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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 PSORIASISDissertation 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 CANDIDATEI here by declare that this dissertation thesis entitled “ROLE OF VIRECHANA KARMAIN THE MANAGEMENT OF PSORIASIS” is a bonafide and genuine research workcarried 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 ofPancha 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 GUIDEThis is to certify that the dissertation entitled “ROLE OF VIRECHANA KARMA IN THEMANAGEMENT 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 GuidePlace: 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 INSTITUTIONThis is to certify that the dissertation entitled “ROLE OF VIRECHANA KARMA IN THEMANAGEMENT OF PSORIASIS” is a bonafide research work done by Girija.M.N. underthe 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 CandidateI here by declare that the Rajiv Gandhi University of health Sciences,Bangalore,Karnataka shall have the rights to preserve, use and disseminate thisdissertation in print or electronic format for academic / research purpose.Date: Signature of the CandidatePlace: Udupi Dr. Girija.M.N. B.A.M.S © Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
  • 6. ACKNOWLEDGEMENT I ACKNOWLEDGEMENTThis 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 akey 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 whosemoral support & great inspiring thoughts towards me had helped me always to achieve mygoals in the most toughest situations of my life. Who has made me to sail always towardssuccess with much difficulty.It is a great pleasure for me to extend my thanks with respect to my Guide, my preacherDr. Shreekanth U.Professor,HOD & Former dean Department of Panchakarma, SDMCollege 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, whosupported 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 conveymy 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 brotherMr.Santosh.M.N for his great friendly advise , all-time support, generous help, not only inthis 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-operationduring my entire course.I thank to all my Seniors & Junior colleagues Dr.Raksha, Dr.vishwanath, Dr.varun,Dr.Vignesh, Dr.Shankarnarayan. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 7. ACKNOWLEDGEMENT III 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 wasindispensable 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. IfI am sailing in the wide ocean of medicine today, it is my patients who add wind to mysails. They are both my ways and my destination too.My special thanks to the Library staff, owner of Samrudhi Xerox, for their co-operationduring my documentation work.I should be very thankful to all of my family members ,they always inspired me to achievethis milestone in my life. I have not been able to find words enough to express mysentiments of love, respect & gratitude for them.Lastly I acknowledge my thanks to those who have directly or indirectly extend thereSupport 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 CountDEPARTMENT 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. : YearsDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI.“ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 10.   ABSTRACT  V ABSTRACT Psoriasis is the most common dermatological condition affecting 1% of the population.It is a chronic inflammatory skin disorder clinically characterized by erythematous,sharplydemarcated papules and rounded plaques, covered by silvery micaceous scale. The cause is unknown but is thought to be related to genetic and environmental factorsthat trigger on over production of epidermal cells. Kushta is Bahudoshaavastajanya vyadhi ,has tridosha involvement along with sapthadhatu as its dushya psoriasis may be put under the categories like kitibha, sidhma, ekakusthaaccording 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 virechanakarma is helpfull to manage psoriasis.Aims and ObjectivesTo evaluate the effect of virechana karma in patients suffering from psoriasis.MethodologyIt is Single blind clinical study with 20 patients having the sign & symptoms of Psoriasiswere selected randomly irrespective sex from O.P.D. & I.P.D. sections of Panchakarmadepartment, S.D.M. Ayurveda Hospital, Kuthpady, Udupi, were diagnosed as psoriasis andfullfilling the criteria of undergoing the process of virechana karma were selected. Patientswere subjected to deepana pachana with chitrakadi vati, after proper amapachna arohanasnehapana was administered with Mahatiktaka gritha till obtaining samyak snigda lakshans.Then from next day of samyak snigdha lakshana, Sarvanga Abhangya with Karanja Tailafollowed by Sarvanga Parisheka with Sidartaka snana choorna was performed for 4 days andduring this period patient advised to avoid consumption of Kaphakara Ahara and Vihara. On4th day depending upon the rogi & roga bala Virechana Karma was performed withAbayadimodaka with sukoshna jala as Anupana. Finally based on Shuddhi lakshanaSamsarjana krama was prescribed. In all cases P.A.S.I. score, candle grease sign and Auspitzsign were noted before and after the Virechana karma.Keywords: - Virechana Karma, Psoriasis, Kushtha, P.A.S.I.   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 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 5PART 1 CONCEPTUAL STUDY 5-99PART 2 DRUG REVIEW 100-108PART 3 METHODOLOGY 109-114PART 4 OBSERVATIONS 115-137PART 5 RESULTS 138-146PART 5 DISCUSSION 147-157PART 6 CONCLUSION 158PART 7 SUMMARY 159-161 BIBLIOGRAPHY 162-181 ANNEXURE
  • 12.   LIST OF TABLES  VI SL. TABLE OF CONTENTS PAGE NO NO. 1. Detail description regarding Virechana in different 6-7 samhithas 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 & 13 agraoushda 5. Showing virechana drugs according to seasons 16 6. Showing virechana kalpas according to charaka 18 7. Showing formulations for virechana based on dosha 19 involvement 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 34 Virechana karma 20. Laingiki shuddhi 35 21. Showing ayoga lakshnas of virechana karma 35 22. Showing Atiayoga lakshnas of virechana karma 36  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 13.   LIST OF TABLES  VII 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 41 Acharyas. 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 64 acharyas. 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 98 psoriasis. 44. Rasa panchaka of Chitrakadi Vati 101-102  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 14.   LIST OF TABLES  VIII 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 15.   LIST OF TABLES  IX 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 16.   LIST OF TABLES  X 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 17. LIST OF FIGURES XI   LIST OF FIGURES SL. PAGE FIGURES No. 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 18. LIST OF FIGURES XII   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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 19. LIST OF FIGURES XIII   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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 20.   LIST OF CHARTS XIV LIST OF CHARTS SL.NO PAGE CHARTS 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 21. INTRODUCTION 1 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 ofcosmetology. 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 seatof Jnanendriya(Cha.Su.8/10) and moreover comparing to all other seats of Jnanendriya’s, Skinenvelope most part of body surface. In other words to say, remaining Netradi four Indriyas havetheir seat on restricted parts of body surfaces like Netra is seat for Chakshurindriya, Jivha isseat for Rasanedriya etc. but Sparshanendriya has its seat in Twacha which covers all most allthe body surface area (Cha.Su. 11/38). From the origin point of view Tvak is considered as Upadhatu of mamsa dhathu, Tvak ishaving direct relationship with Rasa dhatu owing to its nourishment andmaintenance(Cha.Chi15/17).However in the context of Dashavidha pariksha Charak identifiedTwakSara instead of RasaSara (Cha.Vi.8/102-103).Thus healthy status of Rasadhatu is mostessential to maintain the proper structure and functions of Tvak. Psoriasis is one of the most common dermatologic disorder and a chronic skin disordermarked 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 activityleading 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 thebasal layer to the surface in about 4 days. The skin cannot shed these cells quickly enough, sothey build up, leading to thick, dry patches, or plaques. Silvery, flaky areas of dead skin build upon the surface of the plaques before being shed. The underlying skin layer (dermis), whichcontains the nerves and blood and lymphatic vessels, becomes red and swollen1(a).  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 22. INTRODUCTION 2 Kushta is Bahudoshaavastajanya vyadhi ,has tridosha involvement along with saptha dhatu asits dushya psoriasis may be put under the categories like kitibha, sidhma, ekakustha according todifferent presentations Virechana karma is one of the sodhana karma explained for it.As tvachais 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 virechanakarma is helpfull to manage psoriasis. Moreover Charaka identified Kushta as one amongDheergakaalena 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 Psoriasiswere selected and were screened with Haematological tests to rule out other underlyingpathologies and to void possible complications. All the patients were administered withpreliminary Deepana –Pachana with Chitrakadivati. Snehana was achieved by internaladministration of Mahatiktaka Gritha followed by Abhyanaga with karanja taila and Parishekawith sidartaka snana choorna kashaya . Main course of the treatment i.e. Virechana was administered with Abhyadimodaka withSheeta 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 .  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 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  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.  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 25. REVIEW OF LITERATURE 5   PROCEDURE REVIEW HISTORICAL REVIEW PURANA KALAAgnipurana1: . Agni purana has stated virechana as best treatment for the diseases caused dueto 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 vamanaand virechana.Vinayapitaka(Buddhist literature): In the text Vinaya pittaka from Buddha period description of administration ofvirechana was given to Bhagwan Buddha by inhaling powder spread over uthplapatrais available.Kasika2 It is explained that Panchakarma was common method of treatment whichprescribed Poorvakarma such as Snehana, Swedana and Panchakarma,Annasamsarjana etc. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 26. REVIEW OF LITERATURE 6    SAMHITA KALA: Table no :1 showing description of virechana in different samhithas    DRUGS     BOOK     VIRECHAN  VIRECHAN  PROCEDURE,  COMPLICATIO DRUG  KALPA/ YOGA  NS &  STHANA  BENEFITS  TREATMENT  (Chapters/  (Chapters/  (Chapters/  Chapters/Sholka  Sholka)  Sholka)    Sholka)     1/77,75 ;        2/9,10; 4/13   Sutrasthana  15/7;    15/ 17,18,16,  15/ 13 ;  22;   25/40  ‐  16/ 5‐10 ,  16/ 17‐19      22‐26   Vimanasthana  8/136  ‐  ‐  ‐ Charak samhita  Kalpasthana  1/6   7‐12   1/3, 4,5. ;  12   12   Siddhisthana  ‐  ‐  1; 2/11,12,13.  6             Sushruta   Sutrastana   38/30 ;   44   ‐  ‐ Samhita  39/ 4    Chikitsasthan  ‐  ‐  33/19‐47  34    Sutrastana   15/2  ‐  18   18  Astanga  Kalpasthana  ‐  2   ‐  3    Hridaya   Sutrasthana  13/2;14/3‐ ‐  27   27  Astanga  4;15/6  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 27. REVIEW OF LITERATURE 7   sangraha  Kalpasthana  ‐  2   ‐  3    Sutrasthana   ‐  ‐  4 ; 21 ; 23;25  ‐   Kalpasthana  ‐  7 ; 8 ; 9.   ‐  ‐  Bhela  Siddhisthana  ‐  ‐  ‐  1 ; 4  samhita Sharang‐ purvakhanda  4   ‐  ‐  ‐ adhara samhita  Uttarakhanda                              Detail about virechana karma  Vangas‐    ena samhita  Virechanadhik Detail about virechana karma   ara  Bhavaprak Nighantu Part  ‐  5   5   5  asha Chakra – ‐  ‐  71  71   71  datta   Sutrasthana   ‐  ‐  24   ‐ Kashyapa  Siddhisthana  ‐  ‐  2 ; 3 ; 7  ‐ samhita  Khilasthana  ‐  ‐  7   7   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 28. REVIEW OF LITERATURE 8   VIRECHANA The process by which the vitiated doshas are eliminated through theadhobhaga ie guda marga, is called ‘Virechana.This is widely used shodana therapy,is less stressful with least complication.Virechana in broader term denotes bothvamana and virechana.3Etymology:-(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 ofVirechana. According to Charaka, the Virechana drugs first get digested inAmashaya, then reaches to Hridaya, Dhamani, macro and micro channels (srotases) ofthe body and reach the site where Doshas are accumulated.7 Virechana drugs soften the compactness (Sanghata) of the Doshas and breakthe bigger molecules to smaller ones. This process occurs in a proper way byseparation (Viyojana) and combination (Samparchana) of doshas. Up to this stage the action of Virechana is known as its systemic effect and itis obviously governed by Viyojana and Samparchana components of Virechanadravya. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 29. REVIEW OF LITERATURE 9  Definition: iÉ§É SÉåwÉWûUhÉqÉÔkuÉïpÉÉaÉÇ uÉqÉlÉxÉÇ¥ÉMüqÉ,AkÉÉåpÉÉaÉÇ ÌuÉUåcÉlÉ xÉÇ¥ÉMüqÉç .....|8    The act of expelling Doshas through Adhobhaga is known as Virechana. Herethe meaning of Adhobhaga is ‘Guda’ as commented by Chakrapani. ÌuÉUåMüÉå qÉÑZÉmÉÏiÉÇ aÉÑSqÉaÉåïhÉÉliÉ:ÎxjÉiÉxrÉ SÉåwÉxrÉÌlÉ:xÉÉUhÉÇ ...|9 The procedure in which the drug is administered orally, acts on morbidDoshas, specifically on Pitta and expels them out through anal route.ÌuÉmÉYuÉÇ rÉSmÉYuÉÇ uÉÉ qÉsÉÉÌS SìuÉiÉÉÇ lÉrÉåiÉç | UåcÉirÉÌmÉiÉ¥ÉårÉÇ UåcÉlÉÇ Ì§ÉuÉ×iÉÉ rÉjÉÉ ||10 The procedure where the morbid Dosha is expelled out in the form of Dravaeither pakva or apkva state.ÌmɨÉå iÉÑ ÌuÉUåMÇü zsÉåwqÉxÉÇxÉ×¹å uÉÉ iÉixjÉÉlÉaÉiÉå uÉÉzsÉåwqÉhÉÏÌiÉ |11 urÉMÑüsÉÉlÉç xÉͳÉmÉÉiÉÉåijÉÉlÉç mÉæ̨ÉMüÉlÉç MüTüümÉæ̨ÉMüÉlÉç | xÉÇxÉ×¹ÉlÉç MüTüqÉÔsÉÉÇ¶É xÉëÇxÉlÉëålÉÉprÉÑmÉ¢üqÉåiÉç||12 Even though Virechana is best line of treatment modality for pittadosha13it canact on kaphasamsrusta pitta or pittasthanagat kapha.And moreover in case of vatasyopakrama mridu shodhana indicated which refers tomridu Virechana karma14. So Virechana is major line of treatment for morbid pittadosha & also it act onmorbid kapha and vata dosha. Thus action of Virechana is seen on all tridosha. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 30. REVIEW OF LITERATURE 10  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 Induexplains that in the vitiation of Kevala Pitta, Pitta associated with Kapha and inPittasthana Gata Kapha Virechana is the obvious treatment procedure to befollowed18. Charaka explains that,Virechana drug after entering Amashaya dislodges thevitiated Pitta Dosha and henceforth pacifies all Pitta Vikara of the body19. Virechana also cleanses sense organs i.e. improves their function. Just asremoval of water from its reservoir destroys various organisms and plants residing init, in the similar manner removal of excessive Pitta destroys the various symptomscaused due to it20 . Virechana is mentioned as Shodhana procedure in Dusthi of Rasa,Rakta,Mamsa, Asthi, Majja & Shukra Dhatus. Hence in majority of the DhatupradoshajaVikaras 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 hasadhobagahara prabhavam.Virechana dravya has jala and prithwi mahaboothapredominance.21 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 31. REVIEW OF LITERATURE 11  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 6groups,Table.no.02 I) Virechana Dravyas According to their a) Animal origin DRAVYAS origin & parts used b) Plants origin c) Miscellaneous II) According to the mode of action a) Anulomana b) Samsrana c) Bhedana d) Rechana VIRECHANA 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 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: DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 32. REVIEW OF LITERATURE 12  Classification of virechana dravyas based on part of the plant used.Table no: 03. Part of the Sl.no. plant used for Charaka 26 Sushruta 27 Vagbhata 28 virechana. 1. Mulini Hastidanti Trivrit,Shyama virechana Shyama Danti Danti,Kumbha dravya. Trivrit Dravanti (Trivrit) Adhoguda Saptala Gavakshi Saptala Shankhini Shankhini Danti Gavakshi Vishanika Vishanika Gavakshi Ajagandha Chitraka Dravanti Kush, Kasha Avartaki Kinahi 2. Phalini Shankhini Kampillaka Neelini virechana Vidanga Puga Triphala dravya Anupa Eranda,Haritaki Kampillak Sthalaja Bibhitaki, Prakeerya Amalaki Udakeerya Neelini Abhaya Aragwada Anthakotrapuspi Kampillaka Aragwada 3. Ksheera Snuhi ksheera Mahavriksh Snuhi virechana Arka Saptachala Swarna ksheeri dravya. Swarna ksheeri Godugdha 4. Twak Tilwaka Tilwaka Tilwaka virechana Patala Ramyaka dravya Ramyaka 5. Patra virechana Swarna patri Putika Aragwada dravya Aragwada Aragwada Karavellaka Based on Parts of the Dravya used: Sushruta describes the following drugs with priority for Virechana Karma29. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 33. REVIEW OF LITERATURE 13  Classification of virechana dravyas based on main part of the plant usedTable no.04 Mula Virechana Shyama Trivrith Phala Virechana Haritaki Twak Virechana Tilwaka Swarasa Virechana Karvellaka Dugdha Virechana Snuhi Taila Erandamc) Miscellaneous: As Madya, Dhanyamla30,Guda, Ikshu Rasa, Payas, Krishara, Ushna Jala, someminerals - Swarna, Kamsya, Manahsila, Gandhaka, Ratna, Uparatna, Samudraphenaalso have Sara properties.II. Virechana drugs according to their mode of action by Sharangadhara Acharya Sharangdhara has classified according to the action of the Virechanadravyas.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 bringthem to adhomarga for defecation process. These drugs will facilitate the defecationprocess.eg: Hareetaki (Terminalia Chebula). Sushruta considers Sara as the synonym of Anulomana. According to DalhanaAnulomana 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 therectum without digesting them. eg: Aragwada (Casia Fistula). In the context of Jwara Chikitsa it has been mentioned that Sramsana eliminatesthe Pitta and Kapha situated in Pakwashaya 34. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 34. REVIEW OF LITERATURE 14  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 thenevacuating 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.37d) 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) Malasor 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 isknown 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 beclassified into the following categories. A) Mridu Virechana:40 The drugs which are Mridu in Veerya or when combined with opposite Veerya orgiven in low dosage, given to the Ruksha patient and causes less purgation is knownas Mridu Virechana. Those drugs are specifically indicated in weak patients havingmild natured diseases. These drugs may also be given to the patients who have been DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 35. REVIEW OF LITERATURE 15    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.). 43Drugs 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 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 36. REVIEW OF LITERATURE 16    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 Virechanahave been recommended. The drug used in the form of oil or the preparation containing Sneha is known asSneha Virechana, eg: Eranda Taila. Vagbhata recommends the use of Sneha Virechana inall patients except Snigdha patients 54. The use of Sneha Virechana in the patients whohave been given higher dosage of Sneha is contraindicated because, due to this, themoving Doshas may again adhere in the Srotas55. Sneha Virechana should beadministered 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 comparativelytaken more Sneha 57.eg: Danti dravanti V. Virechana drugs according to seasons 58 Table no:05 Showing Virechana drugs according to seasons.  Shishira   Varsha Sharad /Vasanta Greeshma Hemanta All seasonsVirechana Beeja ShyamaTri Shyamatr Shyamatrivrit Trivrit Trivritdrug Trivrit vrit ivrit Chitraka Danti Kutaja Duralabha Pippali Patha Hapusha Pippali Musta Nagara Ajaji Saptala Shunthi Sharkara Sindhu Sarala Katuki Udichya Aruna Vacha Swarnaksiri Shweta Trivrit Hemakshiri Chandana churnaAnupana Draksha Yasti Honey Sugar Warm Bhavana with Rasa and madhu in Water cow ‘s urine madhu Draksha Swarasa or Draksha Swarasa only DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 37. REVIEW OF LITERATURE 17   Adhamalla in Sharangdhara commentary mentioned that the drugs forVirechana in Shishira, Vasanta and Hemanta Rutu are same. Kasiram Vaidya in hiscommentary opined that Saindhava, Vriddhadaru, Shyamatrivrit are to be used forVirechana in Hemanta Rutu. Charaka mentions Trivrit Chitraka, Patha, etc. to be usedfor 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 yogaiv) Madya yoga v) Mutra yoga VI) Mamsarasa yogavii) Bhaksanna yoga viii) Avaleha yogaKshira, Rasa, Kalka, Kashaya, Kwatha and Sita are respectively Laghu. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 38. REVIEW OF LITERATURE 18    Table no:06. Showing 245 Virechana kalpas according to Charaka.59 Kalpana Trivrth Argvada Tilvaka Sudha Saptala Danti Shankini DravantiAmla kanji 2 1 1 1 1 1Mutra 22 - 1 - - -Tushodaka 2 - - 1 1 1Maireya 2 - - - 1 -Yusha 2 - - 1 - 2Kwatha 1 2 1 - 11 -Churna 32 - - 1 1 6Tarpana 8 - - 1 - -Ksheera 2 - - - - -Mamsa ras 2 - - 4 - 6Ikshu ras 1 - - - - 1Swarasa 6 2 1 2 - -Leha 1 1 3 1 3 6Modhaka 7 - - - - -Raga shadava 4 - - - - -Sura Madhya 3 1 2 2 5 4Souvira 2 1 1 1 1 1Sidhu - 1 1 - 1 1Uthkarika 1 - - - - 1Gritha 4 2 4 4 8 6Taila - - - - 6 2Chatusneha - - - - - 1Asavarishta - 1 1 - - 5Greya - - - 1 - -Yavagu - - - - - 1 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 39. REVIEW OF LITERATURE 19    Specific formulations for Virechana Tabe no:07. Showing Formulations for virechana based on dosha involvement.Vata Pradhana Trivrit + Saindhava + Shunthi + Kanji or MamsasaraPitta Pradhana Trivrit Choorna + Draksha KvathaKapha Pradhana Triphala Kvatha, Gomutra, TrikatuChildren 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 Heena for Mridu Madhyama for Uttama for Kalpana Koshta Madhyama Koshta Krura Koshta Kwatha 8 tolas 4 tolas 2 tolas Kalka, Choorna 4 tolas 2 tolas 1 tola Modaka DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 40. REVIEW OF LITERATURE 20  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, Virechanadrugs must be mild and their dose should be minimum; for the Madhyama mediumdose and for Krura Kostha persons, the Virechana drugs should be Tikshna and itsdose 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 VinishchayaSambhara Samgraha:-66Ahara: 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 thepatient fitness in terms of his/her Dosha, Dushya, Atura Bala kala, Desha, Agni,koshta, Sharir & Ahara Satma, Satva etc. for proper adminstration of Virechanakarma. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 41. REVIEW OF LITERATURE 21   Virechana Yogya and Ayogya. Table no:10: Showing Virechana YogyaVirechana Yogya Ch.Si66 Sus.Chi67 A.S.68 A.Hr.69 K.Si.70 Sha.S.U71 Pranavaha srotoduhti vikaraShwasa + - - - - -Kasa + - - - - -Parshvaruja + - - - - - Annavaha srotoduhti vikaraAruchi + + + - - +Avipaka + - + - - -Visuchika + + + - - +Alasaka + + + - - -Chardi + + + + - + Udakavaha srotoduhti vikaraUdara + + + + - + Rasa pradoshaja vikaraPandu + + - - + +Jwara + + + + - +Aruchi + + - - - +Avipaka + - + - - -Hridroga + + - - + + Rakta pradoshaja vikaraKamala + - - + + -Vidradhi - + + + - +Netradaha + + - - - +Aasyadaha + + - - - +Vatarakta + + + + - +Kustha + + - + + +Paittika vyadhi + + + - - -Visarpa + + - - + -Pliha + + + + - + DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 42. REVIEW OF LITERATURE 22  Vyanga + - + + - -Nilika + - - + - -Urdva Raktapitta + + + + + - Mamsa pradoshaja vikaraArbuda + + - - - -Galaganda + - - - - - Meda pradoshaja vikaraPrameha + + - + + +Yoni Dosha + + + + - +Retodosha + - + + - - Mootravaha srotoduhti vikaraMutraghata + + + + - + Purishavaha srotoduhti vikaraArsha + + + + + +Bhagandara + + + - - +Udavarta + - + + +Vibhandha - + + + + -Pakvashaya shoola + + + + - - OtherVisphota - - - - + +Vatavyadhi - - - - + +Garavisha - + + + + + DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 43. REVIEW OF LITERATURE 23    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 AyogyaVirechana 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 + - - - - - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 44. REVIEW OF LITERATURE 24   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 - - - - + - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 45. REVIEW OF LITERATURE 25   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 takenin the condition of Ajirna, it will lead to Vibandha and Glani. If the Doshas are in Amaconditions and anybody tries to remove these Dosha forcefully then it will destroy thebody. If the condition of patient is associated with Ama then Shodhana can only be doneafter the Pachana of Ama by Deepana, Pachana So it is necessary to administer deepan& pachana drugs before the virechana to attain nirama state.86Snehana & Swedana: Snehana includes both Abhyantara (oral ingestion of unctuous material) andBahya Snehana (external application of unctuous material) .Abhyantara Snehapanafollowed 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. Therequired Sneha should be administered early in the morning at Suryodayakala afterobserving Jeerna Ahara Lakshanas of the previous meal and when the patient is emptystomach. The duration of Sneha Pana should be 3 to 7 days88,89. Shodhananga Snehapana is done untill the attainment of ‘Samyak SnigdhaLakshanas’ which can be achieved in 3, 5 and 7 days in Mrudu, Madhyama, andKrura Koshta respectively.Importance: - Action of Snehana and Swedana prior to shodhana explained by Charaka infollowing way.Due to Snehana there will be further vriddhi of doshas, and increase influidity(Vishyandana) and due to Swedana dosha paka along with removal of DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 46. REVIEW OF LITERATURE 26  obstruction at the enterance of the channels.Because of this the doshas leave theShakha and comes to the Koshta.91 Sushrutha says Samshodana given without oleation and fomentation willdestroy the body like the dry wood.92 Thus, Shodhananga Snehapana can be carried out for a maximum period of 7days otherwise it will create Sneha Satmyata92, 93. Dose of Sneha for shodhanamentioned in various classics is as follows.94-96.Table No.12 Showing Sneha matra. Madhyama Matra Charaka Samhita , Ashtanga Sangraha (Dose which digests in 12 hours) Uttama Matra (Dose which digests Ashtanga Hrudaya. in 24 hours) Uttama & Madhyama Matra ChakarapaniShodhananga Snehapana can be administered in 2 methods: a) Arohana Snehapana b) Sadyo Snehapanaa) Arohana Snehapana: Kalyanakaraka first mentioned about increasing dose schedule. He clearlymentioned that Shodhanartha Abhyantara Sneha pana has to be taken in increasingorder (“Krama Vardhitam Pibet”). Vangasena also followed Kalyanakaraka’sVardhamana dose schedule.b) Sadyo Snehapana: Sadyo Snehapana involves administration of large quantity ofSneha to achieve Snigdha Lakshana immediately or within short duration. It isgenerally indicated in Bala, Vriddha, Balaheena, Mrudu koshta, Alpa dosha, Raja,Raja samipya, Sneha parihara asahishnushu.97 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 47. REVIEW OF LITERATURE 27  Table No.13 . Showing Sneha Dravya and Anupana: 98 Sneha Anupana Ghrta Ushnodaka Taila Yusha Vasa & Majja Manda Bhallataka & Tuvaraka Taila Shita JalaIn 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 foodarticles. 100 (2) Pravicharana – denotes administering Sneha by mixing with food articleseither 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 ShodanangaSnehapana.Administration of Sneha for Shodhana: 101 On the day of Snehapana, when the raising sun has attained golden yellowcolour, individual exhibiting Jeerna ahara lakshana (symptoms of digested food ofthe 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 digestedSneha) Lakshanas. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 48. REVIEW OF LITERATURE 28  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 LaghutaTable 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 - - - + DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 49. REVIEW OF LITERATURE 29  Table No:16 . Showing Asnigdha Lakshana. 107-110Lakshana Ch. Sa. Su. Sa. As. Hr. Sh.SGrathitha purisha + + - -Ruksha purisha + + - -Agnimandya + + - -Vayu pratiloma + + - -Khara Gatra + _ - -Ruksha Gatra + - - -Uro vidaha _ + - -Daurbalya _ + - -Dur varna - + - -Krichrat anna Pachana _ + - -Susnigdha Lakshana Viparyaya _ _ + +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 - + - - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 50. REVIEW OF LITERATURE 30    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 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 51. REVIEW OF LITERATURE 31  Table.no.18. DOSE OF VIRECHANA DRUG IN ITS DIFFERENT FORM121-124. Form Of Koshta Dose Sus121,122 Sha123 Van124 Medicine 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 1 Anjali 4 Karsha 2 pala 2 Kwatha Mrudu Heena (4 pala) 2 Karsha Krura Uttama - 2 Karsha Madhyam Madhya 1 Karsha 1 Karsha 1 Karsha 3 Churna Mrudu Heena - ½Karsha Krura Uttama - 8 Karsha Madhyam Madhyam - 4 Karsha 1 pala 4 Svarasa Mrudu Heena - 2 Karsha Krura Uttama - - 5 Kalka Madhyam Madhyam 1 Karsha 1 Karsha Mrudu Heena - - Krura Uttama - - - 6 Modaka Madhyam Madhyam - 1 Karsha - Mrudu Kaneeya - - - 7 Hima& Krura Uttama 8 Karsha - phanta Madhyam Madhyam 1 Anjali 4 Karsha - Mrudu Heena (4 pala) 2 Karsha - - - - - 2 Karsha 8 Sneha - - - - or1 pala - - - - Ushna Mrudu - - - 2 pala 9 jala as Madhyam - - - 4 pala Anoopan Krura - - - 8 pala DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 52. REVIEW OF LITERATURE 32  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 complication128Measures 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 53. REVIEW OF LITERATURE 33  Vega pravartanopaya130: For Vatanulomana and Yogavahi action lukewarm water is taken. Ifmedicinecomposed of Jayapala is given then hot water is contraindicated. If VirechnaVega is notinitiated then Tapa Sweda with help of palm over abdominal region which may helpto 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 andUdgara Shuddhi Once Jeerna Lakshana appears but still only small amount of morbid doshas areexpelled or not yet all, then Physician should administer one more dose of Virechanadrug depending on patient bala132B) 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 drugmay produce severe purgation. In some cases if the drug is digested but properelimination of doshas didn’t occurred, then next day again Virechana drug should begiven.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 theassociated symptoms. If Virechana persists even after manifestation of Hritadoshalakshanas, then vamana should be given.132 If Aushadhi Jeerna Lakshanas are manifested, but Hritadosha Lakshanas are notfound, then Virechana Yoga should be given next day. Even then Virechana does notoccur then Snehana and Swedana should be done again and thereafter Virechana drugshould be administered after 10 days133. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 54. REVIEW OF LITERATURE 34  A) Shuddhi Lakshana:134-137 Finally shuddhi lakshana must assess in terms of Subjective parameters likeLaingiki & Antiki & Objective Parameters like Vaigiki &Manaki. But among thesemore importance should be given to Laingiki Shuddhi138.Table no:19 . Showing Criteria for Antiki, Vegiki and Maniki Shuddhi ofVirechana 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 55. REVIEW OF LITERATURE 35  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 - - + DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 56. REVIEW OF LITERATURE 36  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 + - - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 57. REVIEW OF LITERATURE 37    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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 58. REVIEW OF LITERATURE 38   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 respectively153Table no :23 Showing the Diet Regimen154 Dina Kala Annakala Pradhana Madyama Hina shuddhi shuddhi shuddhi Pratama Prathaha - - - sayankala 1 Peya Peya Peya Dwitiya Prathaha 2 Peya Peya Vilepi sayankala 3 Peya Vilepi kruthaAkrutha yusha Trutiya Prathaha 4 Vilepi Vilepi kruthaAkrutha sayankala 5 Vilepi Akrutha mamsa rasa yusha Samanya bhojana Chaturtha Prathaha 6 Vilepi Krutha yusha - sayankala 7 Akrutha Akrutha - yusha mamsarasa Panchama Prathaha 8 Krutha yusha Krutha - sayankala 9 Krutha yusha mamsa rasa - Samanya bhojana Shasta Prathaha 10 Akrutha - - sayankala 11 mamsarasa - - Krutha mamsa rasa Saptama Prathaha 12 Krutha - - sayankala 13 mamsa rasa - - Samanya bhojana Instead of Peyadi Krama, Sushruta mentions Kulatha, Aadhaki and JangalaMamsarasa155. Dalhana clarifies, Sushruta however agrees Peyadi Krama and he says DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 59. REVIEW OF LITERATURE 39  that incase of Ksheena Kapha, Peya should be given. Mamsarasa should be given toVata pradhana patients having Deeptagni. If Kapha dominance is there according toDosha and Prakriti, then Kulatha Yusha should be given. The Peyadi Krama ends on7th day ins Pradhana Shuddhi patient.Acharya Sushrutha has opined samsarjana kramain respect to bala of the patient156. For the individuals having good strength, threeannakala are advised, 2 annakala for madhyama bala and one annakala for lesserstrength 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 bodyand if the patient is having habit of taking alcohol, he shouldn’t be given PeyadiSamsarjana Krama. Instead he must be given Tarpana i.e., thin or thick soup preparedwith Deepana and Pachana drugs like, Pippali, Dadima etc. In Tarpana, Swaccha Tarpana in place of Peya and Ghana Tarpana in place ofVilepi should be given, according to Chakrapani157. Jejjata mentions Mudga, Yushaand 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 Rasaatmakafood articles are given to patient with proper order & this can be consumed along withPeyadi Samsarjana karma or after it. Table no: 24 Table showing Rasa Samsarjana. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 60. REVIEW OF LITERATURE 40    Author Rasa Effect on Dosha Snigdha,Amla,Swadu Pakvashaya stitha vataprasamanarthaCharaka158 Amla ,Lavana. Urdvastitha agni sandukshnartha Swadu,Tikta Pittasamanartha Kasaya,Katu Pitthaurdvastithakapha prasamanartha Swadu ,Tikta Pravrudha agni vataSushruta159 pittaastaavajayarthamagneha samikarnartha. Snigdha,Amla,Lavana,Katu Vatakaphavajayaarthamagnehasanduksnartha Swadu,Tikta Pittavatavajayartha . 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 61. REVIEW OF LITERATURE 41   Ayoga Atiyoga Adhamana Srava parikartika Jivadana Hritgraha Vibramsha Gatragraha Gudabramsha Kandvadi Vibhramsha Sanjnabhramsha Stambha Upadrava Klama 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 ) DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 62. REVIEW OF LITERATURE 42   Vyapada Lakshana Chikitsa Adhmana Adhmana UdavartaNabhi, Prustha, Abhyanga, Sveda, Phalavarti, Parshva, Shiroruja, Shvasa, Vit Niruha, Anuvasana, Mutra, Vata Sanga Udavartahara Chikitsa Parikartika Gud Parikartana Langhana, Pachana, Ruksha, Tivrashula, Piccha, Rakta, Ushna Bhojana Yashtimadhu Mala Pravritti ,Snehabasti Parisrava Alpa Mala Pravritti, Kandu, Shopha, Vamana, Virechana, Grahani Kustha, Gaurava, Agnimandya, Chikitsa. Asava, Arishta Staimitya, Aruchi, Panduta Hridgraha Hikka, Shvasa, Kasa, Parshvashula, Snigdha Lavana, Sveda, Lalasrava, Akshivibhrama, Shula, Yasti Taila, Anuvasana, Dantatikitkitayana, Jihva, Khodati Tikshna Nasya, Vamana, Sangyanasha Basti Angagraha Stambha, Vepathu, Toda Vatahara Pindikodveshtana, Manthanavat Snehana Pida Svedana Jivadana Rakta Chandrika, Udakasrava, Guda Pittahara, Raktapana, Bhransha, Trishna, Murchha, Mada Raktabasti, Piccha Basti, Ghrita Manda, Anuvasana Vibhransh Only Mala Excreted not Doshas, Kashaya Lepa, Snehana a. Guda Gudabhransha, Sanjna Bransha, Mridu Sveda b. Sanjya Kandu, Pidika, Kustha, Roga Manonukula Chikitsa c.Kandu, Tikshna Shodhana After Snehapana Stambha Vatavarodha, Gudastambha, Langhana, Pachana, Tikshna Gudshula, Alpalpa Mala Pravritti Basti, Virechana Upadrava Stambha, Sula, Gatragraha, Snehana, Svedana Sarvanga Vedana Vataghna Chikitsa Klama Tandra, Gaurava, Klama, Daurbalya, Langhana, Pachana, Sneha, Angasada Tikshna, Shodhana Vamana by Vamana Snehana, Svedana, virechana Virechana Yoga Ayoga Vibhransha, Hikka, Roganusara Chikitsa Pindikodveshtana, Kandu, Urusada, Gomutra Niruha Vaivarnyata Atiyoga Ativirechana Mridu Vamana, Raktapitta vat ChikitsaMODE OF ACTION OF VIRECHANA:165 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 63. REVIEW OF LITERATURE 43   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 thebody which is as follows. The drugs which are Ushna, Tikshna, Shukshma, Vyavayiand Vikashi reach to the heart by virtue of their potency and circulate through thelarge and small Srotas due to its Sukshma and Vyavayi properties and pervade entirebody. Then they liquefies the morbid elements by virtue of their Agneya Guna andcrumbles them by virtue of its Tikshna Guna. Then this liquefies and crumbled massLooses contact with the wall and the channels in the unctuous body, just like thehoney, not adhered to the unctuous vessel. This morbid mass now passes through theminute capillaries and moves towards Kostha by virtue of the AnuPravana Bhava ofthe drug and ultimately reaches the Amashaya. From here it forces the morbid factorsthrough the anal route due to the Bhautika predominancy of Jala and Prithvi andAdhobhaga Prabhava166 (Ch. K.1/4) Chart No.01 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 64. REVIEW OF LITERATURE 44   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                                                                                                              DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 65. REVIEW OF LITERATURE 45   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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 66. REVIEW OF LITERATURE 46   CATHARTICS - MODERN VIEW167 The terms laxatives, cathartics, purgatives, aperients and evacuants often areused interchangeably. However, there is distinction between Laxation and catharsis.Laxation means – the evacuation of formed fecal material from the rectum, whereasCatharsis means – the evacuation of unformed, usually watery fecal material from theentire colon. Most of the commonly used agents promote Laxation but some actuallyare cathartics.Classification of Cathartics: These drugs are usually classified according to their mechanism of action. Thepurgatives 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 acidAnthraquinone group:These are derivatives of plants such as aloe, cascara and senna. These agents can produce giant migrating colonic contractions as well asinduce 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 6to 12 hours, after ingestion. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 67. REVIEW OF LITERATURE 47  Diphenylmethane derivatives: Examples in this group are: Bisacodyl, Phenolphthalein. Pharmacological section is not shown clearly but drug acts as a stimulantmainly on the large bowel after 6 hours and produces soft semi liquid stoolsassociated with a little gripping.Ricinoleic acid: Important among Ricinoleic acid is caster oil. Ricinoleic acid acts as an irritantand produces purgation. As Ricinoleic acid acts on small intestine, it producescopious, liquid stool with associated fluid loss. The action is quicker thanAnthraquinone and is evident within 2 to 3 hours.2. Osmotic Purgatives: The osmotic purgative consists of salts, which though highly soluble, are poorlyabsorbed 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 thebowel. This distends the bowel and stimulates peristalsis, as well as liquefying thebowel contents, making evacuation more rapid. The efficacy of the saline Catharticsis, thus related to the osmotic activity exerted by the unabsorbed fraction within theintestinal 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 ofaction, they are given early in the morning before breakfast. Patients should beinstructed to take plenty of water along with these drugs.example:Magnesiumhydroxide,Magnesium citrate.2. Bulk forming laxatives: These are various natural or semi synthetic polysaccharide and cellulosederivatives. eg. Bran, Psyllium preparation, methyl cellulose, Calcium polycarbophil.These agents absorb water and swell-up, thus providing the stimulus of mechanicaldistinction for evacuation. Their action is mild and is usually seen 12 to 36 hours afteringestion.3. Stool Wetting Agents and Emollient laxatives: The best examples are liquid paraffin, Olive oil, Docusate salts, etc. By oraladministration it is not significantly absorbed and exerts softening and lubricating DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 68. REVIEW OF LITERATURE 48  effects on feces. These laxatives are mild in action and usually seen 1 to 3 days afteringestion 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 laxativesC. 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 69. REVIEW OF LITERATURE 49  SKINAnatomical 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 ofbody and is the seat of Sparshnendriya; it is very extensive among all fivejnanendriyas. According to Ayurveda Twak is derived from Matruja bhava and is theseat of Vayu, which is responsible for tactile sensation. Regarding number of layers of twcha Susrutha mentioned seven layers whileCharaka quotes six, naming the two only.  168,169,170,171Table No. 28. Different Layers of Twacha 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 weekof gestational age(ch sa 4/11). This formation through transformation during fetalstage 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 andprasaada paka. Saarapaka is medas and prasaada paka is twak and vasa. The functionof dathu is stated as lepana, as the masa dahtu is getting nourished from raktha- twakalso possesses porva dhatu guna. That may be the reason that vagbhata explains “ DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 70. REVIEW OF LITERATURE 50 twak prasadat rakthasya prasada”, i.e. purity of the blood will reflect on skin. Skin isthe seat of brachaka pitha, which promotes the luster of the body. Acharya Susrutha explained about seven layers in relation with origin of diseaseas followsTable No.29.Sapta Twacha and Disease Relation172Name Thickness DiseasesAvabhasini 1/18th Vrihi Sidhma & PadmakantakaLohita 1/16th Vrihi Tilakalaka, Nyachcha & VyangaSweta 1/12th Vrihi Charmadala, Ajagallika & MashakaTamra 1/8th Vrihi Kilasa & KusthaVedini 1/5th Vrihi Kustha & VisarpaRohini 1 Vrihi Granthi, Arbuda, Galaganda, Apachi, SleepadaMamsadhara 2 Vrihi Bhagandara, Vidradhi, Arsha  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 71. REVIEW OF LITERATURE 51  DISEASE REVIEWHISTORICAL REVIEW OF KUSHTAPrevedic & VedicPeriodAgnipurana173: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 asKushta. Unmaada,Apasmaara, Prameha etc.Yadjnya valkalsmriti 175: Kushta is known as paparoga and is chronic in nature. & Mandala and Sidma arekinds 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 thedisease and existing of specialists treating the same.Bhana bhatta179:According to him Kushta is one of 52 variety of Sharirika disease.    DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 72. REVIEW OF LITERATURE 52 Table No: 30 AYURVEDA NIDANA SADHYA- PANCHAKA ASADHYATVA CHIKITSA BOOK STHANA (Chapters) (Chapters) (Chapters) Sutrasthana 20 - 1; 3; 4 ; 25 Nidanasthana 5 5 - Charaka samhita Chikitsasthana 7 7 7 Sutrasthana - - 38 Sushrut Nidanasthana 5 5 - samhita Chikitsasthana - - 9 ; 10 Nidanasthana 14 14 14 Astanga Chikitsasthana - 19 19 hridaya Sharirasthana - 5 - Sutrasthana - - 13;15 ;16 Nidanasthana 14 - - Astanga sangraha Chikitsasthana - - 21 Sutrasthana 4; Bhela Nidanasthana 5 - - samhita Chikitsasthana 6 6 6 Chakra - - - 50 dutta Chikitsasthana Kushtachikitsa adhyaya Kashyapa samhita Khilasthana 15 15 15 Harita Tratiyasthana 39 39 39 samhita   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 73. REVIEW OF LITERATURE 53 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 180MüjÉlÉç ...(zÉoSMüsmÉSìÓqÉ )    In Sanskrit language, the word ‘Kushta’ is derived form the ‘Kushnishkarshane’ 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 wordKushtha 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 asdiscoloration 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, RujaVyapam, Pakalam, Hashuram, Kakalam, Amayah, Gadantakam. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 74. REVIEW OF LITERATURE 54 Classification of Kusta According To Different AcharyasTable No: 31 Mahakushta Types of A.Hr185( M.N185(e) B.P.185(fNo. Ch185(a). Sus185(b). c) B.S185(d). ) Kushta . . 1. Kapala + + + + + + 2. Audumbara + + + + + + 3. Mandala + - + + + + Rushyajihv 4. + + + + + + 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 KshudrakushtaNo 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 Table No: 33 KASHYAPOKTA KUSHTA TYPES186 1) Pama 2)Mandala 3)Dadru 4) Kitibha 5)Kapala 6)Vicharchika Sadhya kushta 7) Vishaja 8)Sthularushka 9)Sidma 1)Poundarik 2)Shvitra 3)Rushyajivha 4)ShatarushkaAsadhya kushta 5)Kakana 6) Oudumbara 7)Charmadala 8)Ekakushta 9)Vipadika All These types of Kushta are further classified based on Doshicpredominance. It is more useful for diagnostic and treatment of the disease, which areas follows187 (Cha.Chi.7/27-30)Table No: 34 Kushta and Dosha Relation Doshic No. Name of Kushta predominance 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 KakanakaDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 77. REVIEW OF LITERATURE 57  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. Vedanavishesha - Eg.Kapala kushta Toda bahula; Varna Vishesha- Eg. Kakanaka kushta isGunja beeja varna; Samsathana Vishesha - Eg. Rushyajivha kushta is resembles tothat of deer tongue; prabhava Vishesha - Eg. Kakanaka kushta is Asadhya due to itsPrabhava; Naama Vishesha- Eg. kapala etc. are found in Kushtha because ofAmshamshakalpana of the Doshas189 (Cha.Ni.5/4). According to Charaka, Kushtas are in fact of innumerable types, but forsystemic study they are classified into two major groups 7 Maha Kushtha & 11 189Kshudra Kushtha (Cha.Ni.5/4). There is no difference of opinion between anyAcharya 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 Tendency Penetrates into deeper Less tendency to penetrate in deeper 4. Dhatu dhatu 5. Mahat Chikitsa Alpa Chikitsa Loss of skin functions like Supti 6. Less functional skin deformities etc.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 78. REVIEW OF LITERATURE 58  Chakrapani has clarified that, in Kshudra Kushta the symptoms of Mahakushta aremanifested in milder form191 (Cha.Ni.5/4). According to commentator Gayadas thereis severe and extensive vitiation of Doshas from the very beginning, in Mahakushtha,which penetrate the deeper tissues and cause Mahakushta. But no such severe andextensive vitiation of Doshas occurs in the KshudraKushta from the beginning192(Sus.Ni.5/5)Kushta NidanaTable No: 36 ACCORDING TO DIFFERENT ACHARYAS Nidana of Kushta Cha Sus A.S. A.H B.S.18 H.S M. B.P185(f) 5(d) Ni7/ r. .190( N.19 Ni Ni a) 0(b) 4-8 5/4 14/2 Ni 0 14/2 0 DVADASHAVIDHA AHARAA. SHOOKA DHANYA1. Nava Anna + - - - - +2. Tila + - - - - + +3. Pishta vikara + + - - + + +B. SHAMI DHANYA1. Masha + - - - - + +C. GORASAVARGA1. Dadhi + + - - + + +2. Sarpi + - + + + + -DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 79. REVIEW OF LITERATURE 59 3. Ksheera + - - - + +4. Takra + - - - - - -D. HARITA VERGA1. Moolak + + - - + + +2. Lakucha + - - - + - -E. IKSUVARGA1. Guda + - - - + + +2. Continuous and + - - - - - - excessive use of Madhu3. Continuous and + - - - - - - excessive use of PhanitaF. MAMSAVARGA1. Mastya + + + + + + + +G. AHARAYOGI VARGA1. Ati lavana + - - - - + - consumption2. Ati tila - - + + - - + tailaconsumption3. Ati pippali - - - - + - - consumption VIRUDDA AHARAA. VEERYA VIRUDDHA1. Intake of Chilchim + + + + + + + + fish with milk2. Moolak+ Ksheera+ + - - + + + GudaDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 80. REVIEW OF LITERATURE 60 3. Intake of milk after + - - - - - - - consumption of Moolak/Lashuna / Shigru / Tulasi etc4. Excessive intake of - + - - - - + - Gramya, Anupa, Audaka Mamsa with KsheeraB. SAMYOGA VIRUDDHA1. Mastya+ - - - - + - - - Ksheera+Nimbu2. Continuous and + - - - - - - - excessive use of either single or mixture Madhu, Phanita, Matshya, Lakucha, Mulaka, Kaakmachi or intake of above substances while having AjirnaC. VIDHI VIRUDDHA1. Aharan kramam + + - - - + + muktva nishevinaamD. UPACHARA VIRUDDHA1. Snehapana with + + - - - - - Sheet jala OTHER1. Adyashana + + - - - - + +DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 81. REVIEW OF LITERATURE 61  2. Injestion of Vidahi + - - - + - - food in Vidagdhavasta 3. Asatmya Bhojana + + - - - + - 4. Ahitaashana + + - - - - + 5. Excessive Drava, + - - - - - + + Snigdha, Guru, Ahara   AHARA-VIHARANO. 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  CHIKITSAKRITANO. 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 karma3.  Snehapana with Sheet jala  +  +  ‐  ‐  ‐  ‐  ‐  ‐ 4.  Stambana chikitsa in + + + + - - - + Dushta& Utklishta rakta in Raktapitta5.  Stambana chikitsa in + + + + - - - + Amatisara   ACHARANO. 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       DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 83. REVIEW OF LITERATURE 63  OTHERSNO. Nidana of Kushta Cha. Sus. A.S. A.H B.S. H.S. M.N r. .1. Samsargaja - + + + - - +2. Dushivishajanya + + - - - - - K. 2/323. Adibalapravrutta + + + + - - - Sh Su 8/21 24/64. Raktadushti + - - - + - - Su 24/1 65. Bahya Krimi + - + + - - + Ni 1/.446. Abhyantara krimi - + - + + Ni - - + 14/5 Raktaja krimi 2DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI“ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 84. REVIEW OF LITERATURE 64  TABLE NO : 37 PURVAROOPA Cha. Sus. A.S. A.Hr. B.S. H.SN .110O purvaroopaP (Chi 7/11) (Ni.5/4) (Ni.14) (Ni.14) (Chi.6)A LOCALISED1. 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 asamrohananm18 Raaga - - - - + -19 Roukshyam - - - - + -B GENERALISED1. 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  Table No.38 KUSHTAROOPA Cha. Sus. A.S. A.Hr. B.S. M.N.NO. Kushtaroopa (Chi 7) (Ni.5/) (Ni.14) (Ni.14) (Chi.6) (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 KUSHTA1. 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 + - + + - - DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 86. REVIEW OF LITERATURE 66 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 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 MishribhuyaTiryaga 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 ASADHYA1 Generalised features Atmavat (Who can able to tolerate *Thirst, Burning, Agnimandya,Alpa any type of Medicine or treatment) balavan *Rakta netra, Hata Svaram, Panchakarmagunatita, Prasratanga2 Localised features Absence of Krimi Krimi utpatti3 Predominance of Dosha Vata-Kaphaja Kushtha , Kapha- Tridosha dominance Pitta or Vata-Pitta or only one Dosha4 Involvement of Dhatu Tvacha, Rakta or Mamsa Medogata, Asthigata, Majjagata & dhutagata Shukragata5 Specific type of Kushta114 (Cha.Ni.5/9,10) Kapala , Audumbara, Sidhma, Mandala, Aruna Rushyajihva, Kakanaka, When Sadhya Kushta are not Pundarika types of Kushta treated properly in time or neglected these becomes Asadhya6 Other features Minimum symptoms with Kushta having all the symptoms along with complications like Angapatan, Absence of complication. Jvara,Atisara etc114 (Cha.Ni.5/11) Adibalapravrutta Kushta115 (Sus.Ni.5/19)DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI“ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 89. REVIEW OF LITERATURE 69  The prognosis of Kushtha depends upon many other factors like strength ofNidana 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, Charakahas mentioned that all the Kushthas are caused by Tridosha, so the treatment is to becarried out according to the predominance of Dosha. The predominately vitiatedDosha should be treated first and the treatment of the other subordinate Dosha shouldbe undertaken afterwards199. (Cha. Chi. 7/37-39) To study the treatment of Kushtha systemically, it is necessary to look at threeprinciples 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 furtherprogression of the disease, by restricting vitiation of Doshas. Main etiological factorsof Kushtha are Mithya Ahara-Vihara & Viruddha Ahara so they should be avoided.Acharya Charaka has defined ‘Pathya’ as they are the wholesome drugs and regimenwhich do not adversely affect the body and mind. Those which adversely affect themare considered to be Apathya201 (Cha. Su. 25/45, 46) (2) SAMSHODHANA: The therapy which expels out the morbid Doshas from the body is known asShodhana202(A.Hr.14/5)0. Medicines given after Shodhana are more effective. AllAcharya’s have emphasized on Shodhana therapy in the management of Kushtha dueto 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’DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 90. REVIEW OF LITERATURE 70 By nature, Kushtha is difficult to cure disease, so it is called ‘Duschikitsya’. But bythe application of Shodhana therapy, cure of the disease becomes easier due toremoval of the root cause, hence Shodhana has great importance. According to Charaka & Vagbhata Shodhana should be carried out according topredominance of vitiated Dosha. For instances in Vata dominance Ghritapana, inKapha dominance Vamana and in Pitta dominance Virechana, Raktamokshana are to 205be carried out (Cha.Chi.7/37-39) In excessive morbidity of the Doshas repeatedShodhana should be performed at regular intervals i.e.Vamana Karme once in 15days;Samsrana once in month; Raktamokshana once in 6 months; Nasya Karma oncein 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 thetreatment 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. Aftercompleting the Shodhana Karma, Shaman Chikitsa is indicated to subside theremaining Doshas. Shamana Chikitsa is very useful in those patients who are unableto undergo or contraindicated for Samshodhana. Charaka has advised Shamanatherapy with Tikta and Kashaya Dravyas after administration of proper Shodhana208 (Cha.Chi.7/58). Charaka has also indicated several other drugs & formulation ofShamana therapy in 7th chapter of Chikitsa Sthana.External application: Kushtha, being exhibited through the skin, external application are alsoadvocated. For the external application drug should be applied after elimination of theDoshas from the body by Shodhana Karma and Raktamokshana. Various forms oflocal 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 partsi.e. treatment according to the predominance of Doshas, internal & externalpurification.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 91. REVIEW OF LITERATURE 71 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 Shali, Yava,Shukadhany Godhooma, - -a Tila Purana dhanya. Nishpava, Mudga, Hayanaka,Yav-Shambidhan Adhaki, Kulattha, aka,Chinaka, Priyangu, Tuvarak-ya Uddalaka, Masha Masha Masoora Anoopa Jangala mamsa Anoopa Mamsa Jangala mamsa mamsa, rasa mamsa varga Matsya rasa, vasa Patola ,Tiktka Moolaka, Nimba,chakramard shaka,Punarna ala ,Avalguja, Atasi, Shakha Kakamachi,Ud varga vShaka,Karvel dalaka,Kusumb Atarushaka, Lakucha ka -ha Tila Aragvada, Khadira - Brahati phala, Ashada phala,Phala varga Koshataki, - Jatiphala Bhallatak, Triphala Gorasa Purana Sarpi Ksheera,Dadhi - - varga DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 92. REVIEW OF LITERATURE 72  Tikta ghrita, taila of Nimba, Ingudi, Taila varga Saral Agaru, Tila taila Devadaru, Sarshapa taila Tila tail ShimshipaIkshu varga Makshika Ikshu, Guda Makshika - Go,Khara,Ushtra, - - Ashva,Mahishi -Mutra varga mutra Sahyadri,Vind - hya samudbhva Khadirodaka -Jala Varga nadi jala Kasturika,Gandhas ara;vaman in every Amla rasa 15 days; once in a Dravya, month Lagu Vidahi,Vishta Other rechana;Nasya mbi,drava-guru Divaswapn & Hitakara karma in every 90 anna,Pishta a,atapa Anna days; Rakta vikara,Virudha sevana,, mokshana once in pana-Ashana 6 month, Vyavaya Ksharakarma, DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 93. REVIEW OF LITERATURE 73  PSORIASISINTRODUCTION Psoriasis is a chronic skin disorder marked by periodic flare-ups of sharplydefined red patches, covered by a silvery, flaky surface. The main disease activityleading to psoriasis occurs in the epidermis, the top five layers of the skin. In persons with psoriasis, the keratinocytes multiply very rapidly and travelfrom the basal layer to the surface in about 4 days. The skin cannot shed these cellsquickly 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. Theunderlying skin layer (dermis), which contains the nerves and blood and lymphaticvessels, becomes red and swollen. Its scope can vary considerably; from mild outbreaks, where the person maynot even be aware they have psoriasis, to severe cases, which can be socially disablingand, in rare instances, life-threatening. In principle, people of all ages can getpsoriasis, but the early-onset form of the disease is mostly seen in 16 to 22-year-oldsand the late-onset form strikes those between the ages of 50 and 60.211ETYMOLOGICAL DERIVATION: The word ‘Psoriasis’ is derived from the Greek word ‘Psora’ which means itchor scale, ‘Iasis’ means condition.DEFINITION: Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales212.HISTORY: Psoriasis is probably one of the longest known illnesses of humans andsimultaneously one of the most misunderstood. Some scholars believe psoriasis tohave been included among the skin conditions called tzaraat in the Bible.In more recent times psoriasis was frequently described as a variety of leprosy. TheGreeks used the term lepra (λεπρα) for scaly skin conditions. They used the termpsora to describe itchy skin conditions. It became known as Willans lepra in the lateDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 94. REVIEW OF LITERATURE 74 18th century when English dermatologists Robert Willan and Thomas Batemandifferentiated it from other skin diseases. They assigned names to the condition basedon the appearance of lesions. Willan identified two categories: leprosa graecorum andpsora leprosa.While it may have been visually, and later semantically, confused withleprosy it was not until 1841 that the condition was finally given the name psoriasisby the Viennese dermatologist Ferdinand von Hebra. The name is derived from theGreek word psora which means to itch and asis means condition.It was during the20th century that psoriasis was further differentiated into specific types213.PREVALENCEThe 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 ageneral practitioner in the United Kingdom was 1.5%. A survey conducted by theNational Psoriasis Foundation (a US based psoriasis education and advocacy group)found a prevalence of 2.1% among adult Americans. The study found that 35% ofpeople with psoriasis could be classified as having moderate to severe psoriasis214.ETIOLOGY The cause of psoriasis is not fully understood. There are two main hypothesesabout the process that occurs in the development of the disease. The first considers psoriasis as primarily a disorder of excessive growth andreproduction of skin cells. The problem is simply seen as a fault of the epidermis andits keratinocytes. The second hypothesis sees the disease as being an immune-mediated disorderin which the excessive reproduction of skin cells is secondary to factors produced bythe 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 plaquepsoriasis. Multifactorial inheritance mechanisms and aetiologies without any geneticcomponent have not yet been excluded, although many families appear to exhibitautosomal dominant patterns of inheritance with decreased penetrance. Studies ofDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 95. REVIEW OF LITERATURE 75 twin siblings have shown concordant disease in 73% of monozygotic twins comparedwith 20% in dizygotic twins. Several putative genetic susceptibility loci have alsobeen identified, including psoriasis susceptibility 1 (PSOR1) on chromosome 6, whichis associated with up to 50% of cases. Six other psoriasis susceptibility loci (PSOR2,PSOR3, PSOR4, PSOR5, PSOR6, PSOR7) have been discovered, as well as thetranscription factor RUNX1. While this certainly points to a genetic mechanism, theabsence of 100% concordance among monozygotes suggests that environmentalfactors must play a role in the pathophysiology of this disease215. Genetic Causes of Psoriasis Often, a person with psoriasis has a parent orgrandparent who also has the condition. Researchers estimate that a person with oneaffected parent has about a 10% chance of also having psoriasis. Having two parentswith psoriasis increases the chances to about 30%216.PROVOCATING FACTORS Psoriasis is not contagious—no one can "catch" it from another person. Becauseof their genes, certain people are more likely to develop it, but a "trigger" is usuallynecessary to make psoriasis appear. These factors may provoke onset or aggravationof psoriasis. I. LOCAL FACTORS1. Trauma - All types of trauma can lead to the development of plaque psoriasis (e.g.physical, chemical, surgical, infective, and inflammatory). The development ofpsoriatic lesions at a site of injury is known as the Koebner phenomenon.2. Infection – An acute eruption of guttate psoriasis may be provoked bystreptococcal pharyngitis. HIV infection may be associated with increase in diseaseseverity.3. Sunlight -Although sunlight is generally considered to be beneficial for most of thepatients, strong sunlight may worsen the disease in a small minority. II. SYSTEMIC FACTROS1. Drugs- Lithium, withdrawal of systemic corticosteroids, beta-blockers,antimalarials, and NSAIDs may cause flare of the disease2. Stress - Many patients report an increase in the psoriasis severity withpsychological stress.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 96. REVIEW OF LITERATURE 76 3. Smoking - Cigarette smoking is associated with an increased risk of chronic plaquepsoriasis4. Alcohol - Alcohol is considered a risk factor for psoriasis, particularly in young tomiddle-aged males.5. Endocrine - The disease state may fluctuate with hormonal changes. Psoriasis maybegin during puberty. Pregnancy may improve the disease. While a flare may occurduring post-partum period.6. Weather- Cold weather may make skin drier and more susceptible to a psoriasisoutbreak.7. Diet- Although unproven, changing the diet has helped some people improve theirpsoriasis 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 travelthroughout the body to detect and fight off foreign substances, such as viruses orbacteria. In people with psoriasis, however, the T cells attack healthy skin cells bymistake as if to heal a wound or to fight an infection. Overactive T cells trigger other immune responses that cause an increasedproduction of both healthy skin cells and more T cells. What results is an ongoingcycle in which new skin cells move to the outermost layer of skin too quickly in daysrather than weeks. Dead skin and white blood cells cant slough off quickly enoughand build up in thick, scaly patches on the skins surface. This usually doesnt stopunless treatment interrupts the cycle217.Genetic Causes of Psoriasis Often, a person with psoriasis has a parent or grandparentwho also has the condition. Researchers estimate that a person with one affectedparent has about a 10% chance of also having psoriasis. Having two parents withpsoriasis increases the chances to about 30%218.     DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 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         Clinical Lesions of psoriasis              CLINICAL FEATURE Clinically, psoriasis exhibits itself as dry, well-defined macules, papules andplaques 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) orfigurate 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).DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 98. REVIEW OF LITERATURE 78 Distribution-The lesions are symmetrically disposed on extensor surfaces of thebody. Typical sites of affection are the elbows, knees, shin, knuckles, sacral areas andscalp.Uniformity: The psoriatic plaques tend to have the same features irrespective of siteexcept 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, guttatelesions and pustules, lesions may take on a variety of morphological forms andshapes. Verrucous, lichenoid, follicular, linear, annular, figurate, gyrate are some ofthe 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 adissecting forceps, a candle-grease-like scale can be repeatedly produced even fromthe 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 calledAuspitz sign. The lesions are slightly raised above the surface of the skin, but thereare no indurations.Koebners phenomenon- Psoriatic lesions may develop along the scratch lines in the active phase; thisis called Koebners phenomenon (other common diseases in which Koebnersphenomenon occurs are warts and lichen planus).Reverse-Koebner phenomenon So-called reverse-Koebner reactions have also been noted in which preexisting psoriatic plaques actually clear after injury or trauma to the skin. The centralclearing of the circular lesions produces ringed lesions - Annular psoriasis. PsoriasisDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 99. REVIEW OF LITERATURE 79 is normally characterized by the absence of itching, but in tropical countries, patientscomplain of slight or moderate pruritus which, if accompanied by secondarypsychogenic 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. Thereare no special blood tests or diagnostic procedures for psoriasis. Sometimes a skinbiopsy, or scraping, may be needed to rule out other disorders and to confirm thediagnosis. 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. Eachform has distinct characteristics. Typically, people have only one type of psoriasis at atime, but occasionally two or more different types of psoriasis can occur at the sametime. Psoriasis can also occasionally change from one form to another. Trigger factorsmay "convert" some forms of psoriasis, such as plaque, to another form, such aspustular. Generally, one type of psoriasis will clear and then another form of psoriasiswill appear later222. Thus it occurs in a variety of forms that differ in, their intensity,DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 100. REVIEW OF LITERATURE 80 duration, location, shape and pattern of scales. Some dermatologists classify psoriasisas 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 roughlyequal 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 ofpsoriasis. Its scientific name is psoriasis vulgarise (vulgarise means common). PlaquePsoriasis can most likely to affect the typical areas of the elbows, knees, umbilicusand lower back. Although it seems that the most common areas are the elbows andknees. It is typically appears as raised areas of inflamed skin covered with silverywhite scaly skin. Configuration of plaque psoriasis is sharply circumscribed, round-oval, or nummular (coin-sized) plaques. The lesions may initially begin aserythematous macules (flat and <1 cm) or papules, extend peripherally, and coalesceto form plaques of one to several centimetres in diameter. The shape of the plaque isusually oval but can be irregular in shape. Smaller plaque areas may merge with otherareas and form a large affected area. The skin in these areas, especially when overjoints or on the palms or feet, can split and bleed. A white blanching ring, known asWoronoff’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 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 101. REVIEW OF LITERATURE 81  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. Theselesions usually appear on the trunk and limbs, and sometimes on the scalp. Theyusually are not as thick or scale-covered as plaque psoriasis. It often starts inchildhood or young adulthood. It often comes on quite suddenly. It may be triggeredby strep throat, an infection of the throat. There are also other causes that can triggeran attack of guttate psoriasis such as tonsillitis, a common cold, chicken pox,immunisations, physical trauma, psychological stress, illness, and the administrationof antimalarial drugs. Guttate Psoriasis may clear on its own accord, leaving aperson free from further outbreaks. Or, it may clear for a time only to reappear later aspatches of Plaque Psoriasis. Sometimes guttate can flare throughout childhood, oftendue to repeated bouts of strep infection or other upper respiratory illnesses. Withouttreatment it may represent the initial stage of chronic plaque-type Psoriasis. The acuteguttate form progresses into the chronic plaque form in about 70% of patients. Likeother forms of psoriasis, guttate psoriasis has the tendency to improve during thesummer and worsen during the winter. Once cleared, many patients who experienceacute guttate psoriasis usually have limited or no evidence of psoriasis for prolongedperiods226.Pustular psoriasis It is primarily seen in adults, pustular [PUHS-choo-ler] psoriasis ischaracterized 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 maybe localized to certain areas of the body for example, the hands and feet. Pustularpsoriasis also can DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 102. REVIEW OF LITERATURE 82 be generalized, covering most of the body. It tends to go in a cycle–reddening of theskin followed by formation of pustules and scaling.Types of pustular psoriasisVon Zumbusch The onset of von Zumbusch pustular psoriasis can be abrupt. Widespreadareas of reddened skin develop, and the skin becomes painful and tender. Within afew hours, the pustules appear. The pustules then dry and peel over the next 24 to 48hours, leaving the skin with a glazed, smooth appearance. A fresh crop of pustulesmay 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 causespustules on the palms of the hands and soles of the feet. PPP is characterized bymultiple pencil eraser-sized pustules in fleshy areas of the hands and feet, such as thebase of the thumb and the sides of the heels. The pustules appear in a studded patternthroughout reddened plaques of skin, then turn brown, peel and become crusted. Thecourse of PPP is usually cyclical, with new crops of pustules followed by periods oflow 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 anoverweight stomach (pannus), and under the breasts (inframammary fold). It isaggravated by friction and sweat, and is vulnerable to fungal infections. Flexurallesions are devoid of scale and appear as red, shiny, well demarcated plaquesoccasionally confused with candidal, intertrigo, and dermatophyte infections213.Erythrodermic psoriasis Involves the widespread inflammation and exfoliation of the skin over most ofthe body surface. It may be accompanied by severe itching, swelling and pain. It isDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 103. REVIEW OF LITERATURE 83 often the result of an exacerbation of unstable plaque psoriasis, particularly followingthe abrupt withdrawal of systemic treatment. This form of psoriasis can be fatal, as theextreme inflammation and exfoliation disrupt the bodys ability to regulatetemperature and for the skin to perform barrier functions. It may be triggered bysevere sunburn, by corticosteroids and other medications, or by another type ofpsoriasis thats poorly controlled213.DIFFERENTIAL DIAGNOSIS In the majority of cases, the diagnosis of psoriasis is usually easy if the abovementioned features are borne in mind. Atypical cases may create diagnostic problems.The following conditions must be particularly considered in differential diagnosis ofpsoriasisTable No : 41 Differential Diagnosis Disease Clinical features Cause Diagnosis Scaling annular to round patchesTinea and Dermatophyte and onycholysis and crumbling KOHonycholysis infections nails. Diffuse lesions with greasy scales PossiblySeborrheic Skin biopsy may on scale behind ears, nasolabial overgrowthdermatitis help folds and presternally. pityrosporum Guttate or small scaling plaquesSecondary Positive test for over trunk, like pityriasis rosea, Spirochetesyphilis syphilis RPR but involve palms and soles.Cutaneous Flat to thick plaques with variable T-cell Skin biopsy scaling, this may be identical to lymphoma Sézary cells inT-cell psoriasis anywhere on body. May circulation. T-DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 104. REVIEW OF LITERATURE 84 lymphoma be erythrodermic-Sézary cell gene syndrome. rearrangement Identical skin changes as psoriasis with pustular lesions on palms and Unknown, but Clinical features, soles (keratoderma triggered byReiters arthritis, blennorrhagicum), balanitis certainsyndrome conjunctivitis, circinata; arthritis nail infectious urethritis involvement. Mucous membrane agents changes not seen in psoriasis. Diffuse salmon-colored papulosquamous lesion areas,Pityriasis normal skin in midst, involved Clinical features, Unknown rubra pilaris skin—“island sparing,” skin biopsy keratoderma palm. Keratotic papules on dorsum of fingers.Pityriasis Red, purpuric, vesicular lesionslichenoides evolve into scaling macular and Clinical features, Unknownvarioliformis papular lesions that scar. Lesions skin biopsyacuta occur over entire body.KOH, Potassium hydroxide; RPR, rapid plasma reagin228.     DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 105. REVIEW OF LITERATURE 85 PSORIATIC ARTHRITIS (PsA) Psoriatic arthritis causes inflammation in and around the joints, usually inpeople who already have the skin condition psoriasis. Sometimes, however, thearthritis develops before the psoriasis229. The exact cause of psoriatic arthritis is not known. Many factors seem to beinvolved in its development. Heredity, genes plays a major role. People who areclosely related to someone with psoriatic arthritis are 50 times more likely to developthe disease themselves. Recent studies have located genetic markers shared by mostpeople 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 jointsDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 106. REVIEW OF LITERATURE 86  • high immunosuppressive medication useGood 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).231Table No: 42 CLASSIFICATION OF PSORIATIC ARTHRITIS Asymmetric arthritis does not occur in the same joints on both sides of the body and usually affects Asymmetric 30-50%1. only one to three joints. Typically the knee, hip, arthritis of cases ankle or wrist will be affected This form is generally mild and is the most common This type is similar to rheumatoid arthritis but is 30-50% typically milder and with less cases of deformity.2. Symmetric arthritis of cases It can be severe and multiple joints on both sides of the body may be affected. Distal Sometimes mistaken for osteoarthritis, this type 25%of3. Interphalangeal usually affects the last joint of the fingers and toes cases Predominant (distal interphalangeal joint A rare but serious condition, spondylitis can cause deformity and changes in posture. Inflammation of Psoriatic 30-35%4. the spine is the most common symptom. Spondyloarthritis of cases Movement may be painful as the neck and lower back may also be stiff and inflamed. Usually the small joints in the hands and feet are 50%of affected. This type is unusually severe because it5. Arthritis Mutilans cases may actually destroy the bones and cartilage. Pain may be associated to skin flare-ups and remissionsDEPARTMENT 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 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 rarein psoriasis, and even then, the primary cause of mortality is related to its therapy.Adverse effects of systemic treatments (eg, hepatic fibrosis from methotrexate) andPhototherapy (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 patients 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 withpsoriasis, even in patients with less severe disease.Cohort studies have shown that anincreased risk of nonmelanoma skin cancers and lymphoma is associated withpsoriasis. This risk is higher in patients with more severe disease, but it is not clearwhether 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 medicalconditions it becomes clear that the reduction in quality of life that these patientsexperience is comparable to the reduction in quality of life with other medicalillnesses. On the physical dimensions of health-related quality of life, psoriasis hasless impact than congestive heart failure, but greater impact than hypertension,diabetes, post-myocardial infarction and depression. However, on the mentalDEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 108. REVIEW OF LITERATURE 88 dimensions of health-related quality of life, psoriasis was considered worse than allthese conditions except depression. These findings have importance not just forpsoriasis but for skin disease in general. These are not cosmetic problems; thesediseases cause quantifiable reductions in health-related quality of life. The NationalPsoriasis Foundation (NPF) was founded with the goals of providing psychosocialsupport and education to psoriasis patients. It is important for dermatologists toencourage their patients to join this supportive and politically effectiveorganization233.TREATMENT As Psoriasis is a complex disorder that negatively impacts quality of life,Sotreatment strategies must address both psychosocial and physical aspects of thedisease. Psoriasis can be categorized into localized and generalized forms fortreatment purposes. In either case, the treatment plan should include obtaining rapidcontrol of the disease and maintaining that control. For localized disease, recent datasupport the combined use of topical corticosteroids with a non corticosteroid agent(topical calcipotriene or tazarotene). For generalized disease, UVB phototherapy is aneffective treatment that permits both rapid control and long-term maintenance234.Management principles Treatment is as much guided by the patients perception of their condition as by the objective severity of it. Treatment options have to take into account the patients 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.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 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 ofspecific Psoriasis treatments. Because of this, dermatologists often use a trial-and-error approach to finding the most appropriate treatment for their patient. Thedecision to employ a particular treatment is based on the type of psoriasis, itslocation, extent and severity. The patient’s age, gender, quality of life, co morbidities, and attitude towardrisks Associated with the treatment are also taken into consideration. Medications with the least potential for adverse reactions are preferentiallyemployed. If the treatment goal is not achieved then therapies with greater potentialtoxicity may be used. Medications with significant toxicity are reserved for severeunresponsive 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  Sulphur was fashionable as a treatment for psoriasis in the Victorian andEdwardian eras. It has recently re-gained some credibility as a safe alternative tosteroids and coal tar. On August 27, 2006, scientists led by Jeung-Hoon Lee created in the laboratorysynthetic lipids called pseudoceramides which are involved in skin cell growth andcould be used in treating skin diseases such as atopic dermatitis, a form of eczemacharacterized by red, flaky and very itchy skin; psoriasis, a disease that causes redscaly patches on the skin; and glucocorticoid-induced epidermal atrophy, in which theskin 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   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 111. REVIEW OF LITERATURE 91  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 Safe and effective for both initial clearing and long term control. Efficacy may be increased by day treatment regimens or UVB Phototherapy combination with low-dose acitretin. Narrow-band UVB may be more effective than broadband. More effective than broadband UVB but causes high risk of Psoralen + UVA Cutaneous malignancy. PUVA should probably be used in (PUVA) and PUVA + combination with oral retinoids when possible to help minimize acitretin (Re-PUVA) PUVA exposure. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 112. REVIEW OF LITERATURE 92  Very effective therapy for pustular psoriasis. Less effective as a Acitretin (Soriatane) monotherapy for plaque psoriasis. Very helpful as an adjunct to phototherapy. Relatively safe as a long-term treatment. Highly effective therapy. Patients appreciate the simplicity of the treatment regimen. There is the risk of life-threatening Methotrexate hematologic toxicity at any time during therapy and both acute and chronic hepatotoxicity. Careful monitoring is essential Very effective treatment. Especially helpful for immediate Cyclosporine control of severe disease. Less helpful as a long-term therapy (Neoral) (>1 year) due to renal toxicity. • Mycophenolate mofetil- helpful in combination with other drugs. Monitor for hematologic toxicity. • Hydroxyurea- helpful for patients with cirrhosis who Other immune require systemic therapy. Close hematologic monitoring inhibitors 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   DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 113. REVIEW OF LITERATURE 93  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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 114. REVIEW OF LITERATURE 94  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 orpharmacist. Some should not be used on the face and others must be used only in alimited area. Calcipotriene (Dovonex) should not be used with products that containsalicylic 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.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 115. REVIEW OF LITERATURE 95 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 patients Psoriasis Area and Severity Index (PASI) is a measure of overallpsoriasis severity and coverage. It is a commonly-used measure in clinical trials forpsoriasis treatments. Typically, the PASI would be calculated before, during, and aftera treatment period in order to determine how well psoriasis responds to the treatmentunder 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 willdepend on the researchers and what they are looking for, specifically. The only way tolearn exactly how the PASI has been modified is to read whatever study youreinterested 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 theseareas 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 persons 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 ofthe skin just in that part of the body (not the whole body - see below), and then assignit a score from 0 to 6:DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 116. REVIEW OF LITERATURE 96  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 toother parts of body find the area score for the other three Skin Sections - Alegs, Abodyand 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 ascale 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 its only somewhat red, our Ehead score would be 1. Also calculate Shead (scaling onthe 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 readyto calculate our PASI. For each Skin Section, add up the four severity scores, multiplythe total by the area score, and then multiply that result by the percentage of skin inthat section, as follows:DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 117. REVIEW OF LITERATURE 97  • 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. Thats it. This PASIwill range from 0 (no psoriasis) to 96 (covered head-to-toe, with complete itching,redness, scaling, and thickness) 236.DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 118. REVIEW OF LITERATURE 98  PSORIASIS & KUSHTA Type of the kushtas which resembles the features of psoriasis listed below with theirfeatures: - Table no :43 Showing Features of different types of Kushtha in relation to PsoriasisEKA KUSHTA KITIBHA SIDMA CHARMADALA MANDALA1. Asewdana 1. Kinakhara 1. Sweta 1. Kandu 1. kandu2. Krishna,aruna sparsha tamravar 2. Osha 2.mandalavath varna 2. Kandu na 3. Chosha 3.pidaka3. Matsya 3. Parusha 2. prayena 4. Rakthavarna 4. Raga. shakalopamam 4. Shyava urasi 5. spotha 5.Sthira4. Mahavastu. 5. Punahapuna utpadyate 6. Ruk udpadyate 3. Alpa 7. Dalathi kandu 8. sparshanasaha 4. pooya 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 pictureof psoriasis. There are lacking in such type of correlation, Psoriasis can appear as a milderform 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 ofdisease. Proper diagnosing is the prime step of treatment. So assessments based on doshadushyadi will helps to plan the ideal treatment. In ayurveda importance is not given fornaming 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 inpersons who are having same prakruti. kushta may present either seven or eighteen orinnumerable forms. So naming the disease is not important, undersanding the dosha dushyadiand 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    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 toAcharya Charaka says that an ideal medicine should possesses the qualities ‘Bahuta’,‘Yogyata,’ ‘Anekavidhakalpana,’ and ‘Sampath’. Drug is a part of CikitsaCatushpaada, which has been placed next to the physician. The knowledge of the drugis very important to physician because without knowledge of drug the patient cannotbe treated properly. In this way, all Ayurvedic classics advocate specific formulation for particular disease.Drugs for Deepana Pachana : Chitrakadi Vati 236It 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 . DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 121. DRUG REVIEW 101    Table no:44: RASA PANCHAKA OF CHITRAKADI VATISl. Drug Latin Rasa Guna Virya Vipaka Doshagnata Karmano Name1 Citraka Plumbago Katu Laghu Ushna katu Kaphavata Deepana zeylanica Ruksa shamaka Pachana pita vardaka Arsoghna2 Pippali mula Pipper Katu Laghu Ushna katu Vatakapha Kasahara Longum Ruksa shamaka Deepana Swasahara3 Yava Potasii Katu Laghu Ushna Katu Kapha Deepana Kshara Carbonas Snigdha vatashamaka Pachana4 Sarja Impure Lavana Teekshna Ushna katu Vatashamaka Pachana kshara carbonate Katu of soda5 Saindhava Sodi Madhur Laghu, Sheeta Katu Tridosha Deepana, chloridium Lavana Snigdha shamaka Pachana Ruchya, Vrushya, Netrya6 Sauvarchala Unaqua Katu Sneha, Ushna Katu Vata Deepana, Sodium Laghu, shamaka Rochna, Chloride Vishada Bedhana7 Samudra Sodi Lavana, Guru, Ushna Madhura vatashamaka Deepana, muris Tikta, Snigdha Ruchya, Madhur Pachna8 Vida Lavana Laghu Ushna Madhura Kapha vata Hrudya ,Ushna, shamana Vatanulom - Teeksha, na Sukshma9 Uadbhida - Katu Guru Sheetal Katu Vatashamaka Ruchya Snigda a10 Sunthi Zingeber Katu Guru Ushna Madhura Kaphavata Truptighna DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 122. DRUG REVIEW 102    officinalis Ruksa shamaka Deepana Pachana11 Pippali Pipper Katu Laghu Ushna Katu Vatakapha Kasahara Longum Ruksa Shamaka Deepana Swasahara12 Maricha Pipper Katu Laghu Ushna Katu Vatakapha Deepana Nigrum Ruksa Shamaka13 Hingu Ferula Katu Laghu Ushna Katu Kaphavata Deepana Narthex Ruksa shamaka pitavardaka14 Ajamoda Trachysp- Katu Laghu Ushna Katu Kaphavata Deepana ermum Ruksa shamaka ammi pitavardaka15 Cavya Pipper Katu Laghu Ushna Katu Kaphavata Deepana Chaba Ruksa shamaka pitavardaka 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 123. DRUG REVIEW 103   Table no :45: RASA PANCHAKA OF MAHATIKTHAKA GHRITHASl Drug Latin Rasa Guna Virya Vipaka Doshag KarmaNo name nata.1. Sapta Alstonia Tikta Laghu Usna Katu Tridosh Dipana , parna scholaris ,kasaya , ahara Hrdya snigdh a2. Ativisa Acponitu Katu , Laghu Usna Katu Tridosa Dipana m kasaya , hara ,pacana, heteropyll ruksha krimihara um3. Aragvadh Cassia Madhura Mrudu Sita Madhur Kapha- Sramsana a fistula , pittahar Guru, a Snigd ha4. Patha Cissampel Tikta Laghu Usna Katu Vata- Visaghna, os pariera ,tiksna kaphah Grahi , ara Balya5. Amalaki Embilica Lavanavarj Guru, Sita Madhur Tridosa Vayassthapana officinalis ita Ruksa, a hahara , pancarasa Sita rasyana, cakusya, vrsya6. Haritaki Terminalia Amlavarjit Laghu Usna Madhur Tridosh Anulomana, chebula a , a ahara Rasayana, Pancarasa Ruksa Kustagna7. Vibhitaki Terminalia Kasaya Ruksa, Usna Madhur Kapha- Bhedana, belirica Laghu a pittahar Caksusya a8. Patola Tricosanth Tikta, Laghu Usna Katu Kapha Vrsya, es dicocia Katu , – Varnya , Ruksa pittahar Dipana a DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 124. DRUG REVIEW 104   9. Nimba Azadiracht Tikta, Laghu Sita Katu Kapha- Grahi, a indica Kasaya , pittahar Krimgna, Ruksa a Dipana10 candana Santalum Tikta, Laghu Sita Katu Kapha- Varnya,. album Madura , pittahar Dahaprasaman Ruksh a a a11 Parpata Fumaria Tikta Laghu Sita Katu Kapha- Trsnaninigraha. parviflora pittahar na, a Grahi12 Padmaka Prunus Kasya, Laghu Sita Katu Kapha- Varnya ,. puddum Tikta , pittahar Vrsya snigdh a a13 Haridra Curcuma Tikta, Ruksa, Usna Katu Kapha- Lekana ,. longa Katu Laghu vatahar Varnya , a Visagna14 Daruharid Berberis Tikta, Laghu Usna Katu Kapha- Chedana ,. ra aristata Kasaya , pittahar Varnya Ruksa a15 Vacha Acorus Tikta, Laghu Usna Katu Kapha- Lekaniya , calamus Katu , vatahar Medya Tiksna a16 Satavari Asparagus Madura, Guru, Sita Madura Vata- Rasayna ,. racemosus Tikta Snigd pittahar Vrsya , ha a Stanyajnana17 Sariva Hemedism Madura , Guru, Sita Madura Tridosa Grahi. us indicus Tikta Snigd hara ha18 Murva Marsedina Tikta, Guru, Usna Katu Kapha- Jvarahara. tenacissim Kasaya Ruksa vatahar a a19 Yashti Glycryrrhi Madura Guru, Sita Madura Tridosh Rasayana ,. madhu za glabra Snigd ahara Vrsya, ha Caksusya DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 125. DRUG REVIEW 105   20 Guduchi Tinospora Tikta, Guru, Usna Madura Tridosa Grahi, . cordifolia Kasaya Snigd samaka Medhya, ha 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 Drug Latin Rasa Guna Virya Vipaka Dosgnata KarmaNo name name 1. Karanj Pongamia Tikta, Laghu, Usna Katu Kapha- Bhedana , a pinnata Katu, Tiksna vatahara Sothahara kasaya 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 invishramakala of vamana & virechana. The lepa prepared from this choorna and Udgarshana by this choorna elevatesTvakdosha,Kusta,Sotha and Panduroga. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 126. DRUG REVIEW 106    Table no:47:RASA PANCHAKA OF SIDARTAKA SNANA CHOORNA Sl Drug name Latin name Rasa Guna Virya Vipaka Dosagnata KarmaNo 1. Musta Cyperus Tikta, Laghu, Sita Katu Kapha-pitta Dipana, rotunds Katu, Ruksa hara pacana, Kasaya grahi, lekana 2. Madanaphala Randia Madura, Laghu, Usna Katu Kaphavatahara Chardana, dumetrom tikta, Ruksa Lekhana, 3. Amalaki Embilica Lavanava Guru , Sita Madura Tridosahara Vayastapana, officinalis rjita Ruksha, Rasyana, pancaras Sita caksusya, a vrsya 4. Haritaki Terminalia Amlavarj Laghu, Usna Madhura Tridoshahara Kustagna , chebula ita Ruksha Anulomana, pancaras Rasayana a 5. Vibhitaki Terminalia Kasaya Ruksha Usna Madhura Kapha - Bhedana , belirica , pittahara Caksusya Laghu6. Karanja Pongamia Tikta, Laghu, Usna Katu Kapha Bhedana, pinnata Katu, Tiksna vatahara Sothahara kasaya 7. Aragvadha Cassia fistula Madhura Mrudu , Sita Madhura Kapha- Sramsana Guru , pittahara Snigdha 8. Kutaja Holarrhena Tikta, Laghu, Sita Katu Kapha- Grahi, antidycentrica Kasaya, ruksa pittahara dipana 9. Saptaparni Alstonia Tikta, Laghu, Usna Katu Tridoshahara Dipana, scholaris kasaya Snigdha Hrdya DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 127. DRUG REVIEW 107    DRUG SELECTED FOR VIRECHANA - ABHAYADI MODAKA240 It is explained in Sharngadhara samhitha uttarakhanda 3/26-33 in the context ofVirechana.Indications:Vishamajwara,Mandagni,Pandu,Kasa,Bhangadara,Durnama(Arsas),Kustha,Gulma,Galaganda,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 perthe classics . Along with the seetha jala it is taken.Here in the present study depending upon the agni,bala &kostha of the patient eachModaka measuring of 255mgms each is given along with seetha jala as anupana. Virechana kalpa according to Sharangadhara. 62 Heena for Mridu Madhyama for Uttama forKalpana Koshta Madhyama Koshta Krura KoshtaModaka 4 tolas 2 tolas 1 tola DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 128. DRUG REVIEW 108    Table no:48: RASAPANCAKA OF ABHYADIMODAKAsl Drug Latin name Rasa Guna Viry Vipaka Doshagnata Karman name ao1. Abhay Terminalia Amlavarjita Laghu, Ushn Madhu Tridoshahar Anulomana, a chebula Pancarasa Ruksha a ra a Rasayana ,caksusya2. Marica Piper nigrum Katu Guru, Ushn Ushna Kaphavataha Pramathi Ruksha a ra , Tiksna3. Sunthi Zingiber Katu Guru, Ushn Madhu Vata Bhedana, officinale Ruksha a ra kaphahara Deepana , Tiksna4. Vidang Embelia ribes Katu, Laghu, Ushn Katu Vata Vishgna , a Kasaya Ruksa, a kaphahara Krimgna, Tiksna Dipana5. Amala Embilica Lavanavarji Guru, Sita Madhu Tridoshahar Vayasstapa ki officinalis ta Ruksha ra a na, pancarasa , rasayana, sita caksusya ,vrsya.6. Pippali Piper longum Katu Laghu, Ushn Madhu Vatakaphaha Dipana, Snigdh a ra ra Vrsya, a, Rasayana tiksna7. Mustak Cypreus Tikta, Laghu, sita Katu Kapha Dipana , a rotundus Katu, Ruksha pittahara Pacana, Kashaya Grahi, Lekhana8. Danti Baliposperm Katu Guru , Ushn Katu Kapha Rechana, um Tiksna a vatahara Dipana montanum9. Trivrt Operculina Tikta, Laghu, Ushn Katu Kapha Rechana turpethum Katu Ruksa, a pittahara Tiksna DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS” 
  • 129.                                                                                      METHODOLOGY 109  CLINICAL STUDYAIMS AND OBJECTIVESTo evaluate the effect of Virechana karma in patients suffering from psoriasis.MATERIAL AND METHODSA. 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 CRITERIA1) Patients with signs and symptoms of psoriasis.2) Patients of either sex of age group between 15 to 70 years.EXCLUSIVE CRITERIA1) 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 ontheir status of Agni in terms of Sama and Niramata for 3-7 Days till Nirama Lakshanas areseen. 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 nightmeal. During this period the patients were advised to consume little quantity of hot water inbetween 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 arisesin all the patients. Then patient was continuously observed for appearance of Sneha Jeeryamana, SnehaJeerna features. Based on the time of Snehajeerna lakshana the dose of Sneha for next daywas 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 withKaranja Taila followed by Sarvanga Parisheka with Sidarthakasnana choornaKashaya wasperformed. Thus Bhaya Snehana and Swedana was performed for 4 days and during this periodpatient was advised to avoid consumption of Kaphakara Ahara and Vihara.PRADHANA KARMA On the 4th day depending upon the rogi & roga bala Virechana Yoga Abhyadimodakadose was decided. After the Parisheka procedure, ascertain the patient for proper digestion of previousnight meal. Then above mentioned Virechana yoga with sufficient quantity of Sheeta jala asAnupana was administered to patient on empty stomach in the morning hours in between9.30 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.Pwere 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 theprecautions related to Virechana. Then Samsarjana Karma was decided on the basis of Shuddhi lakshana and it wasstarted 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) wasspecially 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 thebasis 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 - kramashanissaranaAntaki 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 documentedas 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 ofVirechana medicine still the cessation of Vega. In the all cases first one Vega was left forcounting 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 presentstudy.2. Maanaki feature In present study during the each time of defecation the stool and urine was collectedand then it was measured and documented separately. Thus it was performed after each Vegaexcept first Vega . Then finally the value of total quantity of stool and urine added to obtaintotal amount of output. Apart from this total amount of water consumed(Anupana) by patientafter 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 anddocumented 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 scaleswere removed with the help of finger or plane dissecting forceps. Afterwards observe theunderlying surface. It was found that reddish discoloration of underlying surface associatedwith minute vasodilatations of superficial blood vessels and it was considered as positivetests of Auspitz sign.4. Candle Grease Test. The psoriatic lesions were scratched with the point of a dissecting forceps and observefor formation of a candle-grease like appearance on lesion. If it present then it wasdocumented as positive otherwise as negative.5. PASI (Psoriasis Area and Severity Index) To understand overall effect of Virechana karma on Psoriasis, the Psoriasis area andseverity index (P.A.S.I) scoring method was also adopted as follows. For the PASI, the bodyis divided into four sections each of these areas is scored by Skin itself and then the fourscores are combined into the final PASI. The four areas are: the Legs, which have 40% of apersons skin; the Body (trunk area: stomach, chest, back, etc.) at 30%; the Arms (20%); andthe Head (10%). Area: For each Skin Section, measured the amount of skin involve, as a percentage ofthe skin just at that part of the body (not the whole body - see below), and then assign it ascore from 0 to 6:Showing PSAI Coverage area scoreCoverage Score 0% 0 < 10% 110-29% 230-49% 350-69% 470-89% 590-100% 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 ismeasured separately for each Skin Section. These are measured on a scale of 0 to 4, fromnone to maximum, according to the following chart: Severity Score None 0 Some 1 Moderate 2 Severe 3 Maximum 4Totaling Up the Index: When all 20 of the above scores are figured out, then it is ready tocalculate PASI. For each Skin Section, add up the four severity scores, multiply the total bythe area score, and then multiply that result by the percentage of skin in that section, asfollows: • 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 = TotallegsFinally, the PASI is Totalhead+Totalarms+Totalbody+Totallegs. This PASI will range from 0 (nopsoriasis) 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 Virechanathe 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  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. 01Age in Number of 7 7 % year patients 6 5 5 425-35 04 20 4 336-45 07 35 2 2 246-55 05 25 156-65 02 10 0 26- 35- 46- 56- 66- AGE66-75 02 10 35 45 55 65 75 The minimum age of the patient of this study was 25years & maximum was 73years. 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 andminimum 04% was between 56- 65,66-75 age groups. SEX-WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 50 Sex Figure No. 02 No of 95 Sex % patients 100 80 60 Male 19 95 40 5 20 Female 0 SEX 01 5 19 1 According to sex wise distribution of the patients showed that maximum number i.e.95% of the patients was male and 5 % were female. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 136. OBSERVATIONS 116  RELIGION-WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 51Religion Figure No. 03Religion No of % 85 90 patients 80 70 Hindu 17 85 60 50 40 Muslim 02 10 30 20 10Christian 01 05 10 2 0 17 2 1 RELIGION Among 20 patients of these series maximum patients 85% were belonged to theHindu community, whereas 10% was belonged to Muslim &5% Christian communityMARITAL STATUS WISE DISTRIBUTION OF 20 PATIENTS OFPSORIASISTable No: 52 Marital Status Figure No. 04 Marital No of 95 % status patients 100 80 Married 19 95 60 40 5 20Unmarried 01 05 0 MARITAL 19 1 STATUS Among the 20 patients of Psoriasis taken for this study, a maximum of 95%patients were married where as 05% patients are unmarried. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 137. OBSERVATIONS 117  LITERACY WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 53 Literacy incidences Figure No. 05 Education No of % patients 70 65Uneducated 02 10 60 50 Secondary- 02 10 40 School 30 Graduation 13 65 15 20 10 10 10 Primary 03 15 0 2 2 13 3 LITERACY Among all the 20 patients taken for this study, the maximum 65% of patients hadstudied up to graduation; where as 13% of patients had studied up to the level ofprimary 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 ofSite of Onset patients % 50 50Head /Scalp 10 50 45 40 40 35Upper Limb 01 05 30 25Lower Limb 40 20 08 15 10 10 5 Trunk 02 10 5 0 10 1 8 2 ONSET Out of all 20 patients maximum about 50% of patients had history of site ofonset of Psoriatic lesion on Scalp where as on Trunk only 10%. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 138. OBSERVATIONS 118 SEASONAL IMPACT WISE DISTRIBUTION OF 20 PATIENTS OFPSORIASIS Table No: 55 Seasonal Impacts Figure No. 07Season No of % patients 60 55Winter 11 55 50 40 30 Rainy 06 30 30 20 15Summer 03 15 10 5 NoSeason 01 05 0impact 11 6 3 1 SEASO NAL Out of all 20 patients maximum about 55% of patients had history ofexacerbation of Psoriatic lesion during winter season where as minimum of 05% ofpatients had nothing seasonal impact. ADDICTION WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 56 Addictions Figure No. 08 Habit No of 40 40 40 % Patients 35 Alcohol 30 & 3 15 25 Tobacco Smoking 20 15 Alcohol 08 40 15 10 Tobacco 5 5 Smoking 01 05 0 3 8 1 8 None 08 40 ADDICTAION Among 20 patients maximum about 40% of patients had no history of any type ofaddictions but 15% of patients had history of Alcohol imbibing & Tobacco smoking. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 139. OBSERVATIONS 119  DIET WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 57 Diet wise Figure No. 09 No of Diet patients % 80 70 60 Mixed 14 70 30 40 20Vegetarian 06 30 0 DIET 14 6 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 Family No of % 65 History patients 70 60 50 35 Positive 07 35 40 30 20Negative 13 65 10 0 FAMILY 7 13 HISTORY Among 20 patients, 65% of patients had negative history of Psoriasis and only35% of patients were with positive history. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 140. OBSERVATIONS 120  PRAKRUTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No : 59 Prakruti Figure No. 11 Prakruti No of % 65 patients 70 60Vata-Pitta 05 25 50 40 25 30Kapha-Pitta 02 10 20 10 10Kapha-Vata 13 65 0 5 2 13 PRAKR UTI Among 20 patients, 65% of patients were Kapha-Vata and 25% of patients werewith Vata-Pitta and 10% were with Kapha-Pitta Prakruti. DESHA WISE DISTRIBUTION OF 20PATIENTS OF PSORIASIS Table No: 60 Desha Figure No. 12 Desha No of % 75 patients 80 70 Anupa 15 75 60 50 40Sadharana 02 10 30 15 20 10 Jangala 03 15 10 0 DESHA 15 2 3 Out of 20 patients in maximum number of patients i.e. 75% of Anoopa Deshawhere as minimum 10% of patients belongs to Sadarana Desha. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 141. OBSERVATIONS 121  ANALYSIS OF TYPE OF KOSHTA IN 20 PATIENTS OF PSORIASIS Table No: 61 Type of Koshta Figure No. 13 No of 50 Koshta patients % 50 40 Mrudu 05 25 30 25 25 20Madyama 10 50 10 Krura 05 25 0 5 10 5 type of koshta Out of all 20 patients maximum about 50% of patients were belongs toMadhyama Koshta where as minimum of 25% of patients belongs to Mrudu andkrura Koshta. SATVA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 62 Satva Figure No. 14 Satva No of % 85 patients 90 80 70 Avara 02 10 60 50Madhyama 17 85 40 30 20 10 5 Pravara 01 05 10 0 satva 2 17 1 Out of 20 patients in maximum number of patients i.e. 85% of Madhyama satvawhere as minimum 05% of patients belongs to pravara satva . DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 142. OBSERVATIONS 122  SATMYA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 63 Satmva Figure No. 15 Satmya No of % 50 patients 50 45 40 40 Avara 02 10 35 30 25Madhyama 10 50 20 15 10 10 Pravara 08 40 5 0 satmya 2 10 8 Out of 20 patients in maximum number of patients i.e. 50% of Madhyamasatmva 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 Satmya No of % patients 65 70 60 Avara 05 25 50 40 25Madhyama 13 65 30 20 10 Pravara 02 10 10 0 samhana 5 13 2 na Out of 20 patients in maximum number of patients i.e. 65% of Madhyamasamhanana where as minimum 25% of patients belongs to Avara samhanana. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 143. OBSERVATIONS 123  SARA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 65 Sara Figure No. 17 Sara Number of 70 70 % patients 60Twak 01 05 50Rakta 06 30 40 35 30 30 25Mamsa 14 70 20Meda 05 25 10 5 0 0 Asti 07 35 0 twak 1 mamsa asti 7 shukra saraMajja 00 00 14 0Shukra 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% belongedtwak sara . AHARA ABHYAVARANA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 66 Ahara abyavarana shakti Figure No. 18 Satmya No of % 70 patients 70 60 Avara 01 05 50 40 25Madhyama 14 70 30 20 5 Pravara 05 25 10 0 AAS 1 14 5 Out of 20 patients in maximum number of patients i.e. 70% of MadhyamaAharaabyavarana shakti where as minimum 05% of patients belongs to AvaraAharaabyavarana shakti. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 144. OBSERVATIONS 124  AHARA JARANA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 67 Ahara jarana shakti Figure No. 19 Satmya No of % 75 patients 80 70 Avara 01 05 60 50 40Madhyama 15 75 30 20 20 5 Pravara 04 20 10 0 AJS 1 15 4 Out of 20 patients in maximum number of patients i.e. 75% of MadhyamaAhara jarana shakti where as minimum 05% of patients belongs to Avara Ahara jarnashakti. Distribution of 20 patients of Psoriasis according to pachakaagni Table No: 68 Figure No. 20 Agni Number 45 45 of % Patients 40 35 Vishama 03 15% 30 30 25 Teekshna 09 45% 20 15 15 Manda 06 30% 10 10 5 Sama 02 10% 0 agni v3 t9 m6 s2 Among 20 patients, 45% of patients have Teekshnagni,30%have Mandagni,15%have vishamagni,10%have samagni. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 145. OBSERVATIONS 125  VYAYAMA SHAKTI WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 69 Vyama shakti Figure No. 21 Vyama No of shakti % 80 patients 80 70 Avara 01 05 60 50 40Madhyama 16 80 30 15 20 5 Pravara 03 15 10 0 vyama 1 16 3 shakti Out of 20 patients in maximum number of patients i.e. 80% of MadhyamaVyama shakti where as minimum 05% of patients belongs to Avara Vyama shakti. VAYA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 70 Vaya Figure No. 22 Vaya No of % 75 patients 80 70 Bala 00 00 60 50 40 Madhya 15 75 25 30 20 Vrudha 05 25 10 0 0 vaya 0 15 5 Out of 20 patients in maximum number of patients i.e. 75% of Madhya Vayawhere as minimum 25% of patients belongs to vrudha . DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 146. OBSERVATIONS 126  DEHA BALA WISE DISTRIBUTION OF 20 PATIENTS OF PSORIASIS Table No: 71 Deha bala Figure No. 23Deha bala No of % 70 patients 70 60 Avara 04 20 50 40Madhyama 14 70 30 20 20 10 pravara 02 10 10 0 Deha 4 14 2 bala Out of 20 patients in maximum number of patients i.e. 70% of Madhyamadehabala 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 Candle No of 100 Grease patients % 85 Sign 80 60 Positive 17 85 40 20 15 Negative 03 15 0 CANDLE 17 3 GREASE SIGNAmong all patients the maximum percentage of patients shows Candle Grease Signpositive i.e. 85% where as in only 15% of patient this test was negative. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 147. OBSERVATIONS 127  ANALYSIS OF AUSPITZ SIGN IN 20 PATIENTS OF PSORIASIS Table No: 73 Auspitz Sign Figure No. 25Auspitz No of Sign patients % 100 85 80 Positive 17 85 60 40 15 20Negative 03 15 0 17 3 AUSPITZ SIGNAmong all patients the maximum percentage of patients shows Auspitz Sign positivei.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 Involvement No of 80 of Nails patients % 80 70 60 50 Positive 16 80 40 30 20 20 Negative 04 20 10 0 16 4 NAIL INVOLVEMENT Out of 20 patients, in maximum patients i.e. 80% their was absence of Psoriatic nailchanges where as in remaining 20% of patient’s presence of Psoriatic nail changes. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 148. OBSERVATIONS 128  ANALYSIS OF SCALING IN 20 PATIENTS OF PSORIASIS Table No: 75 Scaling Figure No. 27 SCALING No of % 100 100 patients 80 Positive 20 100 60 40 20 Negative 00 00 0 0 20 0 SCALINGAll 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 No of 90THICKNESS patients % 90 80 70 60 Positive 18 90 50 40 30 20 10 Negative 02 10 10 0 18 2 THICKNESS Among the 20 patients registered to this study 90% were associated with more orless thickness of skin and remain 10% their was no thickness. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 149. OBSERVATIONS 129  ANALYSIS OF ITCHING OF SKIN LESIONS IN 20 PATIENTS OF PSORIASIS Table No: 77 Itching Figure No. 29ITCHING No of % 96 patients 100 90 80 Positive 19 95 70 60 50 40 30 5Negative 01 05 20 10 0 19 1 ITCHINGAmong the 20 patients registered to this study 95% were associated with more or lessitching of skin and remain 05% their was no itching. ANALYSIS OF DISCHARGE IN 20 PATIENTS OF PSORIASIS Table No: 78 Discharge Figure No. 30 No of 80DISCHARGE patients % 80 70 60 Positive 16 80 50 40 20 30 20 Negative 04 20 10 0 16 4 DISCHARGOut of all 20 patients maximum about 80% of patients had history of discharge whereas minimum of 20% of patients didn’t have discharge. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 150. OBSERVATIONS 130  ANALYSIS OF TYPE OF KUSHTA IN 20 PATIENTS OF PSORIASIS Table No:79 Type of Kushtha Figure No. 31 Type of No of % Kushtha patients 70 70 Kitibha 14 70 60 Ekakushta 05 25 50 Sidma 02 10 40 30 Mandala 02 10 25 20 Charmadala 01 05 10 10 10 5 0 14 5 2 2 1 TYPE OF KUSHTA Out of all 20 patients maximum about 70% of patients were belongs to Kitibha typeof Kushta where as minimum of 05% of patients belongs to Charmadala type ofKushta. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 151. OBSERVATIONS 131  ANALYSIS OF VIRECHANA Distribution of patients according to days of appearance of samyak snigdha lakshana Table No: 80 Figure No. 32 Days Number % 50 45 of 40 30 patients 30 3 09 45 20 10 10 10 5 4 06 30 0 DAYS 5 02 10 3 4 5 6 7 6 02 10 7 01 05 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 lakshanaon 5th day and 6th day and 1 patient on 7th day. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 152. OBSERVATIONS 132  Total amount of abyantara sneha during the whole course of snehapana in 20 patients of psoriasisTable No: 81 Figure No. 33 Dose No. of % 35 35 patients 30 (In ml) 30 100-200 07 35 25 200-300 06 30 20 16 15 300-400 03 15 15 10 400-500 01 05 5 5 5 5 5 500-600 00 00 0 0 0 0 600-700 01 05 7 6 3 1 0 1 1 0 0 1 MAX.DOS 700-800 01 05 800-900 00 00 900-1000 00 00 1000- 01 05 1100 Maximum 35% of the patients had consumed total amount of sneha in between100-200 ml. where as minimum of only 05% of patient consumed between 1000-1100ml. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 153. OBSERVATIONS 133  Analysis of samyak snigdha lakshana Table No: 82 Figure No.34 Number 100 95 90 90 Lakshana of % 90 85 Patients 80 80 80 Adhastat 16 80% 70 snehadarsana Twaksnigdata 18 90% 60 Gatramardava 19 95% 50 40 Snehodvega 17 85% 40 30 Klama 16 80% 20 20 Vatanulomana 18 90% 10 Angalagava 08 40% 0 16 18 19 17 16 18 8 4 Laxshana Shaitya 04 20% Among 20 patients, 90% of patients had Vatanulomana feature where as minimum20% of patients had Shaitya feature. Analysis of samyak Swinna lakshana Table No: 83 Figure No. 35 Swinna Number Laxshana of % Patients 100 100 Sheeta 00 00 Viparame 90 80 Shula 04 20 80 Viparame 70 Stambha 06 30 60 nigraha 50 Gourava 08 40 40 40 nigraha 30 30 Mardavata 16 80 20 20 Sweda 20 100 10 0 Pradurbhav 0 0 4 6 8 16 20 LAXSHANA Among 20 patients, about 80%patients had tvak mardavata feature where as only30% of patients had Stambha feature. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 154. OBSERVATIONS 134  Analysis of latency period Table No: 84 Figure No. 36 Time Latency % 40 40 In period minutes 35 1-30 05 25% 30 25 25 31-60 08 40% 20 15 15 61-90 02 10% 10 10 10 91-120 03 15% 5 0 121-150 02 10% 5 8 2 3 2 LATENCY PERIOD Time required manifesting first Virechana Vega after administration ofVirechana drug is known as Latency period. In present study, Out of 20 patient’smaximum number of patients i.e. 40% the latency period was between 31-60 minuterange, where as in minimum of 10% of patients latency period was between 121-150minute range. Analysis of Duration of Virechana Table No: 85 Figure No. 37 Duration of Number 30 30 30 Virechana of % (min.) patients 25 120-240 02 10% 20 241-360 02 10% 15 361-480 06 30% 10 10 10 10 481-600 06 30% 5 5 601-720 02 10% 5 721-840 01 05% 0 2 2 6 6 2 1 1 841-960 01 05% 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). DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 155. OBSERVATIONS 135  Analysis of Vaigiki Shuddhi Table no: 86 Figure No. 38 Vaigiki Number % 45 Shuddhi of 45 40 Patient 40 35 Pravara 03 15% 30 (21-30) 25 20 15 Madhyama 08 40% 15 (11-20) 10 5 Avara 09 45% 0 (1-10) 3 8 9 VAIGIKI Out of 20 patient’s, in maximum number of patients i.e.45% Avara Shuddiwas found and minimum of 03% of the patients exhibited with Pravara Shuddi. Analysis of Manaki of VirechanaTable No: 87 Figure No. 39 45 45 40 Manaki Numb er 35 In ml % of 30 patien 25 ts 25 0-1000 01 05% 20 1001-2000 01 05% 15 15 2001-3000 05 25% 10 3001-4000 09 45% 5 5 5 4 5 40001-5000 00 00% 0 0 DOS 1 1 5 9 0 1 3 1 E 5001- 6000 01 05% 6001-7000 3 15% Out 20 patients,In maximum number of patient it in ranges between 3001-4000 ml and in one patient it was above 6000 ml. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 156. OBSERVATIONS 136  Analysis of Anthiki of Virechana Table No: 88 Figure No. 40 Number Anthiki of % Patient 60 60 50 Kaphanta 12 60% 40 Pittanta 03 15% 30 Drava 02 10% 20 15 15 10 malanta 10 Aushdhan 03 15% -ta 0 12 3 2 3 ANTHAKI In maximum number of patient i.e. 60% exhibited Kaphant virechana &minimum of 15 % with the Pittanta and ausdhanta virechana. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 157. OBSERVATIONS 137  Analysis of Laingiki Lakshana of Virechana Table no:89 Figure No. 41 100 Number 100 Laingiki % of 90 90 90 Lakshana Patients 90 80 Laghuta 20 100 80 70 70 Agnivrddhi 18 90% 70 Vatanulomana 18 90% 60 Kramat Vit, 18 90% 50 Pitta 40 35 Kaphagamana 30 Dourbalya 16 80% 20 Karsyata 14 70% 10 Kshut 14 70% 0 Trishna 07 35% 20 18 18 18 16 14 14 7 LAINGIKIDurably a Laingiki features are observed in maximum number of patients, otherinformation shown in above table. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS”
  • 158. RESULTS 138  RESULTS HEAD1] ITCHING Table No: 90 Mean D % Paired t test n BT AT SD SEM t P 20 2.850 1.100 1.750 61.41% 0.550 0.123 14.226 <0.001 Figure No. 42 3 2.5 2.85 2 1.5 1 1.1 0.5 0 BT AT ITCHING The mean score of itching over the head prior to treatment was 2.850 units. Itreduced to 1.100 units after treatment. The change that occurred with the treatment isnot great enough to exclude the possibility that the difference is due to chance.2] ERYTHEMA Table No: 91 Mean D % Paired t test n BT AT 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 2 1.85 1.5 1 0.75 0.5 0 BT AT ERYTHEMA The mean score of erythema over the head prior to treatment was 1.850 unitsbut after treatment it was reduced to 0.750 units. The change that occurred with thetreatment is not great enough to exclude the possibility that the difference is due tochance. 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 D % Paired t test n BT AT SD SEM t P 20 2.250 1.100 1.150 51.12% 0.671 0.150 7.667 <0.001 Figure No. 44 2.5 2 2.25 1.5 1 1.1 s 0.5 0 BT AT SCALING The mean score of Scaling over the head prior to treatment was 2.250 units butafter treatment it was reduced to 1.100 units. The change that occurred with thetreatment is greater than would be expected by chance; there is a statisticallysignificant change.4] THICKNESS Table No: 93 Mean D % Paired t test n BT AT SD SEM t P 20 1.550 0.500 1.050 67.74% 0.945 0.211 4.972 <0.001 Figure No. 45 2 1.5 1.55 1 0.5 0.5 0 BT AT THICKNESS The mean score of thickness over the head prior to treatment was 1.550 unitsbut after treatment it was reduced to 0.500 units. The change that occurred with thetreatment is not great enough to exclude the possibility that the difference is due tochance. 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  TRUNK1] ITCHING Table No:94 Mean D % Paired t test n BT AT SD SEM t P 20 3.150 1.350 1.800 57.15% 0.768 0.172 10.485 <0.001 Figure No. 46 4 3 3.15 2 1 1.35 0 BT AT ITCHING The mean score of itching over the trunk prior to treatment was 3.150 units butafter treatment it was reduced to 1.350 units. The change that occurred with thetreatment is greater than would be expected by chance; there is a statisticallysignificant change.2] ERYTHEMA Table No: 95 Mean D % Paired t test N BT AT SD SEM t P 20 2.700 1.400 1.300 48.14% 0.979 0.979 5.940 <0.001 Figure No.47 3 2.5 2.7 2 1.5 1.4 1 0.5 0 BT AT ERYTHEMA The mean score of erythema over the trunk prior to treatment was 2.700 unitsbut after treatment it was reduced to 1.400 units. The change that occurred with thetreatment is greater than would be expected by chance; there is a statisticallysignificant 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 D % Paired t test n BT AT SD SEM t P 20 2.950 1.700 1.250 42.37% 1.118 0.250 5.000 <0.001 Figure No.48 4 3 2.95 2 1.7 1 0 BT AT SCALING The mean score of Scaling over the trunk prior to treatment was 2.950 unitsbut after treatment it was reduced to 1.700 units. The change that occurred with thetreatment is greater than would be expected by chance; there is a statisticallysignificant change4] THICKNESS Table No:97 Mean D % Paired t test n BT AT SD SEM t P 20 2.600 1.350 1.250 48.07% 0.716 0.160 7.804 <0.001 Figure No. 49 3 2.5 2.6 2 1.5 1.35 1 0.5 0 BT AT THICKNESSThe mean score of thickness over the trunk prior to treatment was 2.600units but aftertreatment it was reduced to 1.350 units. The change that occurred with the treatment isgreater 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 LIMB1] ITCHING Table No:98 Mean D % Paired t test n BT AT SD (+) SE (+) t P 20 3.300 1.550 1.750 53.03% 0.910 0.204 8.596 <0.001 Figure No. 50 4 3 3.3 2 1.55 1 0 BT AT ITCHING The mean score of itching over the upper limbs prior to treatment was 3.300units but after treatment it was reduced to 1.550 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant change.2] ERYTHEMA Table No :99 Mean D % Paired t test n BT AT SDM SEM t P 20 3.150 1.700 1.450 46.03% 0.759 0.170 8.542 <0.001 Figure No. 51 4 3 3.15 2 1.7 1 0 BT AT ERYTHEMA The mean score of erythema over the upper limbs prior to treatment was 3.150units but after treatment it was reduced to 1.700 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant 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 D % Paired t test n BT AT SD SEM t P 20 2.850 1.600 1.250 43.85% 0.851 0.190 6.571 <0.001 Figure No.52 3 2.85 2.5 2 1.5 1.6 1 0.5 0 BT AT SCALING The mean score of Scaling over the upper limbs prior to treatment was 2.850units but after treatment it was reduced to 1.600 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant change4] THICKNESS Table No :101 Mean D % Paired t test n BT AT SD SEM t P 20 2.600 1.200 1.400 51.92% 0.995 0.222 6.294 <0.001 Figure No. 53 3 2.5 2.6 2 1.5 1 1.2 0.5 0 BT AT THICKNESS The mean score of thickness of skin over the upper limbs prior to treatmentwas 2.600 units but after treatment it was reduced to 1.200 units. The change thatoccurred with the treatment is greater than would be expected by chance; there is astatistically 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 LIMB1] ITCHING Table No:102 Mean D % Paired t test n BT AT SD SEM t P 20 3.650 1.650 2.000 54.79% 0.725 0.162 11.831 <0.001 Figure No. 54 4 3.65 3 2 1.65 1 0 BT AT ITCHING The mean score of Itching over the lower limbs prior to treatment was 3.650units but after treatment it was reduced to 1.650 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant change2] ERYTHEMA Table No: 103 Mean D % Paired t test n BT AT SD SEM t P 20 3.500 1.800 1.700 48.57% 0.733 0.164 10.376 <0.001 Figure No. 55 4 3.5 3 2 1.8 1 0 BT AT ERYTHEMA The mean score of Erythem over the lower limbs prior to treatment was 3.500units but after treatment it was reduced to 1.800 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant 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 4 3.5 3 2 1.8 1 0 BT AT SCALING The mean score of Scaling over the lower limbs prior to treatment was 3.500units but after treatment it was reduced to 1.800 units. The change that occurred withthe treatment is greater than would be expected by chance; there is a statisticallysignificant change.4] THICKNESS Table No:105 Mean D % Paired t test n BT AT SD SEM t P 20 3.150 1.750 1.400 44.44% 0.598 0.134 10.466 <0.001 Figure No.57 4 3 3.15 2 1 1.4 0 BT AT THICKNESS The mean score of thickness of Skin over the upper limbs prior to treatmentwas 3.150 units but after treatment it was reduced to 1.750 units. The change thatoccurred with the treatment is greater than would be expected by chance; there is astatistically 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 D % Paired t test n BT AT SD SEM t P 20 12.235 6.235 6.000 49.03% 2.228 0.498 12.042 <0.001 Figure No. 58 15 12.235 10 5 6.235 0 BT AT PASI The mean P.A.S.I. Score prior to treatment was 12.235 units. It reduced to6.235 units after treatment. The change that occurred with the treatment is greaterthan 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                                                                                    DISCUSSION Psoriasis is a major problem among the society till today because of its uglyappearance which may disturb personal, familiar and social life of the patient. Psoriasiscan be very persistent complaint. It does not kill but it is responsible for great deal ofunhappiness, feeling of depression at some point. Psychological problems can arise fromthe feelings of the patients about his/her appearance, social rejection, guilt,embarrassment for self and family, and emptiness. Research studies have shown thatpsychological stress is often caused by psoriasis, and can be a factor in ‘flares’ ofpsoriasis. In Ayurveda, almost all the disorder of the skin describing in the current scienceof dermatology can be taken under generalized term “Kushtha”. Previous researchscholars of Ayurveda have tried to correlate it with Ekakushtha, Kitibha and Sidhma. Buttypically, people suffered from only one type of psoriasis at a time, but occasionally twoor more different types of psoriasis can occur at the same time. However Psoriasis canalso occasionally change from one variety to another. Depending on the expose ofPsoriasis patient to different triggering factors, the existence forms of psoriasis may beget converted to another variety or form. Generally one type of psoriasis will vanishesand later another form of psoriasis will manifest. Thus as the clinical presentation ofPsoriasis 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 orSidhma etc. variety of Kushta or in other words to say as depending on the differentpresentation 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 forproper planning of the line of medicine or line of treatment rather to correlate it withcurrent Science of medicine. Hence by keeping all the above said facts in backdrop thepresent study was planned i.e. Virechana karma to manage the Psoriasis was selectedinstead of concentrating on any single variety of Kushta. In Ayurveda, the importance of DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 168. DISCUSSION 148                                                                                   Shodhana has been stressed, prior to Shamana line of treatment. Therefore in presentstudy Virechana Karma was selected for Shodhana purpose. In Kushta the Raktha dhatu is consider as one of main dhatu which is responsiblefor Prasara stage of Kushta Samprapti. As Sharangadhara described regarding the Pittaand Raktha dhatu have Ashreya-ashryi relationship, hence treatment modality ofPittadosha & Raktha dhatu resembling to each other. However among all the types ofSwedana Karma, Parisheka is one variety of Swedana which should be used in Vataassociated with Pitta disorders. Thus Parisheka is one of the important Bahiparimarjanatypes of treatment modality identified in the management of Kushta. So in this studySidartaka snana choorna kashya is used for parisheka . In all the Brhatrayi there is separate section (usually in Kalpasthana) regardingthe elaborations of Virechana drugs in terms their classification, Synonyms, Qualities,Purification, different methods of administration etc. was found. But still inChikitsasthana, while explaining different lines of treatment for different disorders theyidentified the selection of specific Virechana drug or its preparation, which has definiterole in the Sampapti vighatana of particular disease entity. Thus this specific Virechanayoga targeted towards the separation of exact Dosha dushya Sammurchana and helps toexpel of morbid Dosha out of the body through anal route. Thus most of the authorshighlighted Abhyadi modaka as Virechana yoga in the context of Kushta Chikitsa. Kushta is considering as Santarpanotta Bahudoshaavastha Dhirghakalinamahagada.So it was consider as Kricchrasadhya to treat. Because of this reason repeatedadministration of all the Panchakarma, different varieties of Shamana Chikitsa & evenAgada prayoga in certain stages of Kushta. Virechana is one among the Shodhana line oftreatment modality was identified and it should be administered at least once in sixmonths.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 agegroup of 25-35 yrs. 10% patients to 56-65 yrs & 66-75yrs & 66-75 yrs age groups (Tableno49.). Though psoriasis is a disease that manifests in all the age groups, but its peak DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 169. DISCUSSION 149                                                                                   manifestation occurs during 16-22 years, and the second occurs in persons aged 57-60years. Onset before age 40 usually indicates a greater genetic susceptibility and a moresevere or recurrent course of psoriasis. Psoriasis can occur at any age but due to morestressful life style and dietary disturbances in young age incidence is found more in agegroup of 31-40 years and moreover disease state may fluctuate with hormonal changesespecially during puberty.SEX Sex has no direct relation with psoriasis. It is evident from (Table no50.) thatmaximum no. of patients. 95% was male and 05 % were female. It is established thatPsoriasis affects adult males and females equally.RELIGION Among 20 patients of these series maximum patients 85% were belonged to theHindu community, whereas remaining 10% were Christian and 10% were belonged toMuslim religion(Table No51.).This may be because of the present study was conduced inHindu 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 by15% of primary education and remaining only 10% of the Patients had secondary schooleducation and were uneducated (Table no53.).SITE OF ONSET In present study shows that 50% of patient had history of onset of psoriasis lesionon 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 170. DISCUSSION 150                                                                                   SEASONAL IMPACT In present study 55% of patients had the symptoms aggravation during winterseason (Table no55.) where as 30% in rainy season ,15%in summer season. This showsthat winter season act as triggering factor for Psoriasis. This fact may be understood byseasonal variations in Doshic status. In winter there is dominancy of Kapha and Vatawhich causes increase pattern of Vatakapha Pradhana Vyadhi like psoriasis.ADDICTION: In the present study, 40 % patients were addicted to Alcohol and Tobaccochewing/ Smoking while 40% patients were not addicted any type addiction (Tableno.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 plaquepsoriasis. Alcohol is considered a risk factor for psoriasis, particularly in young tomiddle-aged males. According to latest research studies shows the smoking is associatedwith 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 no57.) were having the habit of vegetarian. As this study was conducted in costal area, somaximum patient were register to this study were mixed diet. Thus present study showsimportance of non-vegetarian as triggering factor for psoriasis.FAMILY HISTORY Positive family history of psoriasis was reported in only 35% patients where asremaining 65% negative history of Psoriasis. Even though Psoriasis has the geneticpredisposition, but in present study only 35% cases reported as positive family history, itmay be because of small sample study and most of the people know the family historyfor hardly up to 2 or 3 decades not more than it. (Table no 58.). DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 171. DISCUSSION 151                                                                                   PRAKRUTI In this series, all the patients were having Dvandaja type of Sharirika Prakritiwhere in 65% patients were of Kapha- Vata Prakriti and 25 % patients were of Vata-Pittaand 10% were of Kapha- Pitta Prakriti . It may be because the study was conducted inAnoopa Desha which was said to be more chances of occurrence of Kapha-Vatajadisorder, moreover Kushta is one among the Santarpanotta and kleda pradhanavikara.(Table no 59.)DESHA In present study out of 20 patients register the 75% of patient belongs to AnoopaDesha, 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 toMadhyama Koshta where as minimum of 25% of patients belongs to Mrudu and kruraKoshta.(Table no 61)SATVA Out of 20 patients in maximum number of patients i.e. 85% of Madhyama satvawhere 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 satmvawhere 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 Madhyamasamhanana where as minimum 25% of patients belongs to Avara samhanana.(Table no64) DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 172. DISCUSSION 152                                                                                   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% belongedtwak sara (Table no 65).AHARA ABHYAVARANA SHAKTI Out of 20 patients in maximum number of patients i.e. 70% of MadhyamaAharaabyavarana shakti where as minimum 05% of patients belongs to AvaraAharaabyavarana shakti.(Table no.66)AHARA JARANA SHAKTI Out of 20 patients in maximum number of patients i.e. 75% of Madhyama Aharajarana shakti where as minimum 05% of patients belongs to Avara Ahara jarnashakti(Table no.67).PACHAKAGNI Among 20 patients, 45% of patients have Teekshnagni,30%have Mandagni,15% havevishamagni,10% have samagni(Table no 68).VYAMA SHAKTI Out of 20 patients in maximum number of patients i.e. 80% of Madhyama Vyamashakti 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 whereas 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 dehabalawhere as minimum 10% of patients belongs to pravara Dehabala(Table no.71) . DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 173. DISCUSSION 153                                                                                   CANDLE GREASE SIGN In present study, 85% of patient shows positive test of Candle grease test where asremaining 15% of patient negative (Table no 72.). This may be evident that Candlegrease 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 ofPsoriasis.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 withPsoriasis 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 scalingi.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 ofskin 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 areassociated 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 themajor symptoms in patient suffering with Psoriasis. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 174. DISCUSSION 154                                                                                   DISCHARGE Maximum 80% of patient had some sort of discharge in terms of Serous/ Bloodmixed 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 Kitibhatype of Kushta where as minimum of 05% of patients belongs to Charmadala type ofKushta.(Table no 79) EFFECTS OF THE THERAPY ANALYSIS OF VIRECHANAEffect of Deepana & Pachana Niraama Awastha was achieved by Pachana with the Chitrakadi Vati 500mgthrice daily. It contain Ushna and Lavana drugs which helps in Pachana on the otherhand 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 italso stimulates Jataragni and dhatvagni in particular to Rasa,Rakta,Mamsa,Medadhatvagni.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 5thday 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 ofsneha in between 100-200 ml. where as minimum of only 05% of patient consumedbetween 1000-1100 ml(Table no.81). DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 175. DISCUSSION 155                                                                                   Samayak snigdha lakshanas Among 20 patients, 90% of patients had Vatanulomana feature where as minimum20% of patients had Shaitya feature(Table no.82).Samayak swinna lakshanas Among 20 patients, about 80%patients had tvak mardavata feature where as only30% of patients had Stambha feature(Table no.83).Latency period Time required manifesting first Virechana Vega after administration of Virechanadrug is known as Latency period. In present study, Out of 20 patient’s maximum numberof patients i.e. 40% the latency period was between 31-60 minute range, where as inminimum of 10% of patients latency period was between 121-150 minute range(Tableno.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 wasfound 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 3001-4000ml and in one patient it was above 6000 ml(Table no.87). DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 176. DISCUSSION 156                                                                                   Antiki shuddhi Out of 20 patients maximum number of patient i.e. 60% exhibited Kaphantvirechana & 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 wasfound that compared to all parts of body itching on head was significantly relived i.e. p=<0.001Effect 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 wasfound that compared to all parts of body on Lower limbs erythema was significantlyrelived i.e. p = <0.001Effect of therapy on Scaling Improvement in Psoriasis was found in terms of Scaling i.e.51.12% relief wasfound 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 highlysignificant.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 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 177. DISCUSSION 157                                                                                   found that compared to all parts of body Thickness of skin on head and upper limb wassignificantly relived i.e. <p =0.001Effect of therapy on PASI scoring The over all effect of therapy was found i.e. total PASI Scoring 49.03% where asp=<0.001 .Thus it indicate the significant relief in symptoms of Itching, Eryrhema,Scaling and Thickness of Skin. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 178. CONCLUSION 158  CONCLUSION Psoriasis is considered to be inherited as autosomal dominant characters . Theexact cause of the disease is not known, but many precipitating factors likeenvironmental, immunological, genetic and psychological have been found. Differentresearch scholars have correlated psoriasis with Ekakushta, Kitibha and Sidhma etc.But as Psoriasis manifest with different presentation based on which Ayurvedicapproach towards Psoriasis in terms of Kushta also varies. Thus, the present studyentitled as “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OFPSORIASIS” instead of considering any one single variety of Kushta. 25ml of gritha was administered on 1st day in all the patients. In Maximumnumber of patients the Samyak Snigdha Lakshana were observed on the 3rd day ofSnehapana.In one patient Samyak Snigdha lakshana was observed on of 7th day. In maximum number of patients the total amount of Abhyantara Sneha requiredduring the whole course of Snehapana was ranging between 100-200 ml. Where as inone patient total 1075 ml of gritha was required for manifestation of Samyak Snigdhalakshana. Out of 20 Patients, maximum of 20(100%) of patient had Swedapradurbhava and16(80%) of patient had Tvak mardavata after Sidarthaka snana choorna kashyaparisheka. Maximum of 31-60 min. Latency period was in found 11(40%) of patients, whereas maximum of 09 patients (45%) the Manaki Lakshana was observed rangesbetween 3001-4000 ml. only, however maximum of 08(40%) had MadhyamaShuddhi 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  SUMMARY The dissertation entitled “ROLE OF VIRECHANA KARMA IN THEMANAGEMENT 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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 180. SUMMARY 160 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 METHODOLOGYThe materials and methods adopted in the study are mentioned in this part .Apart fromthis 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 DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 181. SUMMARY 161  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. DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A. UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 182. ANNEXURE                                     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 / SadaranaMAIN COMPLANTS: Duration :ASSOCIATED COMPLAINTS:HISTORY OF PRESENT ILLNESS:Onset of skin lesions:Site of onset :Character of lesion : Continuous/Intermittent/Progressive/Waxing&weaningFactors aggravating the symptoms :Yes/No  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 183. ANNEXURE                                     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/NoH/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 aharaNon- veg- Matsya/ Ajja mamsa etc. Mamsa ahara Anya -2.Vyasana: Coffee/Tea- Yes/ No If Yes qnt in ml/cups............/day  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 184. ANNEXURE                                     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/heavyNature of work: Physical/Mental/both.4.Nidra:……..Hours/Day-Sound/Disturbed/DelayedDivaswapna ……….Hours/Day Daily/OccasionalRatrijagarna……….Hours/day Daily/OccasionalOther……………5.Mala visarjana:Regular/Irregular/Constipation/LoosestoolFrequency: ……../DayColour-Consistency-Other-6.Mutra visarjana-Normal/Polyurea/Dysurea/OligureaFrequency:Day…..times Night……timesColour-Other-7.Urges-Normal/Supression of ………….urges regularly/occasional8.Others –  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 185. ANNEXURE                                     OBSTETRIC HISTORY:No. of delivery…… Normal……../Surgical Intervention…...Abortions……. Miscarriages …… Last Delivery …… years backLive…. Dead……… Still birth……….GYNAECOLOGICAL HISTORY:Menstrual cycle: …… Regular / Irregular / Menarche …… yearsBleeding phase ….days Menorrhagia / Metrorrhagia / Dysmenorrhoea LeucorrhoeaMenopause since……yearGENERAL EXAMINATION: DASHAVIDHA PARIKSHAPulse …… / min Prakrutitah:V/P/K/VP/VK/PK/KP/KV/PV/VPKB.P …… mm / Hg Vikrutitah: P / M / A Dosha : Dushya : Srotas : Udbavasthana : Sancharasthana : Vyakthasthana :Temperature……F Satwatah: P/M/ARespiratory rate…… / min Saratah: P/M/ANourishment: G / F / P Satmyatah: P / M / ABuilt: Samhanatah: P / M / ANails:Ictrus: Ahara Shaktitah: Abyavaharana: P / M / AConjunctiva: JaranaShaktitah: P / M / ASinuses: Vyayama Shaktitah: P / M / ALymph nodes: Pramanatah: P/M/ADeformities: Height …… cmsContractures: Weight …… KgsNodules: Y / NPallor: Vayataha; Bala / Madya / VradhaOthers:  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 186. ANNEXURE                                    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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 187. ANNEXURE                                     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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 188. ANNEXURE                                    SROTAS PARIKSHA:1.Pranavahasrotas2.Udakavahasrotas3.Annavahasrotas4.Rasavahasrotas5.Rakatavahasrotas6.Mamsavahasrotas7.Medovahasrotas8.Astivahasrotas9.Majjavahasrotas10.Sukravahasrotas11.Mootravahasrotas12.Purishavahasrotas13.Swedavahasrotas14.ArtavahasrotasINVESTIGATIONS:Hb:Tc:Dc:ESR:RBS:ECG:SkinBiopsy(ifneeded)  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 189. ANNEXURE                                    TREATMENT SCHEDULE:POORVA KARMA:Administration of Deepana Pachana: Chitrakadi vati with Ushna Jala Dose.........mg /OD /BD/TDS/QDS/HS for....daysKoshta pariksha- Triphala choorna - Dose.........mg Time- No.of malapravriti: .......... Koshta--------------SNEHAPANA VIDHI:Name of Sneha given- Mahatikthaka grutha with Ushana jala as AnupaanaSNEHAPANA DAYDateTimeQuantityTime ofSnehajeernataSneha jeeryamana lakshanasLAKSHAN Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7ShirorukBhramaNishtivaMoorchaSaadaAruchiKlamaTrishanaDahaSnehaudgarArati  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 190. ANNEXURE                                    Sneha jeerna LakshanasLAKSHANA Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7TrishanaKshudhaUdgarashudhiShiralaghavataVatanulomataSamyak snigdha lakshanas LAKSHANA Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7VatanulomataAgnideeptiSnigdhaasamhatavarchaGatramardavaTwaksnigdhataSnehodvegaKlamaShityaAngalaghavaVISHRAMA KALA:Sarvanga abhyanga with Karanja taila followed by Siddartaka snanaSAMYAK 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  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 191. ANNEXURE                                    PRADHANA KARMA:Administration of virechana yogaAbhyadimodaka 1-4 karsa(depending upon the bala)Anupana : sukoshanajalaTime of administration of Virechana Dravyas-….......1] MANIKI No. of Time Colour Consistency Virikta Water Urine Vega Dravys Consumed 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 30In put = mlOut put = mlTotal Virikta (stool) dravya = mlTotal out put (urine stool) = ml  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 192. ANNEXURE                                    SAMYAK VIRIKTA LAXANASamyak Yoga Ati Yoga AyogaSrotoshuddi Supti AgnimandyaIndriya prasada Angamarda PratishyayaLaguta Klama TandraAgnivrudhi Bhrama ChardiAnamayatva Balaabhava AruchiVitkapha vata Nidraabhava NaVata PratilomatakramashanissaranaVatanulomana Tama Pravesha DahaDaurbalya Netra pravesha KukshiashudhiKarshyata Moorcha KanduHridhvarna shudhi Unmada VitsangaKshuth Hikka MootrasangaThrishna Chima chimayana PidikaKaleVegapravarthnam 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 MedhoKhanda Vatsrava  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 193. ANNEXURE                                    ANTHAKIVEGAKIMANAKILYNGIKIOBSERVATIONOBSERVATION OF VITAL DATA & WEIGHTTime Pulse Blood Pressure Resp.Rate WeightPASCHAT KARMADiet Regimen No. of Annakalas Pravara Shuddhi Madhyama Avara Shuddhi ShuddhiPeyaVeelepiAkrita YushaKrita 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                                     ASSESSMENTCONFIRMATORY SIGNS: Signs BT AT Auspitz sign Candle grease Assessment criteria BT AT Itching Erythema Scales Thickness  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 195. ANNEXURE                                     P.A.S.I SCORING Time Part I E S T TOTAL AREA TOTAL X BEFORE HEAD X0.1VIRECHANA TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER HEAD X0.1 SNEHAPAN TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER HEAD X0.1VIRECHANA TRUNK X0.2 U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE= AFTER HEAD X0.1FOLLOW UP TRUNK X0.2  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 196. ANNEXURE                                     U.LIMB X0.3 L.LIMB X0.4 TOTAL SCORE=I= ITCHINGE= ERYTHEMAS=SCALINGT=THICKNESSRESPONSE TO TREATMENT GOOD: MODERATE: MILD:Administration of internal medication: no of days:Follow up days:Signature of the Candidate Signature of the Guide  DEPARTMENT OF P.G. STUDIES IN PANCHAKARMA, S.D.M.C.A.UDUPI. “ROLE OF VIRECHANA KARMA IN THE MANAGEMENT OF PSORIASIS”
  • 197. Before Treatment After treatment
  • 198. Before Treatment After treatmentNAIL CHANGES IN PSORIASIS
  • 199. MAHATIKTHAKA GHRITHA FOR SNEHAPANA KARANJA TAILA FOR ABHYANGA
  • 200. SIDHARTHAKADI SNANA CHOORNA KASHAYA FOR PARISHEKA VIRECHANA DRUG :ABHYADI MODAKA
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