’ and cGMP may occur dueto deficiency of membrane bound enzymes.II. TRIGGERING FACTORS OF PSORIASIS Psoriasis is a chronic disease marked by periods of remissions and excerbations.Remissions may last for a few weeks to many years. Triggering factors may be local orsystemic.1. Local Factors Psoriatic leasions tend to develop at sites of injury to the skin. Koebnerphenomenon also known as the isomorphic response, refers to the induction of thelesions by cutaneous trauma. Epidermal trauma alone will not induce the lesions. Itshould also involve the papillary dermis. The trauma may be of any kind-physical,chemical, mechanical, allergic or of any other nature. Koebner phenomenon is elicitedat sites of sun brun, operation wounds, vaccination and other skin lesions. It usuallyoccurs within seven to fourteen days, but the interval may be as short as three days, orTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  31. 31. 31as long as three weeks. Psoriasis may occur as Koebner phenomenon, at sites of bites(insects, animals) burns, drug reactions, dermatitis, lichen planus, malaria, kin tests,vitiligo and herpes zoster.2. Seasonal Variations Most patients experience worsening of their skin lesions during winter, 89 % ofthe patients studied by Farber and Nall (1978) had worsening of their disease duringcold weather. High humidity is usually beneficial. Sunlight may worsen psoriasis insome and improves in many.3. Pregnancy Remission of psoriasis may occur during pregnancy, but there is exacerbationduring the postpartum period. Rarely, generalized pustular psoriasis may be precipitatedduring pregnancy probably due to raised levels of progestron during the later half.4. Emotional Stress Proriasis is more stress sensitive than other skin diseases. Many stressful eventsof daily life may excerbate psoriasis. The disease itself can cause a reactive depressionin the patient, which could further exacerbate his psoriasis.5. Infections Upper respiratory tract infections and tonsillitis, especially when caused bystreptococci may cause a flare up of existing psoriasis or may precipitate an attack ofacute guttate psoriasis. This is common in children and is usually associated with anelevated antistreptolysin “O” titer. Innfections by other bacteria and viruses may alsoexacerbate psoriasis.6. Drugs Many drugs are known either to precipitate or to exacerbate psoriasis. Ratherthan being simple drug reactions, these observations throw some light on theeatoipathogenesis of psoriasis. A number of beta adeno receptor blocking drugs.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  32. 32. 32Propranolol, paracetamol, metaprolol and oxyprenolol have been reported to induce apapulo-squamous eruption that resembles psoriasis. Non steroidal anti inflammatory drugs (NSAIDS) such as indomethacin,salicylates, maclofenamate, phenylbutazone oxyphenylbutazone and ibuprofen, whichare commonly used in orthopedic and surgery, have been reported to either precipitateor excerbate psoriasis. Severe psoriasis is commonly associated with depression and may be its cause.Treatment of depression with lithium compounds in tense patients may destabilize andexacerbate the proriasis. Precipitation of generalized pustular psoriasis in patients withstable psoriasis vulgaris has also been reported. Lithium compounds have an inhibitoryeffect on adenly cyclase and reduce hormone-induced accumulation of cAMP in vitro.This may be the mechanism of precipitation of psoriasis in these patients. Rrapid withdrawal of corticosteroid therapy in patients with psoriasis may result inprecipitation of generalized pustular psoriasis or may cause exfoliative dermatitis as arebound phenomenon. Occasionally, topical corticosteroids, especially, the more potentones, also cause precipitation. Chloroquine is another drug that has been known for years to precipitatepsoriasis, often leading to exfoliative dermatitis. Although its exact mechanism incausing such precipitation is not fully understood. It has been suggested that, this maybe due to the sun screening effect of chloroquine or ultraviolet light.III-Special Areas of Pathogenetic importance The literature of recent years contains the investigative observations and datarelating to the pathogenesis of psoriasis. While still inconclusive, they emphasize thecomplexity of the disease process and help in understanding of the clinical featurescourse and treatment of the psoriasis.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  33. 33. 33 Accordingly the discussion of the following is helpful which include epidermalkinetics, molecular mediators, immunologic alterations, and polymorphonuclearleukocyte activity. Vascular abnormalities and viral agents, the inter relation of theseinfluences were only partially understood, and their pathogenetic importance is in theabsence of an etiologic common denominators, still speculative. 1) Accelerated proliferation of keratinocytes and disturbed epidermal maturationare primary alteration in psoriasis. Epidermal cell proliferation in psoriasis was noted to expansion of germinativecell population in psoriasis as a result of mitotic activity in three layers of cells in basalzone, as compared with one layer of basal cells in uninvolved skin. Moreover the lengthof these layers is extended over 3 fold by the enlarged dermal papille in psoriasis. Many researchers confirm that psoriatic epidermis turnover is seven times fasterthan normal skin. The transit time of cells through the stratum malpigium is two days inpsoriatic epidermis and 13 days in normal epidermis. The above description is basedupon research works and knowledge of cell cycle kinetics cited in Mosshella, 1987. 2) The biochemical alternations of psoriasis include: a) Incresed DNA replication b) Altered cyclic nucleotide levels c) Abnormalities in prostoglandine and their precursors d) Altered carbohydrate metabolismThe accelerated epidermopiosis of psoriasis results in signs of disturbed keratinizationclinically, histologically, and chemically. Thus, the production of thick white scales, areduction in tonofilament formation and keratohyaline granules, and a variety of chemicalabnormalities such as high concentrations of lipids and phospholipids, an increse in acidmucopolysaccharides, alpha aminoacids and sulphahydryl groups, and the retention oftaurine are seen along with increased urinary excretion of uric acid.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  34. 34. 34 Prostoglandins, hormone-like substance formed from arachidonic acid by acyclooxygenase enzyme, are synthesized and released at their site of action. They havevarious functions, including stimulating epidermal DNA synthesis, dilating cutaneousvessels, and precipating in inflammatory reactions. Arachidonic acid and one of itsproducts, 12-L-hydroxy- eicosatetraenoic acid (12-HETE) are increased over50 fold in psoriatic lesions as compared with uninvolved epidermis. There are only modest increases in Prostoglandins E2 and F2 indicating, that inpsoriatic plaques an endogenous inhibitor of prostoglandine synthesis from arachidonicacid is present. This increased amount of arachidonic acid may then be diverted to alipoxygenase pathway resulting in leukotriens (LT). LTB4 is one such leukotrine found inextracts of superficial psoriatic scale, and it is the most potent chemotactic agent, known(LTB4) may originate from PMNLS themselves or from kertinocytes or both. Thus LTB4along with arachidonic acid and HETE may have important pathogenetic significance inpsoriasis as chemoattractants of polymorphonuclear cells. Intrestingly, indomethacin, acyclo oxygenase inhibitor, excerbates psoriasis when used orally, and presumably byincreasing the diversion of free arachidonic acid to leukotriens. Appropriately, a lipoxygenase inhibitor, benoxaprofen, may improvepsoriasis; benoxaprofen is a nonsteroidal anti-inflammatory drug introduced in Europefor arthiritis, which was subsequently with drawn because of instances of severe toxicity.An endogenous cyclo-oxygenase inhibitor may, therefore perpetuate plaqueinflammation by maintaining high levels of arachidonic acid and shunting it into pathwaysforming others potent chemoattractants.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  35. 35. 35Vascular Abnormalities: The dermal capillary loops of both involved and uninvolved skin of psoriaticpatients are dilated and abnormally tortouos. Neutrophils and enzymes may be“squirted” into the epidermis from these distorted vessels and stimulate some of theearliest dermo-epidermal changes. Electron microscopic studies have revealed markedly attenuated vessel wallsand gaps between the endothelial cells, primarily in the arterial capillary and lessfrequently in the venous capillary and the pre capillary venule. The vascular changes inpustular psoriasis are identical to those in other forms of the disease, although morerapid epidermal proliferation, as revealed by auto radiographic studies, occurs in thepustular variants.Viral Agents Over the year, infectious agents of all types have been proposed as the possiblecause of psoriasis. Recently, the possible etiologic role of viruses has resurfaced withthe finding of virus like particles in the skin and in PHA stimulated lymphocyte culturesfrom psoriatic patients T cell defects in psoriasis were thus ascribed to such viralinfections. Viral activation under proper environmental conditions, it is suggested, couldbe responsible for the cell proliferation, abnormal pharmacology, and autoimmunephenomena in psoriasis. PATHOGENESIS AND HISTOPATHOLOGIC FEATURES The histopathological features of a fully developed psoriatic lesion are 1. Parakeratosis, which is usually uniform. 2. Presence of ‘microabscesses of Munro’ in the horny layer. They consist of pyknotic nuclei of neutorphils that have migrated from the squirting papillae to the spongiform pustules and then to the horny layer. 3. Absence of a granular layer.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  36. 36. 36 4. Regular elongation of rete ridges. Their lower portion is thickened, sometimes showing a camel foot-like shape. Often they tend to coalese. 5. Regular elongation of the dermal papillae, which are dubbled at their upper portions. There are dilated and tortuous capillaries in the papillae with oedema and perivascular mononuclear cell infiltration. 6. There is thinning of the suprapapillary parts of the statum malpighii, with the occasional presence of small spongiform pustules. In pustular psoriasis, these abscesses are large and prominent. Only spongiform pustules and Munro microabscesses are features truly diagnostic of psoriasis. In their absence the diagnosis of psoriasis can rarely be made with certainty on a histologic basis.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  37. 37. 37 POORVA ROOPA The poorva roopa is defined as the stage where premonitory symptoms appearimmediately after sthanasamshraya. Clinical manifestation of the disease starts duringnthis stage. As there is no mentioning of specific poorva roopas, general poorva roopasexplained in the context of Kusta can be concidered here. Table No 8 showing all poorva roopa mentioned by different acharyas41. Sl. Name of the Charaka Susrutha Vaghbhata Kasyapa Bhavapra No poorva roopa -kasha 1 Aswedanam + + - + + 2 Atiswedanam + + - + + 3 Parushyam + + - - + 4 Atislakshna + - + + + 5 Vaivarnyata + - + + + 6 Kandu + + + - + 7 Supta + + + - + 8 Nistoda + - + - + 9 Lomaharsha + + + + + 10 Kharatwam + - + + + 11 Gouravam + - + + + 12 Swayadhu + - - + - 13 Rukshata + + + + + 14 Pipasa + + - + + 15 Saraga - - - + - 16 Daurbalya + - - + + 17 Pidaka - - - + + 18 Daha - - - + -To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  38. 38. 38 LAKSHANAS OF KITIBHA KUSTA The lakshanas of Kitibha Kusta explained by acharayas have variations among which majority of acharyas opine that Kitibha Kusta is vata kaphatmaka, while some acharyas considered it as pittadhikyam. The lakshanas of Kitibha Kusta explained by different acharyas are as shown in the following table: Table No 9 shows all roopa mentioned by different acharyas42.Sl. Name of the roopa C.S, B.P, S.S A.H B.S K.SNo Y.R.&M.N1 Shyava + _ + + _2 Kinakhara sparsha + _ + + _3 Khara sparsha + _ + + _4 Parusha + _ + + _5 Kandu _ +(Adhika) + + _6 Ahitam _ _ + + _7 Sravi _ + _ _ _8 Vrttam _ + _ _ _9 Ghanam _ + _ _ _10 Snigdham _ + _ _ _11 Krishnam _ + _ _ _12 Drudham _ _ _ _ _13 Punha prasravathi _ _ _ + _14 Roodhanvi tam cha _ _ - + _15 Vardatechasamutpannam _ _ _ + +16 Aruna _ _ _ _ +17 Vriddhimanthi _ _ _ _ +18 Garuni _ _ _ _ +19 Prashantanicha _ _ _ _ + Punarutpadyante To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  39. 39. 39 CLINICAL FEATURES OF PSORIASIS The cutaneous lesions of psoriasis are characteristics for the disease and various morphologic forms of psoriasis have been distinguished and given special names. Terms Describing Morphologic Features of Psoriasis Annular psoriasis Gyrate psoriasis Circinate psoriasis Inverse psoriasis Follicular psoriasis Nummular psoriasis Generalized psoriasis Pustular psoriasis Geographic psoriasis Serpiginous psoriasis Guttate psoriasis Lesions of Psoriasis show Four Prominent Features1) They are sharply demarcated with clear cut borders2) The surface consists of non-coherent silvery scales3) Under the scale, the skin has a glossy homogenous erythema4) There is an auspitz sign The size of a single lesion varies from a pinpoint to plaques that cover largeareas of the body. The clinical presentations of psoriasis is better understood when it isrealized that disease activity can range from a chronic stationary phase, to a resolvingprocess, or to flares of disease that may be associated with numerous sterile pustules. The auspitz sign is a specific feature of the erythro-squamous lesion ofpsoriasis. It is noted when the hyperkeratotic scales are mechanically removed from apsoriasis plaque by scraping within a few seconds after mechanical removal of the scalesmall blood droplets appear on the erythematous surface. The Auspitz sign has diagnostic To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  40. 40. 40value; it is not present in inverse or pustualar psoriasis and may help to differentiatepsoriasis from other skin conditions with morphology similar to psoriasis. In addition to the Auspitz sign, Koebner’s phenomenon can be elicited inapproximately 20% of patients. After non-specific irritation psoriatic lesions develop in areaswhere they were not previously present. Three main morphologic alterations in the structure of the nail areappreciated. 1) Pits are evident within the nail plate. This morphologic pattern apparently is due to defective keratinization of the dorsal side of the proximal nail fold. 2) Yellowish macules beneath the nail plate often extend distally toward the hyponychium. This morphologic pattern appears to be caused by psoriatic processes located in the nail bed. 3) Severe onychodystrophy results in yellowish keratinous material. This morphologic pattern is believed to be secondary to psoriasis involving the nail matrix. In pustular psoriasis the nail changes consist of subungual pustules of the nail bed or the nail matrix. If major portions of either are affected with this process, loss of the nail plate or even dystrophy of the matrix, anonychia, can occur. In pustular psoriasis of the palms and the soles, nail changes are rare. Nail changes are more frequent in-patients with arthritis. Chronic Stationary Psoriasis- Psoriasis Vulgaris: This clinical pattern is the most frequent. Red scaly lesions as described above, persist for months to years. There is constant production of large amounts of scales with little alterations in shape or distribution of individual plaques. Areas of predilection are the elbows, the knees, the scalp, in particular the retroauricular region the lumbar area and the umbelicus. Single small lesions may become confluent, forming plaques where To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  41. 41. 41the borders resemble a land map (psoriasis geographica). Lesions may extend laterallyand become circintat because of the confluence of several plaques (psoriasis gyrata).Occassionally there is partial central clearing, resulting in ring like lesions (Annularpsoriasis). Stationary psoriasis may be localized in the major skin folds such as the axilla,the genitocrural region, and the neck (psoriasis inversa) here scaling is absent and thelesions show a glossy appearence.Eruptive (Guttate) psoriasis Typically this pattern presents as small (0.5 to 1.5cm in diameter) lesions overthe upper trunk and proximal extremities. This form is characteristic of psoriasis of anearly age of onset and as such is frequently found in young adults. As noted intriggering factors streptococcal throat infection frequently precedes the onset or flare ofguttate psoriasis. Occasionally a disseminated macular drug eruption may precede thispattern of psoriasis. Very active lesions of psoriasis of many types can have pustules that are 1-2 mmin diameter and surrounded by an intensive wall of erythema, this process usuallysignals an event of bacterial infection, aggressive local therapy or withdrawal of systemiccorticosteroids.Psoriatic erythroderma Psoriatic erythroderma represents the generalized form of the disease whichaffects all body sites, including the face hands, feet, nails, trunk and extremities,although all of the symptoms of psoriasis are present, erythema is the most prominentfeature and scaling usually is less severe compared with chronic stationary psoriasis.Psoriasis erythroderma may have different degrees of disease activity, presentingsuddenly as a generalized exfoliative phase. In the latter phase there are usually someareas of uninvolved skin.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  42. 42. 42 Psoriatic erythroderma may be the response to non-tolerated topical treatment(eg. Anthralin, U.V.B), representing a generalized Koebner reaction. Generalizedpustular psoriasis may revert to only erythroderma, pustule formation being diminishedor absent. This form shows all the features of pustular psoriasis including fever,malaise, frequent relapses, and relatively high mortality after prolonged courses. Theremay be complete loss of nail growth due to destruction of the nail matrix. Furtherdescriptions of the effects of exfoliative erythroderma on the body are covered.Generalized Pustular Psoriasis (Von Zumbusch) Pustular psoriasis of the von zumbusch type appears as a distinctive acutevariant of psoriasis. It is unusual to see other forms of psoriasis on the skin at the sametime. Attacks of pustular psoriasis are characterized by fever that lasts several days. Asudden generalized eruption of sterile pustules 2-3mm in diameter parallels the onset offever. The pustules are disseminated over the turnk and the extremities including thenail beds, palms, and soles. The pustules usually arise on highly erythematous skin,first as patches and then becoming confluent as disease becomes more severe. In addition to the pustule formation of the nail matrix and the loss of the entirenail. The fingertips may become atrophic in patients with prolonged disease. As withother forms of psoriasis, the face usually remains free of lesions. The erythema, whichsurrounds the pustules often spreads and becomes confluent leading to erythroderma.Characteristically the disease occurs in waves of fever and pustules.Annular Pustular Psoriasis A rare variant of pustular psoriasis is an annular as or circinate form of thedisease occurring during episodes of pustular eruptions. Lesions may appear at theonset of pustular psoriasis, with attendency to spread and form enlarged rings, or theymay develop during the course of genenralized psoriasis.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  43. 43. 43 The main features are pustules on a ring like erythema, which sometimesresembles erythema annular centrifugum. Histologically there is mild acanthosis andneutrophil accumulation with formation of microabscesses. Identical lesions are found inpatients with impetigo herpetiformis, a pustular form of psoriasis associated withpregnancy.Localized Pustular Psoriasis Localized pustular psoriasis presents as two distinct conditions, which may beconsidered separate from the generalized disease. The systemic symptoms are absent.The two distinct varieties are, 1) Palmoplantar pustular psoriasis of barber 2) Acrodermatitis continua hallopeau.Some cases of rather classic subcorneal pustular dermatosis have been reported to leadto psoriasis. TABLE NO: 10 SHOWS COMPARISON BETWEEN THE KITIBHA KUSTA LAKSHANA AND Kitibha Kusta Psoriasis 1 Rooksha Dry 2 Kina Ruda vrana-Granulation site of healing wound 3 Khara Rough 4 Kandu Itching 5 Paruash Hard 6 Prashantanicha Subsides and relapses PunarUtpadyante 7 Vriddhimanthi Spreading in nature 8 Vrittam Round or coin shape lesions 9 Ghanam Well defined borders 10 Snigdham Sticky, unctuous 11 Krisham Black 12 Shyava Bluish Black 13 Aruna Reddish brownTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  44. 44. 44 All the lakshanas are similar to the clinical picture of psoriasis. Only the presence of silvery scales is not mentioned in the context of kitibha kusta. Vyava chedaka nidana (Differential diagonosis) Before confirming the dignosis of Kitibha Kusta it has to be differentiated from the other diseases, which mimic Kitibha Kusta with some specific symptoms. For this one should do proper examination as well as investigations in order to differentiate it from other diseases, which have some similar and specific symptoms. For this the following diseases can be considered: Table no 11 shows differential diagnosis of kitibha kustaSymptoms Of Dadru Kusta Kitibha EkaKusta Sidhma Kusta Charmadala psoriasis Kusta KustaItching Kandu (all Kandu(S.S.& --------- Kandu (S.S) Kandu(.S.S texts) A.H) &C.S)Raised lesion Utsanna- Ghanani ----- ---- ----Erythematous Mandala(A.H) (S.S)Papules orPlaquesSilvery scaling ------ ----- Matsyashakalo Rajah Dalita pamam (A.H) Ghrishtam(C.S) (C.S)Thickening ----- ----- ----- ----- Hastichar- mavat (A.H)Dryness Ruksha (Bhela) Ruksha ----- Ruksha (A.H) -----Pin point Raga ----- ----- ----- RaktadalaBleeding Pidaka(C.S) ----- ----- ---- (A.H)Kobener’s Deergha ----- ----- ---- -----phenomenon pratanavat(A.H)Chronic in Anushank-hini ----- ----- ----- -----natureorhistory (A.H)ofpreviousattack ----- = Denotes not mentioned C.S. = Charaka Samhita S.S = Sushruta Samhita A.H. = Astanga Hridaya Samhita To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  45. 45. 45Diagnosis & Differential Diagnosis of Psoriasis43: The diagnosis is usually easy but occasionally difficult. The points to look out forare the dryness, silvery scaling, and sharp edges characteristc of psoriasis. Scraping thelesions until the typical smooth read surface with bleeding points appears is sometimesof assistance. Psoriasis when not typical may have to be diagnosed from seborrhoea(dandruff) of the scalp, seborrhoeic dermatitis else where, syphilis, both popularsecondary and circinate tertiary types, pityrasis rosea, tinea circinata, lichn planus,eczema on palms and elsewhere, ringworm, and syphilis of nails, and the flexural typesof psorasis from tinea cruris, intertrigo, and seborrheic dermatitis. From dandruff, theprincipal points are that the edges of psoriasis patches are sharp whereas those ofdandruff patches are indefinite. Either disease may involve the whole scalp, but thecharacteristic edges will still be seen at the hairy margins of the scalp. The scales inpsoriasis are drier and more silvery than those of dandruff, which tend to be moister andyellower. The spore of Malassez is present in the scales of dandruff and absent inpsoriasis. The same points hold well in the distinction of psoriasis from seborrhoeicdermatitis elsewhere on the body with the addition that in seborrhoeic dermatitis thereare usually, beyond the edges of the patch, outlying, small, red, follicular papules. Thedistribution of the lesions also tends to be different, seborrhoea usually affecting theflexures, or the middle line of the chest and back, while psoriasis is more common on theextensor surfaces. A scaly papular secondary syphilide is sometimes difficult to distinguish frompsoriasis. The principal points in favour of syphilis are the presence of other signs ofsyphilis, adenitis, mucous patches, anaemia, positive Wassermann reaction, etc., thepresence of lesions on the central parts of the face, a flexor as opposed to an extensordistribution of the lesions, and the results of scraping the papules. When the scalesTo evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  46. 46. 46have been scraped off a psoriasis patch very little infiltration can be felt, in a syphiliticpapule there is still considerable infiltration. A syphilide does not yield the smooth redsurface with bleeding point’s characteristic of psoriasis, but a yellower surface, smallparts of which tend to come away on the blade of the scraper. A scaly circinate tertiarysyphilide also may have to be distinguished form psoriasis and this may be very difficult.In the tertiary syphilide some infiltrated nodules can generally be found, especially at theperiphery, and there may be a small crust here and there. There will usually be somesigns of scarring on the healed areas in the centre, whereas psoriasis, though it maycause temporary pigmentation or depigmentation, never causes scarring. Assistancemay be obtained by finding definitely recognisable syphilitic lesions or their scarselsewhere, e.g. chronic glossitis. The Wassermann reaction is not reliable here because20% of tertiary syphilitics give a negative result. It may be necessary to try the effect ofantisyphilitic treatment in order to arrive at a diagnosis. Lichen simplex chronicus of scalp typically presents with a red scaling patch onthe occiput, which can looks like psoriasis. The intense itching and lichen fed surfaceshould serve to distinguish the two disorders. Multiple patches of ringworm may appear like psoriasis, but the leisons are oftenmore ring –like than psoriasis and can be distinguished by microscopical examination,potassium hydroxide treated skin scrapping mycosis fungicides, a T-cell lymphomapotassium of skin-often evolves through a phase in which there are many psoriasis formlesions on the trunk. They differ from psoriasis by being more irregular in shape andbeing persistent and at differing stages of development. Psoriasis of the palms and/or soles can be very difficult to distinguishfrom eczema affecting these sites. Even after several investigations, including biopsy.The clinical findings may remain undecided as to the correct diagnosis.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)
  47. 47. 47 Superficial basal cell carcinoma of lesions is some times several centimeters indiameter and quite psoriasiform in appearance but have a fine raise, hair-like margin.These are also disorders characterized by the development of pink scaling patches ofunknown cause that have been termed, inappropriately as Parapsoriasis disease. Theyprobably have no proper relationship to psoriasis other than a superficial morphologicalsimilarity in some instances. The psoriasiform appearance is common to a number of dermatomes and biopsyand other investigations are required to reach a definitive diagnosis.The Koebner (Isomorphic) Phenomenon Psoriasis is of several diseases exhibiting this phenomenon. The ‘type reaction’concerned is elicited at the site of trauma, operation wound, sunburn, vaccination or pre-existing disease. It occurs in the eruptive phase of the disease and its presence is anindication for caution in therapy. It appears between 3 and 18 (usually 10-14) days afterinjury and is preceded or accompanied by changes in the capillaries. The healedcenters of annular lesions are usually; though not invariably, immune. Damage both tothe epidermis and to the papillary layers are necessary to evoke the reaction, which canbe enhanced or retarded by various chemical and cytotoxic agents. It has been claimedthat the serum of patients recovering from active psoriasis contains factor, which inhibitsthe development of the koebner phenomenon.To evaluate the efficacy of patoladi compound and yoga basti in Kitibha Kusta (psoriasis)