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ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS, GIRIJA.M.N, DEPARTMENT OF POST GRADUATE STUDIES IN PANCHA KARMA, S. D. M. COLLEGE OF AYURVEDA, UDUPI,

ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS, GIRIJA.M.N, DEPARTMENT OF POST GRADUATE STUDIES IN PANCHA KARMA, S. D. M. COLLEGE OF AYURVEDA, UDUPI,

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  • 1. ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. In partial fulfillment of the regulations for the degree of DOCTOR OF MEDICINE (Ayu) In PANCHA KARMA BY DR. GIRIJA.M.N. B.A.M.S GUIDE: DR. SHREEKANTH U. M D (Ayu) G.A.U Professor, H.O.D. & Former Dean Department of Pancha Karma CO-GUIDE: DR. NIRANJAN RAO M D (Ayu) G.A.U Professor Department of Pancha Karma DEPARTMENT OF POST GRADUATE STUDIES IN PANCHA KARMA S. D. M. COLLEGE OF AYURVEDA, UDUPI 2010-2011
  • 2. Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore DECLARATION BY THE CANDIDATE I here by declare that this dissertation thesis entitled “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” is a bonafide and genuine research work carried out by me under the guidance of Dr.Shreekanth.U. M.D(Ayu) G.A.U, Former dean,HOD & Professor and under Co-Guidance of Dr.Niranjan Rao. M.D.(Ayu) G.A.U, Professor Dept of Pancha Karma, S.D.M.C.A, Udupi. Date: Signature of the Candidate Place: Udupi Dr.Girija.M.N. Department of Pancha Karma S.D.M.C.A.,Udupi
  • 3. Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” is a bonafide research work done by “GIRIJA.M.N.” in partial fulfillment of the requirement for the degree of Doctor of Medicine in Ayurveda, under my guidance Dr Shreekanth.U. M.D. (Ayu)GAU. Date: Signature of the Guide Place: Udupi. Dr .Shreekanth.U. M.D (Ayu) GAU Former dean,H.O.D& Professor Department of Post graduate Studies in Pancha Karma S.D.M.C.A. Udupi
  • 4. Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” is a bonafide research work done by Girija.M.N. under the guidance of Dr.Shreekanth.U. M.D (Ayu) G.A.U,Former dean ,H.OD & Professor and Co- Guidance of Dr. Niranjan Rao. M.D. (Ayu) G.A.U,Professor. Signature of H.O.D Signature of Principal Dr. Shreekanth U, M.D. (Ayu) Dr.U.N Prasad, M.D. (Ayu) Former Dean,Professor and HOD Principal Dept of panchakarma SDMCA,Udupi Date: Place: Udupi
  • 5. COPYRIGHT Declaration by the Candidate I here by declare that the Rajiv Gandhi University of health Sciences, Bangalore,Karnataka shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic / research purpose. Date: Signature of the Candidate Place: Udupi Dr. Girija.M.N. B.A.M.S © Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
  • 6. ACKNOWLEDGEMENT I ACKNOWLEDGEMENT This is unforgettable movement contentment on the successful fulfillment of an ambition & a milestone fostered for long i.e. the completion of this dissertation work. I am highly indebted to my parents Shri.S.Narasimhamurthy & Smt.Mahalakshmi played a key role in molding my thoughts towards higher studies with a constant enthusiastic & affectionate push & who are the driving forces behind this work. I am dedicating this whole work to the feet of my father Mr.S.Narasimhamurthy whose moral support & great inspiring thoughts towards me had helped me always to achieve my goals in the most toughest situations of my life. Who has made me to sail always towards success with much difficulty. It is a great pleasure for me to extend my thanks with respect to my Guide, my preacher Dr. Shreekanth U.Professor,HOD & Former dean Department of Panchakarma, SDM College of Ayurveda & Hospital Udupi. Whose scholarly suggestions, Potential direction, timely supervision & perpetual inspiration made me to complete this work. It is a great pleasure to express my gratitude to my co guide Dr. Niranjan Rao, Professor, Department of Panchakarma, and SDM College of Ayurveda & Hospital, Udupi, who supported me each & every movement of my work. It is a great pleasure to express my gratitude to Dr. Rajlaxmi, M.G, Lecturer & Dr.Padmakiran,Lecturer Department of Panchakarma, SDM College of Ayurveda & Hospital, Udupi, she supported me during my work.At the same time I would like to convey my thanks to the pharmacy staff of our hospital, they help me in preparation of my drugs. I, in this special movement, should be very much thankful to my loving brother Mr.Santosh.M.N for his great friendly advise , all-time support, generous help, not only in this work, but throughout my entirelife . My special acknowledgement to all my friends & batchmates Dr.Riyas, Dr.Greeshma, Dr. Rahul, Dr.Prakash, Dr.Pratimaadarsh,Dr.Seetharam for their wonderful co-operation during my entire course. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” I thank to all my Seniors & Junior colleagues Dr.Raksha, Dr.vishwanath, Dr.varun, Dr.Vignesh, Dr.Shankarnarayan.
  • 7. ACKNOWLEDGEMENT II I take this opportunity to convey my thanks to my juniors Ajisha,Harshitha.B, Deepika, Dr.Ramya, Dr.Vidya BAMS, SDMCA, Udupi. I am thankful to the Panchakarma staff, for their kind co-operation, which was indispensable for the successful completion of this work. I can’t think of the words to thank adequately all my patients for their trust and patience. If I am sailing in the wide ocean of medicine today, it is my patients who add wind to my sails. They are both my ways and my destination too. My special thanks to the Library staff, owner of Samrudhi Xerox, for their co-operation during my documentation work. I should be very thankful to all of my family members ,they always inspired me to achieve this milestone in my life. I have not been able to find words enough to express my sentiments of love, respect & gratitude for them. Lastly I acknowledge my thanks to those who have directly or indirectly extend there Support for the completion of my work. GIRIJA.M.N. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 8. ABBREVIATIONS III ABBREVIATIONS 1. Cha. : Charaka Samhita 2. Sus. : Sushruta Samhita 3. A.S. : Ashtanga Sangraha 4. A.Hr. : Ashtanga Hridaya 5. B.P. : Bhava Prakasha 6. M.N. : Madava nidana 7. Sha. : Sharangadhara Samhita. 8. B.S : Bhela Samhita 9. H.S. : Harita Samhita 10. Ka. : Kashyapa Samhita 11. Van. : Vangasena 12. Y.R. : Yogaratnakara 13. G.D. : GadaNigraha 14. Bhai.Rat : Bhaishajya Ratnavali 15. Nig.A. : Nighantu Adarsha 16. Su. : Sutra Sthana 17. Ni. : Nidana Sthana 18. Vi. : Vimana Sthana 19. Chi. : Chikitsa Sthana 20. K : Kalpa Sthana 21. Si. : Siddhi Stana 22. Pu. : PurvaKhanda 23. M : Madyama Khanda 24. U : UttarKhanda 25. Nig. : Nighantu 26. AT : After treatment 27. BT : Before treatment 28. Cm : Centimeters 29. d : Difference 30. DC : Differential Count DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 9. ABBREVIATIONS IV 31. ESR : Erythrocyte Sedimentation Rate 32. Hb : Hemoglobin 33. No. : Number 34. PASI : Psoriasis Area & Severity Index 35. SD : Standard Deviation 36. SEM : Standard Error Mean 37. TC : Total Count 38. Yrs. : Years DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 10. ABSTRACT  V    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” ABSTRACT Psoriasis is the most common dermatological condition affecting 1% of the population .It is a chronic inflammatory skin disorder clinically characterized by erythematous,sharply demarcated papules and rounded plaques, covered by silvery micaceous scale. The cause is unknown but is thought to be related to genetic and environmental factors that trigger on over production of epidermal cells. Kushta is Bahudoshaavastajanya vyadhi ,has tridosha involvement along with saptha dhatu as its dushya psoriasis may be put under the categories like kitibha, sidhma, ekakustha according to different presentations. Virechana karma is one of the sodhana karma explained for it.As tvacha is a jnanedriya ,thus by virechana karma indriya shudhi takes place. All acharayas explained that kustha is one of the virechana sadhya vyadhi.Thus virechana karma is helpfull to manage psoriasis. Aims and Objectives To evaluate the effect of virechana karma in patients suffering from psoriasis. Methodology It is Single blind clinical study with 20 patients having the sign & symptoms of Psoriasis were selected randomly irrespective sex from O.P.D. & I.P.D. sections of Panchakarma department, S.D.M. Ayurveda Hospital, Kuthpady, Udupi, were diagnosed as psoriasis and fullfilling the criteria of undergoing the process of virechana karma were selected. Patients were subjected to deepana pachana with chitrakadi vati, after proper amapachna arohana snehapana was administered with Mahatiktaka gritha till obtaining samyak snigda lakshans. Then from next day of samyak snigdha lakshana, Sarvanga Abhangya with Karanja Taila followed by Sarvanga Parisheka with Sidartaka snana choorna was performed for 4 days and during this period patient advised to avoid consumption of Kaphakara Ahara and Vihara. On 4th day depending upon the rogi & roga bala Virechana Karma was performed with Abayadimodaka with sukoshna jala as Anupana. Finally based on Shuddhi lakshana Samsarjana krama was prescribed. In all cases P.A.S.I. score, candle grease sign and Auspitz sign were noted before and after the Virechana karma. Keywords: - Virechana Karma, Psoriasis, Kushtha, P.A.S.I.
  • 11. TABLE OF CONTENTS CONTENTS PAGE NO. ACKNOWLEDGEMENT I-II ABBERAVITIONS III-IV ABSTRACT V LIST OF TABLES VI-X LIST OF FIGURES/GRAPHS XI-XIII INTRODUCTION 1-2 OBJECTIVES 3 PREVIOUS WORKS DONE 5 PART 1 CONCEPTUAL STUDY 5-99 PART 2 DRUG REVIEW 100-108 PART 3 METHODOLOGY 109-114 PART 4 OBSERVATIONS 115-137 PART 5 RESULTS 138-146 PART 5 DISCUSSION 147-157 PART 6 CONCLUSION 158 PART 7 SUMMARY 159-161 BIBLIOGRAPHY 162-181 ANNEXURE
  • 12. LIST OF TABLES  VI    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SL. NO TABLE OF CONTENTS PAGE NO. 1. Detail description regarding Virechana in different samhithas 6-7 2. Classification of virechana drugs 11 3. Classification of virechana dravayas based on parts used 12 4. Classification of Virechana dravayas based on parts used & agraoushda 13 5. Showing virechana drugs according to seasons 16 6. Showing virechana kalpas according to charaka 18 7. Showing formulations for virechana based on dosha involvement 19 8. virechana kalpas according to sharangadhara 19 9. Virechana dravyas used as per the dosha 19 10. Showing Virechana yogya 21-22 11. Showing Virechana ayogya 23-24 12. Showing sneha matra 26 13. Showing sneha dravya and anupana 27 14. Showing sneha Jeeryamana and Jeerna lakshana 28 15. Showing Samayak snigdha lakshana 28 16. Showing Asnigdha lakshana 29 17. Showing Atisnigdha lakshana 29 18. Dose of virechana drug in its different form 31 19. Showing criteria for Antiki,Vegiki & Maniki shuddhi of Virechana karma 34 20. Laingiki shuddhi 35 21. Showing ayoga lakshnas of virechana karma 35 22. Showing Atiayoga lakshnas of virechana karma 36
  • 13. LIST OF TABLES  VII    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 23. Showing the diet regimen 36 24. Showing Rasa Samsarjana 40 25. Showing the Ayoga and Atiyoga Lakshanas of Vyapath. 41 26. Showing the Virechana Vyapath According to different Acharyas. 41 27. Showing virechana vyapat with their treatment. 42 28. Showing layers of Twak according to different Acharyas 49 29. Showing Sapta Twacha and Disease Relation. 50 30. Explanation of kustha in different samhithas. 52 31. Showing Maha kushtha according to different acharyas. 54 32. Showing Kusdra kushtha according to different acharyas. 55 33. Kashayapokta kustha types. 56 34. Showing Kusta dosha relation 56 35. Showing difference b/w Mahakustha & Kusdra Kustha 57 36. Showing Nidana of Kustha according to different acharyas. 58-63 37. Showing poorvaroopa of kushtha according to different acharyas. 64 38. Showing kushtha Roopa according to different acharyas. 65-66 39. Showing Sadya-Asadyadtha of kustha 68 40. Showing Pathya-Apathya of kustha . 71-72 41. Differential diagnosis of Psoriasis. 83-84 42. Classification of psoriatic arthritis. 86 42a. Showing PSAI Coverage area score. 96 43. Showing features of different types of kushta in relation to psoriasis. 98 44. Rasa panchaka of Chitrakadi Vati 101-102
  • 14. LIST OF TABLES  VIII    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 45. Rasa panchaka of Mahatikthaka ghritha 103 46. Rasa panchaka of Kranja taila 105 47. Rasa panchaka of sidarthaka snana choorna 105 48. Rasa panchaka of Abhyadimodaka 106 49. Age group Incidence of patients 108 50. Sex Incidence of patients 115 51 Religion wise distribution of patient 115 52. Marital status of patients 116 53. Education level of patients 116 54. Analysis of Psoriasis onset site 117 55. Seasonal impact on Psoriasis 117 56. Addiction wise Incidence 118 57. Dietary habits 118 58. Family history of Psoriasis 119 59. Prakruti of patients 119 60. Desha of patients 120 61. Koshta wise distribution of patient 120 62. Satva 121 63. Satmya 121 64. Samhanana 122 65. Sara 122 66. Ahara-Abhyavaharana Shakti 123 67. Ahara- Jarana Shakti 123 68. Pachakagni 124 69. Vyayama Shakti 124 70. Vaya 125 71. Dehabala 125 72. Analysis of Candle Grease Sign 126 73. Analysis of Auspitz Sign 126
  • 15. LIST OF TABLES  IX    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 74. Involvement of Nails 127 75. Analysis of Scaling 127 76. Analysis of Thickness 128 77. Analysis of Itching 128 78. Analysis of Discharge 129 79. Type of Kushta 129 80. Analysis of samyak snigdha lakshana appearance day 130 81. Analysis of Total amount of abyantara sneha 131 82. Analysis of samyak snigdha lakshana 132 83. Analysis of samyak Swinna lakshana 133 84. Analysis of latency period 133 85. Analysis of Duration of Virechana 134 86. Analysis of Vaigiki Shuddhi 134 87. Analysis of Manaki of Virechana 135 88. Analysis of Anthiki of Virechana 135 89. Analysis of Laingiki Lakshana of Virechana 136 90. Effect on Itching over head 137 91. Effect on Erythema over head 138 92. Effect on Scaling over head 138 93. Effect on Thickness of Skin over head 139 94. Effect on Itching over Trunk 139 95. Effect on Erythema over Trunk 140 96. Effect on Scaling over Trunk 140 97. Effect on Thickness over Trunk 141 98. Effect on Itching over Upper limbs 141 99. Effect on Erythema over Upper limbs 142 100. Effect on Scaling over Upper limbs 143 101. Effect on Thickness of Skin over Upper limbs 143
  • 16. LIST OF TABLES  X    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 102. Effect on Itching over Lower limbs 144 103. Effect on Erythema over Lower limbs 144 104. Effect on Scaling over Lower limbs 145 105. Effect on Thickness of Skin over Lower limbs 145 106. Effect on mean PASI Scoring 146
  • 17. LIST OF FIGURES XI    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” LIST OF FIGURES SL. No. FIGURES PAGE No. 1. Age group Incidence of patients 115 2. Sex Incidence of patients 115 3. Patients according to their religion 116 4. Marital status of patients 116 5. Education level of patients 117 6. Analysis of site of onset of Psoriasis 117 7. Seasonal impact on Psoriasis 118 8. Addiction wise distribution of patients Incidence 118 9. Diet wise distribution of patient 119 10. Family history of Psoriasis 119 11. Prakruti of patients 120 12. Desha of patients 120 13. Koshta of Patients 121 14. Satva 121 15. Satmya 122 16. Samhanana 122 17. Sara 123 18. Ahara-Abhyavaharana Shakti 123 19. Ahara- Jarana Shakti 124 20. Pachakagni 124 21. Vyayama Shakti 125 22. Vaya 125 23. Dehabala 126 24. Analysis of Candle Grease Sign 126 25. Analysis of Auspitz Sign 127 26. Involvement of Nails 127 27. Analysis of Scaling 128
  • 18. LIST OF FIGURES XII    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 28. Analysis of Thickness 128 29. Analysis of Itching 129 30. Analysis of Discharge 129 31. Type of Kushta 130 32. Analysis of samyak snigdha lakshana appearance day 131 33. Analysis of Total amount of abhyantara Sneha 132 34. Analysis of samyak snigdha lakshana 133 35. Analysis of samyak Swinna lakshana 134 36. Analysis of latency period 134 37. Analysis of Duration of Virechana 135 38. Analysis of Vaigiki Shuddhi 135 39. Analysis of Manaki of Virechana 136 40. Analysis of Anthiki of Virechana 137 41. Analysis of Laingiki Lakshana of Virechana 138 42. Effect on Itching over head 138 43. Effect on Erythema over head 139 44. Effect on Scaling over head 139 45. Effect on Thickness of Skin over head 140 46. Effect on Itching over Trunk 140 47. Effect on Erythema over Trunk 141 48. Effect on Scaling over Trunk 141 49. Effect on Thickness over Trunk 142 50. Effect on Itching over Upper limbs 142 51. Effect on Erythema over Upper limbs 143 52. Effect on Scaling over Upper limbs 143 53. Effect on Thickness of Skin over Upper limbs 144 54. Effect on Itching over Lower limbs 144 55. Effect on Erythema over Lower limbs 145
  • 19. LIST OF FIGURES XIII    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 56. Effect on Scaling over Lower limbs 145 57. Effect on Thickness of Skin over Lower limbs 145 58. Effect on mean PASI Scoring 146
  • 20. LIST OF CHARTS XIV    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” LIST OF CHARTS SL.NO CHARTS PAGE NO. 1. Mode of Action of Virechana karma 44 2. Kushtha Samprapti 67 3. Pathology of Psoriasis 77 4. Schematic of treatment ladder Psoriasis 89
  • 21. INTRODUCTION 1   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” INTRODUCTION MÑüwhÉÉÌiÉ uÉmÉÑ CÌiÉ MÑü¸Ç || MÑwhÉÉÌiÉ uÉmÉÑ MÑü¸Ç ||( A.Hr.Ni 14/4)) The above definitions does explain the importance of skin from the point of cosmetology. Disfiguration (MÑüwhÉÉÌiÉ), blackening or changes in normal colour (üMÑwhÉÉÌiÉ) are the two main impacts of any of the kushta. In Ayurveda importance of Skin had been highlighted by identifying it as one of the seat of Jnanendriya(Cha.Su.8/10) and moreover comparing to all other seats of Jnanendriya’s, Skin envelope most part of body surface. In other words to say, remaining Netradi four Indriyas have their seat on restricted parts of body surfaces like Netra is seat for Chakshurindriya, Jivha is seat for Rasanedriya etc. but Sparshanendriya has its seat in Twacha which covers all most all the body surface area (Cha.Su. 11/38). From the origin point of view Tvak is considered as Upadhatu of mamsa dhathu, Tvak is having direct relationship with Rasa dhatu owing to its nourishment and maintenance(Cha.Chi15/17).However in the context of Dashavidha pariksha Charak identified TwakSara instead of RasaSara (Cha.Vi.8/102-103).Thus healthy status of Rasadhatu is most essential to maintain the proper structure and functions of Tvak. Psoriasis is one of the most common dermatologic disorder and a chronic skin disorder marked by periodic flare-ups of sharply defined red patches, covered by a silvery, flaky surface. About the 3% of the world’s population have some form of psoriasis. The main disease activity leading to psoriasis occurs in the epidermis, the top five layers of the skin. In persons with psoriasis, the keratinocytes multiply very rapidly and travel from the basal layer to the surface in about 4 days. The skin cannot shed these cells quickly enough, so they build up, leading to thick, dry patches, or plaques. Silvery, flaky areas of dead skin build up on the surface of the plaques before being shed. The underlying skin layer (dermis), which contains the nerves and blood and lymphatic vessels, becomes red and swollen1(a) .
  • 22. INTRODUCTION 2   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Kushta is Bahudoshaavastajanya vyadhi ,has tridosha involvement along with saptha dhatu as its dushya psoriasis may be put under the categories like kitibha, sidhma, ekakustha according to different presentations Virechana karma is one of the sodhana karma explained for it.As tvacha is a jnanedriya ,thus by virechana karma indriya shudhi takes place (cha.su.8/10). All acharayas explained that kustha is one of the virechana sadhya vyadhi.Thus virechana karma is helpfull to manage psoriasis. Moreover Charaka identified Kushta as one among Dheergakaalena roga (Cha.Su.25/40). Hence the present study was chosen as administration of Virechana Karma in Psoriasis. It is Single blind clinical study with 20 patients having the sign & symptoms of Psoriasis were selected and were screened with Haematological tests to rule out other underlying pathologies and to void possible complications. All the patients were administered with preliminary Deepana –Pachana with Chitrakadivati. Snehana was achieved by internal administration of Mahatiktaka Gritha followed by Abhyanaga with karanja taila and Parisheka with sidartaka snana choorna kashaya . Main course of the treatment i.e. Virechana was administered with Abhyadimodaka with Sheeta jala as Anupana. Depending upon Suddhi Paschat karma was designed. Dosage & duration of all the procedures were in accordance with Doshabala, Agni bala, Koshta etc. Results: On an average on the 3rd day patients attained samyak snigdha lakshana. i.e. maximum of 45% patients attained samyak snigdha lakshana on the third day itself. In maximum number of patients the total amount of Abhyantara Sneha required during the whole course of Snehapana was ranging between 100-400 ml. Maximum of maximum of 20(100%) of patients had Swedapradurbhava and 18(90%) of patient had Tvak mardavata by Sidarthaka snana choorna kashya Parisheka. Maximum of 31-60 min. Latency period was in found 08(40%) of patients. By Virechana karma there is 49.03% improvement in total PASI Scoring .
  • 23. OBJECTIVE OF THE STUDY  3 OBJECTIVE OF THE STUDY To evaluate the effect of virechana karma in patients suffering from psoriasis. Conceptual study of Virechana Karma & Psoriasis   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 24. PREVIOUS WORKS DONE 4    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PREVIOUS WORKS DONE ON PSORIASIS 1. Babu Shankar.A “Effect of Vamana and Virechana in Psoriasis” Govt. Ayurvedic college, Kerala University, Trivendrum – 1988. 2. Anken “Concept of Kitibha (Psoriasis) in Ayurveda and Modern medicine and its treatment with Strikutaja a further study”. Banaras Hindu University, Varanasi - 1991. 3. Ruparel.S.J “Role of Virechana with and without Shamana in the management of Eka kushtha (Psoriasis) ” by Ruparel on 1999 at Gujarat Ayurveda University, Jamanagar- 1999. 4. Jagadeesh.G “Role of Vamana karma in the management of Psoriasis- A clinical study S.D.M. College of Ayurveda, kuthpady Udupi, RGUHS, Karnataka - 2007 . 5. Praveen.V.Devarushi . “Role of Virechana karma in the management of psoriasis ” S.D.M. College of Ayurveda , Kuthpady Udupi RGUHS, Karnataka- 2009.
  • 25. REVIEW OF LITERATURE 5    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  PROCEDURE REVIEW HISTORICAL REVIEW PURANA KALA Agnipurana1 : . Agni purana has stated virechana as best treatment for the diseases caused due to Pitta.Trivrth as best virechaka dravya. It is indicated in urdhwaga rakta pitta, jwara, hridroga.But detailed description of Virechana was not found. In Manu smrithi, it is told that snana is done after the completion of vamana and virechana. Vinayapitaka(Buddhist literature): In the text Vinaya pittaka from Buddha period description of administration of virechana was given to Bhagwan Buddha by inhaling powder spread over uthplapatra is available. Kasika2 It is explained that Panchakarma was common method of treatment which prescribed Poorvakarma such as Snehana, Swedana and Panchakarma, Annasamsarjana etc.
  • 26. REVIEW OF LITERATURE 6    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  SAMHITA KALA: Table no :1 showing description of virechana in different samhithas DRUGS   BOOK       STHANA  VIRECHAN  DRUG  (Chapters/  Sholka)  VIRECHAN  KALPA/ YOGA  (Chapters/  Sholka)    PROCEDURE,  BENEFITS  (Chapters/    Sholka)    COMPLICATIO NS &  TREATMENT  Chapters/Sholka    Sutrasthana  1/77,75 ;  2/9,10; 4/13  15/7;  25/40      ‐      15/ 17,18,16,  22;  16/ 17‐19    15/ 13 ;  16/ 5‐10 ,   22‐26  Vimanasthana  8/136  ‐  ‐  ‐  Kalpasthana  1/6   7‐12   1/3, 4,5. ;  12   12             Charak  samhita  Siddhisthana  ‐  ‐  1; 2/11,12,13.  6               Sutrastana   38/30 ;   39/ 4  44     ‐  ‐ Sushruta   Samhita  Chikitsasthan  ‐  ‐  33/19‐47  34   Sutrastana   15/2  ‐  18   18    Astanga   Hridaya  Kalpasthana  ‐  2   ‐  3      Astanga  Sutrasthana  13/2;14/3‐ 4;15/6  ‐  27   27  
  • 27. REVIEW OF LITERATURE 7    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  sangraha  Kalpasthana  ‐  2   ‐  3   Sutrasthana   ‐  ‐  4 ; 21 ; 23;25  ‐  Kalpasthana  ‐  7 ; 8 ; 9.   ‐  ‐        Bhela  samhita  Siddhisthana  ‐  ‐  ‐  1 ; 4   purvakhanda  4   ‐  ‐  ‐ Sharang‐ adhara  samhita  Uttarakhanda                              Detail about virechana karma   Vangas‐ ena  samhita    Virechanadhik ara     Detail about virechana karma   Bhavaprak asha  Nighantu Part  ‐  5   5   5   Chakra – datta  ‐  ‐  71  71   71   Sutrasthana   ‐  ‐  24   ‐  Siddhisthana  ‐  ‐  2 ; 3 ; 7  ‐    Kashyapa  samhita  Khilasthana  ‐  ‐  7   7  
  • 28. REVIEW OF LITERATURE 8    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  VIRECHANA The process by which the vitiated doshas are eliminated through the adhobhaga ie guda marga, is called ‘Virechana.This is widely used shodana therapy, is less stressful with least complication.Virechana in broader term denotes both vamana and virechana.3 Etymology:- (1) Virechana4 :Vi+Rich+ Nich , lytu-malade: nissernam ......(Vachaspathyam). (2)Virechanaha5 :Vi+Rich+Nich, lytu-Visheshena rechathete ...... (Shabdakalpadruma) The Vircehana word is derived from the ‘Rich’ dhatu ,‘Nich’ &’Lyut’ pratyaya & with ‘Vi’ upasarga. It also means Maladehe nissaranam i.e. expelling out the malas. "Rich" - evacuation. "Rich" - Viyojana (separation). ‘Rich’ meaning – To empty , evacuate, leave, give up.6 The root ‘Rich’ is also very important to understand the systemic action of Virechana. According to Charaka, the Virechana drugs first get digested in Amashaya, then reaches to Hridaya, Dhamani, macro and micro channels (srotases) of the body and reach the site where Doshas are accumulated.7 Virechana drugs soften the compactness (Sanghata) of the Doshas and break the bigger molecules to smaller ones. This process occurs in a proper way by separation (Viyojana) and combination (Samparchana) of doshas. Up to this stage the action of Virechana is known as its systemic effect and it is obviously governed by Viyojana and Samparchana components of Virechana dravya.
  • 29. REVIEW OF LITERATURE 9    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Definition: iÉ§É SÉåwÉWûUhÉqÉÔkuÉïpÉÉaÉÇ uÉqÉlÉ xÉÇ¥ÉMüqÉ,AkÉÉåpÉÉaÉÇ ÌuÉUåcÉlÉ xÉÇ¥ÉMüqÉç .....|8    The act of expelling Doshas through Adhobhaga is known as Virechana. Here the meaning of Adhobhaga is ‘Guda’ as commented by Chakrapani. ÌuÉUåMüÉå qÉÑZÉmÉÏiÉÇ aÉÑSqÉaÉåïhÉÉliÉ:ÎxjÉiÉxrÉ SÉåwÉxrÉ ÌlÉ:xÉÉUhÉÇ ...|9 The procedure in which the drug is administered orally, acts on morbid Doshas, specifically on Pitta and expels them out through anal route. ÌuÉmÉYuÉÇ rÉSmÉYuÉÇ uÉÉ qÉsÉÉÌS SìuÉiÉÉÇ lÉrÉåiÉç | UåcÉirÉÌmÉ iÉ¥ÉårÉÇ UåcÉlÉÇ Ì§ÉuÉ×iÉÉ rÉjÉÉ ||10 The procedure where the morbid Dosha is expelled out in the form of Drava either pakva or apkva state. ÌmɨÉå iÉÑ ÌuÉUåMÇü zsÉåwqÉxÉÇxÉ×¹å uÉÉ iÉixjÉÉlÉaÉiÉå uÉÉ zsÉåwqÉhÉÏÌiÉ |11 urÉMÑüsÉÉlÉç xÉͳÉmÉÉiÉÉåijÉÉlÉç mÉæ̨ÉMüÉlÉç MüTü ümÉæ̨ÉMüÉlÉç | xÉÇxÉ×¹ÉlÉç MüTüqÉÔsÉÉÇ¶É xÉëÇxÉlÉëålÉÉprÉÑmÉ¢üqÉåiÉç ||12 Even though Virechana is best line of treatment modality for pittadosha13 it can act on kaphasamsrusta pitta or pittasthanagat kapha. And moreover in case of vatasyopakrama mridu shodhana indicated which refers to mridu Virechana karma14 . So Virechana is major line of treatment for morbid pittadosha & also it act on morbid kapha and vata dosha. Thus action of Virechana is seen on all tridosha.
  • 30. REVIEW OF LITERATURE 10    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Paryaya: Instead of word Virechana the following terms were used in different context, these all can be consider as synonyms for virechana, • Vireka, • Rechana, • Adhobhagahara. • Anulomana 15 • Praskandana. IMPORTANCE OF VIRECHANA:- Virechana is a sovereign procedure for elimination of Pitta Dosha16,17 Indu explains that in the vitiation of Kevala Pitta, Pitta associated with Kapha and in Pittasthana Gata Kapha Virechana is the obvious treatment procedure to be followed18 . Charaka explains that,Virechana drug after entering Amashaya dislodges the vitiated Pitta Dosha and henceforth pacifies all Pitta Vikara of the body19 . Virechana also cleanses sense organs i.e. improves their function. Just as removal of water from its reservoir destroys various organisms and plants residing in it, in the similar manner removal of excessive Pitta destroys the various symptoms caused due to it20 . Virechana is mentioned as Shodhana procedure in Dusthi of Rasa,Rakta, Mamsa, Asthi, Majja & Shukra Dhatus. Hence in majority of the Dhatupradoshaja Vikaras Virechana is the better option. Vatasyopakrama snehaswedaha samsodhane mridu (A sa su 21/2) Virechana dravya guna karma: The guna of virechana dravya are ushna, tikshna, sukshma, vyavayi, vikashi, these qualities are common in vamana aoushadam, but virechana dravya has adhobagahara prabhavam.Virechana dravya has jala and prithwi mahabootha predominance.21
  • 31. REVIEW OF LITERATURE 11    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  CLASSIFICATION OF VIRECHANA DRUGS:-- The drugs which produce Virechana are known as Virechaka dravyas. According to references available Virechana drugs may be classified in following 6 groups, Table.no.02 I) Virechana Dravyas According to their origin & parts used a) Animal origin b) Plants origin c) Miscellaneous II) According to the mode of action a) Anulomana b) Samsrana c) Bhedana d) Rechana III) According to the intensity of action a) Mrudu b) Madhyama c) Tikshna IV) According to the Rukshata & Snigdhata view. V) Virechana drugs according to the seasons VIRECHANADRAVYAS VI) Virechana drugs according to kalpanas I.Virechana drugs according to their origin and parts used:  a) Animal origin: ∗ Urine.22,23 ∗ Milk 24 ∗ Takra 25 b) Plant Origin:
  • 32. REVIEW OF LITERATURE 12    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Classification of virechana dravyas based on part of the plant used. Table no: 03. Sl.no. Part of the plant used for virechana. Charaka 26 Sushruta 27 Vagbhata 28 1. Mulini virechana dravya. Hastidanti Shyama Trivrit Adhoguda Saptala Danti Gavakshi Vishanika Ajagandha Dravanti Avartaki Trivrit,Shyama Danti Dravanti Saptala Shankhini Vishanika Gavakshi Chitraka Kush, Kasha Kinahi Danti,Kumbha (Trivrit) Gavakshi Shankhini 2. Phalini virechana dravya Shankhini Vidanga Anupa Sthalaja Prakeerya Udakeerya Abhaya Anthakotrapuspi Kampillaka Aragwada Kampillaka Puga Eranda,Haritaki Bibhitaki, Amalaki Neelini Aragwada Neelini Triphala Kampillak 3. Ksheera virechana dravya. Snuhi ksheera Arka Mahavriksh Saptachala Swarna ksheeri Snuhi Swarna ksheeri Godugdha 4. Twak virechana dravya Tilwaka Tilwaka Patala Ramyaka Tilwaka Ramyaka 5. Patra virechana dravya Swarna patri Aragwada Putika Aragwada Karavellaka Aragwada Based on Parts of the Dravya used: Sushruta describes the following drugs with priority for Virechana Karma29 .
  • 33. REVIEW OF LITERATURE 13    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Classification of virechana dravyas based on main part of the plant used Table no.04 Mula Virechana Shyama Trivrith Phala Virechana Haritaki Twak Virechana Tilwaka Swarasa Virechana Karvellaka Dugdha Virechana Snuhi Taila Erandam c) Miscellaneous: As Madya, Dhanyamla30 ,Guda, Ikshu Rasa, Payas, Krishara, Ushna Jala, some minerals - Swarna, Kamsya, Manahsila, Gandhaka, Ratna, Uparatna, Samudraphena also have Sara properties. II. Virechana drugs according to their mode of action by Sharangadhara Acharya Sharangdhara has classified according to the action of the Virechana dravyas. a) Anulomana 31 : M×üiuÉÉ mÉÉMÇü qÉsÉÉlÉÉÇ rÉiÉç ÎpÉiuÉÉ oÉlkÉqÉkÉÉå lÉrÉåiÉç | iÉŠÉlÉÑsÉÉåqÉlÉÇ ¥ÉårÉÇÇ mÉëÉå£üÉ WûUÏiÉMüÐ || These drugs will digest the Apakwa (undigested material) malas and bring them to adhomarga for defecation process. These drugs will facilitate the defecation process. eg: Hareetaki (Terminalia Chebula). Sushruta considers Sara as the synonym of Anulomana. According to Dalhana Anulomana causes expulsion of Vata and Kapha32 . b) Sramsana 33 : mÉ£üurÉÇ rÉSmÉ£üurÉÇ ÎvsÉ¹Ç MüÉã¹ã qÉsÉÉÌSMüqÉç | lÉrÉirÉkÉ:xÉëÇxÉlÉÇ iÉSè rÉjÉÉ xrÉÉiÉç ¢üiÉqÉÉsÉMüqÉç| The drugs which expel the malas adhered to the lumen of intestines in to the rectum without digesting them. eg: Aragwada (Casia Fistula). In the context of Jwara Chikitsa it has been mentioned that Sramsana eliminates the Pitta and Kapha situated in Pakwashaya 34 .
  • 34. REVIEW OF LITERATURE 14    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  c) Bhedana 35 :   qÉsÉÉÌSMüÇqÉoÉ®Ç cÉ oÉ®Ç uÉÉ ÌmÉÎhQûiÉÇ qÉsÉæ:| ÍpÉiuÉÉÅkÉ: mÉÉiÉrÉÌiÉ, iÉSè pÉãSlÉÇ MüOÒûÌMü rÉjÉÉ The drug which disintegrates the ‘Abaddha’ (unformed) or ‘Baddha’ (formed) or ‘Pindita’ (dried fecal mass) forms of Malas by facilitating penetration into it and then evacuating through the lower gut, is known as Bhedana. eg. Katuki. Bhedana is a process in which Shareera Mala Nirharana is brought about. 36 . Charaka has described a group named as ‘Bhedaneeya’. This includes Shyama (Trivrit), Arka, Urubuka (Eranda), Agnimukhi (Kalikari), Chitra (Danti), Chitraka, Chirabilva, Shankhini, Sakuladani (Katuki) and Swarnaksiri.37 d) Rechana 38 : ÌuÉmÉYuÉÇ rÉSmÉYuÉÇ uÉÉ qÉsÉÉÌS SìuÉiÉÉÇ lÉrÉåiÉç | UåcÉirÉÌmÉ iÉ¥ÉårÉÇ UåcÉlÉÇ Ì§ÉuÉ×iÉÉ rÉjÉÉ || The drug which eliminates digested (Pakwam) and undigested (Apakwam) Malas or Doshas by making them watery through the lower gut is known as ‘Rechana’ eg: Trivrit. Virechanopagas: There are certain drugs which help in enhancing the action of Virechana Dravyas is known as Virechanopaga. The drugs described are Draksha, Gambari, Parushaka, Abhaya, Amalaka, Vibhitaka, Kuvala Badara, Karkandhu, and Pilu39 III. Virechana drugs according to intensity of action: According to the degree of potency of the drugs, the Virechana may be classified into the following categories. A) Mridu Virechana:40 The drugs which are Mridu in Veerya or when combined with opposite Veerya or given in low dosage, given to the Ruksha patient and causes less purgation is known as Mridu Virechana. Those drugs are specifically indicated in weak patients having mild natured diseases. These drugs may also be given to the patients who have been
  • 35. REVIEW OF LITERATURE 15    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Shodhita previously or having Alpa Dosha or whose Koshta is unknown. Charaka is of the view that the physician should not hesitate to use Mridu Virechana drugs in weak patients having more Doshas because even repeated elimination of Doshas in small quantity may cure the disease41 The patient who have not taken Virechana drugs in past and whose Koshta is unknown in such persons Sushruta recommends the use of Mridu Virechana drugs in the beginning and after knowing the Koshta required drug may be prescribed 42 Sharangdhara recommends the use of Mridu Virechana drugs in Mridu Koshta (eg. Draksha, Milk, Caster oil, Warm water etc.). 43 Drugs effective in Mridu Koshta are Guda, Ikshu Rasa, Mastu, Ullodita Dadhi, Payas, Kshira, Sarpi, Kashamari, Triphala, Pilu and Taruna Madya44. B) Madhya Virechana: The drugs which are moderate in qualities are known as Madhya Virechana drugs. The drugs are specifically indicated in the patients having Madhya Roga (disease with moderate symptoms). The administration of these drugs in Balavan rogi is useless because, they are unable to eliminate Dosha completely45 .Sharangdhara recommends the use of Madhyama Virechana in Madhyama Koshta. eg. Trivrit, Katuki and Aragvadha46. C) Teekshna Virechana : The drugs, which cause Mahavega and eliminates the Doshas in large quantity by quick Kshipra and Sukha purgation without causing much Glani, is known as Teekshna Virechana. According to Charaka, the drug which has been kept away from water, heat and organisms, cultivated in proper Desha and Kala and which has been given Bhavana with the drugs of same Veerya acquires the Teekshna properties. This type of drugs having all the required properties, when given in prescribed dosage to the patient who has been well Snehita and Swedita, then it causes Teekshna Virechana47 .Sharangdhara recommends use of Teekshna Virechana drugs in Krura Koshta persons. Charaka recommends the use of these drugs in the strong (Balavan) patients with all the symptoms of the diseases i.e. Teekshna Vyadhi51 .It has been further mentioned that the use of these drugs should be avoided in Durbala (weak), Shodhita, and patient having Alpa Dosha and whose Koshta is unknown, otherwise it may cause untoward
  • 36. REVIEW OF LITERATURE 16    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  effects to these patients. Sushruta is of the view that Teekshna drugs given in Mridu Koshta having Deeptagni, passes out quickly without eliminating Doshas properly52 ,Snuhi Kshira is considered as the best amongst these drugs53 .More over Sharangdhara recommend the other drugs like Hemakshiri, Danti, etc. explained in Krura Koshta may also be included in this group. IV.Classification based on guna of drug: In many places in Ayurveda, the uses of Snigdha Virechana and Ruksha Virechana have been recommended. The drug used in the form of oil or the preparation containing Sneha is known as Sneha Virechana, eg: Eranda Taila. Vagbhata recommends the use of Sneha Virechana in all patients except Snigdha patients 54 . The use of Sneha Virechana in the patients who have been given higher dosage of Sneha is contraindicated because, due to this, the moving Doshas may again adhere in the Srotas55 . Sneha Virechana should be administered in Sama-Shitoshma Kala 56 . The preparations, which do not contain Sneha, may be known as Ruksha Virechana. Its use has been recommended in the Snigdha patients who have been comparatively taken more Sneha 57 .eg: Danti dravanti V. Virechana drugs according to seasons 58 Table no:05 Showing Virechana drugs according to seasons.      Varsha Sharad Shishira /Vasanta Greeshma Hemanta All seasons Virechana drug Beeja Trivrit Kutaja Pippali Shunthi ShyamaTri vrit Duralabha Musta Sharkara Udichya Shweta Chandana Shyamatr ivrit Pippali Nagara Sindhu Aruna Trivrit Shyamatrivrit Trivrit Chitraka Patha Ajaji Sarala Vacha Hemakshiri churna Trivrit Danti Hapusha Saptala Katuki Swarnaksiri Anupana Draksha Rasa and madhu Yasti madhu in Draksha Swarasa or Draksha Swarasa only Honey Sugar Warm Water Bhavana with cow ‘s urine
  • 37. REVIEW OF LITERATURE 17    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Adhamalla in Sharangdhara commentary mentioned that the drugs for Virechana in Shishira, Vasanta and Hemanta Rutu are same. Kasiram Vaidya in his commentary opined that Saindhava, Vriddhadaru, Shyamatrivrit are to be used for Virechana in Hemanta Rutu. Charaka mentions Trivrit Chitraka, Patha, etc. to be used for Virechana in Hemanta Rutu. VI.According to Kalpana: Different forms of yogas are prepared to help in enhancing the potency, shelflife and convenience. According to Sushruta following 8 preparations are useful. i) Ghrita yoga ii) Taila yoga iii) Kshira yoga iv) Madya yoga v) Mutra yoga VI) Mamsarasa yoga vii) Bhaksanna yoga viii) Avaleha yoga Kshira, Rasa, Kalka, Kashaya, Kwatha and Sita are respectively Laghu.
  • 38. REVIEW OF LITERATURE 18    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table no:06. Showing 245 Virechana kalpas according to Charaka.59 Kalpana Trivrth Argvada Tilvaka Sudha Saptala Shankini Danti Dravanti Amla kanji 2 1 1 1 1 1 Mutra 22 - 1 - - - Tushodaka 2 - - 1 1 1 Maireya 2 - - - 1 - Yusha 2 - - 1 - 2 Kwatha 1 2 1 - 11 - Churna 32 - - 1 1 6 Tarpana 8 - - 1 - - Ksheera 2 - - - - - Mamsa ras 2 - - 4 - 6 Ikshu ras 1 - - - - 1 Swarasa 6 2 1 2 - - Leha 1 1 3 1 3 6 Modhaka 7 - - - - - Raga shadava 4 - - - - - Sura Madhya 3 1 2 2 5 4 Souvira 2 1 1 1 1 1 Sidhu - 1 1 - 1 1 Uthkarika 1 - - - - 1 Gritha 4 2 4 4 8 6 Taila - - - - 6 2 Chatusneha - - - - - 1 Asavarishta - 1 1 - - 5 Greya - - - 1 - - Yavagu - - - - - 1
  • 39. REVIEW OF LITERATURE 19    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Specific formulations for Virechana Tabe no:07. Showing Formulations for virechana based on dosha involvement. Vata Pradhana Trivrit + Saindhava + Shunthi + Kanji or Mamsasara Pitta Pradhana Trivrit Choorna + Draksha Kvatha Kapha Pradhana Triphala Kvatha, Gomutra, Trikatu Children between the Age group of 4-12 years60 Draksha rasa+ Aragvadha phala majja Virechana Drugs According to Dosha 65 : Table no:09 Virechana Dravyas used as per the Dosha. Sl. No. Dosha Virechana Dravyas 1. Vataja Vikara Snigdha, Ushna virya with Lavana 2. Pittaja Vikara Kashaya, Madhura Rasa Pradhana 3. Kaphaja Vikara Katu Rasa Pradhana Dosage of Virechana drugs according Kosta: Matra of the Virechana drug should be in such a quantity, that the desired effect of Shodhana may be achieved and may be able to avoid Atiyoga. This should be decided according to Dosha, Atura Bala, Bheshaja, Kala, Desha, Agni, Koshta, Shareera, Ahara, Satmya, Satwa, Prakriti, Vaya, Sama Avastha and Vikara 61. Table no.08: Virechana kalpas according to Sharangadhara. 62 Kalpana Heena for Mridu Koshta Madhyama for Madhyama Koshta Uttama for Krura Koshta Kwatha 8 tolas 4 tolas 2 tolas Kalka, Choorna Modaka 4 tolas 2 tolas 1 tola
  • 40. REVIEW OF LITERATURE 20    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  According to Sushruta63 : 1, 2 and 3 Tolas is mentioned for Mridu, Madhyama and Krura Koshta respectively. I. Nature of Koshta and Virechana64 : qÉ×²Ï qÉɧÉÉ qÉ×SÒMüÉå¸å qÉkrÉMüÉå¸å cÉ qÉkrÉqÉÉ | ¢ÔüUå iÉϤhÉÉ qÉiÉÉ SìurÉæqÉ×ïSÒqÉkrÉqÉiÉϤhÉMæü: || Acharya Sharangdhara opines that – for the person Mridu Kostha, Virechana drugs must be mild and their dose should be minimum; for the Madhyama medium dose and for Krura Kostha persons, the Virechana drugs should be Tikshna and its dose is minimum. VIRECHANA VIDHI:-- Virechana Vidhi can be studied under 3 main headings: • Purva Karma (Pre Therapeutic Procedure) • Pradhana Karma (Therapeutic Procedure) • Paschat Karma(Post Therapeutic Procedure) A) PURVAKARMA: 1) Sambhara Samgraha 2) Aatura Pariksha 3) Aatura Siddhata 4) Matra Vinishchaya Sambhara Samgraha:-66 Ahara: Shali.Mudga,Maasha,Yava,Tila,Dugdha,GrithaUshana jala, Mamsa etc. Aushadha: Deepananeeya,Paachaneeya,Upashamaneeya,Vatahara, Sneha,Swedana ,Virechana drugs like Draksha, Triphala, Suoveerak etc. Equipments: Achamani,Udaka koshta , Sharava,Darvi, Tula, Manabhanda,Sutra,Karpasa etc. Atura Pariksha:67 Before performing Virechana karma it is necessary to examine the patient fitness in terms of his/her Dosha, Dushya, Atura Bala kala, Desha, Agni, koshta, Sharir & Ahara Satma, Satva etc. for proper adminstration of Virechana karma.
  • 41. REVIEW OF LITERATURE 21    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Virechana Yogya and Ayogya. Table no:10: Showing Virechana Yogya Virechana Yogya Ch.Si66 Sus.Chi67 A.S.68 A.Hr.69 K.Si.70 Sha.S.U71 Pranavaha srotoduhti vikara Shwasa + - - - - - Kasa + - - - - - Parshvaruja + - - - - - Annavaha srotoduhti vikara Aruchi + + + - - + Avipaka + - + - - - Visuchika + + + - - + Alasaka + + + - - - Chardi + + + + - + Udakavaha srotoduhti vikara Udara + + + + - + Rasa pradoshaja vikara Pandu + + - - + + Jwara + + + + - + Aruchi + + - - - + Avipaka + - + - - - Hridroga + + - - + + Rakta pradoshaja vikara Kamala + - - + + - Vidradhi - + + + - + Netradaha + + - - - + Aasyadaha + + - - - + Vatarakta + + + + - + Kustha + + - + + + Paittika vyadhi + + + - - - Visarpa + + - - + - Pliha + + + + - +
  • 42. REVIEW OF LITERATURE 22    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Vyanga + - + + - - Nilika + - - + - - Urdva Raktapitta + + + + + - Mamsa pradoshaja vikara Arbuda + + - - - - Galaganda + - - - - - Meda pradoshaja vikara Prameha + + - + + + Yoni Dosha + + + + - + Retodosha + - + + - - Mootravaha srotoduhti vikara Mutraghata + + + + - + Purishavaha srotoduhti vikara Arsha + + + + + + Bhagandara + + + - - + Udavarta + - + + + Vibhandha - + + + + - Pakvashaya shoola + + + + - - Other Visphota - - - - + + Vatavyadhi - - - - + + Garavisha - + + + + +
  • 43. REVIEW OF LITERATURE 23    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Some other indications for Virechana are: a) In Swastha.72,73 b) Utkleshita Pitta. Pitta Sthanagata Alpa Kapha Kapha Sthanagata Bahu Pitta74 Pakwashayagata Pitta or Kapha Pitta75 Pittavrita Vata Kaphavrita Vata76 Shonita Roga77 a) As Purvakarma in Rasayana and Vajikarana78,79 TABLE NO:11 Showing Virechana Ayogya Virechana Ayogya Ch.Si80 Sus.Chi81 A.S.82 A.Hr.83 K.Si. 84 Sha.S.U85 Physiological conditions Langitha + - + - - - Upavasita + - - - - - Durbalendriya + - - - - - Durbala + - - - + - Alpagni + + + + - + Shranta + + - - - + Pipasita + + - - - + Karmabharadhvahata + + - - - - Daruna koshtha + - + + - - Kshama + - - - - - Kamadivyagra + + - - - - Bhakta + + - - - - Sukumara - - - - + - Navaprasuta - + - - - + Rathri Jagarana - - + - - - Atiruksha + - + - - + Bhayoptapta - + - - - + Chinta prasaktha + - - - - -
  • 44. REVIEW OF LITERATURE 24    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Maithuna prasaktha + - - - - - Adhyayana prasaktha + - - - - - vyayama prasaktha + + - + - - Garbhini + + - - - - Age related conditions Vriddha + + - - + Bala + + - - + Pathological conditions Kshatkshina + + - - - + Atikrisha + - - - + - Atisthula + + - - + + Muktanala + - + - - - Atisara - - + + - - Adhoga Raktapitta + + + + - - Shosha - - - - - - Rajayakshma - - + - - - Urustambha - - - - + - Madatyaya + + + - - + Talushosha - - - - + - Hridroga - - - - + - Traumatic conditions Abhighata + - - - - - Subhaga + - - - - - Kshataguda + + + - - - Shalyardita + + + + - + Saama conditions Nava Jwara + + + + - + Nava Pratishyaya - + - - - - Some vataroga conditions Kevala Vataroga - - - - + - Hanugraha - - - - + -
  • 45. REVIEW OF LITERATURE 25    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Ardita - - - - + - Purvakarma related conditions. Nirudha + - + - - - Atisnigdha + + + + - + Anupasnigdha - - - - + - Pakshahata - - - - + - Atura Sidhata:- Pachana and deepana:- Ama is considered as one among the etiological factor in most of disease, & Shodhana in ama state is said to be contraindication. If Samshodhana medicine is taken in the condition of Ajirna, it will lead to Vibandha and Glani. If the Doshas are in Ama conditions and anybody tries to remove these Dosha forcefully then it will destroy the body. If the condition of patient is associated with Ama then Shodhana can only be done after the Pachana of Ama by Deepana, Pachana So it is necessary to administer deepan & pachana drugs before the virechana to attain nirama state.86 Snehana & Swedana: Snehana includes both Abhyantara (oral ingestion of unctuous material) and Bahya Snehana (external application of unctuous material) .Abhyantara Snehapana followed by Sarvanga Abhyanga along with Sarvanga Sweda (Whole body sudation) are performed prior to Virechana87 . Snehapana procedure is to be followed after observing Nirama Lakshanas. The required Sneha should be administered early in the morning at Suryodayakala after observing Jeerna Ahara Lakshanas of the previous meal and when the patient is empty stomach. The duration of Sneha Pana should be 3 to 7 days88,89 . Shodhananga Snehapana is done untill the attainment of ‘Samyak Snigdha Lakshanas’ which can be achieved in 3, 5 and 7 days in Mrudu, Madhyama, and Krura Koshta respectively. Importance: - Action of Snehana and Swedana prior to shodhana explained by Charaka in following way.Due to Snehana there will be further vriddhi of doshas, and increase in fluidity(Vishyandana) and due to Swedana dosha paka along with removal of
  • 46. REVIEW OF LITERATURE 26    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  obstruction at the enterance of the channels.Because of this the doshas leave the Shakha and comes to the Koshta.91 Sushrutha says Samshodana given without oleation and fomentation will destroy the body like the dry wood.92 Thus, Shodhananga Snehapana can be carried out for a maximum period of 7 days otherwise it will create Sneha Satmyata92, 93. Dose of Sneha for shodhana mentioned in various classics is as follows.94-96 . Table No.12 Showing Sneha matra. Madhyama Matra (Dose which digests in 12 hours) Charaka Samhita , Ashtanga Sangraha Uttama Matra (Dose which digests in 24 hours) Ashtanga Hrudaya. Uttama & Madhyama Matra Chakarapani Shodhananga Snehapana can be administered in 2 methods: a) Arohana Snehapana b) Sadyo Snehapana a) Arohana Snehapana: Kalyanakaraka first mentioned about increasing dose schedule. He clearly mentioned that Shodhanartha Abhyantara Sneha pana has to be taken in increasing order (“Krama Vardhitam Pibet”). Vangasena also followed Kalyanakaraka’s Vardhamana dose schedule. b) Sadyo Snehapana: Sadyo Snehapana involves administration of large quantity of Sneha to achieve Snigdha Lakshana immediately or within short duration. It is generally indicated in Bala, Vriddha, Balaheena, Mrudu koshta, Alpa dosha, Raja, Raja samipya, Sneha parihara asahishnushu.97
  • 47. REVIEW OF LITERATURE 27    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table No.13 . Showing Sneha Dravya and Anupana: 98 Sneha Anupana Ghrta Ushnodaka Taila Yusha Vasa & Majja Manda Bhallataka & Tuvaraka Taila Shita Jala In general Ushnodaka can be administered as Anupana for all Sneha. Sneha dravya can be administered in 2 ways, (1) Accha Peya99 – denotes consumption of Sneha without mixing with other food articles. (2) Pravicharana 100 – denotes administering Sneha by mixing with food articles either in the form of Odanadi (24 in number) or Rasa Pravicharana (64 in number). Among them, Accha Peya is considered as superior for the purpose of Shodananga Snehapana. Administration of Sneha for Shodhana: 101 On the day of Snehapana, when the raising sun has attained golden yellow colour, individual exhibiting Jeerna ahara lakshana (symptoms of digested food of the previous night) except kshudha (hunger), after performing auspicious rituals, Snehapana is done. After snehapan individual should be observed for Sneha Jeeryamana (symptoms of Sneha undergoing digestion) and Sneha Jeerna (symptoms of digested Sneha) Lakshanas.
  • 48. REVIEW OF LITERATURE 28    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table No.14 Showing Sneha Jeeryamana and Jeerna Lakshana: 102 Sneha Jeeryaman Lakshana Sneha Jeerna Lakshana Shiroruja Shirorujadi Jeeryamana Lakshana prashamana Bhrama Vatanulomana Nisthiva Swasthyata Murcha Kshuda shuddhi Sada Trishna shuddhi Arati Udgara shuddhi Klama, Trishna, Daha Laghuta Table no:15 Showing Samyak Snigdha Lakshana: 103-106 Lakshana Ch. Sa. Su. Sa. As. Hr. Sh.S Vatanulomana + - + + Deepta agni + - + + Snigdha varcha + - + + Asamhatha Varcha + - + + Angha Mardava + - + + Snigdha anga + - + + Snigdha twak - + - - Vit Shaithilya - + - - Glani - + - + Angha laghava - + - + Adhastat sneha darshana - + - - Snehodwega - + - + Vimalendriya - - - +
  • 49. REVIEW OF LITERATURE 29    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table No:16 . Showing Asnigdha Lakshana. 107-110 Table No.17 . Showing Atisnigdha Lakshana.. 111-114 Lakshana Ch. Sa. Su. Sa. As. Hr. Sh.S Pandutha + - - - Gaurava + - - - Jadya + - - - Avipakwa Purisha + + - - Tandra + - - - Aruchi + + - - Utklesha + - - - Mukha srava + + + + Guda srava - + + - Ghrana srava - + - Guda daha + + - + Bhakta dwesha - + - + Pravahika - + - + Purishaati pravritti - + - - Lakshana Ch. Sa. Su. Sa. As. Hr. Sh.S Grathitha purisha + + - - Ruksha purisha + + - - Agnimandya + + - - Vayu pratiloma + + - - Khara Gatra + _ - - Ruksha Gatra + - - - Uro vidaha _ + - - Daurbalya _ + - - Dur varna - + - - Krichrat anna Pachana _ + - - Susnigdha Lakshana Viparyaya _ _ + +
  • 50. REVIEW OF LITERATURE 30    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Bahya Snehana & Swedana: 115 After attainment of Samyak Snigdha Lakshanas, Abhyanga and Swedana should be advised for 4days on the rest day(vishrama kala) and just prior to Pradhana karma on the day of Virechana. SWEDANA:- Dosha Vilayana’ takes place through the Swedana. According to Vagbhata, by the action of Snehana and Swedana, the morbid Doshas are liquefied, dissolved and are brought to koshta116 . Dalhana also mentions that the Dosha which are lodged in Shakha are made to move towards to Koshta by Snehana and Swedana. Vagbhata mentions that the doshas are removed from the shakhas by these two procedures of Snehana and Swedana in the same fashion as dirt of cloth is removed by soap and water117 . Bhojana Vyavastha: During the procedure of Abhyanga and Swedana, Snigdha, Drava,Ushna bhojana, Mamsarasa,Pramanayukta,Anabhishandhi,NatiSnighdha,Asankeerna,Odana, Amla rasa Phala is recommended.118 . Before pradhana karma the diet should be such that, it does not increase ‘Kapha’ otherwise Vamana may occur119 . MATRA VINISCHIYA: 1. The dose of Virechana Yoga should be decided according to Vyadhibala, Aturabala and Agnibala120 . If the dose given more than Vyadhibala, may cause another Vyadhi. If it is more than Agnibala it may cause Ajeerna, Vishtambha, and if it is more than Aturabala then it may cause Atipravrtti or Apravrtti. So, the dose should be in Sama Pramana only and also the dose of Virechana drug of an individual is, one which expels only morbid Dosha out of the body without manifesting any complication.120
  • 51. REVIEW OF LITERATURE 31    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table.no.18. DOSE OF VIRECHANA DRUG IN ITS DIFFERENT FORM121-124 . Form Of Medicine Koshta Dose Sus121,122 Sha123 Van124 Krura Uttama Tikshana Tikshana 1 pala Madhyam Madhyam Madhya Madhya ½ pala 1 Any form Mrudu Heena Mrudu Mrudu 1 Karsha Krura Uttama 8 Karsha Madhyam Madhyam 4 Karsha 2 Kwatha Mrudu Heena 1 Anjali (4 pala) 2 Karsha 2 pala Krura Uttama - 2 Karsha Madhyam Madhya 1 Karsha 1 Karsha 3 Churna Mrudu Heena 1 Karsha - ½Karsha Krura Uttama - 8 Karsha Madhyam Madhyam - 4 Karsha 4 Svarasa Mrudu Heena - 2 Karsha 1 pala Krura Uttama - - Madhyam Madhyam 1 Karsha 1 Karsha5 Kalka Mrudu Heena - - Krura Uttama - - - Madhyam Madhyam - 1 Karsha -6 Modaka Mrudu Kaneeya - - - Krura Uttama 8 Karsha - Madhyam Madhyam 4 Karsha - 7 Hima& phanta Mrudu Heena 1 Anjali (4 pala) 2 Karsha - - - - - - - - - 2 Karsha or1 pala8 Sneha - - - - Mrudu - - - 2 pala Madhyam - - - 4 pala9 Ushna jala as Anoopan Krura - - - 8 pala
  • 52. REVIEW OF LITERATURE 32    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  PRADHANA KARMA: This includes:- 1) Administration of Virechana Yoga. 2) Observations : a) Aushadi Jeerna-Ajeerna Lakshana. b) Hritadosha Lakshana. 3) Shuddhi Lakshana. 4) Management of Vyapada. 1. Administration of Virechana yoga: • Before administering the Virechana yoga, the physician must confirm regarding the following: The diet taken by the patient on the previous day must be digested. • Patient is in mentally balanced state, i.e., without any factors like angry, fear etc. • It should be kept in mind that whether the patient got sound sleep on the previous night or not. Because at the time of drug administration patient must not be drowsy/ sleepy125 . • After confirming diet taken by the patient on the previous day have been digested, patient has to offer oblations and worships before taking the drug.125 • On the day of Virechana karma, after performing the Sarvanga sweda patient is advised to be in empty stomach.126 • Virechana drugs are administered in ‘Shleshma kale gate’ i.e. after Shleshma kala has passed, in appropriate dose and with appropriate anupana127 .If drug is adminsterd in shelma kala and/or after consuming food then, kaphadosha may cause avarana over grahani resulting in mandagni, gourava, Shula,Admana & even Vamana may produced as a complication128 Measures after virechaka Oushadha sevana129 : Just after administration of Virechana Yoga, cold water should be sprinkled on the face to avoid vomiting. • Patient is asked to rinse mouth with hot water and asked to smell the fragrance of jambeera or Surabhi etc.whichever he/she likes. • Pateint is advised that neither to induce Vegas not to suppress them. • Advise to stay in Nirvata place, be in comfort position and avoid sleep, not to suppress natural urges; consume hot water little by little.
  • 53. REVIEW OF LITERATURE 33    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Vega pravartanopaya130 : For Vatanulomana and Yogavahi action lukewarm water is taken. Ifmedicine composed of Jayapala is given then hot water is contraindicated. If VirechnaVega is not initiated then Tapa Sweda with help of palm over abdominal region which may help to stimulate peristaltic movement. OBSERVATIONS: A) Aushadha Jeerna Lakshana131 : The following signs and symptoms of Aushada are to be observed – Vatanulomana, Swasthya, Khsudha,Trishna,Urjamanaswita, Indriya Laghuta and Udgara Shuddhi Once Jeerna Lakshana appears but still only small amount of morbid doshas are expelled or not yet all, then Physician should administer one more dose of Virechana drug depending on patient bala132 B) Ajeerna Aushadha Lakshana: If the drug is not digested it will produce some painful symptoms such as Klama, Daha, Angasadam, Bhrama, Murcha and Shiroruja. In this case the Virechana drug should not be repeated immediately, as the drug may produce severe purgation. In some cases if the drug is digested but proper elimination of doshas didn’t occurred, then next day again Virechana drug should be given. C) Hritadosha Lakshana: The Virechana is considered as Kaphanta and Hritadosha, when Vit, Pitta, Kapha,Anila come out in succession. Gatra Daurbalya,karshya and Laghuta are the associated symptoms. If Virechana persists even after manifestation of Hritadosha lakshanas, then vamana should be given.132 If Aushadhi Jeerna Lakshanas are manifested, but Hritadosha Lakshanas are not found, then Virechana Yoga should be given next day. Even then Virechana does not occur then Snehana and Swedana should be done again and thereafter Virechana drug should be administered after 10 days133 .
  • 54. REVIEW OF LITERATURE 34    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  A) Shuddhi Lakshana:134-137 Finally shuddhi lakshana must assess in terms of Subjective parameters like Laingiki & Antiki & Objective Parameters like Vaigiki &Manaki. But among these more importance should be given to Laingiki Shuddhi138 . Table no:19 . Showing Criteria for Antiki, Vegiki and Maniki Shuddhi of Virechana Karma. Shuddhi Pravara Madhyama Avara Vegiki 30 Vegas 20 Vegas 10 Vegas Maniki 4 Prastha 3 Prastha 2 Prastha Antiki Kaphanta Kaphanta Kaphanta Vegiki shuddhi: The number of Vegas should be counted after leaving the first 2-3 Vegas, as it contain only fecal matter. Then it should be counted till the Kapha comes out. Maniki Shuddhi: While narrating the Avara, Madhyama,and Pravara Shuddhi, Charaka mentioned the quantities of the three shuddhis as two, three and, four prastha respectively. In the context of Vamana, Virechana and Rakta mokshana, prastha should be taken as 13½ pala139 (540gms/ml) 1 prastha generally 640 ml/gm is considered as 1 prastha. Antiki Shuddhi:   The word anthiki means final or terminal  The symptoms which indicate the end process of Virechana can be considered "Antiki Lakshana,.kaphanta is the desired antiki lakshana.
  • 55. REVIEW OF LITERATURE 35    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table No :20.LANGIKI SHUDDDHI : (Samyak Yoga) Lakshanas Of Virechana Karma Lakshanas140-142 C.S S.S Va Sroto Vishuddhi + - - Indriya Prasadana + + - Shareera Laghuta + + - Agnivriddhi + - - Anamayatwa + + - Kramataha Vit Pitta Kaphagamana + + - Vatanulomana - + - Absence of Ayoga Lakshanas - - + Table no:21 Showing Ayoga Lakshanas of Virechana karma. (Ch.si1/17-19,Su chi33/24-26,A Hr su 18/38-40)   Lakshanas C.S S.S Va Kapha Prakopa + + + Pitta Prakopa + + + Vata Prakopa + - - Agnimandya + + - Gaurava + + - Pratishyaya + - + Tandra + - - Chardi + - - Aruchi + + + Vata Pratilomana + - Vatagraha Daha - + + Hridaya Ashuddhi - + + Kukshi Ashuddhi - + + Kandu - + + Vit Sanga + + + Mutrasanga - + - Peedika - - +
  • 56. REVIEW OF LITERATURE 36    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Table no :22 Atiyoga lakshanas of Virechana karma(Ch.si1/17-19,Su chi33/24- 26,A Hr su 18/38-40)  Lakshanas Charaka Sushruta Vagbhata Kapha Kshaya Vikara + + - Pitta Kshaya Vikara + - - Supti + - - Angamarda + - - Klama + - - Vepathu + - - Nidra + - - Balabhava + - - Tamah Pravesha + - - Unmada + - - Hikka + - - Murcha - + - Guda Bhramsha - - - Kapha Pitta rahita Shweta Udaka Nihssarana - - + Kapha Pitta rahita Lohita Udaka Nihssarana - - + Mamsa Dhavana vat udaka srava - - + Medokhandavat Srava - - + Trishna - - + Bhrama - - + Netra praveshanam - - + Raktakshayaja Vikara + - -
  • 57. REVIEW OF LITERATURE 37    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  In these procedures, expulsion occur in 4 different ways • Atipravrutii – Excessive expulsion. • Asamyak(pratiloma) pravrutii – Expulsion by improper route. • Apravrutii – Cessation of process of expulsion or improper elimination. • Alpapravrutii – Expulsion in lesser quantity. Here apravrutti & alpa pravrutii are included in ayoga. Asamyak Pravrutii means expulsion through opposite route, it indicates that expulsion of vitiated Dosha is not in a quantity, which is expected, so it must be considered under the term of ayoga but not mithyayoga143 . Kashyapa Acharya being Paediatrician, to practise Virechana Karma specially for Bala he has been identified Mrudu and/ Sukha type of virechana144 . PASCHAT KARMA:145-147 Pariharya Vishaya: ‐  Once it is confirmed that Virechana Vegas are stopped, then advise the patient to wash hands, feet and face148 .And advise to avoid ashta mahadosha bhavas i.e.1.Ucchabhashana, 2.Rathakshobha, 3.Atichankramana, 4.Atiasana, 5.Adhyashana, 6.Ahita bhojana, 7.Diwaswapna, 8.Maithuna149. Based on shuddui lakshana especially Maniki,Vaigiki advise patient to follow Samsarjana karma. Regimens to be adopted after Virechana karma till the patient able to take normal diet are termed as Paschat karma. As the Virechana karma eliminates dushita Pitta dosha, the patient shouldn’t be allowed to take heavy diet, because there is derangement in power of jatharagni. In this condition if heavy diet is given, it will suppress the digestion power further and causes the vitiation of Agni. So to prevent such condition, samsarjana karma is adopted. a) Samsarjana Krama : As said above, to restore the strength of agni.The patient has to be given the following varieties of diets, from the same day evening or from the next day morning150 After Samshodhana Karma, Agnimandya occurs because the Doshas reach the Amashaya (Jejjata), so Peyadi Krama is recommended to increase the Agni gradually up to the normal level.
  • 58. REVIEW OF LITERATURE 38    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  According to Chakrapani the elimination therapy diminishes the doshas as well as Dhatus, that’s why patient need immediate Dhatu Vardhaka Ahara in terms of Peyadi Samsarjana karma. Acharya Charaka gives beautiful example to explain this, just as the agni flares up by the fuel like dry grass,cow dung,etc.The person who has undergone shodana karma ,agni will gradually gets improved by following samsarjana krama.151,152 .Hence it is decided according to shudhi. i.e. for pravara shuddhi, madhyama shuddhi and avara shuddhi, samsarjana krama is done for 3,5,7 days respectively153 Table no :23 Showing the Diet Regimen154 Dina Kala Annakala Pradhana shuddhi Madyama shuddhi Hina shuddhi Pratama Prathaha sayankala 1 - Peya - Peya - Peya Dwitiya Prathaha sayankala 2 3 Peya Peya Peya Vilepi Vilepi kruthaAkrutha yusha Trutiya Prathaha sayankala 4 5 Vilepi Vilepi Vilepi Akrutha yusha kruthaAkrutha mamsa rasa Samanya bhojana Chaturtha Prathaha sayankala 6 7 Vilepi Akrutha yusha Krutha yusha Akrutha mamsarasa - - Panchama Prathaha sayankala 8 9 Krutha yusha Krutha yusha Krutha mamsa rasa Samanya bhojana - - Shasta Prathaha sayankala 10 11 Akrutha mamsarasa Krutha mamsa rasa - - - - Saptama Prathaha sayankala 12 13 Krutha mamsa rasa Samanya bhojana - - - - Instead of Peyadi Krama, Sushruta mentions Kulatha, Aadhaki and Jangala Mamsarasa155 . Dalhana clarifies, Sushruta however agrees Peyadi Krama and he says
  • 59. REVIEW OF LITERATURE 39    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  that incase of Ksheena Kapha, Peya should be given. Mamsarasa should be given to Vata pradhana patients having Deeptagni. If Kapha dominance is there according to Dosha and Prakriti, then Kulatha Yusha should be given. The Peyadi Krama ends on 7th day ins Pradhana Shuddhi patient.Acharya Sushrutha has opined samsarjana krama in respect to bala of the patient156. For the individuals having good strength, three annakala are advised, 2 annakala for madhyama bala and one annakala for lesser strength person. b) Tarpana : In case of ayoga of Virechana (insufficient elimination of vitiated doshas) associated with predominance of Kapha, Pitta, if the doshas still retained in the body and if the patient is having habit of taking alcohol, he shouldn’t be given Peyadi Samsarjana Krama. Instead he must be given Tarpana i.e., thin or thick soup prepared with Deepana and Pachana drugs like, Pippali, Dadima etc. In Tarpana, Swaccha Tarpana in place of Peya and Ghana Tarpana in place of Vilepi should be given, according to Chakrapani157 . Jejjata mentions Mudga, Yusha and Mamsarasa in place of Peya. Arunadatta recommends Laja Saktu, Jirnashalyodana and Mamsarasa for 3 Annakalas. Rasa samsarjana krama: To maintain the normal status of Dosha especially in Amaashaya & Pakvashya, rasasamsarjana krama is identified in classics. Here particular Rasaatmaka food articles are given to patient with proper order & this can be consumed along with Peyadi Samsarjana karma or after it. Table no: 24 Table showing Rasa Samsarjana.
  • 60. REVIEW OF LITERATURE 40    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Acharya Charaka and Sushrutha has given a special sequence of rasa intake in samsarjana krama to be followed to avoid the chances of vitiation of doshas159 . Acharya Charaka has advised to take madhura, amla and hridhya ,snigdha ahara to pacify vata.Amla lavana to increase agni,Madhura and tikta rasa to pacify pitta dosha,kashaya and katu rasa to pacify kapha dosha160 . Acharya Sushrutha opined that rasa should be started with Madhura and Tiktha to increase the agni and to pacify vata pitta. Then snigda,amla,lavana and katu rasa to reduce vata,kapha dosha followed by madhura tikta rasa to pacify vata pitta dosha,thereafter kashaya katu rasa to pacify kapha pitta.161 .This is followed to do sarva rasa abyasa for the patient during samsarjana krama. VYAPATH 162-164 Vyapath are the complications occurring due to improper handling of shodana karma.Acharaya Charaka has explained 10 vyapath, Chakrapani has divided this 10 Vyapada in two groups i.e. Ayoga and Atiyoga Table No.25 Showing the Ayoga and Atiyoga Lakshanas of Vyapath. Author Rasa Effect on Dosha Snigdha,Amla,Swadu Pakvashaya stitha vataprasamanartha Amla ,Lavana. Urdvastitha agni sandukshnartha Swadu,Tikta Pittasamanartha Charaka158 Kasaya,Katu Pitthaurdvastithakapha prasamanartha Swadu ,Tikta Pravrudha agni vata pittaastaavajayarthamagneha samikarnartha. Snigdha,Amla,Lavana,Katu Vatakaphavajayaarthamagnehasanduksnartha Sushruta159 Swadu,Tikta Pittavatavajayartha .
  • 61. REVIEW OF LITERATURE 41    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Ayoga Atiyoga Adhamana parikartika Hritgraha Gatragraha Kandvadi Vibhramsha Stambha Upadrava Klama Srava Jivadana Vibramsha Gudabramsha Sanjnabhramsha Table no.26. Showing the Virechana Vyapath According to different Acharyas. Vyapath Charaka Sushrutha Vagbhatta Adhmana + + + Parikartika + + + Parisrava + + + Hrdgraha + - + Gatragraha + - Sarvangagraha Jivadana + + + Vibhramsha + - Guda Vibhramsha Stambha + - - Klama + - - Upadrava + - - Vamana - + + Savashesha Aushadhitva - + + Jirna Aushadhitva - + + Hina Aushadhitva - + - Vata Shula - + Vedana Ayoga - + + Atiyoga - + + Hridaya-Upasarana - + - Vibandha - + - Pravahika - + + Visamjnata - - + Table.no.27. Showing virechana vyapat with their treatment.(ch si6/31-93 )
  • 62. REVIEW OF LITERATURE 42    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Vyapada Lakshana Chikitsa Adhmana Adhmana UdavartaNabhi, Prustha, Parshva, Shiroruja, Shvasa, Vit Mutra, Vata Sanga Abhyanga, Sveda, Phalavarti, Niruha, Anuvasana, Udavartahara Chikitsa Parikartika Gud Parikartana Tivrashula, Piccha, Rakta, Mala Pravritti Langhana, Pachana, Ruksha, Ushna Bhojana Yashtimadhu ,Snehabasti Parisrava Alpa Mala Pravritti, Kandu, Shopha, Kustha, Gaurava, Agnimandya, Staimitya, Aruchi, Panduta Vamana, Virechana, Grahani Chikitsa. Asava, Arishta Hridgraha Hikka, Shvasa, Kasa, Parshvashula, Lalasrava, Akshivibhrama, Shula, Dantatikitkitayana, Jihva, Khodati Sangyanasha Snigdha Lavana, Sveda, Yasti Taila, Anuvasana, Tikshna Nasya, Vamana, Basti Angagraha Stambha, Vepathu, Toda Pindikodveshtana, Manthanavat Pida Vatahara Snehana Svedana Jivadana Rakta Chandrika, Udakasrava, Guda Bhransha, Trishna, Murchha, Mada Pittahara, Raktapana, Raktabasti, Piccha Basti, Ghrita Manda, Anuvasana Vibhransh a. Guda b. Sanjya c.Kandu, Only Mala Excreted not Doshas, Gudabhransha, Sanjna Bransha, Kandu, Pidika, Kustha, Roga Kashaya Lepa, Snehana Mridu Sveda Manonukula Chikitsa Tikshna Shodhana After Snehapana Stambha Vatavarodha, Gudastambha, Gudshula, Alpalpa Mala Pravritti Langhana, Pachana, Tikshna Basti, Virechana Upadrava Stambha, Sula, Gatragraha, Sarvanga Vedana Snehana, Svedana Vataghna Chikitsa Klama Tandra, Gaurava, Klama, Daurbalya, Angasada Langhana, Pachana, Sneha, Tikshna, Shodhana Vamana by virechana Yoga Vamana Snehana, Svedana, Virechana Ayoga Vibhransha, Hikka, Pindikodveshtana, Kandu, Urusada, Vaivarnyata Roganusara Chikitsa Gomutra Niruha Atiyoga Ativirechana Mridu Vamana, Raktapitta vat Chikitsa MODE OF ACTION OF VIRECHANA:165
  • 63. REVIEW OF LITERATURE 43    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Action of Virechana Karma can be understood in the following two ways. 1. Systemic – By which it brings down the morbid Doshas, particularly Pitta from the periphery to Amashaya or Pakwashaya. 2. Local evacuant – This is concerned with the evacuation of these doshas in the form of mala from the gut by Adhobhaghahara property. Both the action and related factors are being described here in detail - a) Virechana yoga gets absorbed and due to Veerya, it reaches to the Hridaya, then the Dhamanis and thereafter it reaches to Sthula and Anu Srotas i.e. macro and micro channels of the body. b) The Vyavayi Guna, drug is responsible for quick absorption. c) The Vikashi Guna causes softening and loosening of the bond between Dosha and Dhatu (Shaithilya Karma). d) Due to Ushna Guna, the Dosha Sanghata (compactness) is disintegrated (Vishyandana). e) Action of Teekshna Guna is to break the Mala and Dosha in micro form. According to Dalhana it is responsible for quick transmission (Dosha Sravana Karatwa). f) Due to Sookshma Guna by reaching in micro channels, disintegrates androgenic toxins which are then excreted through micro channels (Anupravana Bhava). g) Mainly due to Prabhava, Prithwi-Jala constitution and presence of Sara Guna Virechana occurs. This is the evacuant action. Acharya Charaka has given brief description how Virechana dravya acts in the body which is as follows. The drugs which are Ushna, Tikshna, Shukshma, Vyavayi and Vikashi reach to the heart by virtue of their potency and circulate through the large and small Srotas due to its Sukshma and Vyavayi properties and pervade entire body. Then they liquefies the morbid elements by virtue of their Agneya Guna and crumbles them by virtue of its Tikshna Guna. Then this liquefies and crumbled mass Looses contact with the wall and the channels in the unctuous body, just like the honey, not adhered to the unctuous vessel. This morbid mass now passes through the minute capillaries and moves towards Kostha by virtue of the AnuPravana Bhava of the drug and ultimately reaches the Amashaya. From here it forces the morbid factors through the anal route due to the Bhautika predominancy of Jala and Prithvi and Adhobhaga Prabhava166 (Ch. K.1/4) Chart No.01
  • 64. REVIEW OF LITERATURE 44    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Virechana dravya                               Ushna,Tikshna,            Shukshma,     Vyavayi and Vikashi    Hridaya                                        By virtue of their potency                                               Circulate through the large and small Srotas                                                                            Through Sukshma and Vyavayi properties    Pervade entire body                                                       With help of Agneya Guna      Liquefies the morbid elements                                         Tikshna Guna    Crumbles the morbid elements                    Looses contact with the wall and the channels in the unctuous body,                           Just like the honey, not adhered to the unctuous vessel.                                                                   By Anu, Pravana Bhava of the drug                                                                                                             
  • 65. REVIEW OF LITERATURE 45    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Passes through the minute capillaries and moves   towards Koshta ultimately reaches the Amashaya                                                               Bhautika predominancy of Jala and                                                                                        Prithvi and AdhobhagaPrabhava                      Expulsion the morbid factors through the anal route 
  • 66. REVIEW OF LITERATURE 46    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  CATHARTICS - MODERN VIEW167 The terms laxatives, cathartics, purgatives, aperients and evacuants often are used interchangeably. However, there is distinction between Laxation and catharsis. Laxation means – the evacuation of formed fecal material from the rectum, whereas Catharsis means – the evacuation of unformed, usually watery fecal material from the entire colon. Most of the commonly used agents promote Laxation but some actually are cathartics. Classification of Cathartics: These drugs are usually classified according to their mechanism of action. The purgatives available for use mainly act in one of the following three ways- • By increasing the volume of intestinal contents, thus distending the bowel and eliciting the peristaltic reflex. • By liquefying and lubricating the intestinal mass. • By direct irritation of the bowel. Hence they are classified in the following manner- 1. Stimulant or Irritant Cathartics. 2. Osmotic Cathartics. 3. Bulk laxatives. 4. Emollient laxative or Lubricant Cathartics. 1. Stimulant or irritant laxatives: In this group, mainly 3 types of drugs are identified. i) Anthraquinone group ii) Diphenylmethane derivatives iii) Ricinoleic acid Anthraquinone group: These are derivatives of plants such as aloe, cascara and senna. These agents can produce giant migrating colonic contractions as well as induce water and electrolyte secretion. They are poorly absorbed in the small bowel, but because they require activation in the colon the laxative effect is not noted until 6 to 12 hours, after ingestion.
  • 67. REVIEW OF LITERATURE 47    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  Diphenylmethane derivatives: Examples in this group are: Bisacodyl, Phenolphthalein. Pharmacological section is not shown clearly but drug acts as a stimulant mainly on the large bowel after 6 hours and produces soft semi liquid stools associated with a little gripping. Ricinoleic acid: Important among Ricinoleic acid is caster oil. Ricinoleic acid acts as an irritant and produces purgation. As Ricinoleic acid acts on small intestine, it produces copious, liquid stool with associated fluid loss. The action is quicker than Anthraquinone and is evident within 2 to 3 hours. 2. Osmotic Purgatives: The osmotic purgative consists of salts, which though highly soluble, are poorly absorbed from the alimentary tract. Such preparations exert an osmotic effect and, thus retain water in sufficient amount to form an isotonic solution in the lumen of the bowel. This distends the bowel and stimulates peristalsis, as well as liquefying the bowel contents, making evacuation more rapid. The efficacy of the saline Cathartics is, thus related to the osmotic activity exerted by the unabsorbed fraction within the intestinal lumen. These preparations will act both on small and large intestines, and therefore, produces watery evacuation within 3-6 hours. Because of their quick consent of action, they are given early in the morning before breakfast. Patients should be instructed to take plenty of water along with these drugs.example:Magnesium hydroxide,Magnesium citrate. 2. Bulk forming laxatives: These are various natural or semi synthetic polysaccharide and cellulose derivatives. eg. Bran, Psyllium preparation, methyl cellulose, Calcium polycarbophil. These agents absorb water and swell-up, thus providing the stimulus of mechanical distinction for evacuation. Their action is mild and is usually seen 12 to 36 hours after ingestion. 3. Stool Wetting Agents and Emollient laxatives: The best examples are liquid paraffin, Olive oil, Docusate salts, etc. By oral administration it is not significantly absorbed and exerts softening and lubricating
  • 68. REVIEW OF LITERATURE 48    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”  effects on feces. These laxatives are mild in action and usually seen 1 to 3 days after ingestion and itself does not initiate peristalsis. General mechanisms of action:- Laxatives generally have been thought to act in one of the following ways: 1. Retention of intraluminal fluid, by hydrophilic or osmotic mechanisms. 2. Decreased net absorption of fluid, by effects on small and large bowel fluid and electrolyte transport. 3. Effects on motility by either inhibiting segmenting (non-propulsive) contractions or stimulating propulsive contractions. Classification according to the site of action - a) Purgatives acting on the small intestine eg. Castor oil b) Purgatives acting on the large intestine eg. Anthraquinone group c) Purgatives acting on both large and small intestine eg. Saline laxatives C. Classification according to source - a) Vegetable purgatives. eg. Castor oil, Olive oil, Croton oil, Oleos, Senna, Cascara sagrada, etc. b) Mineral purgatives. eg. Saline purgatives, liquid paraffin, etc. c) Synthetic purgatives. eg. Phenolphthale.
  • 69. REVIEW OF LITERATURE 49  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SKIN Anatomical consideration of skin: The word “twak” is derived from “tvak samvarane168 ”. That which covers. Twak is external or outermost covering, which envelops the whole surface of body and is the seat of Sparshnendriya; it is very extensive among all five jnanendriyas. According to Ayurveda Twak is derived from Matruja bhava and is the seat of Vayu, which is responsible for tactile sensation. Regarding number of layers of twcha Susrutha mentioned seven layers while Charaka quotes six, naming the two only.   Table No. 28. Different Layers of Twacha 168,169,170,171 Sushruta Charaka Arundatta Sharangadhara Avabhasini Udakadhara Bhasini Avabhasini Lohita Asrukdhara Lohita Lohita Sweta Tritiya Sweta Sweta Tamra Chaturtha Tamra Tamra Vedini Panchami Vedini Vedini Rohini Shasti Rohini Rohini Mamsadhara Mamsadhara Sthula   Physiological consideration of skin: Charaka elaborate the formation of skin during the ebriyogenisis is 12th week of gestational age(ch sa 4/11). This formation through transformation during fetal stage by thridoshas is an activity like formation of a creamy layer over boiling milk. Further in the context of dhatuparinama explains masa dathu has saarapaka and prasaada paka. Saarapaka is medas and prasaada paka is twak and vasa. The function of dathu is stated as lepana, as the masa dahtu is getting nourished from raktha- twak also possesses porva dhatu guna. That may be the reason that vagbhata explains “
  • 70. REVIEW OF LITERATURE 50  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” twak prasadat rakthasya prasada”, i.e. purity of the blood will reflect on skin. Skin is the seat of brachaka pitha, which promotes the luster of the body. Acharya Susrutha explained about seven layers in relation with origin of disease as follows Table No.29.Sapta Twacha and Disease Relation172 Name Thickness Diseases Avabhasini 1/18th Vrihi Sidhma & Padmakantaka Lohita 1/16th Vrihi Tilakalaka, Nyachcha & Vyanga Sweta 1/12th Vrihi Charmadala, Ajagallika & Mashaka Tamra 1/8th Vrihi Kilasa & Kustha Vedini 1/5th Vrihi Kustha & Visarpa Rohini 1 Vrihi Granthi, Arbuda, Galaganda, Apachi, Sleepada Mamsadhara 2 Vrihi Bhagandara, Vidradhi, Arsha  
  • 71. REVIEW OF LITERATURE 51  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” DISEASE REVIEW HISTORICAL REVIEW OF KUSHTA Prevedic & VedicPeriod Agnipurana173 : Some of treatment modalities were explained. Eg. Kadirodaka for panaartha in Kushta, Use of Vajrka gritha, Panchagavya gritha, Panchatikta gritha etc. Koutilya Arthashastra174 : In the chapter, on secret means a number of diseases are mentioned such as Kushta. Unmaada,Apasmaara, Prameha etc. Yadjnya valkalsmriti 175 : Kushta is known as paparoga and is chronic in nature. & Mandala and Sidma are kinds of Leprosy. Brahama Samhita176 : SSìÓeÉÉ CuÉ vÉÑwMümɧÉmÉëMüUÉM×ü̹ÍpÉ:|          Dadru is a disease where affected people used to itch the skin with dry leaves. Kasika177 : Incurable diseases were called Kshetriya and Kushta is one among this category. Kathadi Gana178 : Kushta and Kushtavid are mentioned together which shows the prevalence of the disease and existing of specialists treating the same. Bhana bhatta179 : According to him Kushta is one of 52 variety of Sharirika disease.      
  • 72. REVIEW OF LITERATURE 52  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Table No: 30 AYURVEDA BOOK STHANA NIDANA PANCHAKA (Chapters) SADHYA- ASADHYATVA (Chapters) CHIKITSA (Chapters) Sutrasthana 20 - 1; 3; 4 ; 25 Nidanasthana 5 5 - Charaka samhita Chikitsasthana 7 7 7 Sutrasthana - - 38 Nidanasthana 5 5 -Sushrut samhita Chikitsasthana - - 9 ; 10 Nidanasthana 14 14 14 Chikitsasthana - 19 19 Astanga hridaya Sharirasthana - 5 - Sutrasthana - - 13;15 ;16 Nidanasthana 14 - - Astanga sangraha Chikitsasthana - - 21 Sutrasthana 4; Nidanasthana 5 - -Bhela samhita Chikitsasthana 6 6 6 Chakra dutta - - - 50 Chikitsasthana Kushtachikitsa adhyaya Kashyapa samhita Khilasthana 15 15 15 Harita samhita Tratiyasthana 39 39 39   
  • 73. REVIEW OF LITERATURE 53  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” ETYMOLOICAL DERVATION OF KUSHTA: The word ‘Kushta’ is a broad term which includes almost all skin diseases. MÑüwÉç ÌlÉwMüwÉåï +WûÉÌlÉ MÑüÌwÉÌiÉ || EhÉÉÇ 2/2/ CÌiÉ MüjÉlÉç 180 ...(zÉoSMüsmÉSìÓqÉ )     In Sanskrit language, the word ‘Kushta’ is derived form the ‘Kush nishkarshane’ Sanskrit root, It means that ‘to destroy’, ‘to scarp out’ or ‘to deform’. By adding to it the Pratyaya ‘Kta’ which stands for firmness or certainty, the word Kushtha is derived. Thus the word Kushtha means that which destroys with certainty. DEFINITION Commentator Arundatta mentioned that – 1 rÉiÉç uÉæuÉhrÉïÇ MÑüuÉïÎliÉ iÉiÉç MÑü¸qÉÑzÉÎliÉ | This means that, Kushta is the one which causes vitiation as well as discoloration of the skin181 (A.Hr.Ni 14/3) 2. MÑüwhÉÉirÉ….qÉç | MÑüÎixÉiÉÇ ÌiɹÌiÉ | (AqÉUMüÉåwÉ .̲ÌiÉrÉZÉhQû –qÉlÉÑwrÉuÉaÉï-6) One which has capacity of spreading nature & leads to deformity of skin in the form of discoloration is known as Kushta182 . 3. MÑüwhÉÉÌiÉ iÉxqÉÉiɨÉç MÑü¸ÍqÉirÉÑcrÉiÉå |183 (A.Hr.Ni 14/4)  According to Vaghbhatacharya, if hetu upekshana has been done and is not treated properly at right time then it spreads all over the body hence is called as Kushta. All the above definitions implies to various types of skin disorders & not to a single entity. Acharya’s have opined that the Kushtha is first located in the Tvak, later it progressively involves deeper Dhatu’s. This clearly indicates that in all Kushtha the skin compulsorily get involved at first. KUSHTHA SYNONYMS 184 : Yvadhini, Kutsitam, Vajivrajam, Apyam, Adavaham, Nirujam, Gadah, Ruja Vyapam, Pakalam, Hashuram, Kakalam, Amayah, Gadantakam.
  • 74. REVIEW OF LITERATURE 54  Classification of Kusta According To Different Acharyas Table No: 31 Mahakushta No. Types of Kushta Ch185(a) . Sus185(b) . A.Hr185( c) . B.S185(d) . M.N185(e) . B.P.185(f ) 1. Kapala + + + + + + 2. Audumbara + + + + + + 3. Mandala + - + + + + 4. Rushyajihv a + + + + + + 5. Pundarika + + + + + + 6. Sidhma + - - + + + 7. Kakanaka + + + + + + 8. Dadru - + + - - - 9. Aruna - + - - -   -              DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 75. REVIEW OF LITERATURE 55  Table No: 32 Kshudrakushta No Types of Kusta Cha Sus A.Hr B.S. M.N. B.P. 01 Ekakusta + + + + + + 02 Kitibha + + + + + + 03 Charmadala + + + - + + 04 Pama + + + + + + 05 Vicharchika + + + + + + 06 Charmakhya + - + + + + 07 Vipadika + - + - + + 08 Alasaka + - + - + + 09 Dadru + - - + + + 10 Visphotaka + - + + + + 11 Shataru + - + + + + 12 Sidhma - + + - - - 13 Sthularushka - + - - - - 14 Mahakustha - + - - - - 15 Visarpa - + - - - - 16 Parisarpa - + - - - - 17 Raksha - + - - - - 18 Shvitra - - - + - - 19 Vishaja - - - + - - 20. Kachhu - - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” - - + +
  • 76. REVIEW OF LITERATURE 56  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Table No: 33 KASHYAPOKTA KUSHTA TYPES186 Sadhya kushta 1) Pama 2)Mandala 3)Dadru 4) Kitibha 5)Kapala 6)Vicharchika 7) Vishaja 8)Sthularushka 9)Sidma Asadhya kushta 1)Poundarik 2)Shvitra 3)Rushyajivha 4)Shatarushka 5)Kakana 6) Oudumbara 7)Charmadala 8)Ekakushta 9)Vipadika All These types of Kushta are further classified based on Doshic predominance. It is more useful for diagnostic and treatment of the disease, which are as follows187 (Cha.Chi.7/27-30) Table No: 34 Kushta and Dosha Relation No. Doshic predominance Name of Kushta 1. Vata Kapala 2. Pitta Audumbara 3. Kapha Mandala, Vicharchika 4. VataPitta Rushyajihva,Pundarika,Sidma. 5. VataKapha Ekakushtha, Vipadika ,Kitibha, Charmakhya Alasaka. 6. PittaKapha Pama, Visphotaka, Shataru, Charmadala, Dadru. 7. VataPittaKapha Kakanaka
  • 77. REVIEW OF LITERATURE 57  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” The word ‘Kushta’ is a broad term, which covers almost all the skin diseases. Kushtha is associated with invariably by ‘Saptako drvya Sangraha’188 (Cha.Chi.7/9). But different types of pain, colour, shape, specific manifestation etc. i.e. Vedana vishesha - Eg.Kapala kushta Toda bahula; Varna Vishesha- Eg. Kakanaka kushta is Gunja beeja varna; Samsathana Vishesha - Eg. Rushyajivha kushta is resembles to that of deer tongue; prabhava Vishesha - Eg. Kakanaka kushta is Asadhya due to its Prabhava; Naama Vishesha- Eg. kapala etc. are found in Kushtha because of Amshamshakalpana of the Doshas189 (Cha.Ni.5/4). According to Charaka, Kushtas are in fact of innumerable types, but for systemic study they are classified into two major groups 7 Maha Kushtha & 11 Kshudra Kushtha 189 (Cha.Ni.5/4). 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 Kushtha exists. Table-No-35 The difference between Mahakushta and KshudraKushta 190 No Mahakushta KshudraKushta 1. Bahu Bahul Dosha Arambhata Alpa Dosha Arambhata 2. Bahulakshana Alpalakshana 3. Excessive discomfort Less discomfort 4. Tendency Penetrates into deeper Dhatu Less tendency to penetrate in deeper dhatu 5. Mahat Chikitsa Alpa Chikitsa 6. Loss of skin functions like Supti etc. Less functional skin deformities
  • 78. REVIEW OF LITERATURE 58  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Chakrapani has clarified that, in Kshudra Kushta the symptoms of Mahakushta are manifested in milder form191 (Cha.Ni.5/4). According to commentator Gayadas there is severe and extensive vitiation of Doshas from the very beginning, in Mahakushtha, which penetrate the deeper tissues and cause Mahakushta. But no such severe and extensive vitiation of Doshas occurs in the KshudraKushta from the beginning192 (Sus.Ni.5/5) Kushta Nidana Table No: 36 ACCORDING TO DIFFERENT ACHARYAS Nidana of Kushta Cha Ni7/ 4-8 Sus Ni 5/4 A.S. Ni 14/2 0 A.H r. Ni 14/2 0 B.S.18 5(d) H.S .190( a) M. N.19 0(b) B.P185(f) DVADASHAVIDHA AHARA A. SHOOKA DHANYA 1. Nava Anna + - - - - + 2. Tila + - - - - + + 3. Pishta vikara + + - - + + + B. SHAMI DHANYA 1. Masha + - - - - + + C. GORASAVARGA 1. Dadhi + + - - + + + 2. Sarpi + - + + + + -
  • 79. REVIEW OF LITERATURE 59  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 3. Ksheera + - - - + + 4. Takra + - - - - - - D. HARITA VERGA 1. Moolak + + - - + + + 2. Lakucha + - - - + - - E. IKSUVARGA 1. Guda + - - - + + + 2. Continuous and excessive use of Madhu + - - - - - - 3. Continuous and excessive use of Phanita + - - - - - - F. MAMSAVARGA 1. Mastya + + + + + + + + G. AHARAYOGI VARGA 1. Ati lavana consumption + - - - - + - 2. Ati tila tailaconsumption - - + + - - + 3. Ati pippali consumption - - - - + - - VIRUDDA AHARA A. VEERYA VIRUDDHA 1. Intake of Chilchim fish with milk + + + + + + + + 2. Moolak+ Ksheera+ Guda + - - + + +
  • 80. REVIEW OF LITERATURE 60  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 3. Intake of milk after consumption of Moolak/Lashuna / Shigru / Tulasi etc + - - - - - - - 4. Excessive intake of Gramya, Anupa, Audaka Mamsa with Ksheera - + - - - - + - B. SAMYOGA VIRUDDHA 1. Mastya+ Ksheera+Nimbu - - - - + - - - 2. Continuous and excessive use of either single or mixture Madhu, Phanita, Matshya, Lakucha, Mulaka, Kaakmachi or intake of above substances while having Ajirna + - - - - - - - C. VIDHI VIRUDDHA 1. Aharan kramam muktva nishevinaam + + - - - + + D. UPACHARA VIRUDDHA 1. Snehapana with Sheet jala + + - - - - - OTHER 1. Adyashana + + - - - - + +
  • 81. REVIEW OF LITERATURE 61  2. Injestion of Vidahi food in Vidagdhavasta + - - - + - - 3. Asatmya Bhojana + + - - - + - 4. Ahitaashana + + - - - - + 5. Excessive Drava, Snigdha, Guru, Ahara + - - - -   AHARA-VIHARA NO. Nidana of Kusta Cha Sus - + + A.S. A.Hr. B.S. H.S. M.N. B.P. 1. Divasvapna after lunch + - - - + - + + 2. Vishamashana + + - - - - + - 3. Atyashana + + - - - - - - 4. Sex indulgence in Ajirna + - - - + - + + 5. Suppression of Chhardi, Mutra, Purisha like Vegas + + - - + - + + 6. Sudden diving in to cold water or drinking cold water after fear, exhaustion & coming from sunlight + + - - + - + + 7. Improper consumption of Sheeta&Ushana food articles + - - + + + 8. Atisantapa + - - - + - 9. Mithya vihara - + + + + - - 10. Vega avarodha + + + + - + + 11. Adyashana + - - - + - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 82. REVIEW OF LITERATURE 62  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” CHIKITSAKRITA NO. Nidana of Kushta Cha Sus A.S. A.Hr. B.S. H.S. M.N. B.P. 1.  Panchakarmaapcharinam + - - - - + + 2.  Vyayam & Vyavaya after intake of Snehapana or after Vamana karma - + - - - - - - 3.  Snehapana with Sheet jala  +  +  ‐  ‐  ‐  ‐  ‐  ‐  4.  Stambana chikitsa in Dushta& Utklishta rakta in Raktapitta + + + + - - - + 5.  Stambana chikitsa in Amatisara + + + + - - - +   ACHARA NO. Nidana of Kusta Cha Sus A.S. A.Hr. B.S. H.S. M.N. B.P.  1.  Papa Karma + + + + + + + +  2.  Vipra Guru Tiraskara + - - - - + +  3.  Mithya achara + + - - - - +  4.  Parakrita karma - + - - + ‐  ‐   5.  Sadhu Ninda - - + + - - - -  6.  Use of money & material acquired by unfair means - - + + - + - -      
  • 83. REVIEW OF LITERATURE 63  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” OTHERS NO. Nidana of Kushta Cha. Sus. A.S. A.H r. B.S. H.S. M.N . 1. Samsargaja - + + + - - + 2. Dushivishajanya + + K. 2/32 - - - - - 3. Adibalapravrutta + Sh 8/21 + Su 24/6 + + - - - 4. Raktadushti + Su 24/1 6 - - - + - - 5. Bahya Krimi + - + + Ni 1/.44 - - + 6. Abhyantara krimi - Raktaja krimi + - + + Ni 14/5 2 - - +
  • 84. REVIEW OF LITERATURE 64  TABLE NO : 37 PURVAROOPA N O purvaroopaP Cha. (Chi 7/11) Sus. (Ni.5/4) A.S. (Ni.14) A.Hr. B.S. (Chi.6) H.S .110 (Ni.14) A LOCALISED 1. Aswedanam + + + + - - 2. Atiswedanam + + + + + - 3. Parushyam + + - - - + 4. Atislakshnata + - + + - - 5. Vaivarnyam + + + + + - 6. Kandu + + + + - + 7. Nishtoda + - + + - + 8. Suptata + + + + + + 9. Pariharsha + - + + - - 10. Lomaharsha + + + + + + 11 Kharatvam + - + + - - 12 Usmayanam + - - - + - 13 Gauravam + - - - + - 14 Svayathu + - - - - - 15 Kothonnati + - + + - - 16 Visarpagamanam + + - - - - 17 SvalpamapiVrananam Dushti asamrohananm + - + + - - 18 Raaga - - - - + - 19 Roukshyam - - - - + - B GENERALISED 1. Shrama + - + + - - 2. Klama + - - - + - 3. Kayachhidresu Upadeha + - - - - - 4. Rakta krishnatvam - + + + - - 5. Dourbalya - - - - + - 6. Pipasa - - - - + - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 85. REVIEW OF LITERATURE 65  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Table No.38 KUSHTAROOPA NO. Kushtaroopa Cha. (Chi 7) Sus. (Ni.5/) A.S. (Ni.14) A.Hr. (Ni.14) B.S. (Chi.6) M.N. (49/23) VATAJA KUSHTA 1. Rouksha + - + + + + 2. Shosha + - + + - - 3. Stoda + - + + + - 4. Shula + - + + + + 5. Sankocha + + + + - - 6. Ayama + - + + - - 7. Paurshya + - + + - - 8. Khartva + - + + + + 9. Harsha + - + + - - 10. Shyava- + - + + + + 11. Svapa - + - - - - 12. Asweda - + - - - - 13. Bheda - + - - - - 14. kounya - + - - - - 15. Svaropaghat - + - - - - 16 Shopha - + - - - - PITTAJA KUSHTA 1. Daha + - + + + + 2. Raga + + + + + + 3. Parisrava + - + + - + 4. Paaka + + + + - + 5. Visragandha + - + + - - 6. Kleda + - + + - - 7. Angapatan + + + + - - 8. Karna.Nasa - + - - - - 9. Avadaran - + - - - - 10. Krimi - + - - - - KAPAJA KUSHTA 1. Kleda + - + + - + 2. Kshipramuttishta - - - - + - 3. Jvara - - - - + - 4. Shvaitya + + + + + - 5. Shaitya + - + + - + 6. Kandu + + + + - + 7. Sthairya + - + + - - 8. Utsedha + - + + -- - 9. Gourava + - + + + + 10. Snigdha + - + + + + 11. Jantubhirbhikshana + - + + - -
  • 86. REVIEW OF LITERATURE 66  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 12. Kleda + - + + - + 13. Shopha - + - - - - 14 Srava - + - - - - 15 Gourava - + - - - - 16 Stimita - - - - + - In all the Kushta basically Saptakodravya i.e. Tridosha, Twaka, Rakta, Mamsa, Lasika have important role, but still the end result of kushta shows its sign and symptoms depending upon predominance of Dosha in its pathogenesis. So based on these clinical features one should understand the underlying Dosha and then plan the specific line of treatment193 . (Cha.Chi.7/31-32) Or vice-versa i.e. all varieties of Kushta have their some particular Sign and symptoms; then decide the involved dominant Dosha and according to that one can diagnose the specific type of Kushta and. MÑü¸ÌuÉzÉåwÉæSÉåïwÉÉ SÉåwÉÌuÉzÉåwÉæ: mÉÑlÉ¶É MÑü¸ÉÌlÉ | (Cha.Chi.7/33) SAMPRAPTI 194 SAMPRAPTI GHATAKA: • Dosha :Vata(Vyana vata),Pitta(Brajaka pitta) kapha(kledaka) • Dhatu : Rasa, Rakta,Mamsa. • Upadhatu :Tvacha • Agni : Jataragni, dhatwagni mandya (Rasa,rakta,mamsa) • Srotas : Rasa, rakta, mamsa • Srotas dushti prakara : Sanga • Udbhava sthana : Amashaya,Pakvashaya • Sanchara sthana : Sarvasharira • Adhisthana : Twak, rakta, mamsa, lasika • Vyakta sthana : Twak • Roga marga : Bahya • Swabhava : Chirakari • Sadhyasadhyata : krichrasadhya.
  • 87. REVIEW OF LITERATURE 67  Chart No: 02 SAMPRAPTI CHART(cha chi7/4-10) SAMPRAPTI OF EKAKUSHTHA NIDANA Aharaja/Viharaja/Acharaja/Manasika Bijadoshaja Agnimandya Tridosha Dushya Khavaigunya Prakopa Shaithilya Amotpatti Rasen Saha Mishribhuya Tiryaga Sira Gamanam Dushya Dushti (Tvacha, Rakta, Mamsa) Dosha – Dushya Sammurchana SrotoDushti (Rasavaha, Raktavaha, Mamsavaha, Svedavaha) Lakshanotpatti (Asvedanam ,Mahavastuma etc.) Uttarotara Dhatupravesha (Nail deformity, Psoriatic Arthritis etc.) DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 88. REVIEW OF LITERATURE 68  Table No. 39 SADHYA-ASADHYATA195, 196 SADHYA ASADHYA DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Generalised features1 Atmavat (Who can able to tolerate any type of Medicine or treatment) *Thirst, Burning, Agnimandya,Alpa balavan *Rakta netra, Hata Svaram, Panchakarmagunatita, Prasratanga Localised features2 Absence of Krimi Krimi utpatti Predominance of Dosha3 Vata-Kaphaja Kushtha , Kapha- Pitta or Vata-Pitta or only one Dosha Tridosha dominance Involvement of Dhatu4 Tvacha, Rakta or Mamsa dhutagata Medogata, Asthigata, Majjagata & Shukragata Specific type of Kushta114 (Cha.Ni.5/9,10)5 Kapala , Audumbara, Sidhma, Mandala, Aruna Rushyajihva, Pundarika types of Kushta Kakanaka, When Sadhya Kushta are not treated properly in time or neglected these becomes Asadhya Other features6 Minimum symptoms with Kushta having all the symptoms along with complications like Angapatan, Jvara,Atisara etc114 (Cha.Ni.5/11) Adibalapravrutta Kushta115 Absence of complication. (Sus.Ni.5/19)
  • 89. REVIEW OF LITERATURE 69  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” The prognosis of Kushtha depends upon many other factors like strength of Nidana factors, intensity of Poorvarupa and Roopa, extent of vitiation of Doshas, involvement of Dhatu, Prakriti-Vaya-Avastha of the patient, and nature of the disease, Upadrava and availability of all therapeutic devices. CHIKITSA While explaining line of treatment for different varieties of Kushtha, Charaka has mentioned that all the Kushthas are caused by Tridosha, so the treatment is to be carried out according to the predominance of Dosha. The predominately vitiated Dosha should be treated first and the treatment of the other subordinate Dosha should be undertaken afterwards199 . (Cha. Chi. 7/37-39) To study the treatment of Kushtha systemically, it is necessary to look at three principles of the treatment which are described by Charaka in Krimi Chikitsa i.e. Samshodhana, Samasamana and Nidana Parivarjana separately200 . (Cha.Vi.7/3) (1) NIDANASYA PARIVARJANAM : It means to avoid etiological factors. Nidana Parivarjana stops the further progression of the disease, by restricting vitiation of Doshas. Main etiological factors of Kushtha are Mithya Ahara-Vihara & Viruddha Ahara so they should be avoided. Acharya Charaka has defined ‘Pathya’ as they are the wholesome drugs and regimen which do not adversely affect the body and mind. Those which adversely affect them are considered to be Apathya201 (Cha. Su. 25/45, 46) (2) SAMSHODHANA: The therapy which expels out the morbid Doshas from the body is known as Shodhana202 (A.Hr.14/5)0. Medicines given after Shodhana are more effective. All Acharya’s have emphasized on Shodhana therapy in the management of Kushtha due to some basic things related to Kushtha Roga which are : A person having Kushtha Roga is called ‘Bahu Doshi’ because of vitiation of Dosha in greater extent 203 (Cha.Chi.7/41) Kushtha is considered as a Tridoshaja Vyadhi 204 (Cha.Chi.7/31) and in Kushtha, Doshas are ‘Tiryaggami’
  • 90. REVIEW OF LITERATURE 70  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” By nature, Kushtha is difficult to cure disease, so it is called ‘Duschikitsya’. But by the application of Shodhana therapy, cure of the disease becomes easier due to removal of the root cause, hence Shodhana has great importance. According to Charaka & Vagbhata Shodhana should be carried out according to predominance of vitiated Dosha. For instances in Vata dominance Ghritapana, in Kapha dominance Vamana and in Pitta dominance Virechana, Raktamokshana are to be carried out 205 (Cha.Chi.7/37-39) In excessive morbidity of the Doshas repeated Shodhana should be performed at regular intervals i.e.Vamana Karme once in 15 days;Samsrana once in month; Raktamokshana once in 6 months; Nasya Karma once in 3 days206 (Sus.Chi.9/43). Sushruta has advised to carry out ‘Ubhayato Samsodhana’ even at the Purvarupa condition of Kushtha. Sushruta also advised Samsodhana in the treatment of Rasagata, Raktagata, Mamsagata and Medogata ushtha 207 (Sus.Chi.9/6). (3) SHAMANA CHIKITSA : Shamana therapy is also an important part of the treatment of Kushtha. After completing the Shodhana Karma, Shaman Chikitsa is indicated to subside the remaining Doshas. Shamana Chikitsa is very useful in those patients who are unable to undergo or contraindicated for Samshodhana. Charaka has advised Shamana therapy with Tikta and Kashaya Dravyas after administration of proper Shodhana 208 (Cha.Chi.7/58). Charaka has also indicated several other drugs & formulation of Shamana therapy in 7th chapter of Chikitsa Sthana. External application: Kushtha, being exhibited through the skin, external application are also advocated. For the external application drug should be applied after elimination of the Doshas from the body by Shodhana Karma and Raktamokshana. Various forms of local application are prescribed like Udvartana, Pralepa, Parisheka, Abhyanga, etc. Kshara Karma and Agada Karma are also prescribed in special condition of Kushtha. In short it may be said that the treatment of Kushtha may divided into three parts i.e. treatment according to the predominance of Doshas, internal & external purification.
  • 91. REVIEW OF LITERATURE 71  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Table-No: 40 PATHYAPATHYA 209.210 (Sud.Chi.9/5)-442; (Bhai.Rat.54/359-370) VARGA AHARA DRAVYA AOUSHADHA / CHIKITSA PATHYA APATHYA PATHYA APATHYA Shukadhany a Shali, Yava, Godhooma, Purana dhanya. - - Tila Shambidhan -ya Mudga, Adhaki, Uddalaka, Masoora Nishpava, Hayanaka,Yav- aka,Chinaka, Masha Priyangu, Tuvarak Kulattha, Masha Mamsa varga Jangala mamsa Anoopa mamsa, Matsya Jangala mamsa rasa Anoopa mamsa rasa, vasa Shakha varga Patola ,Tiktka shaka,Punarna vShaka,Karvel ka Moolaka, Kakamachi,Ud dalaka,Kusumb -ha Tila Nimba,chakramard ala ,Avalguja, Atarushaka, Aragvada, Khadira Atasi, Lakucha Phala varga Ashada phala, Jatiphala - Brahati phala, Koshataki, Bhallatak, Triphala - Gorasa varga Purana Sarpi Ksheera,Dadhi - -
  • 92. REVIEW OF LITERATURE 72  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Taila varga Sarshapa taila Tilatail Tikta ghrita, taila of Nimba, Ingudi, Saral Agaru, Devadaru, Shimshipa Tila taila Ikshu varga Makshika Ikshu, Guda Makshika - Mutra varga - - Go,Khara,Ushtra, Ashva,Mahishi mutra - Jala Varga - Sahyadri,Vind hya samudbhva nadi jala -Khadirodaka Other Lagu & Hitakara Anna Kasturika,Gandhas ara;vaman in every 15 days; once in a month rechana;Nasya karma in every 90 days; Rakta mokshana once in 6 month, Amla rasa Dravya, Vidahi,Vishta mbi,drava-guru anna,Pishta vikara,Virudha pana-Ashana Divaswapn a,atapa sevana,, Ksharakarma, Vyavaya
  • 93. REVIEW OF LITERATURE 73  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PSORIASIS INTRODUCTION Psoriasis is a chronic skin disorder marked by periodic flare-ups of sharply defined red patches, covered by a silvery, flaky surface. The main disease activity leading to psoriasis occurs in the epidermis, the top five layers of the skin. In persons with psoriasis, the keratinocytes multiply very rapidly and travel from the basal layer to the surface in about 4 days. The skin cannot shed these cells quickly enough, so they build up, leading to thick, dry patches, or plaques. Silvery, flaky areas of dead skin build up on the surface of the plaques before being shed. The underlying skin layer (dermis), which contains the nerves and blood and lymphatic vessels, becomes red and swollen. Its scope can vary considerably; from mild outbreaks, where the person may not even be aware they have psoriasis, to severe cases, which can be socially disabling and, in rare instances, life-threatening. In principle, people of all ages can get psoriasis, but the early-onset form of the disease is mostly seen in 16 to 22-year-olds and the late-onset form strikes those between the ages of 50 and 60.211 ETYMOLOGICAL DERIVATION: The word ‘Psoriasis’ is derived from the Greek word ‘Psora’ which means itch or scale, ‘Iasis’ means condition. DEFINITION: Psoriasis is an inflammatory disease that manifests most commonly as well- circumscribed, erythematous papules and plaques covered with silvery scales .212 HISTORY: Psoriasis is probably one of the longest known illnesses of humans and simultaneously one of the most misunderstood. Some scholars believe psoriasis to have been included among the skin conditions called tzaraat in the Bible. In more recent times psoriasis was frequently described as a variety of leprosy. The Greeks used the term lepra (λεπρα) for scaly skin conditions. They used the term psora to describe itchy skin conditions. It became known as Willan's lepra in the late
  • 94. REVIEW OF LITERATURE 74  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 18th century when English dermatologists Robert Willan and Thomas Bateman differentiated it from other skin diseases. They assigned names to the condition based on the appearance of lesions. Willan identified two categories: leprosa graecorum and psora leprosa.While it may have been visually, and later semantically, confused with leprosy it was not until 1841 that the condition was finally given the name psoriasis by the Viennese dermatologist Ferdinand von Hebra. The name is derived from the Greek word psora which means to itch and asis means condition.It was during the 20th century that psoriasis was further differentiated into specific types213 . PREVALENCE The prevalence of psoriasis in Western populations is estimated to be around 2-3%. The prevalence of psoriasis among 7.5 million patients who were registered with a general practitioner in the United Kingdom was 1.5%. A survey conducted by the National Psoriasis Foundation (a US based psoriasis education and advocacy group) found a prevalence of 2.1% among adult Americans. The study found that 35% of people with psoriasis could be classified as having moderate to severe psoriasis214 . ETIOLOGY The cause of psoriasis is not fully understood. There are two main hypotheses about the process that occurs in the development of the disease. The first considers psoriasis as primarily a disorder of excessive growth and reproduction of skin cells. The problem is simply seen as a fault of the epidermis and its keratinocytes. The second hypothesis sees the disease as being an immune-mediated disorder in which the excessive reproduction of skin cells is secondary to factors produced by the immune system214 . Genetic factors Genetic factors have been implicated in the pathophysiology of psoriasis. Genetic factors: HLA-B13, -B17,HLA-B27 and -Cw6 are all associated with plaque psoriasis. Multifactorial inheritance mechanisms and aetiologies without any genetic component have not yet been excluded, although many families appear to exhibit autosomal dominant patterns of inheritance with decreased penetrance. Studies of
  • 95. REVIEW OF LITERATURE 75  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” twin siblings have shown concordant disease in 73% of monozygotic twins compared with 20% in dizygotic twins. Several putative genetic susceptibility loci have also been identified, including psoriasis susceptibility 1 (PSOR1) on chromosome 6, which is associated with up to 50% of cases. Six other psoriasis susceptibility loci (PSOR2, PSOR3, PSOR4, PSOR5, PSOR6, PSOR7) have been discovered, as well as the transcription factor RUNX1. While this certainly points to a genetic mechanism, the absence of 100% concordance among monozygotes suggests that environmental factors must play a role in the pathophysiology of this disease215 . Genetic Causes of Psoriasis Often, a person with psoriasis has a parent or grandparent who also has the condition. Researchers estimate that a person with one affected parent has about a 10% chance of also having psoriasis. Having two parents with psoriasis increases the chances to about 30%216 . PROVOCATING FACTORS Psoriasis is not contagious—no one can "catch" it from another person. Because of their genes, certain people are more likely to develop it, but a "trigger" is usually necessary to make psoriasis appear. These factors may provoke onset or aggravation of psoriasis. I. LOCAL FACTORS 1. Trauma - All types of trauma can lead to the development of plaque psoriasis (e.g. physical, chemical, surgical, infective, and inflammatory). The development of psoriatic lesions at a site of injury is known as the Koebner phenomenon. 2. Infection – An acute eruption of guttate psoriasis may be provoked by streptococcal pharyngitis. HIV infection may be associated with increase in disease severity. 3. Sunlight -Although sunlight is generally considered to be beneficial for most of the patients, strong sunlight may worsen the disease in a small minority. II. SYSTEMIC FACTROS 1. Drugs- Lithium, withdrawal of systemic corticosteroids, beta-blockers, antimalarials, and NSAIDs may cause flare of the disease 2. Stress - Many patients report an increase in the psoriasis severity with psychological stress.
  • 96. REVIEW OF LITERATURE 76  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 3. Smoking - Cigarette smoking is associated with an increased risk of chronic plaque psoriasis 4. Alcohol - Alcohol is considered a risk factor for psoriasis, particularly in young to middle-aged males. 5. Endocrine - The disease state may fluctuate with hormonal changes. Psoriasis may begin during puberty. Pregnancy may improve the disease. While a flare may occur during post-partum period. 6. Weather- Cold weather may make skin drier and more susceptible to a psoriasis outbreak. 7. Diet- Although unproven, changing the diet has helped some people improve their psoriasis or avoid flares211 . PATHOGENESIS The cause of psoriasis is related to the immune system, and more specifically, a type of white blood cell called a T lymphocyte or T cell. Normally, T cells travel throughout the body to detect and fight off foreign substances, such as viruses or bacteria. In people with psoriasis, however, the T cells attack healthy skin cells by mistake as if to heal a wound or to fight an infection. Overactive T cells trigger other immune responses that cause an increased production of both healthy skin cells and more T cells. What results is an ongoing cycle in which new skin cells move to the outermost layer of skin too quickly in days rather than weeks. Dead skin and white blood cells can't slough off quickly enough and build up in thick, scaly patches on the skin's surface. This usually doesn't stop unless treatment interrupts the cycle217 . Genetic Causes of Psoriasis Often, a person with psoriasis has a parent or grandparent who also has the condition. Researchers estimate that a person with one affected parent has about a 10% chance of also having psoriasis. Having two parents with psoriasis increases the chances to about 30%218 .        
  • 97. REVIEW OF LITERATURE 77  Chart No: 03 Pathology of Psoriasis Genetic Background  Provocation Factors  Exogenous/Endogenous antigens  Antigen presentation by APCs  T lymphocyte­ mediated Immune response   Secretion of cytokines  Inflammation & cellular hyper proliferation   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”       Clinical Lesions of psoriasis               CLINICAL FEATURE Clinically, psoriasis exhibits itself as dry, well-defined macules, papules and plaques of erythema with layer of silvery scales. The typical lesions are coin-shaped; by confluence, big plaques of the size of the palm of a hand (or even bigger) or figurate areas may be formed219 . Physical Examination: The typical lesions of psoriasis have the following features, • The lesions are very well marginated with distinct border. • The lesions are raised above the surface. • The plaques usually have a diameter of one to several centimetres and have a round or oval shape. The lesions may merge together to give rise to geographic patterns. • The plaques typically have a rich red colour and may be surrounded by a pale halo (the halo of Woronoff). The lesions are covered with a silvery white, mica-like, loosely adherent scales which, on removal may reveal punctuate bleeding points (Auspitz sign).
  • 98. REVIEW OF LITERATURE 78  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Distribution-The lesions are symmetrically disposed on extensor surfaces of the body. Typical sites of affection are the elbows, knees, shin, knuckles, sacral areas and scalp. Uniformity: The psoriatic plaques tend to have the same features irrespective of site except for certain locations like the palms and soles, and the flexors. Variations of lesions: Variations by morphology or shape: Apart from the typical plaque lesions, guttate lesions and pustules, lesions may take on a variety of morphological forms and shapes. Verrucous, lichenoid, follicular, linear, annular, figurate, gyrate are some of the terms used to describe these variants. Variations by site: Scalp: Diffusely involved. Thick scaling, no hair loss. Penis: Well-circumscribed reddish plaque without scales. Hands and feet: Diffuse hyperkeratosis, Thick scales, fissures. Sacral regions: Thick fissures plaques, scaling may be absent. Nails: involved in 25 to 50% of cases211 . Candle-grease Sign- (Tache de bouge) When a psoriatic lesion is scratched with the point of a dissecting 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 bouge). Auspitz sign- The complete removal of a scale produces pin-point bleeding is called Auspitz sign. The lesions are slightly raised above the surface of the skin, but there are no indurations. Koebner's phenomenon- Psoriatic lesions may develop along the scratch lines in the active phase; this is called Koebner's phenomenon (other common diseases in which Koebner's phenomenon occurs are warts and lichen planus). Reverse-Koebner phenomenon So-called reverse-Koebner reactions have also been noted in which pre existing psoriatic plaques actually clear after injury or trauma to the skin. The central clearing of the circular lesions produces ringed lesions - Annular psoriasis. Psoriasis
  • 99. REVIEW OF LITERATURE 79  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” is normally characterized by the absence of itching, but in tropical countries, patients complain of slight or moderate pruritus which, if accompanied by secondary psychogenic stress and lichenification, is more marked220 . Involvement of the nails • Pitting • Onycholysis- Separation of the distal nail plate from the nail bed. • Oily macules / Oil drop Sign -Yellowish flecks beneath the nail plate. Subungual hyperkeratosis. • Acrodermatitis continua of Hallopeau are a painful, localized pustular form of psoriasis which often leads to nail deformity211 . INVESTIGATIONS A diagnosis of psoriasis is usually based on the appearance of the skin. There are no special blood tests or diagnostic procedures for psoriasis. Sometimes a skin biopsy, or scraping, may be needed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show clubbed Rete pegs if positive for psoriasis213 . The main histopathological changes are: • Hyperkeratosis and Parakeratosis. • Epidermal hyperplasia. • Acanthosis and papillomatosis. • Marked infiltrate around dilated capillary loops. • In the Malpeghian layer, neutrophils may accumulate to form the characteristic spongiform pustules of Kogoj221 . CLASSIFICATION Psoriasis is a very diverse skin disease that appears in a variety of forms. Each form has distinct characteristics. Typically, people have only one type of psoriasis at a time, but occasionally two or more different types of psoriasis can occur at the same time. Psoriasis can also occasionally change from one form to another. Trigger factors may "convert" some forms of psoriasis, such as plaque, to another form, such as pustular. Generally, one type of psoriasis will clear and then another form of psoriasis will appear later222 . Thus it occurs in a variety of forms that differ in, their intensity,
  • 100. REVIEW OF LITERATURE 80  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” duration, location, shape and pattern of scales. Some dermatologists classify psoriasis as mild, moderate, or severe. • Mild psoriasis is considered to be scaling over less than 5-10 percent of the body. • Moderate psoriasis is considered to be scaling over 10 to 20 percent of the body. • Severe psoriasis is considered to be scaling over 20 percent of the body. According to the National Psoriasis Foundation, 1 percent of the skin is roughly equal in size to the palm of the hand223 . Plaque psoriasis (psoriasis vulgaris) It affects 80 to 90% of people with psoriasis, thus it is a commonest form of psoriasis. Its scientific name is psoriasis vulgarise (vulgarise means common). Plaque Psoriasis can most likely to affect the typical areas of the elbows, knees, umbilicus and lower back. Although it seems that the most common areas are the elbows and knees. It is typically appears as raised areas of inflamed skin covered with silvery white scaly skin. Configuration of plaque psoriasis is sharply circumscribed, round- oval, or nummular (coin-sized) plaques. The lesions may initially begin as erythematous macules (flat and <1 cm) or papules, extend peripherally, and coalesce to form plaques of one to several centimetres in diameter. The shape of the plaque is usually oval but can be irregular in shape. Smaller plaque areas may merge with other areas and form a large affected area. The skin in these areas, especially when over joints or on the palms or feet, can split and bleed. A white blanching ring, known as Woronoff’s ring, may be observed in the skin surrounding a psoriatic plaque224 . Uncommon subtypes of chronic plaque psoriasis include: • Rupioid psoriasis: Limpet-like cone-shaped lesions of psoriasis • Lichenified psoriasis: Chronically rubbed areas of psoriasis that have become very thickened • Elephantine psoriasis: Very persistent, very thickly scaled, large areas of psoriasis • Ostraceous psoriasis: Very thickly scaled, ring-like areas of psoriasis, resembling an oyster shell • Linear psoriasis: Psoriasis arranged in lines along the body (often corresponding to fatal developmental lines) • Photosensitive psoriasis: Psoriasis worst in the sun-exposed areas of the face, neck, hands and forearms. Most patients with psoriasis find ultraviolet light very helpful for their psoriasis. A small group experience exacerbations of their rash following
  • 101. REVIEW OF LITERATURE 81  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” sun exposure. In these people sometimes clear 'sunburn' lines are seen. They may also have typical plaque psoriasis elsewhere. Strict sun protection, usually in combination with other treatment, is required to control this type of psoriasis. • Psoriasis follicularis-In which minute scaly papules are present at the openings of pilosebaceous follicles225 . Guttate psoriasis Guttate is derived from the Latin word gutta meaning "drop". Guttate Psoriasis looks like small, red, individual drops on the skin. These lesions usually appear on the trunk and limbs, and sometimes on the scalp. They usually are not as thick or scale-covered as plaque psoriasis. It often starts in childhood or young adulthood. It often comes on quite suddenly. It may be triggered by strep throat, an infection of the throat. There are also other causes that can trigger an attack of guttate psoriasis such as tonsillitis, a common cold, chicken pox, immunisations, physical trauma, psychological stress, illness, and the administration of antimalarial drugs. Guttate Psoriasis may clear on its own accord, leaving a person free from further outbreaks. Or, it may clear for a time only to reappear later as patches of Plaque Psoriasis. Sometimes guttate can flare throughout childhood, often due to repeated bouts of strep infection or other upper respiratory illnesses. Without treatment it may represent the initial stage of chronic plaque-type Psoriasis. The acute guttate form progresses into the chronic plaque form in about 70% of patients. Like other forms of psoriasis, guttate psoriasis has the tendency to improve during the summer and worsen during the winter. Once cleared, many patients who experience acute guttate psoriasis usually have limited or no evidence of psoriasis for prolonged periods226 . Pustular psoriasis It is primarily seen in adults, pustular [PUHS-choo-ler] psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. It is not an infection, nor is it contagious. It may be localized to certain areas of the body for example, the hands and feet. Pustular psoriasis also can
  • 102. REVIEW OF LITERATURE 82  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” be generalized, covering most of the body. It tends to go in a cycle–reddening of the skin followed by formation of pustules and scaling. Types of pustular psoriasis Von Zumbusch The onset of von Zumbusch pustular psoriasis can be abrupt. Widespread areas of reddened skin develop, and the skin becomes painful and tender. Within a few hours, the pustules appear. The pustules then dry and peel over the next 24 to 48 hours, leaving the skin with a glazed, smooth appearance. A fresh crop of pustules may then appear. Eruptions often come in repeated waves that last days or weeks. Von Zumbusch pustular psoriasis rarely appears in children, although when it does, the prospect of improvement may be much better than for adults. Palmo-plantar pustulosis Palmo-plantar pustulosis (PPP) is a type of pustular psoriasis that causes pustules on the palms of the hands and soles of the feet. PPP is characterized by multiple pencil eraser-sized pustules in fleshy areas of the hands and feet, such as the base of the thumb and the sides of the heels. The pustules appear in a studded pattern throughout reddened plaques of skin, then turn brown, peel and become crusted. The course of PPP is usually cyclical, with new crops of pustules followed by periods of low activity227 . Flexural psoriasis (inverse psoriasis) Appears as smooth inflamed patches of skin. It occurs in skin folds, particularly around the genitals (between the thigh and groin), the armpits, under an overweight stomach (pannus), and under the breasts (inframammary fold). It is aggravated by friction and sweat, and is vulnerable to fungal infections. Flexural lesions are devoid of scale and appear as red, shiny, well demarcated plaques occasionally confused with candidal, intertrigo, and dermatophyte infections213 . Erythrodermic psoriasis Involves the widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by severe itching, swelling and pain. It is
  • 103. REVIEW OF LITERATURE 83  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic treatment. This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and for the skin to perform barrier functions. It may be triggered by severe sunburn, by corticosteroids and other medications, or by another type of psoriasis that's poorly controlled213 . DIFFERENTIAL DIAGNOSIS In the majority of cases, the diagnosis of psoriasis is usually easy if the above mentioned features are borne in mind. Atypical cases may create diagnostic problems. The following conditions must be particularly considered in differential diagnosis of psoriasis Table No : 41 Differential Diagnosis Disease Clinical features Cause Diagnosis Tinea and onycholysis Scaling annular to round patches and onycholysis and crumbling nails. Dermatophyte infections KOH Seborrheic dermatitis Diffuse lesions with greasy scales on scale behind ears, nasolabial folds and presternally. Possibly overgrowth pityrosporum Skin biopsy may help Secondary syphilis Guttate or small scaling plaques over trunk, like pityriasis rosea, but involve palms and soles. Spirochete Positive test for syphilis RPR Cutaneous T-cell Flat to thick plaques with variable scaling, this may be identical to psoriasis anywhere on body. May T-cell lymphoma Skin biopsy Sézary cells in circulation. T-
  • 104. REVIEW OF LITERATURE 84  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” lymphoma be erythrodermic-Sézary syndrome. cell gene rearrangement Reiter's syndrome Identical skin changes as psoriasis with pustular lesions on palms and soles (keratoderma blennorrhagicum), balanitis circinata; arthritis nail involvement. Mucous membrane changes not seen in psoriasis. Unknown, but triggered by certain infectious agents Clinical features, arthritis, conjunctivitis, urethritis Pityriasis rubra pilaris Diffuse salmon-colored papulosquamous lesion areas, normal skin in midst, involved skin—“island sparing,” keratoderma palm. Keratotic papules on dorsum of fingers. Unknown Clinical features, skin biopsy Pityriasis lichenoides varioliformis acuta Red, purpuric, vesicular lesions evolve into scaling macular and papular lesions that scar. Lesions occur over entire body. Unknown Clinical features, skin biopsy KOH, Potassium hydroxide; RPR, rapid plasma reagin228 .        
  • 105. REVIEW OF LITERATURE 85  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PSORIATIC ARTHRITIS (PsA) Psoriatic arthritis causes inflammation in and around the joints, usually in people who already have the skin condition psoriasis. Sometimes, however, the arthritis develops before the psoriasis229 . The exact cause of psoriatic arthritis is not known. Many factors seem to be involved in its development. Heredity, genes plays a major role. People who are closely related to someone with psoriatic arthritis are 50 times more likely to develop the disease themselves. Recent studies have located genetic markers shared by most people who have the disease230 . Psoriatic arthritis has its own set of symptoms: ♦ Stiffness, pain, swelling, and tenderness in the joints, often worse in the morning. ♦ The joints of the fingers and toes as well as the spine are commonly involved. ♦ Reduced range of motion. ♦ Changes in fingernails, including small indentations or lifting of the nail. ♦ The National Psoriasis Foundation reports nail changes in 80 percent of people with psoriatic arthritis. ♦ Redness and pain in the eye. Patterns of presentation: • Asymmetric oligoarthritis: > 50% • Polyarthiritis with predominantly DIP involvement (classic): 5-19% • Symmetric seronegative polyarthritis simulating RA: up to 25% • Sacroiliitis and spondylitis resembling Ankylosing Spondylitis (AS): 20-40% • Arthiritis mutilans with resorption of the phalanges: 5% • Onset may be insidious (66%) or acute (33%) mimicking gout or septic arthritis. Prognostic factors: Poor prognosis: • late age of onset • five or more effused joints
  • 106. REVIEW OF LITERATURE 86  • high immunosuppressive medication use Good prognosis: • ESR < 15 mm/h • HLA B27 positive in 60-80% of psoriatic spondylitis and 20% of peripheral PsA. • CRP - usually elevated. • Acute serum amyloid A (A-SAA) may be elevated. • ANA may be mildly elevated . • Rheumatoid factor negative (or mildly elevated with titer<1/40, which is cut- off for Rheumatoid Arthritis (RA).231 Table No: 42 CLASSIFICATION OF PSORIATIC ARTHRITIS 1. Asymmetric arthritis 30-50% of cases Asymmetric arthritis does not occur in the same joints on both sides of the body and usually affects only one to three joints. Typically the knee, hip, ankle or wrist will be affected This form is generally mild and is the most common 2. Symmetric arthritis 30-50% of cases This type is similar to rheumatoid arthritis but is typically milder and with less cases of deformity. It can be severe and multiple joints on both sides of the body may be affected. Distal Interphalangeal Predominant Sometimes mistaken for osteoarthritis, this type usually affects the last joint of the fingers and toes (distal interphalangeal joint 25%of cases 3. A rare but serious condition, spondylitis can cause deformity and changes in posture. Inflammation of the spine is the most common symptom. Movement may be painful as the neck and lower back may also be stiff and inflamed. Psoriatic Spondyloarthritis 30-35% of cases 4. 50%of cases 5. Arthritis Mutilans Usually the small joints in the hands and feet are affected. This type is unusually severe because it may actually destroy the bones and cartilage. Pain may be associated to skin flare-ups and remissions DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 107. REVIEW OF LITERATURE 87  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Mortality/Morbidity of Psoriasis: Pustular flares of disease may be provoked by systemic corticosteroid therapy. Such flares can be fatal. Other than this, disease-related mortality is exceedingly rare in psoriasis, and even then, the primary cause of mortality is related to its therapy. Adverse effects of systemic treatments (eg, hepatic fibrosis from methotrexate) and Phototherapy (eg, psoralen plus UVA [PUVA]–induced skin cancers with metastases) are the primary disease-related causes of death. • Morbidity is a much greater problem in patients with psoriasis and is often related to pruritus, dry and peeling skin, fissuring, and the adverse effects of therapy. By far, the patient's quality of life is most affected in plaque psoriasis, and studies have demonstrated patients with psoriasis have deficiencies in quality of life similar to those for persons with congestive heart failure. Self- consciousness and embarrassment about appearance, inconvenience, and the high cost of antipsoriatic treatment regimens all add to the morbidity of this chronic and relapsing disease141 . COMPLICATIONS Chronic plaque psoriasis does not affect longevity. The condition may, however, be complicated by several co morbidities including malignancy, arthritis, and emotional distress from the cosmetic effects of the disease. Depression, anxiety, sexual dysfunction, poor self-esteem, and suicidal thoughts may coexist with psoriasis, even in patients with less severe disease.Cohort studies have shown that an increased risk of nonmelanoma skin cancers and lymphoma is associated with psoriasis. This risk is higher in patients with more severe disease, but it is not clear whether disease severity or treatment accounts for the increased risk232 . QUALITY OF LIFE When one compares the quality of life in psoriasis to that in other medical conditions it becomes clear that the reduction in quality of life that these patients experience is comparable to the reduction in quality of life with other medical illnesses. On the physical dimensions of health-related quality of life, psoriasis has less impact than congestive heart failure, but greater impact than hypertension, diabetes, post-myocardial infarction and depression. However, on the mental
  • 108. REVIEW OF LITERATURE 88  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” dimensions of health-related quality of life, psoriasis was considered worse than all these conditions except depression. These findings have importance not just for psoriasis but for skin disease in general. These are not cosmetic problems; these diseases cause quantifiable reductions in health-related quality of life. The National Psoriasis Foundation (NPF) was founded with the goals of providing psychosocial support and education to psoriasis patients. It is important for dermatologists to encourage their patients to join this supportive and politically effective organization233 . TREATMENT As Psoriasis is a complex disorder that negatively impacts quality of life,So treatment strategies must address both psychosocial and physical aspects of the disease. Psoriasis can be categorized into localized and generalized forms for treatment purposes. In either case, the treatment plan should include obtaining rapid control of the disease and maintaining that control. For localized disease, recent data support the combined use of topical corticosteroids with a non corticosteroid agent (topical calcipotriene or tazarotene). For generalized disease, UVB phototherapy is an effective treatment that permits both rapid control and long-term maintenance234 . Management principles Treatment is as much guided by the patient's perception of their condition as by the objective severity of it. Treatment options have to take into account the patient's ability to understand and follow through with treatment (as there can be issues relating to acceptability of certain treatments). Patient education is important: it is just as important for them to know how to apply their treatment as it is for them to be clear about the management steps decided in their particular case. Associated psychological problems need to be specifically addressed and if necessary, treated in their own right. Most patients with mild or moderate plaque psoriasis responding to topical treatment can safely be managed in the community.
  • 109. REVIEW OF LITERATURE 89  There are three main categories of treatment: local agents, phototherapy and systemic therapy. These may be used sequentially, in combination or in rotation. No active treatment is one of the treatment options235 .   ChartNo.04                 Schematic treatment ladder of psoriasis      There can be substantial variation between individuals in the effectiveness of specific Psoriasis treatments. Because of this, dermatologists often use a trial-and- error approach to finding the most appropriate treatment for their patient. The decision to employ a particular treatment is based on the type of psoriasis, its location, extent and severity. The patient’s age, gender, quality of life, co morbidities, and attitude toward risks Associated with the treatment are also taken into consideration. Medications with the least potential for adverse reactions are preferentially employed. If the treatment goal is not achieved then therapies with greater potential toxicity may be used. Medications with significant toxicity are reserved for severe unresponsive psoriasis. This is called the psoriasis treatment ladder. • As a first step, medicated ointments or creams are applied to the skin. This is called topical treatment. • If topical treatment fails to achieve the desired goal then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy. • The third step involves the use of medications which are taken internally by pill or injection. This approach is called systemic treatment. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 110. REVIEW OF LITERATURE 90  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Sulphur was fashionable as a treatment for psoriasis in the Victorian and Edwardian eras. It has recently re-gained some credibility as a safe alternative to steroids and coal tar. On August 27, 2006, scientists led by Jeung-Hoon Lee created in the laboratory synthetic lipids called pseudoceramides which are involved in skin cell growth and could be used in treating skin diseases such as atopic dermatitis, a form of eczema characterized by red, flaky and very itchy skin; psoriasis, a disease that causes red scaly patches on the skin; and glucocorticoid-induced epidermal atrophy, in which the skin shrinks due to skin cell loss125. Treatments for Localized Psoriasis • Tar • Topical corticosteroids • Topical calcipotriene • Topical tazarotene • Anthralin (short contact therapy) • Corticosteroid tape (Cordran tape) • Intralesional triamcinolone   Topical Corticosteroids • Efficacy is dependent on compliance • Consider oil or foam vehicles for scalp involvement • May be mixed with salicylic acid for treatment of hyperkeratotic lesions • Use when there is underlying dermatitis causing the Koebner phenomenon or for superimposed lichen simplex chronicus    
  • 111. REVIEW OF LITERATURE 91  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Topical Calcipotriene • est used in combination with potent topical corticosteroids • One of the safest treatments for psoriasis (consider use in children or in patients with HIV infection) • No monitoring required with doses <120 g/wk (scale doses down in children based on body surface area) • Do not combine with salicylic acid or other acid agents • Effective in combination with UVB and PUVA   Topical Tazarotene (0.1% and 0.05%) • Cosmetically pleasing gel formulation, once daily dosing • Limited efficacy and high potential for irritation when used as a monotherapy • More effective with less irritation when used in combination with topical corticosteroids • May be used in combination with phototherapy • Retinoids are potentially teratogenic   Treatments for Generalized Psoriasis UVB Phototherapy Safe and effective for both initial clearing and long term control. Efficacy may be increased by day treatment regimens or combination with low-dose acitretin. Narrow-band UVB may be more effective than broadband. Psoralen + UVA (PUVA) and PUVA + acitretin (Re-PUVA) More effective than broadband UVB but causes high risk of Cutaneous malignancy. PUVA should probably be used in combination with oral retinoids when possible to help minimize PUVA exposure.
  • 112. REVIEW OF LITERATURE 92  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Acitretin (Soriatane) Very effective therapy for pustular psoriasis. Less effective as a monotherapy for plaque psoriasis. Very helpful as an adjunct to phototherapy. Relatively safe as a long-term treatment. Methotrexate Highly effective therapy. Patients appreciate the simplicity of the treatment regimen. There is the risk of life-threatening hematologic toxicity at any time during therapy and both acute and chronic hepatotoxicity. Careful monitoring is essential Cyclosporine (Neoral) Very effective treatment. Especially helpful for immediate control of severe disease. Less helpful as a long-term therapy (>1 year) due to renal toxicity. Other immune inhibitors • Mycophenolate mofetil- helpful in combination with other drugs. Monitor for hematologic toxicity. • Hydroxyurea- helpful for patients with cirrhosis who require systemic therapy. Close hematologic monitoring is essential. • Leflunomide- Very long half-life; requires special protocol to speed clearance.   Psoralen plus UVA photochemotherapy (PUVA) • 2-3 x/week treatment • High risk of cutaneous carcinogenesis, should not be done in combination with tanning bed use • Combination with low dose acitretin improves efficacy and may reduce long- term side effects    
  • 113. REVIEW OF LITERATURE 93  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Methotrexate • Effective, but potential for life-threatening side effects • Use of the NPF brochure on methotrexate helps educate patients about potential risks and can help physicians easily document that they have provided information on the risks of treatment • Start with 5 mg test dose, increase in 5 mg/wk intervals until clinical response or maximal dose of 20-25 mg/week is achieved (reduce the initial and incremental doses to 2.5 mg in the elderly or others with suspected renal impairment • Check complete blood count and liver function tests one week after initial dose and after each increase in dose • Trimethoprim-sulfmethaxazole also affects folic acid and should not be taken during methotrexate therapy. Non-steroidal anti-inflammatories can reduce renal function; increased monitoring for methotrexate toxicity is indicated when these agents are started during methotrexate therapy • Be prepared to use folinic acid (not folic acid!) if needed to treat acute toxicity • To reduce nausea, a divided dose may be taken one day a week. Folic acid (1-5 mg/day) may also be helpful. • The cost of oral therapy may be reduced by use of the intravenous solution in place of the pill formulation   Acitretin (Soriatane) • Oral retinoid, associated with high risk of teratogenesis and other retinoid side effects! • Most effective for pustular psoriasis (including palmoplantar psoriasis) • Monotherapy dose 25-50 mg/day • Very effective in combination with UVB and PUVA, use low dose (25 mg/day or every other day) to minimize retinoid side effects • Check liver function tests and triglycerides at baseline and at 2-4 week intervals  
  • 114. REVIEW OF LITERATURE 94  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Cyclosporine • Very useful for rapid, short-term control of psoriasis followed by transition to another treatment • Blood pressure and creatinine measurements should be assessed twice before initiating treatment to establish accurate baseline values • Elevation of blood pressure during cyclosporine therapy may be treated with antihypertensive medications • Reduction in cyclosporine dose is recommended if blood creatinine increases by 30% • Numerous potential drug interactions 143  Side Effects, Cautions and Special Requirements Like all medications, those used for psoriasis may have side effects. Topical treatments should be applied only as directed by your physician or pharmacist. Some should not be used on the face and others must be used only in a limited area. Calcipotriene (Dovonex) should not be used with products that contain salicylic acid (commonly found in over-the-counter psoriasis and acne medications) because acid breaks down its active ingredient. Oral retinoids can cause severe birth defects and should not be taken during pregnancy. Retinoids also may cause eye and lip inflammation, bone spurs and hair loss. Long-term use of PUVA — 250 treatments or more — may increase the risk of skin cancer and possibly melanoma, a deadly form of skin cancer. The higher risk begins about 15 years after the first PUVA treatment. Immune-modulating drugs may cause headache, fever, chills, nausea and myalgia which happen most often after the first dose and then decrease with subsequent doses. Serious, and sometimes fatal, infections have also been reported with these drugs145.
  • 115. REVIEW OF LITERATURE 95  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SELF CARE Keep skin lubricated. Oils, creams and petroleum jelly preparations are suggested. Use a humidifier in the home. Get out in the sun. Be careful not to burn. Exposing only the areas of your body with active psoriasis may be optimal. Bathing in hot water may help reduce scaling. Use mild soaps or soap-free cleaners. Mild soaps such as Nivea Cream, Neutrogena Dry Skin, Dove, or Lever 2000 are recommended. Minimize stress. Protect against skin injuries and skin infections. The Psoriasis Area and Severity Index A patient's Psoriasis Area and Severity Index (PASI) is a measure of overall psoriasis severity and coverage. It is a commonly-used measure in clinical trials for psoriasis treatments. Typically, the PASI would be calculated before, during, and after a treatment period in order to determine how well psoriasis responds to the treatment under test (a lower PASI means less psoriasis, generally). Not all PASIs are the same, however. In clinical trials, it is common that a "modified PASI" is used as the main measurement and how "modified" it is will depend on the researchers and what they are looking for, specifically. The only way to learn exactly how the PASI has been modified is to read whatever study you're interested in, the entire measurement protocol should be written up in detail. Skin Sections: For the PASI, the body is divided into four sections. Each 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: stomach, chest, back, etc.) at 30%; the Arms (20%); and the Head (10%). Area: For each Skin Section, measure the amount of skin involved, as a percentage of the skin just in that part of the body (not the whole body - see below), and then assign it a score from 0 to 6:
  • 116. REVIEW OF LITERATURE 96  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Coverage Score         0%  0     < 10%  1  10‐29%  2  30‐49%  3  50‐69%  4  70‐89%  5  90‐100%  6  So, if head is 37% covered, then area score for head - Ahead - would be 3. Similarly to other parts of body find the area score for the other three Skin Sections - Alegs, Abody and Aarms. Severity: The severity is measured by four different parameters: Itching, Erythema (redness), Scaling and Thickness (psoriatic skin is thicker than normal skin). 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', according to the following chart: Severity None Some Moderate Severe Maximum Score 0 1 2 3 4 So, if head psoriasis itches moderately, that would mean that Ihead would be 2. If it's only somewhat red, our Ehead score would be 1. Also calculate Shead (scaling on the head) and Thead (thickness of the head psoriasis) scores, as well as all four scores (I, E, S and T) for the other three Skin Sections. Toting Up the Index: When all 20 of the above scores are figured out, then it is ready to calculate our PASI. 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 skin in that section, as follows:
  • 117. REVIEW OF LITERATURE 97  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” • Head : (Ihead+Ehead+Shead+Thead) x Ahead x 0.1 = Totalhead • Arms : (Iarms+Earms+Sarms+Tarms) x Aarms x 0.2 = Totalarms • Body : (Ibody+Ebody+Sbody+Tbody) x Abody x 0.3 = Totalbody • Legs : (Ilegs+Elegs+Slegs+Tlegs) x Alegs x 0.4 = Totallegs( • ( I= Itching ; E=Erythema ; S=Scaling ; T= Thickness of Skin ) Finally, the PASI is Totalhead+Totalarms+Totalbody+Totallegs. That's it. This PASI will range from 0 (no psoriasis) to 96 (covered head-to-toe, with complete itching, redness, scaling, and thickness) 236 .
  • 118. REVIEW OF LITERATURE 98  PSORIASIS & KUSHTA Type of the kushtas which resembles the features of psoriasis listed below with their features: - Table no :43 Showing Features of different types of Kushtha in relation to Psoriasis EKA KUSHTA KITIBHA SIDMA CHARMADALA MANDALA 1. Asewdana 2. Krishna,aruna varna 3. Matsya shakalopamam 4. Mahavastu. 1. Kinakhara sparsha 2. Kandu 3. Parusha 4. Shyava 5. Punahapuna udpadyate 1. Sweta tamravar na 2. prayena urasi utpadyate 3. Alpa kandu 4. pooya 1. Kandu 1. kandu 2. Osha 2.mandalavath 3. Chosha 3.pidaka 4. Rakthavarna 4. Raga. 5. spotha 5.Sthira 6. Ruk 7. Dalathi 8. sparshanasaha In Ayurveda all the kushta are considered on the basis of Tridosha. Even though there is a dominance of one Dosha invariably remaining two Doshas are also involved in the manifestation of Kushta. Here in this case of psoriasis involvement of three Doshas are seen. In the same way attribution of one particular Kushta is not sufficient in case of diagnosis. Here a different way has to be thought of. Depending upon the presentations of psoriasis we may attribute a specific kushta in each patient / presenting form. Some of the examples listed below Silvery scales of psoriasis is used to compare with eka kushta. Eryhtramatous eruption, candlegrease sign, recurrence and manifestation in the chest can be correlated with sidma kushta. Scaling, auspitz sign etc are similar to that of charmadala. Itching is seen in kitibha,chrmadala, sidma. Stable nature are seen in mandala. It is a well understood fact that these types of correlations are fail to give complete picture of psoriasis. There are lacking in such type of correlation, Psoriasis can appear as a milder form to severe form. i.e. kshudra to maha kushta nature. Can create many complications like   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 119. REVIEW OF LITERATURE 99  psoriatic arthritis. So different type of understanding is mandatory for the identification of disease. Proper diagnosing is the prime step of treatment. So assessments based on dosha dushyadi will helps to plan the ideal treatment. In ayurveda importance is not given for naming the disease, acharyas clearly says that assess the “dosha dushyadi” on the basis of “amshasha kalpana” and treat accordingly. Charakas idea behind naming the kushta: “lÉ cÉ ÌMüÎgcÉSÎxiÉ MÑü¸qÉåMüSÉåwÉ mÉëMüÉåmÉ ÌlÉÍqɨÉqÉç, AÎxiÉ iÉÑ ZÉsÉÑ xÉqÉÉlÉ mÉë¢ÑüiÉÏlÉqÉÌmÉ MÑü¸lÉÉqÉç SÉåwÉÉÇvÉÉÇvÉÌuÉMüsmÉÉlÉÑoÉlkÉxjÉÉlÉ ÌuÉpÉÉaÉålÉ uÉåSlÉÉuÉhÉï xÉÇxjÉÉlÉmÉëpÉÉuÉ lÉÉqÉ ÍcÉÌMüÎixÉiÉ ÌuÉvÉåwÉÈ| xÉ xÉmiÉÌuÉkÉÉåŹÉSvÉÌuÉkÉÉåÅmÉËU xÉÇZrÉårÉÌuÉkÉÉå uÉÉ pÉuÉÌiÉ||” (ch ni 5/4) kushta always originate with tridosha involvement. Its presentation is going to vary in persons who are having same prakruti. kushta may present either seven or eighteen or innumerable forms. So naming the disease is not important, undersanding the dosha dushyadi and deciding the treatment is important.   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 120. DRUG REVIEW 100    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. DRUG REVIEW oÉWÒûiÉÉ iÉ§É rÉÉåarÉiuÉqÉlÉåMüÌuÉkÉMüsmÉlÉÉ || xÉÇmÉccÉåÌiÉ cÉiÉÑwMüÉåÅrÉÇ SìurÉÉhÉÉÇ aÉÑhÉ EcrÉiÉå || (cÉ.xÉÔ.9/7) Drug place an important role in the Pada Chatushtayam. According to Acharya Charaka says that an ideal medicine should possesses the qualities ‘Bahuta’, ‘Yogyata,’ ‘Anekavidhakalpana,’ and ‘Sampath’. Drug is a part of Cikitsa Catushpaada, which has been placed next to the physician. The knowledge of the drug is very important to physician because without knowledge of drug the patient cannot be treated properly. In this way, all Ayurvedic classics advocate specific formulation for particular disease. Drugs for Deepana Pachana : Chitrakadi Vati 236 It is explained in 15th chapter of charaka chikitsa i.e Grahanichikitsa. Explained in the context of Ama pachana. By the intake of this it does the pachana of the Ama &Jataragni deepthi . “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 121. DRUG REVIEW 101    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. Table no:44: RASA PANCHAKA OF CHITRAKADI VATI Sl. no Drug Latin Name Rasa Guna Virya Vipaka Doshagnata Karma 1 Citraka Plumbago zeylanica Katu Laghu Ruksa Ushna katu Kaphavata shamaka pita vardaka Deepana Pachana Arsoghna 2 Pippali mula Pipper Longum Katu Laghu Ruksa Ushna katu Vatakapha shamaka Kasahara Deepana Swasahara 3 Yava Potasii Kshara Carbonas Katu Laghu Snigdha Ushna Katu Kapha vatashamaka Deepana Pachana 4 Sarja kshara Impure carbonate of soda Lavana Katu Teekshna Ushna katu Vatashamaka Pachana 5 Saindhava Sodi chloridium Madhur Lavana Laghu, Sheeta Snigdha Katu Tridosha shamaka Deepana, Pachana Ruchya, Vrushya, Netrya 6 Sauvarchala Unaqua Sodium Katu Sneha, Laghu, Vishada Ushna Katu Vata shamaka Deepana, Rochna, Chloride Bedhana 7 Samudra Sodi muris Lavana, Tikta, Madhur Guru, Snigdha Ushna Madhura vatashamaka Deepana, Ruchya, Pachna 8 Vida - Lavana Laghu ,Ushna, Teeksha, Sukshma Ushna Madhura Kapha vata shamana Hrudya Vatanulom na 9 Uadbhida - Katu Guru Snigda Sheetal a Katu Vatashamaka Ruchya 10 Sunthi Zingeber Katu Guru Ushna Madhura Kaphavata Truptighna “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 122. DRUG REVIEW 102    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. officinalis Ruksa shamaka Deepana Pachana DRUG SELECTED FOR SNEHAPANA Mahatikthaka Gritha237 It is explained in the 7th chapter of charaka chikitsa i.e Kustha chikitsa. By the intake of this gritha depending upon the Bala,Kala and Matra of the rogi it passifes Kustha,Raktapitta,PrablaArsas,Visarpa,Amlapitta,Vatarakta,Pandu,Vispota,pama,Un mada,kamala,Jwara,kandu,Hridroga,Gulma,Pidaka,Asrukdara and Gandamala. The diseases which are not passified by usage of shatashaa yogas such Mahavyadhis are passified by this Gritha. 11 Pippali Pipper Longum Katu Laghu Ruksa Ushna Katu Vatakapha Shamaka Kasahara Deepana Swasahara 12 Maricha Pipper Nigrum Katu Laghu Ruksa Ushna Katu Vatakapha Deepana Shamaka 13 Hingu Ferula Katu Laghu Ushna Katu Kaphavata Narthex Ruksa shamaka pitavardaka Deepana 14 Ajamoda Trachysp- ermum ammi Katu Laghu Ruksa Ushna Katu Kaphavata shamaka pitavardaka Deepana 15 Cavya Pipper Chaba Katu Laghu Ruksa Ushna Katu Kaphavata shamaka pitavardaka Deepana “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 123. DRUG REVIEW 103    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. Table no :45: RASA PANCHAKA OF MAHATIKTHAKA GHRITHA Sl No . Drug Latin name Rasa Guna Virya Vipaka Doshag nata Karma 1. Sapta parna Alstonia scholaris Tikta ,kasaya Laghu , snigdh a Usna Katu Tridosh ahara Dipana , Hrdya 2. Ativisa Acponitu m heteropyll um Katu , kasaya Laghu , ruksha Usna Katu Tridosa hara Dipana ,pacana, krimihara 3. Aragvadh a Cassia fistula Madhura Mrudu , Guru, Snigd ha Sita Madhur Kapha- pittahar a Sramsana 4. Patha Cissampel os pariera Tikta Laghu ,tiksna Usna Katu Vata- kaphah ara Visaghna, Grahi , Balya 5. Amalaki Embilica officinalis Lavanavarj ita pancarasa Guru, Ruksa, Sita Sita Madhur a Tridosa hahara Vayassthapana , rasyana, cakusya, vrsya 6. Haritaki Terminalia chebula Amlavarjit a Pancarasa Laghu , Ruksa Usna Madhur a Tridosh ahara Anulomana, Rasayana, Kustagna 7. Vibhitaki Terminalia belirica Kasaya Ruksa, Laghu Usna Madhur a Kapha- pittahar a Bhedana, Caksusya 8. Patola Tricosanth es dicocia Tikta, Katu Laghu , Ruksa Usna Katu Kapha – pittahar a Vrsya, Varnya , Dipana “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 124. DRUG REVIEW 104    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. 9. Nimba Azadiracht a indica Tikta, Kasaya Laghu , Ruksa Sita Katu Kapha- pittahar a Grahi, Krimgna, Dipana 10 . candana Santalum album Tikta, Madura Laghu , Ruksh a Sita Katu Kapha- pittahar a Varnya, Dahaprasaman a 11 . Parpata Fumaria parviflora Tikta Laghu Sita Katu Kapha- pittahar a Trsnaninigraha na, Grahi 12 . Padmaka Prunus puddum Kasya, Tikta Laghu , snigdh a Sita Katu Kapha- pittahar a Varnya , Vrsya 13 . Haridra Curcuma longa Tikta, Katu Ruksa, Laghu Usna Katu Kapha- vatahar a Lekana , Varnya , Visagna 14 . Daruharid ra Berberis aristata Tikta, Kasaya Laghu , Ruksa Usna Katu Kapha- pittahar a Chedana , Varnya 15 Vacha Acorus calamus Tikta, Katu Laghu , Tiksna Usna Katu Kapha- vatahar a Lekaniya , Medya 16 . Satavari Asparagus racemosus Madura, Tikta Guru, Snigd ha Sita Madura Vata- pittahar a Rasayna , Vrsya , Stanyajnana 17 . Sariva Hemedism us indicus Madura , Guru, Sita Madura Tikta Snigd ha Tridosa hara Grahi 18 . Murva Marsedina tenacissim a Tikta, Kasaya Guru, Ruksa Usna Katu Kapha- vatahar a Jvarahara 19 . Yashti madhu Glycryrrhi za glabra Madura Guru, Snigd ha Sita Madura Tridosh ahara Rasayana , Vrsya, Caksusya “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 125. DRUG REVIEW 105    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. 20 . Guduchi Tinospora cordifolia Tikta, Guru, Usna Madura Tridosa samakaKasaya Snigd ha Grahi, Medhya, Javarahara OIL USED FOR ABHYANGA KARANJA TAILA238 (su chi 9/53) It is explained 9th chapter of Sushrutha chikitsa i.e Kustha chikitsa. It is used in the application of Dustavrana and in Kustha. Table no :46 : RASAPANCHAKA OF KARANJA TAILA Sl No Drug name Latin name Rasa Guna Virya Vipaka Dosgnata Karma 1. Karanj a Pongamia pinnata Tikta, Katu, kasaya Laghu, Tiksna Usna Katu Kapha- vatahara Bhedana , Sothahara DRUG USED FOR PARISHEKA SIDARTHAKA SNANA CHOORNA 239 It is explained in the 7th chapter of charaka chikitsa i.e Kustha chikitsa. The usage of this choorna kashaya as a parisheka after the snehapana in vishramakala of vamana & virechana. The lepa prepared from this choorna and Udgarshana by this choorna elevates Tvakdosha,Kusta,Sotha and Panduroga. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 126. DRUG REVIEW 106    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. Table no:47:RASA PANCHAKA OF SIDARTAKA SNANA CHOORNA Sl No Drug name Latin name Rasa Guna Virya Vipaka Dosagnata Karma 1. Musta Cyperus rotunds Tikta, Katu, Kasaya Laghu, Ruksa Sita Katu Kapha-pitta hara Dipana, pacana, grahi, lekana 2. Madanaphala Randia dumetrom Madura, tikta, Laghu, Ruksa Usna Katu Kaphavatahara Chardana, Lekhana, 3. Amalaki Embilica officinalis Lavanava rjita pancaras a Guru , Ruksha, Sita Sita Madura Tridosahara Vayastapana, Rasyana, caksusya, vrsya 4. Haritaki Terminalia chebula Amlavarj ita pancaras a Laghu, Ruksha Usna Madhura Tridoshahara Kustagna , Anulomana, Rasayana 5. Vibhitaki Terminalia belirica Kasaya Ruksha , Laghu Usna Madhura Kapha - pittahara Bhedana , Caksusya 6. Karanja Pongamia pinnata Tikta, Laghu, Usna Katu Kapha vatahara Bhedana, Katu, Tiksna Sothahara kasaya 7. Aragvadha Cassia fistula Madhura Mrudu , Guru , Snigdha Sita Madhura Kapha- pittahara Sramsana 8. Kutaja Holarrhena antidycentrica Tikta, Laghu, Sita Katu Kapha- pittahara Grahi, dipanaKasaya, ruksa 9. Saptaparni Alstonia scholaris Tikta, kasaya Laghu, Snigdha Usna Katu Tridoshahara Dipana, Hrdya “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 127. DRUG REVIEW 107    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. DRUG SELECTED FOR VIRECHANA - ABHAYADI MODAKA240 It is explained in Sharngadhara samhitha uttarakhanda 3/26-33 in the context of Virechana. Indications: Vishamajwara,Mandagni,Pandu,Kasa,Bhangadara,Durnama(Arsas),Kustha,Gulma,Ga laganda,Brama,udara,Vidaha,Pleeha,Meha,Yakshma,Akshivikara,Vataroga,Adhmana, Mutrakruchra,Ashmari,prustaprasvaruja,Jangaudararuja,Jaganaruja,Ururuja, It also alleviates Palithya. 1 Modaka prepared of 1karsha pramana should be taken in the early morning as per the classics . Along with the seetha jala it is taken. Here in the present study depending upon the agni,bala &kostha of the patient each Modaka measuring of 255mgms each is given along with seetha jala as anupana. Virechana kalpa according to Sharangadhara. 62 Kalpana Heena for Mridu Koshta Madhyama for Madhyama Koshta Uttama for Krura Koshta Modaka 4 tolas 2 tolas 1 tola “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 128. DRUG REVIEW 108    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. Table no:48: RASAPANCAKA OF ABHYADIMODAKA sl n o Drug name Latin name Rasa Guna Viry a Vipaka Doshagnata Karma 1. Abhay a Terminalia chebula Amlavarjita Pancarasa Laghu, Ruksha Ushn a Madhu ra Tridoshahar a Anulomana, Rasayana ,caksusya 2. Marica Piper nigrum Katu Guru, Ruksha , Tiksna Ushn a Ushna Kaphavataha ra Pramathi 3. Sunthi Zingiber officinale Katu Guru, Ruksha , Tiksna Ushn a Madhu ra Vata kaphahara Bhedana, Deepana 4. Vidang a Embelia ribes Katu, Kasaya Laghu, Ruksa, Tiksna Ushn a Katu Vata kaphahara Vishgna , Krimgna, Dipana 5. Amala ki Embilica officinalis Lavanavarji ta pancarasa Guru, Ruksha , sita Sita Madhu ra Tridoshahar a Vayasstapa na, rasayana, caksusya ,vrsya. 6. Pippali Piper longum Katu Laghu, Ushn a Madhu ra Vatakaphaha ra Dipana, Snigdh a, tiksna Vrsya, Rasayana 7. Mustak a Cypreus rotundus Tikta, Laghu, sita Katu Kapha pittahara Dipana , Katu, Ruksha Pacana, Kashaya Grahi, Lekhana 8. Danti Baliposperm um montanum Katu Guru , Ushn a Katu Kapha vatahara Rechana, Tiksna Dipana 9. Trivrt Operculina turpethum Tikta, Laghu, Ushn a Katu Kapha pittahara Rechana Katu Ruksa, Tiksna “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 129.                                                                                      METHODOLOGY 109  CLINICAL STUDY AIMS AND OBJECTIVES To evaluate the effect of Virechana karma in patients suffering from psoriasis. MATERIAL AND METHODS A. Selection of Patients • It is Single blind clinical study with 20 patients having the sign & symptoms of Psoriasis were selected • Patients were selected randomly irrespective of sex from O.P.D. & I.P.D. sections of Panchakarma department, S.D.M. Ayurveda Hospital, Kuthpady, Udupi. ` B. Criteria for Diagnosis • The patients were diagnosed on the basis of signs and symptoms of Psoriasis. • A specific proforma was prepared and the patients of the present study were examined in detail as per proforma. • Routine haematological investigations were carried out before treatment to rule out the other associated pathology. • In all cases PASI Scoring was applied and recorded the scoring before Snehapaana, After Sneha pan, After Virechana and after follow up period (15 Days). INCLUSIVE CRITERIA 1) Patients with signs and symptoms of psoriasis. 2) Patients of either sex of age group between 15 to 70 years. EXCLUSIVE CRITERIA 1) Patients suffering from Diabetes mellitus, Hypertension, Hridroga and other Systemic diseases. 2) Patients who are anarha for virechana karma. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 130.                                                                                      METHODOLOGY 110  INTERVENTION: POORVAKARMA 1. Deepana – Pachana : Chitrakadivati 1 tid with sukhoshna jala was administered to patients depending on their status of Agni in terms of Sama and Niramata for 3-7 Days till Nirama Lakshanas are seen. 2. Snehana : The Mahatikthaka gritha was given to all the 20 patients. The initial dose was 25ml (Hrisiyasi matra) with Luke warm water in early morning, after the digestion of the last night meal. During this period the patients were advised to consume little quantity of hot water in between and to follow all the restriction of Snehapaana in terms of diet (Time of food intake, Nature of food) , Sleep (Avoid Divasvapna & Rathri jagaran) etc. Thus Aroohanakarma Snehapana was administered still samyak snigdha lakshana arises in all the patients. Then patient was continuously observed for appearance of Sneha Jeeryamana, Sneha Jeerna features. Based on the time of Snehajeerna lakshana the dose of Sneha for next day was decided. As soon as Samyak Snigdha Lakshana are seen, the Sneha pana was stopped. 3. Swedana : Once samyak snigdha lakshana appears then, from next day Sarvanga Abhangya with Karanja Taila followed by Sarvanga Parisheka with Sidarthakasnana choornaKashaya was performed. Thus Bhaya Snehana and Swedana was performed for 4 days and during this period patient was advised to avoid consumption of Kaphakara Ahara and Vihara. PRADHANA KARMA On the 4th day depending upon the rogi & roga bala Virechana Yoga Abhyadimodaka dose was decided. After the Parisheka procedure, ascertain the patient for proper digestion of previous night meal. Then above mentioned Virechana yoga with sufficient quantity of Sheeta jala as Anupana was administered to patient on empty stomach in the morning hours in between 9.30 AM – 10.00 PM. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 131.                                                                                      METHODOLOGY 111  Before & after virechana karma, vitals like Temperature, Pulse, Respiratory rate, B.P were recorded & careful monitor of the patients during virechana process was done. Then Patient was advised all the restriction and regulation on the day of Virechana karma. Finally Shuddhi lakshana in terms of Laingiki, Vaigiki, Antiki, and Maniki were assessed. PASCHAT KARMA The Virechana was executed successfully in all the patients for deciding the Shuddhi, Laingiki, Vaigiki Antiki and Manaki parameters were considered. After the successful completion of Virechana, the patients were asked to follow all the precautions related to Virechana. Then Samsarjana Karma was decided on the basis of Shuddhi lakshana and it was started from the same day evening still for 3/5/7 days. ASSESSMENT CRITERIA Sign and Symptoms of Samyak and Asamyak Virechana. Patients will be evaluated for severity of illness during and after the intervention. Subjective Parameters Symptoms of Psoriasis. Among all the clinical features of Psoriasis the itching ( important symptom) was specially identified as subjective criteria. Symptoms of Samyak and Asamyak Virechana Laxanas i.e. Laingiki and Antaki. Laingiki features All the Laingiki features were identified as immediate and remote features on the basis of their time of appearance during and after the Virechana karma. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 132.                                                                                      METHODOLOGY 112  Sl. Immediate features Late Manifestation 1 KaleVegapravarthnam Indriya prasada 2 Daurbalya Agnivrudhi 3 Karshyata Anamayatva 4 Vatanulomana Srotodushti 5 Vit,Pitta, kapha, vata kramashanissarana - Antaki feature:- Antaki feature was identified at the end of Virechana karma based on the colour, consistence etc. parameters of Stool and finally depending on observation it was documented as Pittant / Kaphanta/ Aoushadhanta/ Malanta/ Vatanta. Objective Parameters:- 1.Signs of Samyak and Asamyak Virechana Laxanas i.e.vaigaki and Maanaki. 1. Vaigiki feature It is nothing but total number of motion passed by patient after administration of Virechana medicine still the cessation of Vega. In the all cases first one Vega was left for counting and from second Vega the actual counting of Vega done still the end of (stoppage) of Vega. Thus finally total number of Vega was documented as Vaigiki feature of present study. 2. Maanaki feature In present study during the each time of defecation the stool and urine was collected and then it was measured and documented separately. Thus it was performed after each Vega except first Vega . Then finally the value of total quantity of stool and urine added to obtain total amount of output. Apart from this total amount of water consumed(Anupana) by patient after passing each Vega was documented and it was consider as total amount of input. Afterwards difference between total amount of output and input was calculated and documented as Manaki feature in terms of millilitres. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 133.                                                                                      METHODOLOGY 113  3. Auspitz Sign. Psoriatic lesion which has well covered scales was selected and then slowly scales were removed with the help of finger or plane dissecting forceps. Afterwards observe the underlying surface. It was found that reddish discoloration of underlying surface associated with minute vasodilatations of superficial blood vessels and it was considered as positive tests of Auspitz sign. 4. Candle Grease Test. The psoriatic lesions were scratched with the point of a dissecting forceps and observe for formation of a candle-grease like appearance on lesion. If it present then it was documented as positive otherwise as negative. 5. PASI (Psoriasis Area and Severity Index) To understand overall effect of Virechana karma on Psoriasis, the Psoriasis area and severity index (P.A.S.I) scoring method was also adopted as follows. For the PASI, the body is divided into four sections each of these areas is scored by Skin 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: stomach, chest, back, etc.) at 30%; the Arms (20%); and the Head (10%). Area: For each Skin Section, measured the amount of skin involve, as a percentage of the skin just at that part of the body (not the whole body - see below), and then assign it a score from 0 to 6: Showing PSAI Coverage area score Coverage Score 0% 0 < 10% 1 10-29% 2 30-49% 3 50-69% 4 70-89% 5 90-100% 6 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 134.                                                                                      METHODOLOGY 114  Severity: The severity is measured by four different parameters: Itching, Erythema (redness), Scaling and Thickness (psoriatic skin is thicker than normal skin). 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', according to the following chart: Severity Score None 0 Some 1 Moderate 2 Severe 3 Maximum 4 Totaling Up the Index: When all 20 of the above scores are figured out, then it is ready to calculate PASI. 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 skin in that section, as follows: • Head : (Ihead+Ehead+Shead+Thead) x Ahead x 0.1 = Totalhead • Arms : (Iarms+Earms+Sarms+Tarms) x Aarms x 0.2 = Totalarms • Body : (Ibody+Ebody+Sbody+Tbody) x Abody x 0.3 = Totalbody • Legs : (Ilegs+Elegs+Slegs+Tlegs) x Alegs x 0.4 = Totallegs Finally, the PASI is Totalhead+Totalarms+Totalbody+Totallegs. This PASI will range from 0 (no psoriasis) to 96 (covered head-to-toe, with complete itching, redness, scaling, and thickness). Thus P.A.S.I. was calculated. Investigations:- To evaluate other pathologies and to avoid possible complications during Virechana the following laboratory investigations are carried out. 1) Hb, TC, DC, ESR, Blood Sugar 2) ECG, Skin Biopsy (if needed). DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 135. OBSERVATIONS 115  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” OBSERVATIONS • Number of patients registered in study - 20 • Number of patients completed the study - 20 AGE-WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 49 Age Figure No. 01 4 7 5 2 2 0 1 2 3 4 5 6 7 26- 35 35- 45 46- 55 56- 65 66- 75 AGE Age in year Number of patients % 25-35 04 20 36-45 07 35 46-55 05 25 56-65 02 10 66-75 02 10 The minimum age of the patient of this study was 25years & maximum was 73 years. Table shows that nature of distribution of patients in every 9-years age group. The maximum percentage of patients i.e. (35%) was between 36-45 age groups and minimum 04% was between 56- 65,66-75 age groups. SEX-WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 50 Sex Figure No. 02 95 5 0 20 40 60 80 100 19 1 SEX Sex No of patients % Male 19 95 Female 01 According to sex wise distribution of the patients showed that maximum number i.e. 95% of the patients was male and 5 % were female. 5
  • 136. OBSERVATIONS 116  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” RELIGION-WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 51Religion Figure No. 03 85 10 2 0 10 20 30 40 50 60 70 80 90 17 2 1 RELIGION Religion No of % patients Hindu 17 85 Muslim 02 10 Christian 01 05 Among 20 patients of these series maximum patients 85% were belonged to the Hindu community, whereas 10% was belonged to Muslim &5% Christian community MARITAL STATUS WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 52 Marital Status Figure No. 04 95 5 0 20 40 60 80 100 19 1 MARITAL STATUS Marital status No of patients % Married 19 95 Unmarried 01 Among the 20 patients of Psoriasis taken for this study, a maximum of 95% patients were married where as 05% patients are unmarried. 05
  • 137. OBSERVATIONS 117  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” LITERACY WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 53 Literacy incidences Figure No. 05 10 10 65 15 0 10 20 30 40 50 60 70 2 2 13 3 LITERACY Education No of patients % Uneducated 02 10 Secondary- School 02 10 Graduation 13 65 Primary 03 15 Among all the 20 patients taken for this study, the maximum 65% of patients had studied up to graduation; where as 13% of patients had studied up to the level of primary education and 10% had studied up to the level of secondary school and 10% were uneducated. SITE OF ONSET WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 54 Site of Onset Figure No. 06 No of patients 50 5 40 10 0 5 10 15 20 25 30 35 40 45 50 10 1 8 2 ONSET Site of Onset % Head /Scalp 5010 Upper Limb 0501 Lower Limb 4008 Trunk 02 Out of all 20 patients maximum about 50% of patients had history of site of onset of Psoriatic lesion on Scalp where as on Trunk only 10%. 10
  • 138. OBSERVATIONS 118  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” SEASONAL IMPACT WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 55 Seasonal Impacts Figure No. 07 55 30 15 5 0 10 20 30 40 50 60 11 6 3 1 SEASO NAL Out of all 20 patients maximum about 55% of patients had history of exacerbation of Psoriatic lesion during winter season where as minimum of 05% of patients had nothing seasonal impact. Season No of patients % Winter 11 55 Rainy 06 30 Summer 03 15 No Season impact 01 05 ADDICTION WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 56 Addictions Figure No. 08 40 5 40 15 0 5 10 15 20 25 30 35 40 3 8 1 8 ADDICTAION Among 20 patients maximum about 40% of patients had no history of any type of addictions but 15% of patients had history of Alcohol imbibing & Tobacco smoking. Habit No of Patients % Alcohol & Tobacco Smoking 3 15 Alcohol 08 40 Tobacco Smoking 01 05 None 08 40
  • 139. OBSERVATIONS 119  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” DIET WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 57 Diet wise Figure No. 09 70 30 0 20 40 60 80 14 6 DIET Diet No of patients % 14 70Mixed Vegetarian 06 30 Among 20 patients maximum percentage of patients belonged to mixed diet (Vegetarian & Non-vegetarian) i.e. 70% and remains 30% are Vegetarian. FAMILY HISTORY WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No:58 Family History Figure No. 10 % 35 65 0 10 20 30 40 50 60 70 7 13 FAMILY HISTORY Family History No of patients Positive 07 35 Negative 13 65 Among 20 patients, 65% of patients had negative history of Psoriasis and only 35% of patients were with positive history.
  • 140. OBSERVATIONS 120  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” PRAKRUTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No : 59 Prakruti Figure No. 11 25 10 65 0 10 20 30 40 50 60 70 5 2 13 PRAKR UTI Prakruti No of patients % 05 25Vata-Pitta 02 10Kapha-Pitta Kapha-Vata 13 65 Among 20 patients, 65% of patients were Kapha-Vata and 25% of patients were with Vata-Pitta and 10% were with Kapha-Pitta Prakruti. DESHA WISE DISTRIBUTION OF 20PATIENTS OF PSORIASIS Table No: 60 Desha Figure No. 12 75 10 15 0 10 20 30 40 50 60 70 80 15 2 3 DESHA Desha No of patients % Anupa 15 75 Sadharana 02 10 Jangala 03 15 Out of 20 patients in maximum number of patients i.e. 75% of Anoopa Desha where as minimum 10% of patients belongs to Sadarana Desha.
  • 141. OBSERVATIONS 121  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF TYPE OF KOSHTA IN 20 PATIENTS OF PSORIASIS Table No: 61 Type of Koshta Figure No. 13 25 50 25 0 10 20 30 40 50 5 10 5 type of koshta No of patientsKoshta % Mrudu 05 25 Madyama 10 50 Krura Out of all 20 patients maximum about 50% of patients were belongs to Madhyama Koshta where as minimum of 25% of patients belongs to Mrudu and krura Koshta. SATVA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 62 Satva Figure No. 14 10 85 5 0 10 20 30 40 50 60 70 80 90 2 17 1 satva Out of 20 patients in maximum number of patients i.e. 85% of Madhyama satva where as minimum 05% of patients belongs to pravara satva . 05 25 Satva No of patients % Avara 02 10 Madhyama 17 85 Pravara 01 05
  • 142. OBSERVATIONS 122  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” SATMYA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 63 Satmva Figure No. 15 10 50 40 0 5 10 15 20 25 30 35 40 45 50 2 10 8 satmya Satmya No of patients % Avara 02 10 Madhyama 10 50 Pravara 08 Out of 20 patients in maximum number of patients i.e. 50% of Madhyama satmva where as minimum 10% of patients belongs to Avara satmva . SAMHANANA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 64 Samhanana Figure No. 16 25 65 10 0 10 20 30 40 50 60 70 5 13 2 samhana na Out of 20 patients in maximum number of patients i.e. 65% of Madhyama samhanana where as minimum 25% of patients belongs to Avara samhanana. 40 Satmya No of patients % Avara 05 25 Madhyama 13 65 Pravara 02 10
  • 143. OBSERVATIONS 123  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” SARA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 65 Sara Figure No. 17 5 30 70 25 35 0 0 0 10 20 30 40 50 60 70 twak 1 mamsa 14 asti 7 shukra 0 sara Sara Number of patients % Twak 01 05 Rakta 06 30 Mamsa 14 70 Meda 05 25 Asti 07 35 Majja 00 00 Maximum number of patients i.e 70% of them belonged to mamsa sara ,35% belonged to asti sara, 30% belonged to rakta ,25% belonged to meda,5% belonged twak sara . AHARA ABHYAVARANA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 66 Ahara abyavarana shakti Figure No. 18 5 70 25 0 10 20 30 40 50 60 70 1 14 5 AAS Out of 20 patients in maximum number of patients i.e. 70% of Madhyama Aharaabyavarana shakti where as minimum 05% of patients belongs to Avara Aharaabyavarana shakti. Shukra 00 00 Satmya No of patients % Avara 01 05 Madhyama 14 70 Pravara 05 25
  • 144. OBSERVATIONS 124  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” AHARA JARANA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 67 Ahara jarana shakti Figure No. 19 5 75 20 0 10 20 30 40 50 60 70 80 1 15 4 AJS Satmya No of patients % Avara 01 05 Madhyama 15 75 Pravara 04 20 Out of 20 patients in maximum number of patients i.e. 75% of Madhyama Ahara jarana shakti where as minimum 05% of patients belongs to Avara Ahara jarna shakti. Distribution of 20 patients of Psoriasis according to pachakaagni Table No: 68 Figure No. 20 15 45 30 10 0 5 10 15 20 25 30 35 40 45 v3 t9 m6 s2 agni Among 20 patients, 45% of patients have Teekshnagni,30%have Mandagni,15% have vishamagni,10%have samagni. Agni Number of % Patients Vishama 03 15% Teekshna 09 45% Manda 06 30% Sama 02 10%
  • 145. OBSERVATIONS 125  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” VYAYAMA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 69 Vyama shakti Figure No. 21 5 80 15 0 10 20 30 40 50 60 70 80 1 16 3 vyama shakti Out of 20 patients in maximum number of patients i.e. 80% of Madhyama Vyama shakti where as minimum 05% of patients belongs to Avara Vyama shakti. VAYA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Vyama shakti No of patients % Avara 01 05 Madhyama 16 80 Table No: 70 Vaya Figure No. 22 0 75 25 0 10 20 30 40 50 60 70 80 0 15 5 vaya Out of 20 patients in maximum number of patients i.e. 75% of Madhya Vaya where as minimum 25% of patients belongs to vrudha . Pravara 03 15 Vaya No of patients % Bala 00 00 Madhya 15 75 Vrudha 05 25
  • 146. OBSERVATIONS 126  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” DEHA BALA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 71 Deha bala Figure No. 23 20 70 10 0 10 20 30 40 50 60 70 4 14 2 Deha bala Deha bala No of patients % Avara 04 20 Madhyama 14 70 pravara 02 10 Out of 20 patients in maximum number of patients i.e. 70% of Madhyama dehabala where as minimum 10% of patients belongs to pravara Dehabala . ANALYSIS OF CANDLE GREASE SIGN IN 20 PATIENTS OF PSORIASIS Table No:72. Candle Grease Sign Figure No. 24 85 15 0 20 40 60 80 100 17 3 CANDLE GREASE SIGN Among all patients the maximum percentage of patients shows Candle Grease Sign positive i.e. 85% where as in only 15% of patient this test was negative. Candle Grease Sign No of patients % Positive 17 85 15Negative 03
  • 147. OBSERVATIONS 127  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF AUSPITZ SIGN IN 20 PATIENTS OF PSORIASIS Table No: 73 Auspitz Sign Figure No. 25 85 15 0 20 40 60 80 100 17 3 AUSPITZ SIGN Among all patients the maximum percentage of patients shows Auspitz Sign positive i.e. 85% where as in only 15% of patient this test was negative. ANALYSIS OF NAIL INVOLVEMENT IN 20 PATIENTS OF PSORIASIS Table No: 74. Involvements of Nails Figure No. 26 Auspitz Sign No of patients % Positive 17 85 1503Negative 80 20 0 10 20 30 40 50 60 70 80 16 4 NAIL INVOLVEMENT Involvement of Nails No of patients % Positive 16 80 Negative 04 20 Out of 20 patients, in maximum patients i.e. 80% their was absence of Psoriatic nail changes where as in remaining 20% of patient’s presence of Psoriatic nail changes.
  • 148. OBSERVATIONS 128  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF SCALING IN 20 PATIENTS OF PSORIASIS Table No: 75 Scaling Figure No. 27 100 0 0 20 40 60 80 100 20 0 SCALING No of patients % SCALING Positive 20 100 Negative 0000 All the 20 patients registered to this study were associated with scaling. ANALYSIS OF THICKNESS OF SKIN LESION IN 20 PATIENTS OF PSORIASIS Table No: 76 Thickness Figure No:28 Among the 20 patients registered to this study 90% were associated with more or less thickness of skin and remain 10% their was no thickness. THICKNESS No of patients % Positive 18 90 90 10 0 10 20 30 40 50 60 70 80 90 18 2 THICKNESS 02 10Negative
  • 149. OBSERVATIONS 129  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF ITCHING OF SKIN LESIONS IN 20 PATIENTS OF PSORIASIS Table No: 77 Itching Figure No. 29 96 5 0 10 20 30 40 50 60 70 80 90 100 19 1 ITCHING Among the 20 patients registered to this study 95% were associated with more or less itching of skin and remain 05% their was no itching. ITCHING No of patients % Positive 19 95 Negative 01 05 ANALYSIS OF DISCHARGE IN 20 PATIENTS OF PSORIASIS Table No: 78 Discharge Figure No. 30 80 20 0 10 20 30 40 50 60 70 80 16 4 DISCHARG No of patientsDISCHARGE % 16 80Positive Negative Out of all 20 patients maximum about 80% of patients had history of discharge where as minimum of 20% of patients didn’t have discharge. 04 20
  • 150. OBSERVATIONS 130  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF TYPE OF KUSHTA IN 20 PATIENTS OF PSORIASIS Table No:79 Type of Kushtha Figure No. 31 70 25 10 10 5 0 10 20 30 40 50 60 70 14 5 2 2 1 TYPE OF KUSHTA Type of Kushtha No of patients % Kitibha 14 70 Ekakushta 05 25 Sidma 02 10 Mandala 02 10 Charmadala 01 05 Out of all 20 patients maximum about 70% of patients were belongs to Kitibha type of Kushta where as minimum of 05% of patients belongs to Charmadala type of Kushta.
  • 151. OBSERVATIONS 131  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” ANALYSIS OF VIRECHANA Distribution of patients according to days of appearance of samyak snigdha lakshana Table No: 80 Figure No. 32 45 30 10 10 5 0 10 20 30 40 50 3 4 5 6 7 DAYS Days Number of patients % 3 09 45 4 06 30 5 02 10 6 02 10 About 45% of the patients developed samyak snigdha lakshana on 3rd day & 30% were on 4th day itself. But only two patients developed samyak snigdha lakshana on 5th day and 6th day and 1 patient on 7th day. 7 01 05
  • 152. OBSERVATIONS 132  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Total amount of abyantara sneha during the whole course of snehapana in 20 patients of psoriasis Table No: 81 Figure No. 33 16 35 30 15 5 0 5 5 0 0 5 0 5 10 15 20 25 30 35 7 6 3 1 0 1 1 0 0 1 MAX.DOS Dose (In ml) No. of patients % 100-200 07 35 200-300 06 30 300-400 03 15 400-500 01 05 500-600 00 00 600-700 01 05 700-800 01 05 800-900 00 00 900-1000 00 00 Maximum 35% of the patients had consumed total amount of sneha in between 100-200 ml. where as minimum of only 05% of patient consumed between 1000-1100 ml. 1000- 1100 01 05
  • 153. OBSERVATIONS 133  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Analysis of samyak snigdha lakshana Table No: 82 Figure No.34 80 90 95 85 80 90 40 20 0 10 20 30 40 50 60 70 80 90 100 16 18 19 17 16 18 8 4 Laxshana Lakshana Number of Patients % Adhastat snehadarsana 16 80% Twaksnigdata 18 90% Gatramardava 19 95% Snehodvega 17 85% Klama 16 80% Vatanulomana 18 90% Angalagava 08 40% Shaitya 04 Among 20 patients, 90% of patients had Vatanulomana feature where as minimum 20% of patients had Shaitya feature. Analysis of samyak Swinna lakshana Table No: 83 Figure No. 35 0 20 30 40 80 100 0 10 20 30 40 50 60 70 80 90 100 0 4 6 8 16 20 LAXSHANA 20% Swinna Laxshana Number of Patients % Sheeta Viparame 00 00 Shula Viparame 04 20 Stambha 06 30 nigraha Among 20 patients, about 80%patients had tvak mardavata feature where as only 30% of patients had Stambha feature. Gourava nigraha 08 40 Mardavata 16 80 Sweda Pradurbhav 20 100
  • 154. OBSERVATIONS 134  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Analysis of latency period Table No: 84 Figure No. 36 25 40 10 15 10 0 5 10 15 20 25 30 35 40 5 8 2 3 2 LATENCY PERIOD Time required manifesting first Virechana Vega after administration of Virechana drug is known as Latency period. In present study, Out of 20 patient’s maximum number of patients i.e. 40% the latency period was between 31-60 minute range, where as in minimum of 10% of patients latency period was between 121-150 minute range. Time In Latency period % minutes 1-30 05 25% 31-60 08 40% 61-90 02 10% 91-120 03 15% 121-150 Analysis of Duration of Virechana Table No: 85 Figure No. 37 10 10 30 30 10 5 5 0 5 10 15 20 25 30 2 2 6 6 2 1 1 DURATION Out of 20 patients, in maximum number of patients i.e. 30% the duration of onset & stoppage of Virechana was between 6 - 8 hours (361-480) minute and 8-10hours(481- 600). 02 10% Duration of Virechana (min.) Number of patients % 120-240 02 10% 241-360 02 10% 361-480 06 30% 481-600 06 30% 601-720 02 10% 721-840 01 05% 841-960 01 05%
  • 155. OBSERVATIONS 135  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Analysis of Vaigiki Shuddhi Table no: 86 Figure No. 38 15 40 45 0 5 10 15 20 25 30 35 40 45 3 8 9 VAIGIKI Out of 20 patient’s, in maximum number of patients i.e.45% Avara Shuddi was found and minimum of 03% of the patients exhibited with Pravara Shuddi. Vaigiki Shuddhi Number of Patient % Pravara 03 (21-30) 15% Madhyama 08 (11-20) 40% Avara (1-10) Analysis of Manaki of Virechana Table No: 87 Figure No. 39 09 45% Manaki In ml 5 5 25 45 0 5 15 4 0 5 10 15 20 25 30 35 40 45 1 1 5 9 0 1 3 1 DOS E Numb er of patien ts % 0-1000 01 05% 1001-2000 01 05% 2001-3000 05 25% 3001-4000 09 45% 40001-5000 00 00% 5001- 6000 01 05% 6001-7000 3 Out 20 patients,In maximum number of patient it in ranges between 3001- 4000 ml and in one patient it was above 6000 ml. 15%
  • 156. OBSERVATIONS 136  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Analysis of Anthiki of Virechana Table No: 88 Figure No. 40 60 15 10 15 0 10 20 30 40 50 60 12 3 2 3 ANTHAKI Anthiki Number of Patient % Kaphanta 12 60% Pittanta 03 15% Drava 02 10% malanta Aushdhan -ta 03 In maximum number of patient i.e. 60% exhibited Kaphant virechana & minimum of 15 % with the Pittanta and ausdhanta virechana. 15%
  • 157. OBSERVATIONS 137  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” Analysis of Laingiki Lakshana of Virechana Table no:89 Figure No. 41 100 90 90 90 80 70 70 35 0 10 20 30 40 50 60 70 80 90 100 20 18 18 18 16 14 14 7 LAINGIKI Number of Patients %Laingiki Lakshana Laghuta 20 100 Agnivrddhi 18 90% Vatanulomana 18 90% Kramat Vit, 18 90% Pitta Kaphagamana Dourbalya 16 80% Karsyata 14 70% Kshut 14 70% Trishna 07 35% Durably a Laingiki features are observed in maximum number of patients, other information shown in above table.
  • 158. RESULTS 138  RESULTS HEAD 1] ITCHING Table No: 90 Mean Paired t test n BT AT D % SD SEM t P 20 2.850 1.100 1.750 61.41% 0.550 0.123 14.226 <0.001 Figure No. 42 1.1 2.85 0 0.5 1 1.5 2 2.5 3 BT AT ITCHING The mean score of itching over the head prior to treatment was 2.850 units. It reduced to 1.100 units after treatment. The change that occurred with the treatment is not great enough to exclude the possibility that the difference is due to chance. 2] ERYTHEMA Table No: 91 Mean Paired t test n BT AT D % SD SEM t P 20 1.800 0.750 1.050 58.34% 0.686 0.153 6.842 <0.001 Figure No.4 3 0.75 1.85 0 0.5 1 1.5 2 BT AT ERYTHEMA The mean score of erythema over the head prior to treatment was 1.850 units but after treatment it was reduced to 0.750 units. The change that occurred with the treatment is not great enough to exclude the possibility that the difference is due to chance. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 159. RESULTS 139  3] SCALING Table No: 92 Mean Paired t test n BT AT D % SD SEM t P 20 2.250 1.100 1.150 51.12% 0.671 0.150 7.667 <0.001 Figure No. 44 1.1 2.25 0 0.5 1 1.5 2 2.5 BT AT SCALING s The mean score of Scaling over the head prior to treatment was 2.250 units but after treatment it was reduced to 1.100 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. 4] THICKNESS Table No: 93 Mean Paired t test n BT AT D % SD SEM t P 20 1.550 0.500 1.050 67.74% 0.945 0.211 4.972 <0.001 Figure No. 45 0.5 1.55 0 0.5 1 1.5 2 BT AT THICKNESS The mean score of thickness over the head prior to treatment was 1.550 units but after treatment it was reduced to 0.500 units. The change that occurred with the treatment is not great enough to exclude the possibility that the difference is due to chance. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 160. RESULTS 140  TRUNK 1] ITCHING Table No:94 Mean Paired t test n BT AT D % SD SEM t P 20 3.150 1.350 1.800 57.15% 0.768 0.172 10.485 <0.001 Figure No. 46 1.35 3.15 0 1 2 3 4 BT AT ITCHING The mean score of itching over the trunk prior to treatment was 3.150 units but after treatment it was reduced to 1.350 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. 2] ERYTHEMA Table No: 95 Mean Paired t test N BT AT D % SD SEM t P 20 2.700 1.400 1.300 48.14% 0.979 0.979 5.940 <0.001 Figure No.47 1.4 2.7 0 0.5 1 1.5 2 2.5 3 BT AT ERYTHEMA The mean score of erythema over the trunk prior to treatment was 2.700 units but after treatment it was reduced to 1.400 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 161. RESULTS 141  3] SCALING Table No:96 Mean Paired t test n BT AT D % SD SEM t P 20 2.950 1.700 1.250 42.37% 1.118 0.250 5.000 <0.001 Figure No.48 1.7 2.95 0 1 2 3 4 BT AT SCALING The mean score of Scaling over the trunk prior to treatment was 2.950 units but after treatment it was reduced to 1.700 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change 4] THICKNESS Table No:97 Mean Paired t test n BT AT D % SD SEM t P 20 2.600 1.350 1.250 48.07% 0.716 0.160 7.804 <0.001 Figure No. 49 1.35 2.6 0 0.5 1 1.5 2 2.5 3 BT AT THICKNESS The mean score of thickness over the trunk prior to treatment was 2.600units but after treatment it was reduced to 1.350 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 162. RESULTS 142  UPPER LIMB 1] ITCHING Table No:98 Mean Paired t test n BT AT D % SD (+) SE (+) t P 20 3.300 1.550 1.750 53.03% 0.910 0.204 8.596 <0.001 Figure No. 50 1.55 3.3 0 1 2 3 4 BT AT ITCHING The mean score of itching over the upper limbs prior to treatment was 3.300 units but after treatment it was reduced to 1.550 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. 2] ERYTHEMA Table No :99 Mean Paired t test n BT AT D % SDM SEM t P 20 3.150 1.700 1.450 46.03% 0.759 0.170 8.542 <0.001 Figure No. 51 1.7 3.15 0 1 2 3 4 BT AT ERYTHEMA The mean score of erythema over the upper limbs prior to treatment was 3.150 units but after treatment it was reduced to 1.700 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 163. RESULTS 143  3] SCALING Table No:100 Mean Paired t test n BT AT D % SD SEM t P 20 2.850 1.600 1.250 43.85% 0.851 0.190 6.571 <0.001 Figure No.52 1.6 2.85 0 0.5 1 1.5 2 2.5 3 BT AT SCALING The mean score of Scaling over the upper limbs prior to treatment was 2.850 units but after treatment it was reduced to 1.600 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change 4] THICKNESS Table No :101 Mean Paired t test n BT AT D % SD SEM t P 20 2.600 1.200 1.400 51.92% 0.995 0.222 6.294 <0.001 Figure No. 53 1.2 2.6 0 0.5 1 1.5 2 2.5 3 BT AT THICKNESS The mean score of thickness of skin over the upper limbs prior to treatment was 2.600 units but after treatment it was reduced to 1.200 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 164. RESULTS 144  LOWER LIMB 1] ITCHING Table No:102 Mean Paired t test n BT AT D % SD SEM t P 20 3.650 1.650 2.000 54.79% 0.725 0.162 11.831 <0.001 Figure No. 54 1.65 3.65 0 1 2 3 4 BT AT ITCHING The mean score of Itching over the lower limbs prior to treatment was 3.650 units but after treatment it was reduced to 1.650 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change 2] ERYTHEMA Table No: 103 Mean Paired t test n BT AT D % SD SEM t P 20 3.500 1.800 1.700 48.57% 0.733 0.164 10.376 <0.001 Figure No. 55 1.8 3.5 0 1 2 3 4 BT AT ERYTHEMA The mean score of Erythem over the lower limbs prior to treatment was 3.500 units but after treatment it was reduced to 1.800 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 165. RESULTS 145  3] SCALING Table No:104 Mean Paired t test n BT AT D % SD SEM t P 20 3.500 1.800 1.700 48.57% 0.865 0.193 8.794 <0.001 Figure No. 56 1.8 3.5 0 1 2 3 4 BT AT SCALING The mean score of Scaling over the lower limbs prior to treatment was 3.500 units but after treatment it was reduced to 1.800 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change. 4] THICKNESS Table No:105 Mean Paired t test n BT AT D % SD SEM t P 20 3.150 1.750 1.400 44.44% 0.598 0.134 10.466 <0.001 Figure No.57 1.4 3.15 0 1 2 3 4 BT AT THICKNESS The mean score of thickness of Skin over the upper limbs prior to treatment was 3.150 units but after treatment it was reduced to 1.750 units. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 166. RESULTS 146  Changes occurred in P.A.S.I. score before and after the Virechana Krama Table No: 106 Mean Paired t test n BT AT D % SD SEM t P 20 12.235 6.235 6.000 49.03% 2.228 0.498 12.042 <0.001 Figure No. 58 6.235 12.235 0 5 10 15 BT AT PASI The mean P.A.S.I. Score prior to treatment was 12.235 units. It reduced to 6.235 units after treatment. The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change . DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 167. DISCUSSION 147                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” DISCUSSION Psoriasis is a major problem among the society till today because of its ugly appearance which may disturb personal, familiar and social life of the patient. Psoriasis can be very persistent complaint. It does not kill but it is responsible for great deal of unhappiness, feeling of depression at some point. Psychological problems can arise from the feelings of the patients about his/her appearance, social rejection, guilt, embarrassment for self and family, and emptiness. Research studies have shown that psychological stress is often caused by psoriasis, and can be a factor in ‘flares’ of psoriasis. In Ayurveda, almost all the disorder of the skin describing in the current science of dermatology can be taken under generalized term “Kushtha”. Previous research scholars of Ayurveda have tried to correlate it with Ekakushtha, Kitibha and Sidhma. But typically, people suffered from only one type of psoriasis at a time, but occasionally two or more different types of psoriasis can occur at the same time. However Psoriasis can also occasionally change from one variety to another. Depending on the expose of Psoriasis patient to different triggering factors, the existence forms of psoriasis may be get converted to another variety or form. Generally one type of psoriasis will vanishes and later another form of psoriasis will manifest. Thus as the clinical presentation of Psoriasis varies, similarly Ayurvedic approach towards diagnosis of Kushta also differs. So it is very difficult to say that Psoriasis is equal to either Kitibha or Ekakushta or Sidhma etc. variety of Kushta or in other words to say as depending on the different presentation of Psoriasis, one should diagnose the variety of Kushta . Moreover in Ayurveda the understanding of involvement of predominant Dosha, Dhatu, Mala. Srotas etc. Samprapti ghatak in disease have their own importance for proper planning of the line of medicine or line of treatment rather to correlate it with current Science of medicine. Hence by keeping all the above said facts in backdrop the present study was planned i.e. Virechana karma to manage the Psoriasis was selected instead of concentrating on any single variety of Kushta. In Ayurveda, the importance of
  • 168. DISCUSSION 148                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Shodhana has been stressed, prior to Shamana line of treatment. Therefore in present study Virechana Karma was selected for Shodhana purpose. In Kushta the Raktha dhatu is consider as one of main dhatu which is responsible for Prasara stage of Kushta Samprapti. As Sharangadhara described regarding the Pitta and Raktha dhatu have Ashreya-ashryi relationship, hence treatment modality of Pittadosha & Raktha dhatu resembling to each other. However among all the types of Swedana Karma, Parisheka is one variety of Swedana which should be used in Vata associated with Pitta disorders. Thus Parisheka is one of the important Bahiparimarjana types of treatment modality identified in the management of Kushta. So in this study Sidartaka snana choorna kashya is used for parisheka . In all the Brhatrayi there is separate section (usually in Kalpasthana) regarding the elaborations of Virechana drugs in terms their classification, Synonyms, Qualities, Purification, different methods of administration etc. was found. But still in Chikitsasthana, while explaining different lines of treatment for different disorders they identified the selection of specific Virechana drug or its preparation, which has definite role in the Sampapti vighatana of particular disease entity. Thus this specific Virechana yoga targeted towards the separation of exact Dosha dushya Sammurchana and helps to expel of morbid Dosha out of the body through anal route. Thus most of the authors highlighted Abhyadi modaka as Virechana yoga in the context of Kushta Chikitsa. Kushta is considering as Santarpanotta Bahudoshaavastha Dhirghakalina mahagada.So it was consider as Kricchrasadhya to treat. Because of this reason repeated administration of all the Panchakarma, different varieties of Shamana Chikitsa & even Agada prayoga in certain stages of Kushta. Virechana is one among the Shodhana line of treatment modality was identified and it should be administered at least once in six months. AGE In this series, maximum number of patients i.e. 35% belonged to age group of 36- 45 yrs, followed by 25 % patients to 46-55yrs. age group, 20% patients belonged to age group of 25-35 yrs. 10% patients to 56-65 yrs & 66-75yrs & 66-75 yrs age groups (Table no49.). Though psoriasis is a disease that manifests in all the age groups, but its peak
  • 169. DISCUSSION 149                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” manifestation occurs during 16-22 years, and the second occurs in persons aged 57-60 years. Onset before age 40 usually indicates a greater genetic susceptibility and a more severe or recurrent course of psoriasis. Psoriasis can occur at any age but due to more stressful life style and dietary disturbances in young age incidence is found more in age group of 31-40 years and moreover disease state may fluctuate with hormonal changes especially during puberty. SEX Sex has no direct relation with psoriasis. It is evident from (Table no50.) that maximum no. of patients. 95% was male and 05 % were female. It is established that Psoriasis affects adult males and females equally. RELIGION Among 20 patients of these series maximum patients 85% were belonged to the Hindu community, whereas remaining 10% were Christian and 10% were belonged to Muslim religion(Table No51.).This may be because of the present study was conduced in Hindu community dominant area. MARITAL STATUS It is clear from (Table no.52) that maximum i.e. 95% of the patients were married, followed by 05% patients were unmarried. EDUCATION In this series, maximum each of 65 % of the patients were Graduates, followed by 15% of primary education and remaining only 10% of the Patients had secondary school education and were uneducated (Table no53.). SITE OF ONSET In present study shows that 50% of patient had history of onset of psoriasis lesion on head / Scalp it was followed by 40% on Lower limbs, 05% on Upper limbs and 10% on Trunk. (Table no54).It shows impact of sun rays as triggering factor for Psoriasis.
  • 170. DISCUSSION 150                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SEASONAL IMPACT In present study 55% of patients had the symptoms aggravation during winter season (Table no55.) where as 30% in rainy season ,15%in summer season. This shows that winter season act as triggering factor for Psoriasis. This fact may be understood by seasonal variations in Doshic status. In winter there is dominancy of Kapha and Vata which causes increase pattern of Vatakapha Pradhana Vyadhi like psoriasis. ADDICTION: In the present study, 40 % patients were addicted to Alcohol and Tobacco chewing/ Smoking while 40% patients were not addicted any type addiction (Table no.56). Alcohol is considered a risk factor for psoriasis, particularly in young to middle- aged males. Cigarette smoking is associated with an increased risk of chronic plaque psoriasis. Alcohol is considered a risk factor for psoriasis, particularly in young to middle-aged males. According to latest research studies shows the smoking is associated with the clinical Severity of psoriasis and thus highlights the importance of smoking & alcohol cessation in patients with psoriasis. DIET Maximum patients 70% of this series were mixed diet and only 30% (Table no 57.) were having the habit of vegetarian. As this study was conducted in costal area, so maximum patient were register to this study were mixed diet. Thus present study shows importance of non-vegetarian as triggering factor for psoriasis. FAMILY HISTORY Positive family history of psoriasis was reported in only 35% patients where as remaining 65% negative history of Psoriasis. Even though Psoriasis has the genetic predisposition, but in present study only 35% cases reported as positive family history, it may be because of small sample study and most of the people know the family history for hardly up to 2 or 3 decades not more than it. (Table no 58.).
  • 171. DISCUSSION 151                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PRAKRUTI In this series, all the patients were having Dvandaja type of Sharirika Prakriti where in 65% patients were of Kapha- Vata Prakriti and 25 % patients were of Vata-Pitta and 10% were of Kapha- Pitta Prakriti . It may be because the study was conducted in Anoopa Desha which was said to be more chances of occurrence of Kapha-Vataja disorder, moreover Kushta is one among the Santarpanotta and kleda pradhana vikara.(Table no 59.) DESHA In present study out of 20 patients register the 75% of patient belongs to Anoopa Desha, 15% of patient of jangala Desha and only 10% of sadarana Desha (Table no 60.). Thus this study shows that Kushta is predominantly manifested in Anoopa Desha. KOSHTA Out of all 20 patients maximum about 50% of patients were belongs to Madhyama Koshta where as minimum of 25% of patients belongs to Mrudu and krura Koshta.(Table no 61) SATVA Out of 20 patients in maximum number of patients i.e. 85% of Madhyama satva where as minimum 05% of patients belongs to pravara satva .(Table no 62.) SATMYA Out of 20 patients in maximum number of patients i.e. 50% of Madhyama satmva where as minimum 10% of patients belongs to Avara satmva (Table no63) SAMHANANA Out of 20 patients in maximum number of patients i.e. 65% of Madhyama samhanana where as minimum 25% of patients belongs to Avara samhanana.(Table no 64)
  • 172. DISCUSSION 152                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SARA Out of 20 patients maximum no of patients i.e 70% of them belonged to mamsa sara ,35% belonged to asti sara, 30%belonged to rakta ,25% belonged to meda,5% belonged twak sara (Table no 65). AHARA ABHYAVARANA SHAKTI Out of 20 patients in maximum number of patients i.e. 70% of Madhyama Aharaabyavarana shakti where as minimum 05% of patients belongs to Avara Aharaabyavarana shakti.(Table no.66) AHARA JARANA SHAKTI Out of 20 patients in maximum number of patients i.e. 75% of Madhyama Ahara jarana shakti where as minimum 05% of patients belongs to Avara Ahara jarna shakti(Table no.67). PACHAKAGNI Among 20 patients, 45% of patients have Teekshnagni,30%have Mandagni,15% have vishamagni,10% have samagni(Table no 68). VYAMA SHAKTI Out of 20 patients in maximum number of patients i.e. 80% of Madhyama Vyama shakti where as minimum 05% of patients belongs to Avara Vyama shakti(Table no 69). VAYA Out of 20 patients in maximum number of patients i.e. 75% of Madhya Vaya where as minimum 25% of patients belongs to vrudha(Table no.70) . DEHABALA Out of 20 patients in maximum number of patients i.e. 70% of Madhyama dehabala where as minimum 10% of patients belongs to pravara Dehabala(Table no.71) .
  • 173. DISCUSSION 153                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” CANDLE GREASE SIGN In present study, 85% of patient shows positive test of Candle grease test where as remaining 15% of patient negative (Table no 72.). This may be evident that Candle grease test is one among the diagnostic criteria for Psoriasis. AUSPITZ SIGN 85% patients of this series reported as positive test of Auspitz sign and only 15% Negative (Table no 73.). Thus Auspitz sign is consider as definitive diagnostic criteria of Psoriasis. INVOLVEMENT OF NAILS Nail changes occur in Psoriasis in terms of onycholysis, Oil drop sign etc. However in present study 80% of patient had involvement of nail associated with Psoriasis but in 20% of patient there is no involvement of nail changes (Table no.74). This shows that Psoriasis can manifest even without nail involvement. SCALING Most common sign of psoriasis reported by the patients of this series was scaling i.e. all the patient had scaling. (Table no 75.) THICKNESS OF SKIN In this series, maximum of 90% of the patients were associated with thickness of skin where as in remaining only 10% of patient not associated with thickness of skin (Table no 76.) it may suggest that most of the patient suffering with Psoriasis are associated with of thickness of skin. ITCHING 95% of patients were reported with itching on Psoriatic skin lesion and only 05% devoid of itching. (Table no 77.) Thus this study is evidence for itching is one of the major symptoms in patient suffering with Psoriasis.
  • 174. DISCUSSION 154                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” DISCHARGE Maximum 80% of patient had some sort of discharge in terms of Serous/ Blood mixed etc. and remaining 20% of patient of psoriasis hadn’t any discharge (Table no 78.). TYPE OF KUSHTA Out of all 20 patients maximum about 70% of patients were belongs to Kitibha type of Kushta where as minimum of 05% of patients belongs to Charmadala type of Kushta.(Table no 79) EFFECTS OF THE THERAPY ANALYSIS OF VIRECHANA Effect of Deepana & Pachana Niraama Awastha was achieved by Pachana with the Chitrakadi Vati 500mg thrice daily. It contain Ushna and Lavana drugs which helps in Pachana on the other hand capable to perform Deepana & Pachana. However Kushta is also Kleda pradhana disease as it has Rasa,Rakta.Lasika etc. Saptakodrvya sangraha. Thus Chitrakadi vati apart from digestion of Sama condtion it also stimulates Jataragni and dhatvagni in particular to Rasa,Rakta,Mamsa,Meda dhatvagni. Days of appearance of samayak snigdha lakshana About 45% of the patients developed samyak snigdha lakshana on 3rd day & 30% were on 4th day itself. But only two patients developed samyak snigdha lakshana on 5th day and 6th day and 1 patient on 7th day(Table no 80). Total amount of abhyantarasneha during the whole course of snehapana Among 20 patients, maximum 35% of the patients had consumed total amount of sneha in between 100-200 ml. where as minimum of only 05% of patient consumed between 1000-1100 ml(Table no.81).
  • 175. DISCUSSION 155                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Samayak snigdha lakshanas Among 20 patients, 90% of patients had Vatanulomana feature where as minimum 20% of patients had Shaitya feature(Table no.82). Samayak swinna lakshanas Among 20 patients, about 80%patients had tvak mardavata feature where as only 30% of patients had Stambha feature(Table no.83). Latency period Time required manifesting first Virechana Vega after administration of Virechana drug is known as Latency period. In present study, Out of 20 patient’s maximum number of patients i.e. 40% the latency period was between 31-60 minute range, where as in minimum of 10% of patients latency period was between 121-150 minute range(Table no.84). Duration of virechana Out of 20 patients, in maximum number of patients i.e. 30% the duration of onset & stoppage of Virechana was between 6 - 8 hours (361-480) minute and 8-10hours(481- 600)(Table no.85). Vaigiki shuddhi Out of 20 patient’s, in maximum number of patients i.e.45% Avara Shuddi was found and minimum of 03% of the patients exhibited with Pravara Shuddi(Table no.86). Manaki shuddhi Out 20 patients,In maximum number of patient it in ranges between 3001-4000 ml and in one patient it was above 6000 ml(Table no.87).
  • 176. DISCUSSION 156                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Antiki shuddhi Out of 20 patients maximum number of patient i.e. 60% exhibited Kaphant virechana & minimum of 15 % with the Pittanta ana ausdhanta virechana(Table no.88 ). Laingiki lakshana of virechana Langiki features Lagutha,Agnivrudhi,Vatanulomana,Kramatvitpittakaphaagamana,Dourbalya,Karsyata, Kshut,Trishna are observed in maximum number of patients.(Table no89) Effect of therapy on Itching The itching on head was relived up to 61.41%, on trunk it was 48.14% relived, over upper limbs 53.03 % where as on Lower limbs it was reduces up to 54.79 %. It was found that compared to all parts of body itching on head was significantly relived i.e. p =<0.001 Effect of therapy on Erythema 61.14% relief was found in Erythema on head, on trunk it was 48.14% relived, over upper limbs 46.03%, where as on Lower limbs it was reduces up to 48.57% . It was found that compared to all parts of body on Lower limbs erythema was significantly relived i.e. p = <0.001 Effect of therapy on Scaling Improvement in Psoriasis was found in terms of Scaling i.e.51.12% relief was found in Scaling on head, on trunk it was 42.37% relived, over upper limbs 43.85 %, where as on Lower limbs it was reduces up to 48.57 %. p = <0.001 which indicate highly significant. Effect of therapy on Thickness of Skin The thickness of Skin on head was relived up to 67.74%, on trunk it was 48.07% relived, over upper limbs 51.92 % where as on Lower limbs it was reduces up to 44.44 %. It was
  • 177. DISCUSSION 157                                                                                    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” found that compared to all parts of body Thickness of skin on head and upper limb was significantly relived i.e. <p =0.001 Effect of therapy on PASI scoring The over all effect of therapy was found i.e. total PASI Scoring 49.03% where as p=<0.001 .Thus it indicate the significant relief in symptoms of Itching, Eryrhema, Scaling and Thickness of Skin.
  • 178. CONCLUSION 158  CONCLUSION ety of Kushta. on the 3 day of th total 1075 ml of gritha was required for manifestation of Samyak Snigdha atient had Tvak mardavata after Sidarthaka snana choorna kashya 9 patients (45%) the Manaki Lakshana was observed ranges yama Psoriasis is considered to be inherited as autosomal dominant characters . The exact cause of the disease is not known, but many precipitating factors like environmental, immunological, genetic and psychological have been found. Different research scholars have correlated psoriasis with Ekakushta, Kitibha and Sidhma etc. But as Psoriasis manifest with different presentation based on which Ayurvedic approach towards Psoriasis in terms of Kushta also varies. Thus, the present study entitled as “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” instead of considering any one single vari 25ml of gritha was administered on 1st day in all the patients. In Maximum number of patients the Samyak Snigdha Lakshana were observed rd Snehapana.In one patient Samyak Snigdha lakshana was observed on of 7 day. In maximum number of patients the total amount of Abhyantara Sneha required during the whole course of Snehapana was ranging between 100-200 ml. Where as in one patient lakshana. Out of 20 Patients, maximum of 20(100%) of patient had Swedapradurbhava and 16(80%) of p parisheka. Maximum of 31-60 min. Latency period was in found 11(40%) of patients, where as maximum of 0 between 3001-4000 ml. only, however maximum of 08(40%) had Madh Shuddhi ended up with Kaphanta. Statistical data reveals that there is 49.03% reduction in total PASI Scoring i.e. p=<0.001 there is statistically significant change. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 179. SUMMARY 159  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SUMMARY The dissertation entitled “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” it comprises Review of Literature, Methodology, Results, Discussion, Conclusion, and Summary. PART-1 Review of Literature. Conceptual study deals with the Virechana Karma in detail, it comprises of Historical Review, Etymology, Definition and Synonyms. There is a mentioning of general indication and contraindication of Virechana. There after tabular presentation indicating classification of Virechana Yoga are discussed based on their origin, part used, Mode of action, In relation with fat as a media and fermented Virechana drug ,Virechana Yogas, different Kalpana,. Procedure includes Poorva Karma, Pradhana karma, Paschat Karma of Virechana, Tabular presentation of Dose of Virechana drug in its different forms, afterwards Samykyoga, Ayoga, Atiyoga lakshana of Virechana karma and finally Mode of mechanism of Virechana Karma was discussed. PART-2 DISEASE REVIEW KUSHTA – It includes historical review of kushta, Etymological derivation of Kushtha, Definition, Synonyms, Etiology, Classification and Pathology of the disease, Poorvarupa, Rupa, Sadhyasadhyatha are discussed in detail. The treatment of the disease is also elaborated in terms of Shodhana karma. Shaman and Nidansya Parivarjana. And at last Pathyaptha were discussed. PSORIASIS -- Study of psoriasis consists of Introduction, Etymological derivation, Definition, History, incidence and prevalence, Etiology, Provocation factors, Pathogenesis, Clinical feature, Investigations, Classification, Differential diagnosis, Psoriatic arthritis, Mortality/Morbidity of Psoriasis, Complications, Quality of Life, Treatment and Finally PASI Scoring was elaborated.
  • 180. SUMMARY 160  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PART-3 DRUG REVIEW In this section all the drugs used for present study were discussed in detail i.e. Chitrakadi vati, Mahatiktaka Gritha and Sidarthaka snana,Abhyadimodka . All were discussed in terms of their Rasa panchaka, Varities, Method of Collection, Preparation, Chemical composition, Active ingredient and its medicinal importance. PART-4 METHODOLOGY The materials and methods adopted in the study are mentioned in this part .Apart from this it includes Protocol of the study viz objective of the study. Inclusion and exclusion criteria of the patients, Intervention and criteria of assessment. Review of previous work done on Virechana karma and Psoriasis. PART-5 RESULTS The observation made on demographic incidence of age, sex, habits etc. were presented in the form of bar diagrams. The result of Virechana Karma in management of Psoriasis was statistical analyses and finally represented in the form of Tabular presentation and Line diagram. PART-5 DISCUSSION The interpretation of conceptual study, clinical study and probable reason for change in them P.A.S.I. score, describes the logical interpretation of observation obtained in the clinical study. Which are as follows Numbers of patients were registered in this study 20 . 20 patients who are fulfilling the inclusion criteria of this study, out of which 35% were in the age group of 36-45 yrs, 95% were married, 95% each were male and 05% of female and 85% Hindus, each 65% of the patients of this study registered were educated up Graduation, 70%. had mixed diet and 40% had alcoholic and Tobacco Smokiing addictions, 65% patients give Negative family history , 75% of patients
  • 181. SUMMARY 161  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” belongs to Anoopa Desha. All the patients registered to this study had scaling where as each of 90% of patients had Thickness of Skin and Itching. In maximum number of patient’s samyak snigdha lakshna was obtained on the third day. Mean total of Grita required to attained samyak snigdata was 327.75 ml. On day of vishrama kala, (i.e. after Samyak Snigdha Lakshna) during which abhyanga were performed with Karanja taila followed by Sidarthaka snana kasaya parisheka was given. Then on 4th day Virechana yoga Abayadimodaka was administered. Average time taken to start Average time taken to start Virechana was 91.80 minutes. Mean duration of Virechana was 449.5 minutes. An average of 11 Vegas was noted. Samyak Shuddhi lakshana with Kaphanta was observed in 60% of patient Study shows significant improvement of psoriasis (49.03% improvement in P.A.S.I. score). PART-6 CONCLUSION On an average on the 3rd day patients attained samyak snigdha lakshana. i.e. maximum of 45% patients attained samyak snigdha lakshana on the third day itself. In maximum number of patients the total amount of Abhyantara Sneha required during the whole course of Snehapana was ranging between 100-400 ml. Maximum of maximum of 20(100%) of patients had Swedapradurbhava and 18(90%) of patient had Tvak mardavata by Sidarthaka snana choorna kashya Parisheka. Maximum of 31-60 min. Latency period was in found 08(40%) of patients. By Virechana karma there is 49.03% reduction in total PASI Scoring and p=<0.001.
  • 182. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PROFORMA DEPARTMENT OF PANCHAKARMA S.D.M COLLEGE OF AYURVEDA KUTHPADY, UDUPI ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS Guide:Dr.SHREEKANTH.U. Co- Guide:Dr.NIRANJAN.RAO Scholar : Dr. GIRIJA.M.N. Name : Serial No : Age : OPD No : Sex : M / F IPD No : Religion : H / M / C / O DOA : Education : UE / P / M / MS / GR / PG DOD : Marital Status : UM / M / D / W Diagnosis : Social Status : VP / P / LM / M / UM / RVR Result : Occupation : Postal Address : Desha : Anupa / Jangala / Sadarana MAIN COMPLANTS: Duration : ASSOCIATED COMPLAINTS: HISTORY OF PRESENT ILLNESS: Onset of skin lesions: Site of onset : Character of lesion : Continuous/Intermittent/Progressive/Waxing&weaning Factors aggravating the symptoms :Yes/No
  • 183. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Food Veg……………………….. Non -Veg ………………………… Season -Rainy/Winter/Summer Others - Releving factors: Yes/No Food Veg……………………….. Non -Veg ………………………… Season -Rainy/Winter/Summer Others - HISTORY OF PAST ILLNESS: H/O Similar complaints earlier than present- Yes/No H/O Systemic illness: H/O Others: FAMILY HISTORY: TREATMENT HISTORY: 1.Ayurveda –Shodana – Duration: Shamana- 2.Allopathic - Duration: 3.Others - Duration: PERSONAL HISTORY: 1.Ahara: Vegetarian/Non vegetarian Veg –Yava/Shali Snigdha/Madhura,Amla,Lavana,Katu, rasa pradhana ahara Ksheera/Dadhi Moolak /Vrunthka/any kanda shaka ahara Non- veg- Matsya/ Ajja mamsa etc. Mamsa ahara Anya - 2.Vyasana: Coffee/Tea- Yes/ No If Yes qnt in ml/cups............/day
  • 184. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Tobacco Chewing-Yes/No If Yes qnt ………../day/week/ month. Duration: Beedi/Cigarette-Yes/NoIfYesno…………….../day/week/month Duration: Alcohol–Yes/NoifYesqnt……….......day/week/month Duration: Others…………………. 3.Vyayama: Work –sedentary/moderate/heavy Nature of work: Physical/Mental/both. 4.Nidra: ……..Hours/Day-Sound/Disturbed/Delayed Divaswapna ……….Hours/Day Daily/Occasional Ratrijagarna……….Hours/day Daily/Occasional Other…………… 5.Mala visarjana: Regular/Irregular/Constipation/Loosestool Frequency: ……../Day Colour- Consistency- Other- 6.Mutra visarjana- Normal/Polyurea/Dysurea/Oligurea Frequency:Day…..times Night……times Colour- Other- 7.Urges- Normal/Supression of ………….urges regularly/occasional 8.Others –
  • 185. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” OBSTETRIC HISTORY: No. of delivery…… Normal……../Surgical Intervention…... Abortions……. Miscarriages …… Last Delivery …… years back Live…. Dead……… Still birth………. GYNAECOLOGICAL HISTORY: Menstrual cycle: …… Regular / Irregular / Menarche …… years Bleeding phase ….days Menorrhagia / Metrorrhagia / Dysmenorrhoea Leucorrhoea Menopause since……year GENERAL EXAMINATION: DASHAVIDHA PARIKSHA Pulse …… / min Prakrutitah:V/P/K/VP/VK/PK/KP/KV/PV/VPK B.P …… mm / Hg Vikrutitah: P / M / A Dosha : Dushya : Srotas : Udbavasthana : Sancharasthana : Vyakthasthana : Temperature……F Satwatah: P / M / A Respiratory rate…… / min Saratah: P / M / A Nourishment: G / F / P Satmyatah: P / M / A Built: Samhanatah: P / M / A Nails: Ictrus: Ahara Shaktitah: Abyavaharana: P / M / A Conjunctiva: JaranaShaktitah: P / M / A Sinuses: Vyayama Shaktitah: P / M / A Lymph nodes: Pramanatah: P / M / A Deformities: Height …… cms Contractures: Weight …… Kgs Nodules: Y / N Pallor: Vayataha; Bala / Madya / Vradha Others:
  • 186. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SYSTEMIC EXAMINATION: CNS : CVS : RS : GUS : P/A : LOCOMOTOR SYSTEM: Skin: A) Colour: Normal/Black/Grey/Greyish white/White. Abnormal- Rookshata: Snigdha: B) Lesion: 1) Character of a lesion – size…..colour…..pattern…….others…… 2) Individual lesion- Macule/Papule/Plaque/Nodule/Lichinification Other…… 3) Presence of Scales-Yes/No Colour…… Nature-Powder/Flake/Dry/ Moist/Greasy Other- 4) Itching- Yes/No Time-Day/Night/both Other- 5) Discharge-Yes/No Colour-White/Red/ RedishWhite/Watery Contain-Blood/Pus/Clearfluid Other- 6)Area of skin affected-Knee/Elbow/Scalp/Neck Other….. 7)Distribution-Symmetrical/Asymmetrical/Flexor/Extensor/Exposed Body part/unexposed body part Other- 8)Superficial sensation on lesion-Normal/Anasthesia/Parasthesia/Asthesia
  • 187. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 9)Associated with: Pain/Swelling/Inflammation Other- 10)Others- Confirmatory signs-Candlegrease sign- Auspitz sign- Nails- colour – Normal/Clubbing/Koilonychia/Pitting/Onchyolosis Other- Hairs-Colour- Distribution
  • 188. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” SROTAS PARIKSHA: 1.Pranavahasrotas 2.Udakavahasrotas 3.Annavahasrotas 4.Rasavahasrotas 5.Rakatavahasrotas 6.Mamsavahasrotas 7.Medovahasrotas 8.Astivahasrotas 9.Majjavahasrotas 10.Sukravahasrotas 11.Mootravahasrotas 12.Purishavahasrotas 13.Swedavahasrotas 14.Artavahasrotas INVESTIGATIONS: Hb: Tc: Dc: ESR: RBS: ECG: SkinBiopsy(ifneeded)
  • 189. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” TREATMENT SCHEDULE: POORVA KARMA: Administration of Deepana Pachana: Chitrakadi vati with Ushna Jala Dose.........mg /OD /BD/TDS/QDS/HS for....days Koshta pariksha- Triphala choorna - Dose.........mg Time- No.of malapravriti: .......... Koshta-------------- SNEHAPANA VIDHI: Name of Sneha given- Mahatikthaka grutha with Ushana jala as Anupaana SNEHAPANA DAY Date Time Quantity Time of Snehajeernata Sneha jeeryamana lakshanas LAKSHAN Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7 Shiroruk Bhrama Nishtiva Moorcha Saada Aruchi Klama Trishana Daha Snehaudgar Arati
  • 190. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” Sneha jeerna Lakshanas LAKSHANA Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7 Trishana Kshudha Udgarashudhi Shiralaghavata Vatanulomata Samyak snigdha lakshanas LAKSHANA Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7 Vatanulomata Agnideepti Snigdha asamhata varcha Gatramardava Twaksnigdhata Snehodvega Klama Shitya Angalaghava VISHRAMA KALA: Sarvanga abhyanga with Karanja taila followed by Siddartaka snana SAMYAK SWINNA LAKSHANAS LAKSHNAS DAY1 DAY 2 DAY 3 DAY4 Sheeta uparama Shoola uparama Stambha nigraha Gaurava nigraha Mardavata Sweda virathi/sheetaartitva Vyadi haani Laghutava Sweda srava Agni deepti Twak prasada Bhakta shrudda Strotasam nirmalatva Nidra hani Tandra hani
  • 191. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” PRADHANA KARMA: Administration of virechana yoga Abhyadimodaka 1-4 karsa(depending upon the bala) Anupana : sukoshanajala Time of administration of Virechana Dravyas-…....... 1] MANIKI No. of Vega Time Colour Consistency Virikta Dravys Water Consumed Urine 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 In put = ml Out put = ml Total Virikta (stool) dravya = ml Total out put (urine stool) = ml
  • 192. ANNEXURE                                        SAMYAK VIRIKTA LAXANA Samyak Yoga Ati Yoga Ayoga Srotoshuddi Supti Agnimandya Indriya prasada Angamarda Pratishyaya Laguta Klama Tandra Agnivrudhi Bhrama Chardi Anamayatva Balaabhava Aruchi Vitkapha vata kramashanissarana Nidraabhava NaVata Pratilomata Vatanulomana Tama Pravesha Daha Daurbalya Netra pravesha Kukshiashudhi Karshyata Moorcha Kandu Hridhvarna shudhi Unmada Vitsanga Kshuth Hikka Mootrasanga Thrishna Chima chimayana Pidika KaleVegapravarthnam Pipilika sancharaivaange Mandalotpthi Hridayodveshtana Pitika Jarjaribhava Vidaha Vishangnatva shtevana Jalabasa Kukshishoola Shoonyata Nabhistabdata Shanka Sankocha Shopha Parshwa Shoola Guda Shoola Parikartika Angamarda Gudanissarana Gudabramsha Kapha Pitarahita sweta Udakanissarana Kapha Asrapittaan Lakshayalakshana Mamsadhavana Vatudaka Nissarana DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” MedhoKhanda Vatsrava
  • 193. ANNEXURE                                        ANTHAKI VEGAKI MANAKI LYNGIKI OBSERVATION OBSERVATION OF VITAL DATA & WEIGHT Time Pulse Blood Pressure Resp.Rate Weight PASCHAT KARMA No. of Annakalas Diet Regimen Pravara Shuddhi Madhyama Shuddhi Avara Shuddhi Peya Veelepi Akrita Yusha Krita Yusha DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 194. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” ASSESSMENT CONFIRMATORY SIGNS: Signs BT AT Auspitz sign Candle grease Assessment criteria BT AT Itching Erythema Scales Thickness
  • 195. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” P.A.S.I SCORING Time Part I E S T TOTAL AREA X TOTAL BEFORE VIRECHANA HEAD X0.1 TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER SNEHAPAN HEAD X0.1 TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER VIRECHANA HEAD X0.1 TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER FOLLOW UP HEAD X0.1 TRUNK X0.2
  • 196. ANNEXURE                                        DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= I= ITCHING E= ERYTHEMA S=SCALING T=THICKNESS RESPONSE TO TREATMENT GOOD: MODERATE: MILD: Administration of internal medication: no of days: Follow up days: Signature of the Candidate Signature of the Guide
  • 197. Before Treatment After treatment
  • 198. Before Treatment After treatment NAIL CHANGES IN PSORIASIS
  • 199. MAHATIKTHAKA GHRITHA FOR SNEHAPANA KARANJA TAILA FOR ABHYANGA
  • 200. SIDHARTHAKADI SNANA CHOORNA KASHAYA FOR PARISHEKA VIRECHANA DRUG :ABHYADI MODAKA
  • 201. BIBLIOGRAPHY 162    BIBLIOGRAPHY 1. Agni-purana, Maharshi Veda Vyasa, 1st edi.,Acharya Baladeva Upadhyaya, Chaukhamba Sanskrit Series,Varanasi, 1996, pp 563, page no.412 1(a).Fauci AS, Braunwald E,Kasper DL, Hauser SL, Longo DL ,Jameson JL , Loscalzo.editors Volume 1 17th Edition MC Graw -Hill Medical Publishing division , Pp- 1364 Page no-315 2. Dr. Sharma P.V. Indian Medicine In The Classical Age” Choukhamba Amarabharati Prakashana ; 2nd Edition : Pp. no -269;Page no. 69 3. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no. 651. 4.Tarka Sri Taranatha ,Vachaspathyam, Vachaspathhi Chaukamba Varanasi 1962 . 5. Deva Raja radha kantha “Shabda kalpadruma” Nag publishers ; New Delhi, 1987 . 6.Sir Monier Monier –Williams “A Sanskrit-English Dictionary”, Reprint -2005, Motilal Banarsidas Publisher’s pvt. Ltd. Delhi , Pp no.1333, page.no 880. 7.Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no. 651 8. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no. 651 9. Vagbhata Acharya “Astanga Hrudayam” with Sarvanga Sundara Commentry of Arunadatta and Ayurveda Rasayana Commentary of Hemadri-Reprint 2005, Choukhamba Orienalia- Varanasi U.P. Pp-956, Page no-16 10.Sharangadhara, Sharangadhara Samhita, ParshuramPandit Shastri Vidhyasagar, Choukhambha Orientalia- Varanasi,6th Edition -2005,Pp398 Page no.34 11. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-322 12.Vriddha jivaka “Kashyapa Samhita” Sddisthana 7th Chapter, Hindi Translation of Sanskrit Introduction by Ayurvedalankar ,Srisatypala Bhisagacharya.   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 202. BIBLIOGRAPHY 163    13. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no. 131 14.Vagbhata Acharya “Astanga Hrudayam” with Sarvanga Sundara Commentry of Arunadatta and Ayurveda Rasayana Commentary of Hemadri-Reprint 2005, Choukhamba Orienalia- Varanasi U.P. Pp-956, Page no-211 15. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-97 16. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-115. 17.Vagbhata Acharya “Astanga Hrudayam” with Sarvanga Sundara Commentry of Arunadatta and Ayurveda Rasayana Commentary of Hemadri-Reprint 2005, Choukhamba Orienalia- Varanasi U.P. Pp-956, Page no-16 18. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-203 19. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-115. 20. Acharya Sushruta “Sushruta Samhita” with Nibandha Sangraha Commentary of Dalhana and the Nyayachandrika Panjika of Gayadasa on Chikitsa Sthana;6th edition, 1997, Choukhambha Orientalia- Varanasi U.P; Pp-824, Page no-519 21. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-651. 22. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-127 23. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-21. 24.. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-22.   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 203. BIBLIOGRAPHY 164    25. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-127 26. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-29. 27. Acharya Sushruta “Sushruta Samhita” with Nibandha Sangraha Commentary of Dalhana and the Nyayachandrika Panjika of Gayadasa on Sutra Sthana;6th edition, 1997, Choukhambha Orientalia- Varanasi U.P; Pp-824, Page no-170 28. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-127. 29. Acharya Sushruta “Sushruta Samhita” with Nibandha Sangraha Commentary of Dalhana and the Nyayachandrika Panjika of Gayadasa on Sutra Sthana;6th edition, 1997, Choukhambha Orientalia- Varanasi U.P; Pp-824, Page no-190 30. Vagbhatacharya “Ashtanga Sangraha” with Shasilekha Commentary of Indu, 1991,CCRAS Publication,New Delhi,Part-ka, Pp659 , Page no-127 31. Sharangadhara, Sharangadhara Samhita, ParshuramPandit Shastri Vidhyasagar, Choukhambha Orientalia- Varanasi,6th Edition -2005,Pp398 Page no.33. 32. Acharya Sushruta “Sushruta Samhita” with Nibandh Sangraha Commentary of Dalhana and the Nyayachandrika Panjika of Gayadasa on Sutra Sthana;6th edition, 1997, Choukhambha Orientalia- Varanasi U.P; Pp-824, Page no-233. 33. Sharangadhara, Sharangadhara Samhita, ParshuramPandit Shastri Vidhyasagar, Choukhambha Orientalia- Varanasi,6th Edition -2005,Pp398 Page no.36 34. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-413. 35. Sharangadhara, Sharangadhara Samhita, ParshuramPandit Shastri Vidhyasagar, Choukhambha Orientalia- Varanasi,6th Edition -2005,Pp398 Page no.33 36. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-32. 37. Agnivesh “Charaka Samhita”, Revised by Charaka and Dridhabala with the Ayurveda Dipika commentary of Chakrapanidatta, Reprint 2004, Choukhambha Samskrit Samsthana, and Varanasi U.P. Pp-738 page no-32.   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
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