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Takradhara kitibha pk009-gdg

Takradhara kitibha pk009-gdg



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

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



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    Takradhara kitibha pk009-gdg Takradhara kitibha pk009-gdg Document Transcript

    • Evaluation of the Efficacy of Takradhara in Kitibhakushta (Psoriasis) By Chandramouleeswaran P. Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. G. Purushothamacharyulu, M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani, M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2006.
    • Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled“Evaluation of the Efficacy of Takradhara in Kitibhakushta(Psoriasis)” is a bonafide and genuine research work carried outby me under the guidance of Dr. G. Purushothamacharyulu, M.D.(Ayu) , Professor and H.O.D, Post-graduate department ofPanchakarma and co-guidance of Dr. Shashidhar. H. Doddamani,M.D.(Ayu) , Assistant Professor, Post graduate department ofPanchakarma.Date:Place: Chandramouleeswaran P.
    • CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “Evaluationof the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafideresearch work done by Chandramouleeswaran P. in partial fulfillment ofthe require ment for the degree of Ayurveda Vachaspathi. M.D.(Panchakarma).Date:Place: Dr. G. Purushothamacharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Panchakarma.
    • ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “Evaluation ofthe Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafideresearch work done by Chandramouleeswaran P. under the guidance ofDr.G. Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Postgradu-ate department of Panchakarma and co-guidance of Dr. Shashidhar.H.Doddamani, M.D. (Ayu), Assistant Professor, Post graduate department ofPanchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
    • CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “Evalua-tion of the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is abonafide research work done by Chadramouleeswaran P. in partial ful-fillment of the requirement for the degree of Ayurveda Vachaspathi.M.D. (Panchakarma).Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).Place: Assistant Professor, Post graduate Department of Panchakarma.
    • COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of HealthSciences, Karnataka shall have the rights to preserve, use and dissemi-nate this dissertation / thesis in print or electronic format for academic /research purpose.Date: Chandramouleeswaran P.Place:© Rajiv Gandhi University of Health Sciences, Karnataka.
    • I Acknowledgement “Many hands make light work”. I take this opportunity to mention mydeep gratitude to several personalities who have helped me in the successful completionof this work. I express my obligation to my honorable Guide Dr. G.Purushothamacharyulu M.D. (Ayu), H.O.D., P.G. Department of Panchakarma,P.G.S&R, D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for thecompletion of this work. I am extremely grateful and obliged to my co-guide Dr. Shashidhar.H.Doddamani, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for his guidance andencouragement at every step of this work. I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C,Gadag, for his encouragement as well as providing all necessary facilities for thisresearch work. I express my sincere gratitude to Dr. P. Shivaramudu M.D (Ayu),Assistant Professor and Dr. Santhosh. N.Belavadi MD (Ayu), Dr. M.D. Samudri,Lecturers for their sincere advices and assistance. I express my sincere gratitude to Dr. V. Varadacharyulu M.D (Ayu),Dr.M.C.Patil M.D (Ayu), Dr. Mulgund M.D (Ayu), Dr. K. S. R. Prasad M.D (Ayu), Dr.Dilip Kumar M.D (Ayu), Dr. R.V. Shetter M.D (Ayu), Dr. Kuber Sankh M.D (Ayu),Dr.G.Danappagowda M.D (Ayu) Dr. Jagadish Mitti M.D (Ayu) Dr. Nidagundi M.D(Ayu) and other PG staff for their constant encouragement. I also express my sincere gratitude to Dr.B.G.Swamy, Dr.U.V.Purad,Dr.K.S.Paraddi, Dr.G.Yargeri, Dr.S.H.Radder and other undergraduate teachers for theirsupport in the clinical work. I thank to Shri. Hadapad (Statistician) Shri. Nandakumar(Statistician), Shri. V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (labtechnician), Shri. Basavaraj (X-Ray technician) and other hospital and office staff fortheir kind support in my study.
    • II I express my sincere thanks to my colleagues and friends Dr. UdaykumarA.A.N., Dr. Ratnakumar K., Dr. Ashwinidev, Dr. Krishnkumar K., Dr. Sreena, Dr.Soumya, Dr. Devanathan, Dr. Subin V., Dr.Satheesh. R.Warrier, Dr. Febin .K. Anto,Dr.Renjith.P.Gopinath, Dr. Prassannakumar L., Dr.Shajil.N, Dr. Shyju Ollakode, Dr.Gavi Patil., Dr.Santhosh.L.Y, Dr.Varsha.S.Kulkarni, Dr. Anjaykannan, Dr. KrishnkumarK.M., Dr. Jayaraj Basarigidad, Dr. Kendadamath, Dr.V.M.Hugar, Dr. Shaila.B, Dr.Suresh Hakkandi, Dr.Manjunath Akki, Dr. L. R.Biradar, Dr.Vijay Hiremath, Dr. Sajjan,Dr. Bhingi, Dr. Sunita, Dr. Veena Dr. venkareddy, Dr. Kalamath B.L., Dr. Pradeep, Dr.Basavaraj Ganti., Dr. Anitha., Dr. Shibaprasad, Dr. H.S. Madhushri., Dr. DevendrappaBudi., Dr. Payyappagoudar., Dr. Ashok., Dr. Sharanu., Dr. Anand Doddamani., Dr.Kumbar., Miss Meena B. and other post graduate scholars for their support. I pay my respect to my philosopher and uncle Late Dr. Srinivasan LI.M.who had been a source of inspiration for me and prime cause for taking this nobleprofession. I would like to mention the support and inspiration provided by Dr. S.N.Suresh., Dr. Krishnkutty Nair and also acknowledge the support and inspiration providedby my teachers Dr. Ramadass., Dr. S. Swaminathan., Dr. Vasudev Reddy., Dr.Saikumar., Shri. Venugopal. I also thank Shri. Habib I. Khatib and family for the supportand encouragement provided during my stay at Gadag. I acknowledge my patients for their wholehearted consent to participate inthis clinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. I also express my wholehearted thanks to my family members Mr. & Mrs.Balasubramnyam and Mr. & Mrs. Ganesan, Shivaramkrishnan, Kartikeyan, Soundaryaand Ravikumar. Finally I dedicate this work to my respected parents Shri. ParameswaranK., Sreemati Subbulakshmi P. and my brother Er. Jayaraman P. who are the primereasons for all my success.Date : Signature of the scholarPlace : Gadag. (Dr.Chandramouleeswaran P.)
    • III Abbreviations01. C.S. – Charaka Samhita.02. S.S. – Sushruta Samhita.03. A.H. – Ashtanga Hridaya.04. B.S. – Bhela Samhita.05. K.S. – Kahsyapa Samhita.06. M.N. – Madhava Nidana.07. B.P. – Bhavaprakasha.08. Y.R. – Yoga Ratnakara.09. B.R. – Bhaishajya Ratnavali.10. PASI – Psoriasis Area severity Index.11. C.R. – Complete remission.12. Bt.R. – Best reduction.13. Mo.I. – Moderate improvement.14. Mi.I. – Mild improvement.15. N.I. – No improvement.
    • IV Abstract The study “Evolution of the efficacy of Takradhara in Kitibha Kushta(Psoriasis)” is focused on an important technique Takradhara and a commonpsychosomatic disorder Kitibha kushta (Psoriasis). The objectives of this study are – 1. To evaluate the efficacy of Takradhara inKitihba kushta (Psoriasis), 2. To evaluate the efficacy of Aragwadi gana kashayaTakradhara in Kitibha kushta (Psoriasis). The aim of the study was to find out the psychosomatic effect of AragwadadiGana kashaya Takradhara in Kitibha kushta (Psoriasis). The study design selected for thepresent study was an observational study, After treatment out of 30 patients 8 patients (26.66%) got complete remissionform the symptoms, 4 patients (13.33%) showed marked improvement, 7 patients(25.90%) got moderate improvement and 5 patients (16.66%) showed mild improvement.No response was found in 6 patients (20%). Among all the parameters Itching andScaling showed high significant in all the parts. Other parameters like Erythema andThickness were not significant in body and legs (As by using paired t test). Triggering factors like Bhaya, Krodha Chettodvega and Shoka were also studiedand they showed high significant response.(As by using paired t test) Kitibha kushta is a form of kshudra kushta. Based on the similarities of symptomsand other description available in the medical literature many of the Ayurvedicresearchers who have worked on skin disorders have equated it to Psoriasis. Psoriasis ismore stress sensitive than other Skin disorders.Aragwadadi gana kashaya Takradhara,which was selected for the study showed that it is having the role in reducing vitiatedmanasika as well as shareerika doshas.
    • V TABLE OF CONTENTSChapters Page No.1. Introduction 1-32. Objectives 4-73. Review of literature 8-904. Methodology 91-1075. Results 108-1376. Discussion 138-1627. Conclusion 163-1648. Summary 1659. Bibliography10. Annexure
    • VI List of TablesTable Showing the Page No. No. 01. Layers of skin according to Charaka 17 02. Layer of the skin according to Sushruta 17 03. Correlation between the Ayurvedic & Modern skin layers 18 04. Relation between skin and hormones 26 05. Difference between Maha Kushta and Ksudra kushtas 47 06. Classification of Kushta according to different Acharyas 47 07. Relation between doshas and kushtas 48 08. Symptoms according to dosha predominant 49 09. Aharaja Nidana of Kitibha kushta 49 10. Viharaja Nidana of Kitibha 50 11. Daivapacharaja Nidana of Kitibha 51 12. Poorvaroopas mentioned by different acharyas 60 13. Lakshanas of Kitibha Kushta 61 14. Comparison between the kitibha kushta lakshana and psoriasis 66 15. Differential diagnosis of Kitibha kushta 67 16. Pharmacodynamics of drugs of Aragwadadi Gana 91 17. Pharmacodynamics of Drugs Used For Moorchana of 93 Tilataila 18. Chemical composition of the drugs used in Tilataila 95 moorchhana 19. Showing the Pharmacaodynamics of drugs of Gandharva Hastadi 96 Kashaya 20. Drugs used for preparing of Medicated Milk 97 21. Qualities of Takra 97 22. Method to assess PASI score 104 23. Distribution of patients by Age 108 24. Distribution of patients by Sex 109 25. Distribution of patients by Occupation 109 26. Distribution of patients by Economical status 109 27. Distribution of patients by Religion 110 28. Distribution of patients by Marital status 110 29. Distribution of patients by Dietary habits 110 30. Distribution of patients by Addiction 111 31. Distribution of patients by Agni 111 32. Distribution of patients by Koshta 111 33. Distribution of patients by Nidra 112 34. Distribution of patients by Deha prakriti 112 35. Distribution of patients by Satmya 112 36. Distribution of patients by Sara 113 37. Distribution of patients by Samhana 113 38. Distribution of patients by Satwa 113
    • VII39. Distribution of patients by Ahara shakti 11440. Distribution of patients by Vyayama shakti 11441. Distribution of patients by Onset 11442. Distribution of patients by Dominant rasa 11543. Distribution of patients by Nidana 11544. Distribution of patients by Viruddha ahara 11645. Distribution of patients by Mithya ahara 11646. Distribution of patients by Mithya vihara 11747. Distribution of patients by Manasika Nidana 11748. Distribution of patients by Family history 11849. Distribution of patients by Chronicity 11850. Distribution of patients by Medication 11951. Distribution of patients by Aggravating season 11952. Distribution of patients by Types of Psoriasis 11953. Distribution of patients by Chief complaints 12054. Distribution of patients by Associated complaints 12055. Distribution of patients by Confirmation test 12156. Distribution of patients by Precipitating factor 12157. Distribution of patients by Psoriasis with different site of 121 involvement58. Distribution of patients by Particular site involvement 12259. Overall response to the treatment 12260. Distribution of patients with different severity scorings in Head 12361. Distribution of patients with Itching Head 12362. Distribution of patients with scaling Head 12463. Distribution of patients with Erythema Head 12464. Distribution of patients with Thickness Head 12565. Distribution of patients with Area Head 12566. Distribution of patients with different coverage area in Head 12667. Distribution of patients with Head total PASI score 12668. Distribution of patients with different severity scorings in Arms 12769. Distribution of patients with Itching Arms 12770. Distribution of patients with Erythema Arms 12771. Distribution of patients with scaling Arms 12872. Distribution of patients with Thickness Arms 12873. Distribution of patients with Area Arms 12974. Distribution of patients with different coverage area in Arms 12975. Distribution of patients with Arms total PASI score 13076. Distribution of patients with different severity scorings in Body 13077. Distribution of patients with Itching Body 13178. Distribution of patients with Erythema Body 13179. Distribution of patients with scaling Body 13280. Distribution of patients with Thickness Body 13281. Distribution of patients with Area Body 13382. Distribution of patients with different coverage area in Body 133
    • VIII83. Distribution of patients with Body total PASI score 13384. Distribution of patients with different severity scorings in Legs 13485. Distribution of patients with Itching Legs 13486. Distribution of patients with Erythema Legs 13587. Distribution of patients with scaling Legs 13588. Distribution of patients with Thickness Legs 13689. Distribution of patients with Area Legs 13690. Distribution of patients with different coverage area in Legs 13791. Distribution of patients with Legs total PASI score 13792. Total PASI scoring for all 30 patients 13893. After treatment statistical results of PASI score of different areas 13994. After treatment statistical results of PASI score of different 139 symptoms of head95. After treatment statistical results of PASI score of different 140 symptoms of arms96. After treatment statistical results of PASI score of different 140 symptoms of body97. After treatment statistical results of PASI score of different 141 symptoms of legs98. After treatment statistical results of PASI score of total PASI for 141 all parts99. Statistical results of manasika bhavas 141
    • IX List of Graphs01. Graph No. 01. Showing the distribution of patients by Age groups.02. Graph No. 02. Showing the distribution of patients by Deha prakriti.03. Graph No. 03. Showing the distribution of patients by Onset.04. Graph No. 04. Showing the distribution of patients by Samanya Nidana.05. Graph No. 05. Showing the distribution of patients by Manasika Nidana.06. Graph No. 06. Showing the distribution of patients by Family history.07. Graph No. 07. Showing the distribution of patients by Chronicity.08. Graph No. 08. Showing the distribution of patients by Aggravating factor.09. Graph No. 09. Showing the distribution of patients by Type of Psoriasis.10. Graph No. 10. Showing the distribution of patients by Chief complaints.11. Graph No. 11. Showing the distribution of patients by Associated complaints12. Graph No. 12. Showing the distribution of patients by Confirmation test.13. Graph No. 13. Showing the distribution of patients by Sites of involvement.14. Graph No. 14. Showing the Overall response to the treatment. List of flow charts1. Samprapti of Kushta according to Charaka 552. Samprapti of Kushta according to Sushruta 553. Samprapti of Kushta according to Vagbhata 564. Samprapti of Kushta according to Bhela 565. Samprapti of Kitibha Kushta 57 List of Figure01. Figure No. 01. Showing Histology of skin.02. Figure No. 02. Showing histological changes in skin of Psoriasis. List of Photographs01. Photo No. 01. Showing the medicaments used for Takradhara.02. Photo No. 02. Showing the procedure of Takradhara and the effect of therapy before and after treatment.
    • INTRODUCTION Ayurveda the eternal science took birth with world itself and is not liable to changeat any time or in any part of the world. Aim of Ayurveda is to promote health and curediseases. Ayurveda has designed a variety of treatment modalities among whichPanchakarma is the most superior. Panchakarma mitigates the root causes of the diseasesand promotes health. Man, the gifted creature of God is running behind everything today. Nobodywants to spend sufficient time on required day-to-day activities. Due to the fast movinglife style all the daily activities of the man turned up side down and gave to two types ofdisorders viz. Somatic and Psychosomatic. The main discussion of this thesis, Kitibhakushta (Psoriasis) is a disorder of psychosomatic in nurture, which arises due to the faultylife style. Position of anything that made of silver is identified as a sign of wealth. But notthe silvery scales, which is the cardinal symptom of Psoriasis. This obnoxious illnessthough not contagious, isolates the patient from their family and society or else thepatient himself hesitates to move with his family and society fearing dejection. The history of psychosomatic problem is as old as the history of humancivilization. Till today somatogenic and psychogenic solution are put forward althoughboth are extremists. In our classics Manas and Shareera are regarded as separate entitiesbut not in the sense of separation, because an organism is a complex combination ofAtma, Manas, and Shareera i.e. soul, mind and body. So Ayurvedic approach to a diseaseis definitely psychosomatic in nature. For example – Kushta is due to disrrespective givento Gurus, Bramahanas, doing Papakarmas, etc. So our Acharyas has given more emphasisto the integrated aspect of mind and body. 1 Introduction
    • Kitibha kushta of Ayurveda closely resembles the clinical symptoms of Psoriasis.As per the of disease nature, this is a chronic recurrent dermatosis. The primary lesion isan epidermal papule. The Psoriatic papule is pink in colour of various intensities. Thefresh lesions are brighter and older ones are darker. The papules are flat and have roughsurface covered with silver white microlamellar scales, which scrap off easily. At first thepapules have a regular round, countour and a diameter of 1-2 mm each. Later they spreadperipherally after attaining size with an intensive itching sensation of the skin. If weconsider the above symptoms they closely resembles the symptoms of Kitibha kushta.And also the researchers those who worked on skin disorders have correlated Kitibhakushta with Psoriasis. So the present study entitled “The Evaluation of The Efficacy ofTakra Dhara in Kitibha Kushta (Psoriasis)” was undertaken. The main aim of the study is to focus the psychosomatic treatment for Psoriasis. Itis more stress sensitive than other skin disorders since anxiety and tension aggravate thecondition. As stated before Shareera and Manas go hand-in-hand in causing the disease,hence a humble attempt is made to pacify vitiated Manasika and Shareerika bhavas. Ayurveda considers Kushta as an important disease and categorized it as a“MAHAROGA”. Though curative and preventive measures are in full swing and underthe guidance of W.H.O., the central and state governments and voluntary organizations,several measures are being persuaded for warding of Kushta. The grim reality would beto reveal all steps already taken and still in progress or quite insufficient for immunizingof this dreaded disease. In this circumstances along with Ayurvedic physicians andscientists, practitioners of Unani, Siddha, and other allied systems should also raise equalto the occasion and work whole heartedly and dedicated spirit for eradicating this dreadeddisease from the world permanently. 2 Introduction
    • Science is a gradual evolution; it is not a sudden invention. Ayurveda as a scienceis not an exception for it. The imperishable fundamentals of Ayurveda, which were laiddown by great sages of the olden days, are still applicable because of scientific andeternal background. Such fundamentals must be subjected to scientific research not onlyto prove its certainty but also to add something new to the existing knowledge. Bykeeping this in mind the present study was undertaken. 3 Introduction
    • NEED FOR THE STUDY Takradhara is one among the Keraleeya chikitsa krama. It is said to be the best fordhatu shaithilya and all kinds of doshakopa. It is the process in which the medicatedbuttermilk is poured in a continuous stream on the head especially on the forehead in thespecific manner. Procedure of any kind of Dhara has been mentioned in our classics. But indifferent contexts the word Parisheka has been mentioned which is equated to dhara.Vagbhata considered Seka as one of the type of Moordhini taila. Bhavaprakasha in hisnetra roga chikitsa adhikara mentioned Seka for the eyes, which means a sukshma dhara. Kitibha kushta is a form of Kshudra kushta. Based on the similarities ofsymptoms and other description available in the medical literature, many of theAyurvedic researchers and authors of recent past who have worked on skin disordershave equated to Psoriasis. However the correlation of Kitibha kushta to Psoriasis ordetailed description of Psoriasis is not the subject of the study. Psoriasis affects 1-3% of the world population. It occurs with almost equalfrequency in males and females, however a high prevalence in males (24%) to females(0.8%) is noted in earlier studies. Contemporary systems of medicine has paid a lot ofattention to counter this dreadful disease. The modalities of the management of Psoriasisare only palliative and recurrence oriented. The external applications and the internalmedications provide only a temporary relief to the patient and also most of the drugs usedfor the remission of this disorder are known for their side effects. In the above situation Ayurveda has got the answer for the treatment of such skindiseases. Among the various treatment modalities, which are good for various skinailments, Takradhara plays pivotal role and is stated best for both Shareerika andManasika doshas, as stress and tension aggravate the Psoriasis. 4
    • PREVIOUS WORK DONE ON KITIBHA KUSHTA (PSORIASIS)Trivendrum : - 01. Dr. Patil 1980. Worked on the effect of Snehapana in Kushta (W.S.R.T. Psoriasis). 02. Jayarama 1988. Studied classical management of Kushta (W.S.R.T. Psoriasis). 03. Dr. Mohan 1984. Studied the role of Takradhara in the Management of Kitibha Kushta (Psoriasis).Jamanagar : - 01. Dr. Makwana 1979. Worked on Efficacy of Arogyavardhini and Gandhaka Rasayana internally, Gandhaka Malahara externally Kitibha (Psoriasis). 02. Dr. Sabu 1988. Worked on Comparative Efficacy of Raktamokshana and Brihat Manjishtadi Kashaya with Talasindhoor in Kitibha (Psoriasis)Ahamedabad : - 01. Dr. Kale 1993. Worked on Comparative Efficacy of Virechana and Shamana with Panchatikta Ghrita Guggulu and Chandamaruta Sindhoora externally in Kitibha (Psoriasis).B.H.U. : - 01. Dr. Tangoria 1989. Studied the Management of Kitibha (Psoriasis) by an indigenous drug Stree Kutaja. 02. Dr. Anken 1991. Studied Concept of Kitibha in Ayurveda and Modern medicine and its Treatment with Stree Kutaja – A further study. 5
    • Banglore : - 01. Dr. Rajeshwari 1986. Studied Jalokavacharana in Kitibha Kushta (Psoriasis). 02. Dr. Jayashree 1986. Studied Efficacy of Panchakarma in the Management of Kitibha kushta (Psoriasis). 03. Dr. Rekha 1995. Studied The effect of Vamana and Virechana on Psoriasis. Takradhara is a simple technique; ingredients are easily available and economicaland is also indicated in dhatu shaithilya and doshakopa, which is normally seen inKushta. Considering the utility of Seka and Takra in different Kushtas the expandedversion will be studied as Takradhara. 6
    • OBJECTIVES OF THE STUDY 01. To Evaluate the efficacy of Takradhara in Kitibha kushta (Psoriasis) 02. To Evaluate the efficacy of Aragvadadi gana kashaya Takradhara in Kitibha kushta (Psoriasis). 7
    • HISTORICAL REVIEWKARMA It is essential to know any Panchakarma procedures or any KeraleeyaChikitsakrama, which are available in Vedas. As they are the prime sources of ancientwisdom, from the research point of view one must search for such and possibleevidences. Such search of Vedas for reference regarding Panchakarma, Keraleeyachikitsakrama, Seka or Dhara in particular was not fruitful. But, if we go through ourSamhita granthas carefully, we can find ample references for Seka. Among all theSamhita granthas Charaka Samhita (1000 B.C.)1 was the first to describe Seka indifferent diseases. Acharya Bhela2, Kashyapa3, Sushruta Samhita4, Vagbhat5, had considered seka asthe type of moordhini taila. The latter texts such as Bhavaprakasha6, Yoga Ratnakara7,Chakradutta8 have also mentioned about Seka. Even though the therapeutic utility ofSeka in various disorders has been mentioned in our classics the utility of Takraseka orTakradhara has not been explained. Reference for the Takra is available from the Vedicperiod to Samhita kala. Takra is said to be Amruta9 and it is even difficult for Indra10 toget it. Different forms of takra and its kalpanas11 are also mentioned in classics. Textbooks on Ayurveda originated form Kerala such as Dharakalpam12,Keraleeya chikitsakramam13, Chikitsa Sangraham14, Ayurvedic treatments of Kerala15had described Takradhara as an effective technique for all kinds of doshakopa16 anddhatu shaithilyata17, which is normally seen in Kushta. 8
    • VYADHI01. Vedic Period18 Vedas are considered as the oldest and the first available literature of the world.The history of Indian medicine starts with Vedas, so the history of Twak rogas beginsfrom vedic period. Many references regarding kushta are found in Vedas. A. Rigveda18a – In Rigveda there is no complete description of kushta. But somedescription indicates that kushta was prevalent in that period also. The Charmaroga of Aapala was cured by the Lord Indra. Ghosa was suffering form Kushta roga. She was disliked by her husband becauseof her ugly looks due to kushta roga. By administration of proper medication she gotcured and ultimately accepted by her husband. B. Yajurveda18b – Shukla Yajurveda mentioned various medicines having kushtanashahara properties. C. Atharvana Veda18c – In Atharvana veda, the various sites for disease havebeen described and amongst them skin has been described as one of the chief site of thedisease. The names of the various diseases have been illustrated where by kushta hasbeen described as Kshatriya roga. There is description of some herbs like Rama, Neeli,Asaru, Shyama, etc. for the treatment of kushta. Shringa i.e. Horn of deer possessing aproperty of twak rogahara has been mentioned.02. Purana Kala A. Mahabharata18d – It is mentioned that the person suffering from twak doshais not fit to be a king. This reference highlights that at that time people suffering formkushta were looked down by the society. 9
    • B. Agni Purana18e – Kushtahara medicines are mentioned under the heading ofNanarogahara aushadhani. C. Garuda Purana18f – In various chapters of Garuda purana description aboutTwak roga has been explained viz. Kushta, Sidhma kushta, etc. D. Panini18g – In Ashtadhyaya of Panini grammatical literature about the diseaseis explained. The diseases like Atisara, Arsha, Kushta have been explained and also thediseases caused by Anuvamshika doshas and vyadhis are also been explained. E. Kaushika Sutra18h – The reference of Kushta and its treatment is mentionedin Kaushika Sutra like chanting Mantras, external application of paste made up of drugslike Bhringaraj, Haridra, Indravaruni, Neelika pushpa, etc.03. Samhita kala19 A. Charaka Samhita – Charaka described in detail for the first time, a long rangeof skin diseases with their etiology, pathogenesis and specific classification under theheading of Kushta. Charaka has described eighteen types of kushta. Seven types ofkushtas have been described under the category of Mahakushta in Nidanasthana19a. InChikitsasthana19b eighteen types of Kushta have been classified under seven Mahakushtaand eleven Kshudra kushta. Apart from these; description of kushta is available in the following chapters – 01. Kushta is described as samanya hetu of Nija shotha19c. 02. Kushta is considered as a Santarpanajanya vyadhi19d. 03. It is included as one of the disease caused by the rakta19e. 04. Use of stamabana dravyas in the initial stage of Raktapitta, Raktarsha, and Amatisara leads to kushta. 10
    • 05. Kushta is noted in Lekhana yogya and Pracchana yogya vyadhis19f. 06. Agni karma is contraindicated in kushtaja vrana19g. B. Sushruta Samhita – Acharya Sushruta, for the first time clearly described theAnuvamshika (Hereditary) and Krimija (Infectious), nidanas as a causative factors forkushta20. Kushta has been included in Aupasargika roga which may spread from oneperson to other21. He also explained dhatugatatwa and uttarottara dhatu pravesha ofkushta roga22. The number of kushta rogas described by Sushruta is the same as that ofCharaka, but Dadru has been mentioned under Mahakushta and Siddhma under kshudrakushta. Sushruta describes the chikitsa in two chapters i.e. Kushta chikitsa andMahakushta chikitsa. Guggulu, Shilajatu, Shweta bakuchi, etc and rasayana drugs arealso mentioned. C. Ashtanga Hridaya – Vagbhata has followed Sushruta regarding classificationof Mahakushta and Kshudrakushta23. But Kitibha kushta has been mentioned underkshudrakushta with some lakshanas as described by Charaka24. D. Bhela Samhita25 – Bhela Samhita has described kushta roga in both nidanaand chikitsasthana. He has mentioned that polluted water is the main etiological factor ofkushta. E. Kashyapa Samhita26 – Kashyapa samhita has described eighteen types ofkushtas as Charaka except the Shwitra, Vishaja kushta and Sthul ruksha kushta, Insteadof Charma kushta, Alasaka and Visphotaka. Kahsyapa has given the classification ofkushta on the basis of sadhyasadhyata. Thereby nine kushtas are described as Sadhyawhile others as Asadhya. 11
    • 04. Sangraha Kala A. Madhava Nadana27 – Madhava has described Nidana panchaka of kushtaaccording to Charaka and Vagbhata. While dhatugatatwa, sadhyasadhyata andSankramakata (contagious) have been described according to Sushruta. B. Sharangadhara Samhita28 – Classification of kushta has been described inPoorvakhanda. He describes Tamra which is the fourth layer of skin is the site for alltypes of kushtas. C. Vangasena29 – Vangasena has mentioned seven types of special causes ofkushta i.e. Taila, Kulatha, Valmika linga roga, Mahisha dugdha, Mahisha dadhi andVruntaka. D. Bhavaprakasha30 – Bhavaprakasha has described a detail description ofkushta roga. He has followed Charaka for classification and nomenclature of kushta. Thedhatugatatwa and sahdyasadhyata are compiled form Sushruta. F. Yogaratnakara31 – Yogaratnakara describes kushta according to the earlierclassics, contagious aspect of kushta is also described by him. G. Rasaratna Samucchya32 – In third chapter, while explaining Gandhaka gunashe mentioned that it is useful in kushta. H. Rasatarangini33 – In Gandhaka prakara, Gandhaka taila is indicated isMahakushta and other skin diseases. 12
    • VYUTPATTI & PARIBHASHA The word Takradhara is comprised of two words viz. Takra and Dhara. Takra34 – This word is derived form Tak + Rak pratyaya. It is napumsakalinga,if ¼th of water is added to it then is called as Takra. Dhara35 – Means, Dharabhir Nivruttam | It is napumsakalingam, Dhara which ischaracterized by streams – means the fall of liquid substance in a stream.Vyutpatti of Kushta (Derivation of Kushta) The word kushta is derived form the root “Kush” which means that which comesout from inner part to outer part36. In the term kushta the word “Kush” is added to “Hani” to form kushta, whichgives a meaning that it gives an ugly look to the body37a. The word kushta is derived form the dhatu “Kush” meaning; the morbid factormainly rakta is drawn towards the region of twak so as to cause kushta37b.Paribhasha (Definition of Kushta) According to Arundutta, kushta is defined as that which causes disfigurement tothe body38.Nirukti & Paribhasha of Kitibha kushta The term Kitibha is constituted by the combination of “Kiti” and “Bha”. The wordKiti refers to variety of insects, which is black in colour, stays in kesha pradesha or inhair39. The word “Kiti” is also termed as “Akuna” by Hemadri. This indicates that it iseither a louse or some other insect, which is similar to louse. 13 Vyutpatti & Paribhasha
    • The word “Bha” refers to the resemblance or similarity. So the term Kitibha,which is constituted by suffixing “Bha” to “Kiti”, suggests something, which resembleslouse. The similarity is mentioned only in colour (Krishna), as it resembles, the colour oflouse but not referred to its shape or size. So the definition of Kitibha is “A pathological skin condition where the colour ofskin is black like Kiti i.e. Louse. Sushruta has also given one more meaning to Kitibha; itis an upadrava caused as a result of the bite of the poisonous variety of insect40. Etimology of Psoriasis – The word “Psoriasis” is derived from the Greek work“Psora” which means “itch” or “scale”.Definitions of Psoriasis Psoriasis is defined as a skin disorder, which have been classified and discussedunder various headings. Keratinization disorder is one group, in which there will behyperkeratinization of the basal cells of epidermis. Kitibha kushta is which skin becomeshard or horny, as like psoriasis in contemporary context. Psoriasis is one among thekearatinization disorders of the skin, which also involves either genetic or immunologicalderangements. According to various authors the psychosomatic disorder, psoriasis is defined andcharacteristic features are established as under – 01. Psoriasis is characterized by the development of erythmatous, well defined,dry, scaly papules and plaques of sizes ranging from a pin head to larger lesions(Pavitram K 1994.). 14 Vyutpatti & Paribhasha
    • A common genetically determined disease of the skin consisting of well definedpink or dull red lesions surrounded by the characteristic silvery scale. (Baker Harvey &Wilkinson. D. S. 1986.) A chronic disease characterized by sharply defined patches of erythema coveredby silvery scales (Kirbua John D. 1986.)It is a common chronic and non-infectious skin disease characterized by well-defined,slightly raised, dry erythematous macules with silvery scales and typical extensordistribution. (Bhela P. N. 1987.) 15 Vyutpatti & Paribhasha
    • RACHANA SHAREERA OF TWAK Beauty is an important part of human experience. Beauty without perfect blemishless skin is incomplete. Clean skin suggests absence of acquired or inherited healthdisorders. Hence, people spend much time and money to restore skin to a more normal oryouthful appearance.Ayurvedic View In Ayurveda, the word “Twacha” or “Charma” is used for skin41. Twacha isderived from “Twacha Samvarne” dhatu means – the covering of body. It can be definedas body substance that covers the internal tissues like Rakta, Mamsa, Medas, and otherdhatus.Synonyms of Twacha Twak, Charma, Sparshanendriya, etc.Formation of the skin Sushruta described the process of formation of twacha in the developing foetus.He says that after formation of the ovum twacha develops just like a cream on the surfaceof the milk42. In the uterus during the course of development of garbha differentiation ofthe layers of the skin takes place and is produced by all three doshas particularly by pittadosha. Twacha develops consecutively in seven layers by the synchronized peculiaraction of dosha. Vagbhata described the formation of twacha due to paka of rakta dhatu by itsdhatwagni in the foetus. After paka, it dries up to form twacha just like the deposition ofthe cream over the surface of the boiled milk43. 16 Shareera
    • Layers of the Twacha A. There are differences of opinion regarding the layers of skin. Charaka hasdescribed six layers of the skin. Out of these six he has given names to the first andsecond layer. The rest four layers have been described in terms of the disease44.Table No. 01. Showing layers of skin according to Charaka. No. Layer Disease 01. Udakadhara - 02. Raktadhara - 03. Triteeya Sidhma, Kilasa 04. Chaturtha Dadru, Kushta 05. Panchama Alaji, Vidradi. 06. Shashta Arhsa, Bhagandhara B. Sushruta has described seven layers of the skin along with the specific names.He has also mentioned the thickness of each layer along with the disease, which are proneto that layer45.Table No. 02. Showing the layer of the skin according to Sushruta.No. Name Thickness Disease01. Avabhasini 1/18th of Vrihi (0.05-0.06 mm) Sidhma, Padmakantaka02. Lohita 1/16th of Vrihi (0.06-0.07mm) Tilakalaka, Nyachya, Vyanga03. Shweta 1/12th of Vrihi (0.08-0.9 mm) Charmadala, Mashaka, Ajagallika.04. Tamra 1/8th of Vrihi (0.12-0.50 mm) Kilasa, Kushta.05. Vedini 1/5th of Vrihi (0.2-0.3mm) Kushta, Visarpa06. Rohini 1 Vrihi (1-1.1mm) Shleepada, Arbuda, Granthi, Apachi, Galaganda07. Mamasadhara 2 Vrihi (2-2.1 mm) Arsha, Bhagandara, Vidrudhi 17 Shareera
    • C. Vagbhata has described seven layer of skin without naming them.Commentators Arunadutta and Hemadri named them according to Sushruta46. D. Sharangadhara has also mentioned seven layers of the skin along with theprobable onset of disease. The names of the six layers of the skin are same as Sushrutabut seventh layer is named as Sthula, which is the site of Vidradhi47. Dr. Ghanekar, the commentator of Sushruta shareerasthana has correlated thelayers of the skin with the latest modern anatomy.Table No. 03. Showing the correlation between the Ayurvedic & Modern skin layers.No. Ayurvedic Terminology Modern Terminology Types of Skin01. Avabhasini Stratum corneum Epidermis02. Lohita Stratum lucidum Epidermis03. Shweta Stratum granulosum Epidermis04. Tamra Malpighian layer Epidermis05. Vedini Papillary layer Dermis06. Rohini Reticular layer Dermis07. Mamsadhara Subcutaneous tissue & Muscular layer DermisKriya Shareera of twak The Kriya Shareera of the twaka can be understood by knowing its relation withthe dosha, dhatu, mala which are the basic structural and functional units of the body.01. Twak & Tridosha – Twacha is said to be one of the sites of Vata and Pitta dosha48. A. Twacha & Vata Dosha – Charakacharya has described Twacha as a sparshanendriya adhishthana. Sparsha i.e. touch sense is the subject of sparshanendriya which is performed by Vata dosha49. 18 Shareera
    • B. Twacha & Pitta dosha – Bhrajaka pitta, which is located in the skin is responsible for the luster of the skin. It is also called as Bhrajakagni. Charaka did not specified about the types of pitta, but he has said that theproduction of normal and abnormal temperature as well as the normal and abnormalcolour of the skin is due to the pitta dosha. Commenting on this Chakrapani says bodyheat regulation and variation in the colour of the body are the functions of the bhrajakapitta50. Sushruta describes it as a bhrajakagni and it enables the digestion and utilizationof substances used through Abhyanga, Pariseka, Alepa, Avagaha, etc. It indicates theglow of one’s natural complexion51. According to Bhela bhrajaka pitta is that which is responsible for themanifestation of the specific characteristics of the body. It emphasizes its importance increating different prabhas (Hues) of the head, hand, feet, sides, back, abdomen, thighs,face, nails, eyes and hair. It also brightens them52. Vagbhata mentioned bhrajaka pitta is situated in the skin. It is so called because itimparts lusture to the skin and makes it radiate. Arundutta says it is so called because itperforms deepana-pachana of substances used for abhyanaga, lepa, pariseka, etc. C. Twacha & Kapha dosha – The Snigdhata, Shlakshnata, Mriduta, Sheetata, Prasannata are the attributes to the presence of kapha dosha in the skin. Ropana karma i.e. self healing process is also one of the function of kapha dosha.02. Twacha & Saptadhatu – A. Rasa dhatu – In Several places twacha has been used as synonym of rasa dhatu like Twaka sara purusha, etc. Sushruta mentioned that in early stages Kushta is situated only in Twacha. Dalhanan commented on that and says it as Twachashrita i.e. Rasashrita kushta53. 19 Shareera
    • B. According to Chakrapani, Udakadhara which is the first layer of skin maintains water content of the body. Rasadhatu is jalamahabhoota pradhana in its panchabhautika constitution. This declairs the relation between rasadhatu and twacha. C. Twacha and raktadhatu – Sushruta has described varnaprasadana as one of the functions of raktadhatu i.e. it imparts the colour to skin. Raktadhatu is also responsible for the proper conduction of tactile sensation of the skin54. D. Twak and Mamsa dhatu – Twacha is an upadhatu of Mamsa dhatu. Development and nourishment of twacha is depending on the dhatupakavastha of Mamsa dhatu55.03. Twacha and Trimala – Mala, Mutra and Sweda are the three main malas are theoutcome of sarakitta vibhajana process during dhatwagni viparyaya. The kitta part isexcreted out from the body. The sweda is the mala of Medo dhatu, which is excreted outfrom the swedavahi strotas of twacha. Sweda maintains luster and humidity of the skin56. According to our science nails and hairs are the mala of asthi dhatu and twachagatsneha is the mala of Majja dhatu57. Kustha involve morbidity of seven dravyas. They are Tridosa and four Dhatus(Rasa, Rakta, Mamsa and Lasika). So from above description one can easily understandthe importance of these units. The Vikrti of these seven essentials leads to the occurrenceof many skin diseases i.e. Occurrence of many Kustha Rogas. 20 Shareera
    • Modern View – Anatomy of Skin58 Skin is one of the largest organ in the body in surface area and weight. In adultsthe skin covers an area of about two square meters and weights 4.5-5 kgs. It ranges inthickness from 0.5-4.0 mm. depending on location. From all the body’s organs none ismore easily inspected or more exposed to infection, disease and injury than the skinbecause of its visibility. Skin reflects our emotions some aspects of normal physiologicalprocess, which are held in our body. All the constituents are derived from ectoderm or mesoderm. 01. The epithelium structure i.e. epidermis pilosebaceous / apocrine units, eccrine sweat units and nail units are ectodermal derivations. 02. Melanocytes, nerves and specialized sensory receptors arise from the neuro- ectoderm. 03. The other elements in the skin i.e. Langer Han’s cells, macrophages, mast cells, fibroblasts, blood vessels, lymph vessels, muscles and lipocytes originate from mesoderm.Microanatomy of Skin Structurally the skin consists of two principal parts – A. The superficial thinner portion, which is composed, of epithelial tissue is called epidermis. B. The epidermis is attached to the deeper thicker connective tissue called dermis. C. Deep to the dermis there is a subcutaneous layer, which is called superficial fascia or hypodermis, which consists areolar and adipose tissue. 21 Shareera
    • Epidermis The epidermis is defined as squamous epithelium, which is about 0.1 greater up to0.8-1.4 mm on the palm and sole. Its prime function is to act as a protective barrier. Keratinocyte is the main cell of this layer, which produces a protein keratin. Thefour layers of the epidermis represent the stages of maturation of keratin by keratinocytes. 01. Basal layer – Stratum basale. 02. Prickle cell layer – Stratum spinosum. 03. Granular layer – Stratum granulosum. 04. Stratum lucidum 05. Horny layer – Stratum corneum. Stratum Basale – The basal cell layer of the epidermis is comprised mostly ofkeratinocytes which are either dividing or non dividing. The cells contains keratin,tonofibrins are secured to basement membrane by hemidesmosomes. Melanocytes makeup 05-10% of the basal cell population. These cells synthesis melanin and transfer it viadenritic process to neighboring keratinocytes. Melanocytes are most numerous on theface and other exposed sites and are of neural crust origin. Merkel cells are also found abit in frequently in the basal cell layer. These cells are closely associated with terminalfilaments of cutaneous nerve and seem to have a role in sensation. Their cytoplasmcontains neruopeptid granules as well as neurofilaments and keratin. Stratum spinosum – Daughter basal cells migrates upwards to form these layer ofpolyhedral cells, which are interconnected by dermosomes. Keratin tonofibrils form asupportive mesh in the cytoplasm of these cells. Langer Hans cells are mostly found inthis layer. 22 Shareera
    • Stratum granulosum – Cells become flattened and loose their nuclei in thegranular cell layer. Keratohyalin granules are seen in the cytoplasm together withmembrane coating granules, which expel their lipid contents into the intercellular space. Stratum lucidum – Normally only thick skin of the palms and the soles has thislayer. It consists of 3-5 rows of clear flat dead cells that contains droplet of anintermediate substance that is formed from keratohyalin and is eventually transformed tokeratin. Stratum corneum – The end result of keratinocytes maturation can be found in thehorny layer which is comprised of sheets of overlapping polyhedral cornified cells withno nuclei (corneocytes). The layer is several cells thick on the palms and the soles butless thick else where. The corneocyte cells envelop is broadened and the cytoplasm isreplaced by keratin tonofiriles in a matrix formed from the keratohyalin granules cellswhich are struck together by a lipid glue which is partly derived from membrane coatinggranules.Dermis The dermis is derived as a tough supportive connective tissue matrix containingspecialized structures found immediately below and intimately connected with epidermis.It varies in thickness being thin 0.6 mm on the eyelids and thicker more than 3 mm onpalm and soles. The dermis chiefly consists of white fibrous tissue, elastic fibers and non-stripedmuscles and contains blood vessels, nerves, hair, sweat gland, sebaceous glands andnerve corpuscles. The outer portion of dermis is about 1/5th of the thickness of the totallayer is named as papillary region. The deeper portion of the dermis is called as reticularregion. It consists of dense irregular connective tissues containing interlacing bundles ofcollagen and coarse elastic fibers. 23 Shareera
    • The reticular region is attached with underlying organs such as bone and musclesby the subcutaneous layer also called as hypodermis or superficial fascia.PHYSIOLOGY OF SKIN59 The skin is metabolically active organ with vital functions including theprotection and maintaining homeostasis of the body.Functions of the skin 01. Regulation of the body temperature. 02. Protection 03. Immunity 04. Sensation 05. Excretion 06. Blood reservoir 07. Synthesis of vitamin DKeratin Maturation The differentiation of basal cells into dead but functionally important coenocytesis a unique feature of the skin. The horny layer is important in preventing all types ofagents from entering the skin including microorganisms, water and a particular matter.The epidermis also prevents the body fluids from getting out. Epidermal cells undergo the following sequence during keratinocyte maturation. 01. Undifferentiated cells in the basal layer immediately above divide continuously. Half of these cells remain in place and half progress upwards and differentiate. 24 Shareera
    • 02. In the prickle cell layer cells change from being columnar to polygonal. Differentiating keratinocytes synthesize keratin, which aggregate to form tonofilaments. The desmosomes connecting keratinocytes are condensation of ton filaments. Desmosomes distributes structural stresses throughout the epidermis and maintain a distance of 20 mm between advancement cells. 03. In the granular layer enzymes induce degradation of nuclei and organelles. Keratinohyalin granules mature the keratin and provide an amorphous protein matrix for the tonofilaments. Membrane coating granules attach to the cell membrane and release an impervious lipid containing cement which contributes to cell adhesion and to the horney layer. 04. In the horney layer the dead flattened corneocytes have developed thickened cell envelops encasing a matrix of keratin tonofibils. The disulfide bonds of the keratin provide strength to the stratum corneum but the layer is also flexible and can absorb up to 3 times its own weight in water however if it dries out i.e. water content falls below 10% pliability falls. 05. The corneocytes are eventually shed from the skin surface. Rate of Keratin maturation – Kinetic studies show that on an average thedividing basal cells replicate every 200-400 hours and the resultant differentiating cellstake about 14 days to reach the stratum corneum and a further 14 days to be shed. Thecell turnover time is considerably shortened in keratinization disorders, such as psoriasis. Biochemistry of the skin – The important molecules synthesized by the skin are(a) keratin, (b) melanin (c) collagen and (d) glycosaminoglycans. Hormones and the skin – the skin is the site of production of one hormone (vit.d) but it is often a target organ for other hormones and is frequently affected in endocrinediseases. 25 Shareera
    • Table No. 04. Showing the relation between skin and hormones.No. Hormone Site of Production Effects01. In dermis from precursor Important for the absorption of Vit – D through the action of UV Ca-. and for calcification. radiation02. - Receptors on several cells in both epidermis and dermis - Produce vasoconstriction Corticosteroids Adrenal cortex - Reduce mitosis by basal cells. - Generate anti-inflammatory effects on leukocytes. - Inhibit phospholipase A03. - Receptors on hair follicles and Androgens Adrenal cortex and gonads sebaceous glands. - Stimulate terminal hair growth and increase output of sebum04. MSH & ACTH Pituitary glands - Stimulate melanogenesis05. Estrogens Adrenal cortex and ovaries - Stimulate melanogenesis06. - Receptors found on keratinocytes, hair follicles, and Epidermal Skin sebaceous glands and sweat duct growth factor cells. - Stimulates differentiation after Calcium metabolism.07. Cytokines and Effects on immune functions, eicosanoids Cell membrane inflammatory and cell proliferation. 26 Shareera
    • Immunology of Skin :60 The skin is an important immunological organ and normally contains nearly allthe elements of cellular immunity with the exception of B-Cells. Much of the originalresearch into immunology was done under the skin as a model. The immunologicalcomponent of skin can be separated into. 1. Structures 2. Cells 3. Functional systems 4. Immunogenetics. Structure – The epidermal barrier is an important example of innate immunitysince most microorganisms that have contact with the skin don’t penetrate it. Equally thegenerous blood and lymphatic supplies to the dermis are important channels throughwhich immune cells can pass to or from their sites of action. Cells – Langerhans Cells : The langerhans cells of the epidermis are theoutermost sentinels of the cellular immune system. They are dendritic, bone - marrowderived cells characterized ultra structurally by a unique cytoplasmic organelle known asthe “Birbeck granule”. Langerhans cells play an important role in antigen presentation.Dendritic cells are also seen in the dermis these lack the birbeck granule but their othercharacter suggests that they too can present antigen. T-Lymphocyte : T-Lymphocytes are now believed to circulate through normalskin where they are thought to mature. Different types of T-Cells are recognized. i.e. 1. Helper - Facilitate immune reaction 2. Delayed hypersensitivity - Specially sensitized. 3. Cytotoxic suppressor - Regulate other lymphocytes. 27 Shareera
    • Surface receptors detectable by the use of monoclonal antibodies on tissuesections help to categorize the subgroups. Helper T- Cells often show the CD-4 receptorsand suppressor T- Cells shows the CD-9. B-lymphocytes are not found in normal skin butare seen in some diseases. Mast cell : These are normal residents of the dermis as are macrophages, bothmay be recruited to the site during inflammatory reactions. Keratinocyte : It has recently been recognized to have an immunologicalfunction. They can produce pro-inflammatory cytokines (specially interteukin-1) and canexpress on their surface immune reactive molecules such as MHC Class II antigens e.g.HLA – DR and Inter cellular Adhesion molecules ( ICAM-I)Functional Systems 01. Skin associated lymphoid tissue : The skin with its atternt blood supplylymphatic drainage, regional lymph nodes, circulating lymphocytes and resident immunecells can be viewed as forming a regulatory immunological unit. 02. Cytokines are soluble molecules that mediate actions between cells. they areproduced by t-lymphoctyes and sometimes by other skin cells including langerhans cells,keratinocytes, fibroblasts, endothelial cells and macrophages. Eicosanoids are nonspecificinflammatory mediators (e.g. Prostaglandis, Thromboxanes and Leukotrienes) and are producedfrom Arachidonic acid by most cells, macrophages and keratinocytes. 03. Adhesion Molecules : The Adhesion molecules particularly ICAM-1 are cellsurface molecules found on lymphocytes and some times on endothelial cells andkeratinocytes. By interacting with leukocyte functional antigens they help to bind t-cells andincrease cell trafficking to the area. 28 Shareera
    • 04. Immunogenetics : The tissue type antigens of an individual are found in theMajor Histocompatibility Complex (MHC) located in man on the HLA gene cluster onchromosome 6. The MHC Class-II antigens of which the commonest is HLA-DR areexpressed on B-lymphocytes, Langerhans cells, sometimes T-cells, Marophages,Epithelical cells and Keratinocytes. They are vital for immunological recognition but alsoare involved in transplant rejection. In addition the appearance of specific HLA genes is associated, with an increaselikelihood of certain diseases, some of which are Autoimmune in nature. 29 Shareera
    • DHARAKARMA61a Shira seka is one of the many special types of treatments widely practiced inKerala for diseases of head. In classical medical literature one meets with the causalreferences for this as well, but details are not available from any of them. Shiraseka otherwise called as Dhara is the process in which medicated oil, milk orbuttermilk, is poured in a continuous stream on the head especially on the forehead in aspecific manner. Dhara is a method of the Kerala special treatment evolved from the genius of themedical tradition there. Many such distinctive and excellent forms of treatments notpracticed in other parts of India, are conducted by the Kerala physicians. Dhara is oneamongst them and the most important. Although there are many physicians conductingthis treatment, only a few manage it with a thorough understanding of its principles. Toconduct a dhara in a proper manner order is very difficult and expensive too. To manageit properly without any omission or mishaps, the physician should be well studied andexperienced. Besides, to select the suitable cases for dhara, he must have gooddiscretionary ability. To speak the truth, dhara is good for all diseases. Changing the liquid as per thedosha condition with necessary alteration in its process is useful to alleviate any dosha.For instance, oils medicated with appropriate medicines in vata, ghee prepared with pittahealing medicines in pitta and mere oils in kapha can be used. For a healthy man,Yamaka (mixture of oil and ghee) is preferred as per tradition. According to anotherversion, the suitable liquid medium for vata is unctuous liquids (as oils, ghee, etc.) forpitta milk and for kapha buttermilk. Sometimes in pitta diseases as per the conditions, 30 Takradhara
    • dhara with tender coconut water, or breast milk or cold water is performed. Similarly forkapha, dhara with some decoctions and in vata with Dhanyamla (a vinegar prepared withcereals, citrus fruits, etc.) is also conducted. This can be carried on with other liquids alsoas per our discretion looking into the details of the doshas, diseases and their seats. There are varieties of dhara. They are mainly grouped as Moordhanya (on thehead), Sarvanga (all over the body) and Pradeshika (local). The most important of these isMoordhyanya. It is employed in diseases like insanity, diseases of the head and eyes,chronic cold, sinusitis (peenasa), diseases of the ear, mouth, Vata diseases, etc. thesecond is Sarvanga dhara. It is to be done in Sarvanga vata (Vata affecting the wholebody), Sarvangeena shopha (anasarca, swelling all over the body), etc. Pradeshika orlocal in cases of rheumatoid arthritis, swelling, ascitis, abscesses, wounds, etc.MOORDHANYA DHARA There are many varieties of Moordhnidhara. The following are the importantamong them. a. Takra dhara b. Ksheera dhara c. Stanya dhara d. Sneha dhara Not only for Moordhanya dharas but for all dharas many arrangements are to bemade ready earlier. The following are the important once.DHARAPATI OR DRONI The first requirement is the proper droni. To make a proper dharapati, manyorderly steps are to be followed. The first one is the selection of the suitable wood. Manytrees as Deodar, Pine, Punnaga (Calophyllum inophyllum) Mango tree and others arespecially recommended for this. 31 Takradhara
    • The ideal wood universally accepted by physicians is Nuxvomica. But the woodof jack and Asana (Madras Kino wood) are also good. An average Dharapatti must be 55to 80 cm in breadth and 2.5 to 3 meters in length. On the head side the part that comesunder the neck of the patient when lying, is elevated. Behind it there is a pit to whichliquid flows when dhara is conducted. There is a hole to the pit to allow the liquid to flowout, so that the flow of the liquid to the part of the Droni where the body rests isprevented. The part of the droni where the head rests should be low by 9 to 12 cm. Thereshould be an outlet on the foot side also to allow the fluid to go out. Besides, there shouldbe handles on all the four corners 12 to 24 cm long. It is to help carry the patientsconveniently from each of the four extremes to keep the droni up from the floor. Theheight of the support is to be 24 to 36 cm. The droni for Sarvanga dhara is to have itsborders higher than other ones. Here the heights of the supports also are to be altered. Onthe head side they should be higher and on the foot side lower.DHARACHATTI (The vessel for Dhara) Amongst the apparatus required for a dhara, one very essential is the dhara vessel.It is to be made with the utmost care. It can be made with metals like Gold, Silver, etc.but some liquids used for dhara may not agree with some metal containers. So thesevessels are usually made of clay, which is best and congenial to, all alike. This vesselshould contain at least 5.5 liters of liquid and so formed that the liquid is drawn to thebottom from all sides evenly. Otherwise, when the vessel is moved to and fro, the liquidmay overflow and the steady downward flow is hindered. There is no need foremphasizing that the vessel should be made of pure clay, well baked and made durable.The edges of the vessel is to be thick a turned outwards, so that it is easy to tie a rope 32 Takradhara
    • around it for hanging. A hole is bored in the very center of this vessel. The circumferenceof this hole should be large enough to allow the insertion of the finger of the patient oranybody else. A wick of thread is pushed down through this hole along which the liquidis allowed to flow down. This wick should be of well spun thread soft and even. This is tobe tied (in the form of a ring) in the middle of a strong stick, about 12 cm in length. Thestick is then placed inside the vessel and the wick is let down through the hole. To place acoconut shell, bored in the center between the stick and the hole, is a practice amongphysicians. A coconut shell with regular slope is selected avoiding soft spots and is madesmooth. The edge of this shell is serrated. The shell is placed mouth downwards at thevery center of the vessel. The stick is fixed above the shell and the wick of the thread isallowed to pass down through the holes of the shell and the vessel. The benefits of thisdevice are that, when the vessel, is moved to and fro, the range of movements of the rollis controlled. If the stick is placed just inside the vessel above the hole with no coconutshell between them. The whole thread hanging down swings uncontrollably. Since thereis space between the teeth of the coconut shell, there is no chance of any hindrance to theflow of the liquid. Along with this, another trick is also done. Between the shell and thevessel round piece of plantain leaf (made out by heating) is put. This leaf is bored hereand there at various spots. This helps regulates the speed and girth of the flow, in itsabsence, there is probability of forceful rush of the liquid down when refilling the vesselrepeatedly. Fall of the liquid on the head, sometimes feebly, may create troubles. Theedge of the vessel is to be wound with strong ropes and made ready for suspending fromabove. 33 Takradhara
    • DHARADRAVAM (The liquid for Dhara) How to prepare the liquid for Dhara is our next concern. This is the mostimportant item in dhara. Dharas are named after the liquids employed for them. Theeffect of a dhara mainly depends upon the quality of the fluid selected. So we have toseparately deal with the liquids commonly used and with the differences in naming theirvarieties etc. Whatever be the fluid for the dhara on the head, its quantity is to be not lessthan 1800 ml or more than 3600 ml. Usually an average of 2700 ml is taken. Dhara, themost important among them in vague is Takradhara. This is not simply with rawbuttermilk as the name suggests. Dhara simply with raw buttermilk is very rare. Usuallythe buttermilk is mixed with the decoction of Amalaka (Emblica myrobalans) or someother liquids. The preparation of this buttermilk also has to be managed with special care.The tubers of Musta (Cyprus rotundus) for which outer skin removed, are taken in theratio of 30 gms/450ml of buttermilk, tied in bundle and put in milk with four times ofwater. Remove the water completely by boiling. The milk must be pure. When boiling asteady and mild fire is to be maintained. Too much blazing or drying must be avoided. Ifthe water is not removed completely, it may be the cause of many troubles. Duringboiling, the milk is to be stirred repeatedly. Even after removing the milk from the stove,the lading is continued until it cools down. The ferment is put only when the milk issufficiently cooled. On the first day, ordinary buttermilk without any water is used as aferment, since the medicated buttermilk prepared on the above lines is not available then.After adding the ferment it should be kept closed in a safe place and on the next daymorning the butter is removed by churning well. The bundle of the medicines put in themilk earlier is squeezed well and removed when the boiling process is over. But some 34 Takradhara
    • told that the best time for its removal is only when the curd is churned. The quantity ofmilk required for next day’s dhara fluid and also for preparing the ferment is to becollected and boiled. Besides Musta, other medicinal herbs like Chandana (Sandal wood),Usheera (Vettiver), Madhuyashti (Liquuorice) and Hribera (Coleus vettiveroides) are alsoput in the milk while boiling. Such choice is left to the direction of the physician.Whatever may be the number of medicines, the total quantity should not exceed the ratioof 30 grams for 450 ml. Generally for all diseases, Musta enough for the intendedbenefits.ATTENDANTS The attender is the next important requirement for dhara. There must be at leastthree of them. They are to be well trained, experienced in having worked together co-operatively, attentive, with love and attachment towards the patients so that he also likesand feels confidence in their care and interest towards him.THE PHYSICIAN In all treatments, the main part belongs to the physician. Dhara can never be donewithout him. The patient may have undergone many dhara treatments earlier, theattendants may be well experienced and clever, still to start a dhara in the absence of aphysician is completely wrong. The physician, who is well versed in the medical scienceand one with good experience in treatment, must have a thorough knowledge of thenature of the patient. He must be intelligent and wise so that no mistakes are committedand if anything goes wrong, he is able to rectify it immediately. Attention should be paidby him not only when dhara is being done, but also in gathering the equipments and inthe daily routine of the patient. 35 Takradhara
    • Although not so important as the above, there are other minor things also to beprepared earlier. A bed sheet, pillow, a roll of cloth to tie around the head, pieces of cloth,a bath towel, a vessel to collect the dhara liquid. Coming out form the droni, two suitablereceptacles to receive liquid and pour it again into the dhara vessel, two or three smallcups made of leaves, two or three small seats for the physician and attendants, a lampwith oil and wick, a time keeper, oil for the head and kuzhampu or Trivritasneha for thebody, herbal shampoo, water boiled with Amalaka for washing the head, powder of greengram or hours gram for removing the oil on the body, another fresh bath towel for dryingthe head, the medicine to be taken immediately after bath, the food at the proper time,places selectively arranged for undergoing dhara, lying and sitting all these are to be setready before the dhara. Some of these that are to be specially attended to are pointed outbelow – Bed sheet – Must be pleasing to the patient, soft and clean, but not too warm. Pillow – This is a temporary pillow prepared with soft cloth folded repeatedly. Ifis finally covered by a plantain leaf made soft by heating. This leaf cover preventswetting and since it extended to the top of the droni, from where it is let out. The length,height and thickness of the pillow are adjusted for the comfortable resting of the headduring dhara. Carelessness in this may cause many troubles. Pillows can be made of verysoft leather or oilcloth. This pillow is to be used only at the time of Dhara. At other timesthe ordinary pillow is enough for use. Varti (Roll of cloth) – This is prepared by wrapping old soft cloth. This is tiedaround the head to prevent the liquid form coming down. It is to be as thick as the thumb 36 Takradhara
    • of the patient and long enough to be wound around the head and tied at a side. It is betterto wet the parts of the cloth that goes round the head in the dhara liquid earlier. Oil for the head – Medicated oil for the head is to be selected to suit thetemperature of the patient and the symptoms of the disease. It should be kept safe formcold. The quantity for immediate use is taken in another pot or cup. Take care to this cupwell before use. If wet, it may cause troubles. Generally Bhringamalaki tailam,Manjishtadi tailam, Asanavilwadi tailam, Triphaladi tailam, Chadanadi tailam (Big),Tungadhrumadi tailam and Balaguduchyadi tailam are taken for this purpose. Kuzumpu for the body – These also are to be mediciated as those for the head.Usually pinda tailam, Dhanwantaram tialam, Sudhabala, Ksheerabala, Prabhanajanavimardhana, Lakshadi and Balashwagandhadi are applied warm on the body. The amalaka water – This has to be made ready, boiled and cooled the previousday. The mentioned preparation is the same as for the Paneeyas of the Ayurvedicformulary. 10 grams of Amalaki (Emblica myrobalan) seedless are put in 1800 ml ofwater (Prastha) boiled and reduced to half. Reducing only ¼ th part and leaving ¾ th foruse, is also accepted. The total quantity of Amalaka water, should not be less than sixprastha (10800 ml). For those with excess of pitta, vettiver or clearing nut (Kataka) andfor those suffering form cold, pepper leaves itself, for those with vata troubles the leavesof bala (Sida cardifolia) and for those with excess of kapha, Haritaki, are also addedwhen for preparing Amalaka water as per the tradition of the physician. Hot water – This is water was boiled with herbs healing vata such as the leaves ofcastor plant or leaves of jack tree, etc. This is not to be too hot. It has to be adjusted tosuit the temperature of the patient. 37 Takradhara
    • The power for rubbing on the crown – Rasnadi power is the one commonly used.But for those with an excess of Pitta, Kachoradi power is better. Manjishtadi also isrecommended. Amalaka and pepper are roasted and powdered and made use of. The medicine to be taken in – Generally, in all treatment of dhara, Pizhichil,Navarkizhi, etc. Gandharvahastadi kashayam is the accepted medicine is to be taken inthe morning. It’s both laxative and digestive. But sometimes in pitta predominancy, thism ay prove unfavorable. In such conditions, for proper evacuation of the bowelsdecoction of grapes and haritaki is better. This can be used in all treatments as per theneed. Drakshadi kashayam, Mridweeki kashayam, Dhanwantarm kashaya also can beprescribed as per the condition of the patient. Here, the physician has to use hisdiscretion, observing the doshas, the tissues involved, etc.PROCEDURE OF TREATMENT Karkatakam (July-August), Tulam (October-November) and Kumbham(February-March) are considered as the best time for this treatment. In these monthswhen the climatic conditions are favorable, free form excess of wind, mist cold, rain etc.,on an auspicious day, in the morning hours, the treatment is generally started. In aspacious room protected form wind and other excesses, the Dhara droni which has beenset up, already well washed and dried on the previous day itself, is now brought in andagain wiped with a cloth and placed with its head towards the east. The head part is to bea bit raised and leg part lowered. If the supports of the Droni are not suited for thisposition, the height is to be adjusted by placing adequate pieces of wood etc., under theDroni. The droni is to be firmly fixed. It is to be remembered that the purpose of raisingthe head portion of the droni is to have space enough to place the receptacles (small 38 Takradhara
    • droni) for receiving Dhara liquid flowing form the Droni and also for the convenienthandling of the Dahra vessel by the physician seated on a stool. The Dhara vessel shouldbe suspended exactly above the head of the patient lying in the Droni. How to set up theDhara vessel in this way is already explained. The wick of thread hanging from the vesselshould be so adjusted as to be just 5 cm (two fingers) (according to ayurvedic treatmentof Kerala four finger) space form above the forehead of the patient, lying supine in theDroni. Then spread the sheet in the Droni and set the pillow on its position. Thereceptacle, the cups for refilling and seats are all to be placed in their respective positions.Now make sure whether the oil for the head and Dhara liquid, the bath towel and othernecessary equipments are all ready and then light the lamp already placed on the south,the head side. The wicks of the lamp should be laid prominently to the west and then tothe east. Seeing that everything is ready and in order, the physician can now allow thepatient to enter. The patient in his turn should be ready by this time after having attendedto the calls of nature and cleaning the mouth, teeth, etc. When the physician calls him, heshould wash his feet once again, enter the treatment room and then stand facing the eastbefore the lamp. He is to submit offerings to his own deities or as directed by thephysician and having performed auspicious rituals, offer Dakshina to the physician alsoaccording to his mite. Then with the permission of the physician, he seats himself in thedroni facing the east. The physician now stands at the right side of the patient facing the east. Thenpaying homage mentally to his teacher and the God and taking oil on his palm he appliesit on the crown of the patient. This is repeated thrice. Then the patient himself can apply 39 Takradhara
    • the oil. But not too much as to trickle down. If the patient has long hair, it has to beparted and tied in the back. The next step is to tie the Varti around the head just above theears, eyebrows. It is not to be too tight or loose. If too tight, the blood supply may behindered, if too loose, it allows the Dhara liquid to pass through it to the inside of theDroni and to the body. The knot should be only on the side of the head. If it is on theback, it creates difficulties to lie with the head placed in order. If it is on the forehead, ithinders Dhara. Now the patient is to lie in a supine position in the Droni. Then inspect theposition of the pillow, the thread hanging down form the vessel, its height and thicknessare all found to be in order, the liquid is poured into the dhara vessel. When pouring,draw back the vessel form the upper part of the head with one hand, and firmly close thehole at the bottom of the vessel with the other hand. So it is clear that another personpours the fluid. Pouring is to be done very slowly to prevent scattering and spraying.After the whole liquid is poured, the finger at the whole is loosened very slowly andgradually and the liquid is let down along the wick. If the wick is too thick, some threadis drawn out form it. If not which enough press the hole tightly to stop the flow and thenadd more thread to the wick. When the wick is wet and the liquid starts to flow along it,its edges are to be cut even, with scissors, even if they have been cut earlier. After theseprecautions, the vessel is brought forward above the forehead and moved to and fro, i.e.left and right slowly. As per traditions, the movements of the wick to the left and right, need no bemore than 5 cm form the center of the forehead, the middle of the eyebrows. But therecould not be any objection to make some alterations so as to allow the liquid to spread allover the head in the beginning. Massaging the scalp under the hair with the free palm of 40 Takradhara
    • the physician or the attender, first in the beginning and then at intervals is advised toprevent delay in wetting the whole head with the liquid. Even if the liquid falls correctlyon the head, it is the duty of the physician to make sure that it is also flowing out throughthe proper channel. If it is not followed properly, it may be either because of the hole ofthe droni is blocked or the diverted liquid flows to the part of the droni where the bodylies. Whatever may be the reason; it has to be corrected immediately. So the physicianwho handles the suspended dhara vessel, should be vigilant and pay concentratedattention. If he fails in fall in this and doesn’t hold the vessel firmly, the scattered liquidmay fall in the eyes or nose of the patient, or fail to fall properly on the head, orsometimes when refilling the vessels, may collide with each other, break and createavoidable difficulties. So the physician, should be vigilant with a firm hold on the ropeand vessel, so that in case of collision or the breaking of the tie of the rope, the danger ofthere falling down is always prevented. The attendants also should be equally careful.The receptacles should be placed exactly where the liquid comes out. When onereceptacle is full, it is immediately replaced. The full vessel is removed carefully andslowly without spilling and again poured inside the dhara vessel with no chance ofclashes. This goes on continuously. It is always better to take the receiving vessel beforeit is full and empty it, unto the dhara vessel. Paying attention to the filling and emptyingof the vessel, one can has to adjust the speed of the refilling. The fall of the dhara liquid from too high, or too low level is both harmful. It isthe same if it is too fast, or too slow. Both increase or decrease in the thickness of flow isnot good. As per tradition, if the wick through which the liquid flows is two fingers (5cm) above the forehead, circumference of the hole is the size of the little finger of the 41 Takradhara
    • patient and if the dhara liquid is neither too thick nor too thin everything is satisfactory.But in these matters, it will be better to consider the comfort of the patient also. For somepeople, the fall form 5 cm height may be intolerable for others too low a position may bedisagreeable. Some patients like a thick flow, while others a thinner one. Thesedifferences in reaction may be due to the difference in temperaments. Sometimes it mayalso be due to the difference in doshas. For instance, in Pitta a low fall, but with morethickness is beneficial. A patient with Kapha temperaments may like the fall form ahigher position. He also appreciates a speedy flow. Different liquids also can create this change in reactions. We have to observeclosely and judge accurately. A fall from a higher position causes headache, fever,burning sensation, etc. Too low a fall not only fails to alleviate the disease, but alsosometimes, even aggravates the condition. A speedy flow provokes vata and createsheadache, swoon, etc. If too slow, kapha is increased and heaviness of the head is felt.The disturbance created by using too thick a fall is the same as due to increase in heightand slow flow. Too thin a fall fails to give any good results. On the contrary, it causes,cold. One has to closely observe and understand these changes. Various other aspects likeviscidity are to be considered carefully. Thus, until the scheduled time is over, all have to do their work earnestly andcarefully and the patient is to lie still. He is not to turn on his sides, but lie supine. Suchnecessities as urination, etc It should not arise during this time if it is unavoidable itshould be done in lying position without any movement of the head. Sneezing, coughing,etc in this position also create troubles. In urgency, the physician is to be informed so thathe can draw back the dhara vessel from the forehead and hold it aside until it is over. He 42 Takradhara
    • must be very careful to avoid any interruption in the flow by drawing back the vessel toomuch. When refilling also, the best thing is to draw the vessel a little to the back and stopthe movement to avoid the troubles. If somewhat the dhara liquids happens to drop in theeyes or the face, immediately wipe it well. It is for this purpose that storage of old clothesis suggested. One hour dhara on the first day is the usual practice in all common disease. Thenthe duration is increased by five minutes each day, so that on seventh day it is one and ahalf hour (3¾ Nazhikas). On the eight day also, the same time is taken as on seventh.From the ninth day onwards, a reduction of five minutes is done so that on the fourteenthday it is again one hour as on the starting day. This order is for a fourteen-day course. If itis a twenty-one days course, the order of increasing the time is the same as given beforeuntil the seventh day i.e. reaching to one and a half hour on the seventh day. But from theseventh to fifteenth day, the same duration is kept. From sixteenth day, a reduction of fiveminutes per day is effected, so that it is one hour again on the twenty-first day. Usuallythe time for the course of dhara. Is either fourteen or twenty one day. But there is noobjection in extending or reducing the duration as per the condition of the patient. Suchdiscretion is the responsibility of the physician. Well-considered decisions are alwayswelcome. But prolongation of the dhara time to more than one and a half hours isunnecessary, inconvenient and objected to by the shastras. In unavoidable circumstances,competent physicians resort to extensions of the number of days. There is also a versionthat the maximum time allowed is only three Nazhikas (75 minutes). The minimum timeallowed is one Nazhika or 25 minutes. The physician has to choose the time limitconsidering all factors like the nature of the disease, doshas and the tolerance of thepatient. 43 Takradhara
    • DUTIES AFTER DHARA At least five minutes before the compilation of Dhara all attendants should beparticularly vigilant. Everything for the next step, like bath towel, etc are to be keptready. Refilling the Dhara vessel is to be stopped some seconds earlier before the exactstopping time. At the exact moment, stop Dhara by drawing the vessel back. Then wipethe head with the towel. This is not to be done by the patient himself to avoid anyshaking. After wiping well, same oil applied himself earlier is again smeared. Then hemay take bath as usual. But Amalaka water for some people for the head and warm waterfor the body are indispensable. But for some people warm water may not be agreeable.For them cold water for the body may not be harmful. To remove the oil from the body,pasted greengram, horsegram etc. and the head, shampoos of leaves like Vellila(Mussaenda frondosa) which are neither too cold not too hot in potency are used. Formen of pitta temperament, the residue of the Amalaka water prepared as a paste can bemade use of. After bath wipe the head without delay. It has to be done carefully so that nomoisture is retained. After wiping well with a wet towel again wipe with a dry one also.After wiping, part the hair and rub medicated powder. As said earlier it is Rasnadi power,which is usually taken for this. This prevents cold better. Powers like Kachoradi also canbe used as per the disease. After bath, enter the room slowly, and then facing the east takein the prescribed medicine. Then lie down for a while on the left. Care should be taken toarrange the bed earlier. But, this rest is only for a while, from a minimum of five minutesto a maximum of thirty minutes only. Then take food with the prescribed restrictions. 44 Takradhara
    • RESTRICTIONS DURING DHARA Chilies, tamarind, newly harvested paddy, fish, seasum, black gram, pumpkin,brinjal, onion, drumstick, asafetida are harmful. Natural urges should not be stopped. Daysleep, exposure to mist, sun, dust, wind, and rain are being avoided. Walking long timetraveling in jerky vehicles, prolonged standing and sitting are harmful.Effects of Takradhara 61b This Dhara treatment cures premature graying of the hairs, fatigue, infirmity andemaciation, headache, lack of vitality, pricking pains of the palm and sole, diabetes, lackof proper functioning of the limb, joints, pain in the chest, heart diseases, disgust forfood, indigestion, dyspepsia and diseases of the eyes, nose throat and ears. This Dharaalso alleviates the derangement of the three doshas and improves the power of all sensoryorgans. 45 Takradhara
    • KITIBHA KUSHTA –Classification Of Kushta The word Kushta is widely used for all types of skin diseases. It is a broad term,which covers almost all the skin diseases. Kushta is produced invariably by the vitiationof the seven factors i.e. 3 Doshas and 4 Dushyas62. But different types of pain, colour,shape, specific manifestation etc. are found in Kushta because of Amshamsha kalpana ofthe Doshas. Accordingly Charaka Kushtas are in fact of innumerable types, but forsystemic study they are classified into two major groups 7 Maha Kushta & 11 KsudraKushta63. There is no difference of opinion between any Acharya about the total number ofKushta, but difference of opinion in symptoms & names of some of Kushta exists. According to Chakrapani in Kshudra kushta, the symptoms of Mahakushta aremanifested in milder form. Dalhana explained about the word Mahata’ that it has theability to penetrate to the deeper Dhatu while the Kshudra Kushta do not have the abilityto penetrate the deeper tissue64. According to commentator Gayadas there is severe andextensive vitiation of Doshas from the very beginning, in Mahakushta, which penetratethe deeper tissues and cause Mahakushta. But no such severe and extensive vitiation ofDoshas occurs in the Kshudra kushta from the beginning. 46
    • Table No. 05. Showing the difference between Maha Kushta and Kshudra kushtas. No. Mahakustha KsudraKustha 01. Bahu Bahul Dosa Arambhata Alpa Dosa Arambhata 02. Bahulakshana Alpalakshana 03. Excessive discomfort Less discomfort 04. Penetrates into deeper Dhatus Less tendency to penetrate in deeper Dhatu 05. Mahat Chikitsa Alpa Chikitsa 06. Chronic Less Chronic 07. Loss of skin function like Supti Less functional skin deformities.Table No. 06. Showing Classification of Kushta according to different Acharyas. No. Types of Kustha C.S. S. S A.H K.S. B.S. M.N. B.P. Mahakushta 01. Kapala + + + + + + + 02. Audumbara + + + + + + + 03. Mandala + + + + + + 04. Risyajivha + + + + + + + 05. Pundarika + + + + + + + 06. Sidhma + - - + + + + 07. Kakanaka + + + - + + + 08. Dadru - + + - - - - 09. Aruna - + + - - - -Kshudra kushta 01. Ekakushta + + + + + + + 02. Kitibha + + + + + + + 03. Charmadala + + + + - + + 04. Pama + + + + + + + 05. Vicharchika + + + + + + + 06. Charmakhya + - + - + + + 47
    • 07. Vipadika + - + + - + + 08. Alasaka + - + - - + + 09. Dadru + - - + + + + 10. Visphotaka + - + - + + + 11. Sataru + - + + + + + 12. Sidhma - + + - - - - 13. Sthularuksha - + - - - - - 14. Mahakushta - + - - - - - 15. Visarpa - + - - - - - 16. Parisarpa - + - - - - - 17. Ruksha - + - - - - - 18. Shwitra - - - - + - - 19. Vishaja - - - + + - - Charaka did another classification on the basis of Doshic predominance in typesof Kushta. It is more useful for diagnosis and treatment of the disease, which are asfollows66.Table No. 07. Showing relation between doshas and kushtas.Sl. Doshic Name of Kushta predominance01. Vata Kapala02. Pitta Audumbara03. Kapha Mandala, Vicharchika04. Vata-kapha Sidhma, Ekakushta, Alasaka, Charmakhya, Kitibha, Vaipadika05. Vata-pitta Rishyajivha06. Kapha-pitta Pundarika, Dadru, Charmadala, Pama, Vispotaka, Shataru07. Sannipatika Kakanaka Charaka also described symptoms of predominance Dosha in Kushta. It is alsouseful in the diagnosis and management of the disease67. 48
    • Table No. 08. Showing symptoms according to dosha predominant.Sl. Dosha Symptoms01. Vata Rukshata, Shosha, Toda, Shula, Sankocha, Ayama, Parushyata, Kharata, Harsha, Shyava-Arunata.02. Pitta Daha, Raga, Parisrava, Paka, Visragandha, Kleda, Angapatana.03. Kapha Shaithya, Shaithilya, Kandu, Sthairya, Utsedha, Gauravata, Sneha, Kleda.NIDANA There is no specific description of etiological factors of the disease kitibha kushta.Being it is being a variety of kshudra kushta. Some of the etiological factors of kushta areto be accepted as the etiological factors of kitibha kushta. Our acharyas have describedgeneral causative factors i.e. Samanya Nidana for all types of kushtas instead of specificNidana type of kushta. The etiological factors of kushta, which includes kitibha kushta,may be classified into following groups – A. Ahara hetu B. Vihara hetu C. Achara hetu like Daiva apacharaja D. Other nidanas like Chikitsa sambandhi, Sankramika, etc.Table No. 09. Showing Aharaja Nidana of Kitibha kushta68.No. Aharaja Nidana C.S. S.S. A.H. B.S.01. Viruddha ahara + + + +02. Ajeerna, Adhyashayana + + - +03. Matsyati sevana + + - +04. Dugdhati sevana + + - -05. Amlati sevana + - - -06. Guru ahara + - - -07. Gramyodaka with Anupamamsa sevana - + - + 49
    • 08. Dadhi sevana + - - +09. Snehati sevana + - - +10. Lakucha and Kakamachi + - - +11. Matsya with Payasa + - - +12. Ahitashana - + - -13. Drava, Snigdhahara sevana + - - -14. Uddalaka, Kusumba + - - -15. Navanna, Yavaka, Kulatha + - - -16. Lavana, Hayanaka, Atasi + - - -17. Moolaka, Satatamadhu sevana + - - -18. Tilapishti, Guda + - - -19. Chilachima matsya with milk + - - -20. Madyamladravya with milk - - - +21. Guda with milk - - - +22. Matsya, Nimba with milk - - - +23. Matsya with Madhu - - - +24. Papodaka (Dushta jala) - - - -25. Pippali, Haritashakha Vidangdhahara sevana - - - +26. Guda with Moolaka - - - +27. Haviprashana (One of the type of Ghrita) + - - -Table No. 10. Showing the Viharaja Nidana of Kitibha68.No. Viharaja Nidana C.S. S.S. A.H. B.S.01. Chhardinigraha + + - -02. Vegavarodha + + - -03. Sheetambusnana after Atapa sevana + + - -04. Diwaswapna + - - +05. Ratri Jagarana - - - +06. Mithya vihara - + + -07. Vyayama atisantapa bhuktopa sevana + - - -08. Shrama bhayartana sheetambu sevana + - - - 50
    • 09. Ajeernapi vyayama + - - -10. Senha pitasya vanatasyava vyayama - + - -11. Vyavaya after vidahi ahara sevana - - - -12. Gramyadharma sevana - + - -Table No. 11. Showing Daivapacharaja Nidana of Kitibha68.No. Daivapacharaja Nidana C.S. S.S. A.H.01. Vipran guruna garshayatam + + -02. Papakarma + + -03. Poorvakrita papakarma + + -04. Killing of female and elders - + +05. Use of money or material aquired through theft - + -06. Sadhuninda, Apamana and Vadha - - -07. Gohatya - - +Nidana of Kitibha kushta due to mithya Chikitsa (Due to improper treatment) 69 Acharyas like Charaka, Sushruta and Vagbhata considered Panchakarma mithyaapachara as a Nidana for kushta. Especially ayoga of vamana and virechana is the maincausative factor for kushta. Due to ayoga of vamana and virechana the vitiated doshas arenot eliminated properly. Hence, doshas accumulates in the srotas. Thereby causingkushta. Similarly, if Brimhana therapy is applied even after attainment of samyakBrimhana lakshana would lead to aggravation of kapha dosha and rasa dhatu. Therekledatwadi vriddhi resulting in the shithilata which ultimately leads to manifestation ofkushta.Sankramika Nidana70 Sushruta acharya has mentioned the nature of kushta i.e. the kushta may spreadfrom the affected by inhalation, physical contact, indulging into sexual intercourse, etc 51
    • though he had not mentioned the above things in the context of Nidana of kushta, it wiseto include above said things into Nidana because sankramika hetu is one of the factorwhich is causing kushta.ETIOLOGY OF PSORIASIS71 Even though extensive research has been carried out in the field of medicine toevaluate the cause of psoriasis, but it is hard to find out the exact cause of psoriasis. Someof the causative factors been evaluated through the extensive research are listed below – 01. Abnormal immune response – Our immune system consists of complex variety of cells ranging form B cells to T cells (TH Cells). In psoriasis the T cells are present more than its normal limits. The activated T cells infiltrate the skin cells in psoriasis. T cells normally stimulates B cells to produce antibodies. In case of psoriasis whoever they appear to direct the B cells to produce auto antibodies by that they target self antigens in skin cells. TH cells also stimulate the production of powerful immune factors called cytokines. In small amounts cytokines are indispensable for healing. If over production however, they can cause serious damage. In psoriasis cytokines known as GRO alpha, tumour necrosis factor and interlukins–8 (IL-8), IL-11 and IL-12 are playing strong role in the causation of disease. 02. Genetic cause of Psoriasis – A combination of genes is involved with increasing persons susceptibility to the conditions leading to psoriasis. Mainly 4 genes are involved in the causation of psoriasis. These genes regulates the human lucocyte antigen (HLA) system. The HLA molecules are designed to produce foreign substances to the immune system so they can be destroyed. 52
    • But this process is malfunctioning in psoriasis. Psoriasis patients with specific HLA genetic factor called HLA–CW6 have tendency to develop at an earlier age.03. Precipitating / Triggering factors – Psoriasis is a chronic disease marked by periods of remissions and excerbations. Remissions may last for a few week to many years. Triggering factors may be local or systemic. A. Local factors – Psoriasis tend to develop at sites of injury to the skin. “Koebner Phenomenon” also known as isomorphic response refers to the induction of the lesion by cutaneous trauma. The trauma may be of any kind – physical, chemical, mechanical, allergic or of any other nature. B. Seasonal variations – Most of the patients worsening of their skin lesions during winter, 89% of the patients studied by Farber and Nail (1978) had worsening of the disease during cold weather. High humidity is usually beneficial. Sunlight may worsen psoriasis in some and improves in many. C. Pregnancy – Remission of psoriasis may occur during pregnancy, but there is exacerbation during the postpartum period. Rarely, generalized postural psoriasis may be precipitated during pregnancy probably due to raised levels of progesterone during the later half. D. Emotional stress – Psoriasis is more stress sensitive than other skin diseases. Many stressful events of daily life exacerbate psoriasis. The disease itself can cause a reactive depression in the patients, which could further exacerbate his psoriasis. 53
    • E. Infections – Upper respiratory tract infections and tonsillitis, especially when caused by streptococci may cause a flare up of exciting psoriasis or may precipitate an attack of acute guttate psoriasis.F. Drugs – A number of drugs can worsen or induce pre-existing latent psoriasis, including the following – a. The anti-malarial drug chloroquine. b. Certain drugs used for hypertension and heart problems, including angiotensin converting enzyme (ACE) inhibitors. Beta blockers may actually trigger the onset of psoriasis and produce flare ups in people who already have it. c. Progesterone used in female hormone therapies. d. Lithium, which is used in bipolar disorder. (It may trigger the onset of the disease and cause severe flare ups in people who already have psoriasis). e. Indomethacin, a non-steroidal anti-inflammatory drug (NSAID), can cause or worsen psoriasis. (It should be noted that other NSAIDs such as meclofenamate, might actually improve the condition.) f. Withdrawing form oral steroid or high potency ointment that covers wide skin areas can cause flare-ups of severe psoriasis. Because these drugs are also used to treat psoriasis, this rebound effect is of particular concern. g. Agents that cause rashes, a side effect of many drugs, can trigger psoriasis as part of the Kobner response. 54
    • SAMPRAPTI OF KUSHTA72 Our acharyas have not mentioned specific samprapti for each and every kushta,but they have mentioned samanya samprapti for all kinds of kushtas. The samanayasamprapti of kushta according to different Acharyas are given below.Flow chart No. 01. Showing Samprapti of Kushta according to Charaka.According to Charaka73 – Saptadravyas are palyaing as a sannikrishta hetus for Kushta. Nidana Sevana Vitiation of Tridoshas Vitiated doshas Vitiates twacha, mamasa, rakta, lasikaCombination of all these seven dravyas leads to kushta as they will be lodged in between twcha and mamsa. According to the site and nature of the lesion kushtas are named differently.Flow chart No. 02. Showing Samprapti of Kushta according to Sushruta.According to Sushruta74 Nidana sevana Vitiates vata Vitiated vata along with vitiated kapha and pitta enters into siras Pitta and kapha is deposited over the skin by vitiated vata The areas of the skin in which the morbid doshas are deposited became marked with mandalas or skin patches (Mandalani pradurabhavanti). 55
    • The doshas thus lodged into the skin continue to aggravate and having beenneglected at the outset tend to enter into deeper dhauts and further vitiates the dhatus. Butthis stage has to be considered for Mahakushta. Kshudra kushta is to be limited to thestage of madalani pradurbhavati.Flow chart No. 03. Showing Samprapti of Kushta according to Vagbhat75 Nidana sevana Doshas gets vitiated Spreads to tiryaga siras Vitiates twacha, lasika and asruk and produces shaithilyata, vaivarnya of bahirtwacha The disease kushta manifests wherever the morbid doshas gets lodged.Madhavakara76 Madhavakara followed Charakas description, however in place of lasika he usedthe term ambu among the sapta dravyas. Bhavaprakasha77 and Yogaratnakara78 followed Madhavakara.Flow chart No. 04. Showing Samprapti of Kushta according to Bhela Samhita79 Mandagni Vitiation of vata Vitiated vata vitiates other doshas in their sanchayavastha Depending on the rutus. The doshas gets lodged in rudhira and vitiates rudhira followed by mamsa The combination of these doshas along with rakta and mamsa gives rise to 18 types of kushtas depending upon the etiological factors. 56
    • From the above samprapti it is clear that acharya Charaka has stresses to the roleof vata and kapha in kitibha kushta On the other hand Sushruta has stressed the role of pitta in the pathogenesis ofkitibha kushta.Samprapti of Kitibha kushtaFlow chart No. 05. Showing Samprapti of Kitibha Kushta. Nidana sevana Vitiates pitta and shleshma Leads to margavarodha of vata This margavarodha leads to vata vriddhi. This vitiated vata carries vitiated pitta, shleshma and lasika in tiryaga siras and lodge them in the udakadhara, raktadhara and mamsadhara twak. Along with tridoshas kleda playas an important role in the pathogenesis of Kitibha kushta. Both pitta and shleshma being drava dhatus are considered as kledakarakasannikrishta Nidana. The accumulation of kleda results in srotorodha leading to vatavriddhi, because of the combined effect of vata vriddhi and srotavarodha, the rasa dhatudoesnot enter in the srotas. Twcha being dependent on rasa dhatu, because of impropercirculation of rasadhatu shithilata of twacha taking place along with shyava varnabecause of vata vriddhi. At the same time due to ushna guna of pitta. The dravamsha ofkleda escapes through sweda. Due to loss of this dravamsha the kleda that remains intwacha will be ghanibhuta kleda. This effects in parushata and khara sparsha of twacha inkitibha kushta. 57
    • PATHOLOGY OF PSORIASIS80 Psoriasis appears to be largely a disorder of keratinization. The basic defect israpid replacement of epidermis in psoriatic lesion (3 to 4 days instead of 28 days innormal skin.) In addition, there are marked vascular changes in upper dermis in the formof tortuosity and dilatation. Recently, the presence of abnormal neural cells has beendemonstrated in psoriatic plaques. Histochemical studies have revealed an increase in both oxidative and anaerobicmetabolism with increase pentose, glycogen, purines, sulphydral groups and solubleproteins and a decrease in activity of dipeptidases. It has been discovered that apparently normal skin of both the psoriatics and theirrelations show these changes in miniature Latent psoriasis. Histology is characteristic and consists of –i) Parakeratosisii) Thinning of Supra-papillary portion of the stratum malpighiiii) Elongation of ridgesiv) Oedema and clubbing of papillaev) Micro-abscesses of Munrovi) Dilated and tortuous capillaries in upper dermisvii) Oedema and round cell infiltration in the papillae and upper dermis. 58
    • Figure No. 01. Showing Histology of psoriasis. Normal Psoriasis Parakeratosis Micro abscesses Dilated and tortuous capillary loops Irregular thickening of epidermis Upper dermal T lymphocytes infiltrate Two molecule-specific histological reagents have recently become popular; theseare antibodies and laetins. Immunochemical staining shows a number of abnormalmacromolecules in the epidermis, possibly as a result of increased permeability of thevessels. Cell surface antigens on infiltrating lymphocytes show that these are mainly Tcells; the helper: suppressor ratio is normal in quiescent lesions but may increase duringexacerbation. Lectin studies suggest a disturbance of glycoprotein synthesis, much of thematerial remaining in the cytoplasm rather than appearing at the plasma membrane.POORVA ROOPA81 Poorvaroopa is the stage where premonitory symptoms appear immediately aftersthana samsraya. Clinical manifestation of the disease starts during this stage. As there isno specific poorvaroopa mentioned for kitibha, we have to consider samanyapoorvaroopa of kushta. 59
    • Table No. 12 Showing poorvaroopa mentioned by different Acharyas. Purvarupa Ca. S. Su. S. A.S. A.H. B. S. M.N. B.P.Aswedanam + + + + + + -Atiswedanam + + + + + + +Parusyam + + - - - - -Atislaksnata + - + + - + +Vaivarnyam + - + + + + +Kandu + + + + - + +Nistoda + - + + - + +Suptata + + + + + + +Pariharsa + - + + + + +Lomaharsa + + + + + + +Kharatvam + - + + - + +Usmayanam + - - - + - -Gauravam + - - + + - -Svayathu + - - - - - -Kothonnati + - + + - + +Srama + - + + - - -Klama + - - - - - -Visarpagamanam + + - - - - -Kayachidresu Upadehana + - - - - - -Pakva-Dagdha- DastaBhanga-Ksata- + - + + - - -Upaskalitesu.Atimatram VedanaSvalpamapi Vrananam + - + + - - -DustiSvalpamapi Vrananam as - - + + - - -amrohananmAsrujah Krisnata - + + + - - -Vrananam Shighrah - - + + - - -Utpatti Cirah Sthiti 60
    • LAKSHANAS OF KITIBHA KUSHTA82 Different acharyas have mentioned different symptoms (lakshana) of kitibhakushta. Majority of acharyas opine that kitibha kushta vata kaphatmaka. While someacharyas considered it as pittatmaka.Table No. 13. Showing the lakshanas of Kitibha kushta. Sl. Roopa C.S., B.P., S.S. A.H. B.S. K.S. No. Y.R.,M.N. 01. Shyava + - + + - 02. Kinakhara sparsha + - + + - 03. Parusha + - + + - 04. Khara sparsha + - + + - 05. Kandu - + + + - 06. Ahitam - - + + - 07. Stravi - + - - - 08. Vrittam - + - - - 09. Ghanam - + - - - 10. Snigdham - + - - - 11. Krishnam - + - - - 12. Drudhama - - - - - 13. Punaha Prasravati - - - + - 14. Rudhanvitam cha - - - + - 15. Vardatecha samutpannam - - - + + 16. Aruna - - - - + 17. Vriddhimati - - - - + 18. Garuni - - - - + 19. Prashanth nicha - - - - + Punarutpadyante 61
    • CLINICAL FEATURES OF PSORIASIS83 Clinically psoriasis exhibits itself as a dry well defined macules, papules andplaques of erythma with layer of silvery scales. The appearance of a typical lesion ischaracteristic of psoriasis. The typical lesion or coin shaped by confluence, big plaques ofthe size of the palm of a hand or figurate areas may not all be present at the same time orin every case and are sometimes obscured. However, in a disease of so many variationstheir future remains linchpin of diagnosis when other criteria are absent.Types of psoriasis 01. Plaque psoriasis – Plaque (Plak) is the most prevalent form of the disease. About 80% of all those who have psoriasis have this form. Scientifically it is called as Psoriasis vulgaris. A. Character of lesion – Raised inflamed red lesion covered by a silvery white scale. B. Site of lesion – Elbows, Kees, Scalp and lower back although it can occur on any area of the skin. 02. Guttated psoriasis – The guttate means in latin “a drop”. It often comes on quite suddenly. Infections such as upper respiratory infection, streptococcal infection, tonsillitis, stress, injury to the skin and the Administration of certain drugs like anti malerials and beta clockers. A. Character of the lesion – Red individual spots on the skin. These spots are normally as thick or as crusty as lesion of plaque psoriasis. B. Site of lesion – Usually trunk and limbs. 62
    • 03. Inverse psoriasis – It is found in the armpits, groins under the breasts and in other skin folds, around the genitals and buttocks. This type of psoriasis first shows up as lesions that are very red and usually lack the scale associated with plaque psoriasis. It may appear smooth and shiny. Inverse psoriasis is particularly subject to irritation form rubbing and sweating because of its location in skin folds and tender areas. It is more common and troublesome in overweight people.04. Erythrodermic psoriasis – It is a particularly inflammatory form of psoriasis that often affects most of the body surface. It may occur in association with Von Zumbush Pustular psoriasis. It generally appears on people who have unstable plaque psoriasis where lesions are not clearly defined. A. Character of the lesion – It is characterized by periodic widespread, fieryredness of the skin. The erythema and exfoliation of the skin or often accompanied bysever itching and pain.05. Pustular psoriasis – This form of psoriasis is primarily seen in adults. Pustular psoriasis is characterized by white pustules (blisters of non infectious pus) surrounded by red skin. The pus consists of white blood cells. It is not an infection nor is it contagious. This is relatively unusual form of psoriasis. It may be localized to certain areas of the body for example the hand and feet. Pustular psoriasis also can be generalized. Pustular psoriasis can appear suddenly as the first sign of psoriasis or plaque psoriasis can turn into pustular psoriasis. It is triggered by UV light, pregnancy, systemic steroids, infection, emotional stress, etc. 63
    • Types of Pustular psoriasis 01. Von zumbusch – The onset of this psoriasis can be abduct wide spread areas of reddened skin develop and the skin becomes actually painful and tender within as little as a few hours the pustule appears. The pustule then dry and peel over the next 24 to 48 hours. Leaving the skin glazed, smooth appearance. It can be triggered by an infection sudden withdrawal of tropical or systemic steroids. This form is associated with fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anaemia, weight loss and muscular weakness. 02. Palmoplantar pustulosis – Pamoplantar pustulosis (PPP) is a type of pustular psoriasis that generally affects people between the ages of 20 and 60 years and causes pustules on the palms of the hand and soles of the feet. It is triggered by infection or stress. PPP is characterized by multiple pencil eraser sized pustules in fleshy areas of the hands and feet such as base of the thumb and the sites of the heals. The postules appears in a studded pattern through reddened plaques of the skin, then turns brown peel and become crusted. 03. Acro pustulosis – This is a rare type of psoriasis characterized by skin lesion on the ends of the fingers and sometimes on the toes. The eruption occasionally starts after an injury to the skin or infection. Often the lesions are painful and disabling producing deformity of the nails. Occasionally bone changes make occur in severe cases.Psoriasis on specific skin sites Psoriasis can occur at any part of body. Psoriasis sometimes appears on theeyelids, ears, mouth and lips as well as arm, skin folds, the hands, feet and nails. 64
    • Genital psoriasis Psoriasis can occur in genital area at the same time it occurs elsewhere on thebody or it can appear in genital area only. People with genital psoriasis may have affectedareas that range form small, red spots to large patches. The most common type of psoriasis in genital region is inverse psoriasis.Scalp psoriasis – It is very common in fact at least half of all people who have psoriasishave it on their scalp. As with psoriasis elsewhere on the body, skin cells grow tooquickly on the scalp and causes red lesions covered with scale to appear. Scalp psoriasis can be very mild, with slight, fine scaling. It can also be verysevere with thick, crusted plaques covering the entire scalp, which commonly can causehair loss. Psoriasis can extend beyond the hairline onto the forehead, the back of the neckand around the ears (a common area). Most of the time people with scalp psoriasis havepsoriasis on other parts of their body as well. But, for some, the scalp is the only affectedarea.Conception, Pregnancy & Psoriasis Psoriasis go through the child bearing phase of the lives just like other people.Psoriasis in and off itself doesn’t affect the reproductive system of a woman or man.Although some women reported their psoriasis improves or worsens during pregnancy.Psoriatic Arthritis About 10% to 30% of people with psoriasis also develop psoriatic arthritis, whichcauses pain stiffness and swelling in and around joints. 65
    • Table No. 14. Showing the comparison between the kitibha kushta lakshana andpsoriasis.Sl. Kitibha lakshana Psoriasis01. Rooksha Dry02. Kina Ruda vrana-granulation site of healing wound03. Khara Rough04. Kandu Itching05. Parusha Hard06. Prashantanicha Punar Utpadyante Subsides and relapses07. Vriddhimanthi Spreading in nature08. Vrittam Round or coin shape lesion09. Ghanam Thickness of lesion10. Snigdham Sticky, Unctuous11. Krisham Black12. Shyava Bluish black13. Aruna Reddish black 66
    • VYAVACCHEDAKA NIDANA Before confirming the vyadhi vinischyaya i.e. Kitibha kushta it has to bedifferentiated form the other diseases, which mimic kitibha kushta. For the differentiationpurpose we can consider the following table –Table No. 15. Showing differential diagnosis of Kitibha kushta. Symptom of Dadru Kitibha Ekakushta Sidhma Charmada psoriasis kushta kushta kushta kushtaItiching Kandu Kandu - Kandu Kandu (All texts) (S.S.& (S.S.) (S.S.&C.S.) A.H.)Erythematous Manadala (S.S.)papules or (A.H.)plaquesSilvery scaling - - Matsyashakalo Rajah Dalita (C.S.) pamam (A.H.) Ghrishtam (C.S.)Thickening - - - - Hasticharmavat (A.H.)Dryness Ruksha Ruksha - Ruksha - (Bhela) (A.H.)Pin point RagaBleeding Pidaka - - - Raktadala (C.S.) (A.H.)Kobner’s Deergha - - - -Phenomenon Pratanavat (A.H.)Chronic in Anushank - - - -Natureorhistory hini (A.H.)of previousattack 67
    • DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF PSORIASIS84 Physical examination : Psoriasis may appears anywhere on the body thoughsome areas are favored. Careful examination must be done on scalp fingernails andtonsils for reddening and scaling skin that is characterized by erythematous, sharplydemarcated papules and round plaques, covered with silvery micaceous scales, which iseasily removed and may accumulate in the patients clothing of bed in folded areas ofskin, sometime the scales do not form, but the lesion remain red and sharply defined. Thedistribution, coulour, and typical silvery scaling of lesion in chronic plaque psoriasis arecharacristic. Classically the lesions are distributed symmetrically over the areas of bonyprominence such as elbows and knees. The lesions are also commonly occur on the trunk and scalp and in the intergluetalcleft sometimes scalp lesions may be mistaken for seborrhoeic dermatitis. Palms andsoles may be involved with defuse redness and scaly. The skin lesions of psoriasis arevariably pruritic. Nail involvement occurs in up to 50% of patients. Small pits, lifting onthe end of the nail plate and debris under the nail plate on the figures and toenails aresigns of psoriasis. Colour : A full, rich red (salmon pink) with a particular depth of hue and opacity.This quality of colour is at special diagnostic value in lesion on the palm, soles and scalp. Scaling : The amount of scaling is variable. It may, as in Rupoid forms, be waxyyellow or orange brown. A similar colour occurs in nails (oil drop sign). In Guttatelesion, a single waxy scale may be present, inviting confusion with Pityriasis lichenoideschronica, but most psoriatic lesions are surmounted by the very characteristic silverywhite scaling which may exceed in thickness the erythematous lesion beneath it. 68
    • Auspitz sign : This sign occurs only in psoriasis. Psoriasis can be diagnosedwhen there is a classical silvery white scaling and the Auspitz sign. When hyperkeratotic scales are mechanically removed from a psoriatic plaque byscratching, within few minutes, small blood droplets appear on erythamatous surface.This phenomenon is called Auspitz sign. Koebners Phenomenon : Psoriatic lesions may develop along with the scratchlines in the active phase. This is called Koebner phenomenon. This phenomenon is calledthe artificial production of the psoriatic lesion. It is better known as the isomorphic orKoebner phenomenon. Candle grease sign : When a psoriatic lesion is scratched with the point of a dis-secting forceps, a candle grease like scale can be repeatedly produced even from the non-scaling lesions. This is called the candle grease sign (Tache de bougie).Differential diagnosis85/ Some of the conditions that can be confused with the psoriasis Reiter’s syndrome,Pityrasis rosea, Secondary syphilis, lichen planus, eczema. Seborrheic dermatitis, Tineaversicolor, basal cell carcinoma, squamous cell carcinoma or a drug reaction. 1) Reiter’s syndrome – This syndrome is characterized by erythematous silvery scaled plaques, hyperkeratotic papules of palms and soles distribution is similar to psoriasis. Frequent in mouth or genital. Other features include nail involvement arthritis, urethritis, conjunctivitis, iritis. 2) Pityrasis rosea – Tannish, pink, oval, papules and plaques with delicate collarette scale, may or may not be prutitic. 69
    • Distribution – Rash preceded by herald patch, Christmas tree pattern on trunk, sparea face, extremities. No mucus membrane involvement. May be associated with upper respiratory infection.3) Secondary syphilis – Harm red or copper coloured scaly papules and plaques and sometimes annular. Generalized distribution, with palms and soles often involved. Mucus membrane involvement may be there. Condyloma warts of Anala area, condylomata in genital area; serological test for syphilis positive.4) Lichen planus – Violaceous polygonal flat – topped papules with white scale or wickman’s triae. May be hyperkeratotic, annular or bulbous lesions; pruritic. Distribution often on wrists and ankles, but can be generalized. Kobner reaction, frequent reticulated white patches or erosive lesions in mouth or genital areas. Occasionally involves nails. Drugs can cause similar reaction.5) Eczema – Vesiculobullous lesions on red place often form unusual patterns of contact with substances.6) Seborrheic dermatitis – Inflammatory, yellow, greasy, scaling patches overlying erythematous patches or plaques on scalp, retro auricular areas, eye brows, nasolebial folds, axilla, groin, submammary folds and gluteal cleft occurs in areas of high concentration of sebaceous glands; may be related to intrinsic yeast in skin.7) Tinea versicolor – Oval scaly mucus, papules and patches concentrated on the chest, shoulders, and back but only rarely on the face or distal extremities. On dark skin they often appears as hypo pigmented areas. While on light they are slightly hyperpigmented. 70
    • SADHYASADHYATA (PROGNOSIS) If treatment is not given properly at early stage then it will become asadhya. Evenif the treatment is given properly at time, the patient is not following pathya then also itwill become asadhya. When the treatment is not started in proper time and if it is neglected the sadhyakushtas including kitibha becomes asadhya. Because krimi invade the twak mamsa, rakta,lasika and cause kotha, kleda (exudates) and sweda. (Sweat) and eat away the dhatus andderange the doshas and dhatus further resulting in complication. In kushta if the patient develops prasrava, vrinas in lesions, trishna, jwara atisara,dourbalya, arochaka and avipaka, then this disease should considered as asadhya. According to Charaka a weak patient of kushta with all the lakshanas along withcomplication like trishna, daha, agnimandya, is to be avoided by the wise physician86. Vata kapahaja kushta can be cured easily, kapha-pittaja and vata pittaja is difficultto cure. According to Sushruta a patient who has full control over his gyanendriya as andthe kushta is confined to twak, rakta and mamsa dhatu it is sukha sadhya. If the diseasereaches meda dhatu it becomed yapya. If kushta spreads to deeper dhatus it becomesasadhya87. According to Vagbhata kushta is said to be asadhya if all the three doshas areinvolved, appearance of arishta lakshanas and when the disease spreads to asthi, majja,shukra dhatu. Kushta becomes yapya when it reaches meda dhatu involving pitta dosha.If kushta is due to vata and kapha it is said to be sadhya88. Form the above statements of various acharyas it is clear that vata kaphaja kushtasare sadhya in nature. 71
    • PROGNOSIS OF PSORIASIS89 It is impossible to say in any particular case how long the disease will lastwhether a relapse will occur or for what period of time the patient will remain free fromPsoriasis. Psoriasis is at all time and under all forms a very troublesome and often anintractable disease, but it is rarely dangerous to life. Remissions and exacerbations are the rule in most of the psoriatic cases but somepatient remains relatively unchanged for years after the onset of the disease. Withavailable therapy satisfactory control of the disease is possible in the majority of patients.The prognosis of psoriasis also depends upon the type of psoriasis and presence orabsence of associated diseases. Guttate attacks carry a better prognosis then those of aslower and more diffuse onset and have longer remissions after treatment. At the otherextreme, erythrodermic and pustualr forms carry an appreciable mortality and arthropathic forms aconsiderable morbidity. An early onset and a family history of the disease appear to worsen theprognosis. 72
    • UPADRAVA 90 The common upadravas possible in kushta are as follows – 01. Prasravanam – Excessive exudation. 02. Angabheda – Ulceration of organs. 03. Patanaani angavayavanam – Sequenstration of the organs of the body. 04. Trishna – Thirst. 05. Jwara – Fever. 06. Atisara – Diarrhoea. 07. Daha – Burnng senstion. 08. Dourbalya – Weakness. 09. Arochaka – Anorexia. 10. Avipaka – Indigestion.Complications of Psoriasis91 The common complications of psoriasis explained in modern medical literaturesare as follows – 01. Pruritus : It is very variable in psoriasis, ranging form complete absence to severe pruritus; pustular and erythematous forms are usually accompanied by sensations of burning or itching. 02. Pustulation : A sudden withdrwal of cortico-steroids in treatment of psoriasis of a relapse of exfoliative psoriasis lead to postulation associated with high fever and severe systemic upsets. The pustules, which are sterile, appear in crops or waves, relapses are frequent and prognosis in poor. 03. Psoriatic arthritis : Joint involvement is the most disabling complications of psoriasis, limb joints are commonly involved, and distal arthritis involving distal interphalageal and other small joints is the commonest presentation. 73
    • CHIKITSA Treatment of a disease in Ayurveda starts with Nidana parivarjana. This should bethe first line of treatment for all diseases. The general management of kushta includesdaivavyapashraya Chikitsa, yuktivyapashraya chikitsa and satwavajaya Chikitsa throughpresent is minimum. The planning of treatment depends on the vitiated doshas. In vatajakushta snehana, pittaja kushta virechana and rakta mokshana, vamana karma in kaphajakushta should be carried out92. Ashatanga Hridaya prescribes snehapana for all varieties of kushta, for thepurpose of Shareera dushti. Dosha shodhana is followed by snehapana93. Sushruta mentioned periodic shodhana karma for kushta, which is supported bymost of the other classical authors. Vamana once inforth night, virechana once in a month, nasya once in three days ifthe pathology is located above the neck. Raktamokshana is advised once in six months94. After preliminary shodhana the following treatments are to be carried out. Lepana – if disease is there in twak. If raktadhatu involved – shodhana and anulepana. If rakta and mamsa are involved – then also shodhana and lepana must be carriedout. Along with this special medicine remedies prepared form Bhallataka, Shilajatu,Guggulu, Agaru, Tuvaraka, Khadira, Asana should be used according to rules. Kushtainvading deeper dhatus such as asthi and majja should be given up, as they’re incurable. The general line of treatment should consider for Kitibha kushta as there is nospecific line of treatment available. In kitibha because of the involvement of tawak orrasa, rakta, mamsa, the line of treatment should be shodhsna, alepana with internalmedication. 84
    • However the general measures of management mentioned in the context of kushtaseems to be most practical, the doshic predominance has to be taken into account andrespective therapies should be administered. For snehapana purpose formulation based on ghee such as Tikta shatpala ghrita,maha tiktaka ghrita, mahakhadira ghrita, panchatikta ghrita are vary beneficial95. Vamana (Emesis) – May be induced after snehapana, with decoction of Kutaja,Madanaphala, Yastimadhu, Patola, Nimba. Virechana (Purgation) – Virechana may be induced with drugs like Trivritta,Danti moola, Triphala, Manibhadra gula, etc. Vasti (Medicated Enema) – Charaka advocates a number of medicated enemas forthe treatment of kushtas. Among them Panchatikta, panchaprastika vastis, speciallyindicated in kushta. A decoction of Patola, Nimba, Bhoonimba, Rasna and Saptaparna –each 4 prasthas – is to be mixed one prastha of ghee and to which a paste made out ofmustard should be added. This panchatikta nirooha basti will alleviate prameha,abhishandya and kushta96. Some vata-kaphaja kushtaghna yogas – paste of the following dravyas preparedby adding dadhi manda (thin butter milk) cures kushta caused by vata and kapha97. 01. Chitraka, Shobhanjana, Guduchi, Apamarga, Devadaru, Khadira. 02. Dhava, Shyama, Danti, Dravanti, laksha, Rasanjana, Ela and Punarnava. 03. In charmadala which is one of the vatakaphaja kushta, charaka advised seka and pradeha. 04. While giving importance to Vidanaga in Kushta Chikitsa Charaka explained, it can be used for sechana, pana and dhoopana purpose. 85
    • Sushruta advised lepana should be prepared out of Kushta, Sarshapa, Sriniketana,Vyosha, Chakramarda beeja by mixing with takra is useful in charmadala, kitibha, etc98. Ashtanaga Hirdaya99 – Powders of Vidanga, Khadira is mixed with honey andghee and consumed by the person who part takes little quantities of healthy foods onlygets cure of Kitibha, Shwitra and Dadru. Equal quantities of each of Nimba, Daruharidra,Suras, Patola, Kushta, Ashwagandha, Suradaru, Shigru, Sarshapa, Tumburu dhanya,Vanya and Chandana are converted into powder, macerated in the butter milk and keptready. The body of the patient is first anointed with mediated oil and then massaged withthis paste. It cures Dadru (eczema) with itching, Kitibha (Psoriasis), Pama (Scabies) andVicharchika. Paste of Chitraka, Shobhanjana, Guduchi, Apamarga, Devadaru, Khadira, Dhava,Shyama, Danti, Dravanti, Laksha, Rasanjana, Ela, Punarnava mixed with Dadhi mandawhen applied over the body cures Kushta arising form vata and kapha. Ashtanaga Samgraha100 – Powder of Khadira shaka (bark of Khadira) mixedwith Shilajatu, Vidanga and consumed along with the honey and ghee in proper dose by aperson who takes which is easily digested, less in quantity, who maintain celibacy andkeeps control of himself cures Dropsy, Kitibha, Kotha, Shwitra and Leprosy. Katu taila medicated with Sikta (Bee’s wax) Tuttaka, Guggulu, Sindura andRasanjana is best for anointing the body in case of Pama, Kitibha, Vicharchika. Yogaratnakara101 – 01. Chakramardadi lepa –Chakramarda beeja, Twak, to be grounded in dugdha and later mixed in Gomutra can used as lepa to pacify kushta. 86
    • 02. Pippalyadi lepa – Pippali, Karanaja, Haritaki, Kushta, Gorochana, and Chitraka to be taken in equal quantity and grinded into fine powder and used for external application. 03. A lepa should be prepared out of Karpasa patra, Kaka jangha and Moolaka beeja mixed with takra should applied on the skin of the patient who is suffering form Sidhma kushta having the predominance of Vata and kapha.Bhaishajya Ratnavali102 – 01. Patra of Aragwadha, pasted with butter milk and should be applied to the patient who has already undergone abhyanga cures Kitibha, Dadru, etc. Gada nigraha also mentioned the above prayoga.TREATMENT OF PSORIASIS103 Agents appalled to the skin are usually the first line of defense in treatingpsoriasis. Researchers believes psoriasis occurs when faulty signals in the immunesystem cause skin cells to grow too rapidly, creating dry, red scaly patches called lesions.Topicals slow down or normalize the excessive cell reproduction and reduce rednessassociated with psoriasis. The treatment starts usually with these topical agents or phototherapy for mild tomoderate psoriasis, because they may be more appropriate than other treatments. Anthralin – This prescription topical can be very effective in treating plaquepsoriasis. It does not work as quickly or as super potent topical steroids, but unlikesteroids, it has no known long-term side effects. Dovonex – A form of synthetic vitamin D3 approved for treating psoriasis,available by prescription. It slows down the rate of skin cell growth, flattens psoriasislesions and removes scale. Donovex also can be used on the scalp and for nail psoriasis. 87
    • Salicylic acid – Also known as “Sal acid” salicyclic acid helps remove scales andis often combined with topical steroids, anthralin or tar to enhance effectiveness.Availability in both OTC and prescription forms. Tar – Coal tar is available over the counter in crude and refined forms to treatmild, moderate and severe psoriasis. For decades, tar was viewed as the “traditional”treatment for psoriasis, and it remains a safe, effective and readily available treatmentoption for many people. Tazorac – Tazorac topical gel and cream (also known by its genetic nametazarotene) are FDA approved for treating plaque psoriasis. Tazorac is a vitamin Aderivative and is also as a topical retinoid. It is available by prescription.Topical steroids – Corticosteroids, ordinarily called “Steroids”, are routinely used to treatpsoriasis. Topical steroid medications can be very effective in controlling mild tomoderate psoriasis lesions. They are easy and work relatively quickly. Other OTC topical – Information about bath solutions, moisturizers andnonprescription medications that can be used to moisturize, soothe, remove scale orrelative itching. Phototherapy – Topical treatments (treatments that are applied to the skin’ssurface) are usually the first line of defense against psoriasis, but if the psoriasis isextensive, ultraviolet light treatment (photo therapy) can be used. Photo therapy involves exposing the skin to wavelengths of ultraviolet light undermedical supervision. UVB photo therapy – UVB treatment involves exposing the skin to an artificialUVB light source for a set length of time on a regular schedule, either under a doctor’sdirection in a medical setting or with a home unit purchased with a doctor’s prescription. 88
    • PUVA – PUVA is an acronym for psoralen (a light sensitizing medication)combined with exposure to ultraviolet light A, UVA, like UVB, is found in sunlight. Byitself, however, UVA is not normally used to clear psoriasis. It is relatively ineffectiveunless used with a light sensitizing medication such as psoraten. Laser – Targeted UVB treatment and pulsed dye lasers can be used to treatchronic localized plaque lesions.PSORIASIS SYSTEMIC TREATMENT Systemic medications are prescription medications that affect the entire body, andare usually reserved for patients with moderate to severe psoriasis to or eligible forconventional topical medications or ultraviolet (UV) light treatment. Sun and Water Therapy – Sunlight and water are natural therapies that can helpimprove psoriasis and or psoriatic arthritis for many people. Eighty percent of the peoplewho use regular daily doses of sunlight enjoy improvement or cleaning of their plaquespsoriasis. Water can help soften psoriasis lesions. Biologics – These medications are developed form living sources, such as cells,rather then combinations of chemicals like traditional drugs. Generally, they are designedto block or eliminate various immune system cells involved in psoriasis and psoriaticarthritis. Other systemic medications for these diseases can also impact the immunesystem, but usually in a broader, less specific way. Cyclosporine – Cyclosporine is a prescription systemic medication used to treatpsoriasis. Cyclosporin has been available since 1995 to help prevent organ rejection intransplant patients. In 1997, the FDA approved Neoral (one band name of cyclosporine)as a psoriasis treatment. Methotrexate – Methotrexate is a systemic medication usually sold as a generic.Initially used to treat cancer, methotexate was discovered to be effective in cleaningpsoriasis in the 1950’s and was eventually approved for this use by the FDA in the1970’s. 89
    • Soriatane – Soriatane (also known by its genetic name acitretin) is a prescriptionmedication called an oral retinoid, which is a synthetic form of vitamin A. syntheticretinoids were introduced as experimental drugs in the mild 1970’s and were approved inthe United States in the 1980’s. Soriatane is currently the oral retinoid approved by theFDA specially for treating psoriasis. Other systemic – Accutanem Hydrea, Mycophenolate mofetil, Sulfasalazine, 6-Thioguanine.PATHYAPATHYA The diet regimen explained in the context of management of kushta is as follows Pathya 01. Anna varga – Puranashali, Shashtika shlai, Godhuma, Kora, Shyamaka,Uddataka, Yava. 02. Yusha varga – Mugda. 03. Shaka – Tikta patola, Nimba, Triphala, etc. 04. Sneha varga – Samskaritha ghrita, Sarshapa, Taila, etc. 05. Mamsa varga – Jangala, Amedaska. 06. Jala varga – Khadirodaka. 07. Rasa – Vratha, Dana, Seva, Thyaga, Dwija, Guru, Surapuja, Bhaskara,Aradhana, Maithrie. Apathya Kulattha, Masha, Nispava, Snigdha, Abhishyandhi, Guru, Ushan, Amla, Lavana,Vidahi dracyas, Anupamamsa, Vasa, Majja, Tila, Guda, Dugdha, Dadhi, Taila,Ikshuviakra, Pishtavikara, Sura, Viruddhashana, Adhyashayana, AjirnashakaDivaswapna, Vyayama, etc. 90
    • DRUG REVIEWTable No. Showing the Pharmacodynamics of drugs of Aragwadadi Gana104.Sl. Name Botanical Family Part Chemical Properties Dosha name used composition Karma Rasa Guna Veerya Viapaka01. Aragwada Cassia fistula Caesalpiniodeae Bark Barbalion, Madhura Mridu, Sheeta, Madhura Kapha- and Fistucacidin, etc. Guru, Ushna pittahara heart Snigdha (DN) wood02. Indrayava Holarrhena Appocyanacea Seeds Conessidine, Tikta, Laghu, Sheeta Katu Kapha- antidycentrica Conessimine, etc Kashaya Ruksha pittahara03. Pathali Stereosprmum Bignonaceae Stem Bark contains Tikta Lahgu, Anushna Katu Tridoshahara sauvealens bark. crystalline bitter kashaya Ruksha substance04. Kakamachi Solanum Solanaceae Whole Solasonine, Tikta Laghu, Anushna Katu Tridoshahara (Kakatikta) nigrum plant Solamargin, etc Snigdha05. Nimba Azadiractta Meliaceae Stem Nimbin, Nimbidin, Tikta, Laghu, Sheeta Katu Kapha- indica bark etc Kashaya Ruksha pittahara06. Amruta Tinospora Menispermaceae Stem Tinosporin, Tikta, Guru, Ushna Madhura Tridosha cardifolia Tinsporidinene kashaya Snighda shamaka07. Moorva Marsdenia Asclepiadaceae Root Marsdenin, Tiktam Guru, Ushna Katu Kapha- (madhurasa) tenacissima Asclepobiose Kashaya Ruksha vatahara08. Vikhangata Flacourita Flacourtiaceae Bark Tannin, Flacourtin Amla, Laghu Sheeta Madhura Vata- (Sruvavriksha) ramontchi Madhura pittahara09. Patha Cissampelos Menispermaceae Bark Hayatin, Hayatinin Tikta Laghu, Ushna Katu Vata- pariera & Tikshna kaphahara Root10. Bhunimba Pwerita Gentianaceae Whole Amarogentin, Tikta Laghu, Sheeta Katu Kapha- chirata plant Chiratol, etc Ruksha pittahara
    • 11. Sahachara Barleria Acanthaceae Root Tikta, Laghu Ushna Katu Khpaha-vata prionitis Madhura shamaka12. Patola Tricosanthes Cucurbaitaceae Whole Cucurbita-5-24- Tikta, Laghu, Ushna Katu Kapha- diocia part dienol, etc Katu Ruksha pittahara13. Karanja Pongimia Fabaceae Stem Karanjin, Tikta, Laghu, Ushna Katu Kapha- pinnata bark Pongipin, etc Katu, Teekshna vatahara Kashaya14. Latakaranja Caesalpina Caesalpiniaceae Stem L.r- Tikta, Laghu, Ushna Vipaka `tridoshahara crista Bark ethylideneglutamic Kashaya Rukha acid, Amino acids, etc15. Saptachhada Aistonia Apocynaceae Stem Akuamidine, Tikta, Laghu, Ushna Katu Tridoshahara scolaris bark Picrinine, etc Kashaya Snigdha16. Agni Plumbago Plumbaginacea Root Chitranone, Katu Laghu, Ushana Katu Vata- zeylanica bark Plumbagin, etc Ruksha kaphahara17. Karavellaka Momordica Cucurbibitaceae Whole Charantin, Tikta, Laghu, Sheeta, Katu Kapaha- charantia plant Polypeptides, etc Katu Ruksha Ushna pittahara (KN)18. Madanaphala Randia Rubiaceae Fruit Citric acid, Tannic Madhura, Laghu, Ushna Katu Kapha- dumetorum acid, etc. Tikta Ruksha vatahara19. Sahachara Barleria Acanthaceae Root Tikta, Laghu Ushna Katu Khpaha-vata prionitis Madhura shamaka20. Badara Ziziphus Rhamnaceae Bark Leucocyanidine, Madhura, Guru, Sheeta Madhura Vata- mauritiana etc. Amla Snigdha pittaharaNote : In original sutra instead of Kakamachi (4) Kakajangha is mentioned on this Dalhana commented and said Kakajangha meansKakamachi.Note : Sushavi – Karavellaka – By – Dalhana on Aragwadadhi gana.Abbreviations : D.N. – Dhanwatari Nighatu, K. N. – Kaiayadeva Nighantu.
    • Table No. 17 Showing Pharmacodynamics of Drugs Used For Moorchana of Tilataila105.Sl. Useful Drug Family Name Latin Name Rasa Guna Virya Vipaka Dhoshagnatha Karma part01. Manjistha Rubiaceae Rubia Madhura Guru Ushna Madhura Kaphanashaka Rakth prasadaka Kanda Cordifolia Kashaya02. Haritaki Combretaceae Terminalia Lavana Varjita Laghu Ushna Madhura Triadoshahara Deepana, Phala chebula Kashayapradhana Ruksha Pachana, Pancha Rasa Anulomana, Rechana03. Vibhitaki Combretaceae Terminalia Kashaya Laghu Ushna Madhura Tridoshanara, Deepana, Phala bellirica Ruksha Especially Anulomana Kaphahara04. Amalaki Euphorbiaceae Emblica Lavana Varjita Guru Sheeta Madhura Tridoshahara Deepana, Phala Officinalis Amlapradhana Ruksha, Pachana, Pancha Rasa Sheeta Anulomana, Rasayana05. Mustha Cyperaceae Cyperus Tikta, Katu Sheeta Sheeta Katu Kaphapitta Deepana, Kanda rotundus Kashaya Shamaka Pachana, Grahi, Mutrala06. Hardira Zingiberaceae Curcuma Titka, katu Ruksha, Ushna Katu Tridoshahara Ruchya, Kanda longa Laghu Anulomana, Pitta Rechaka.
    • 07. Lodra Symplocaceae Symplocos Kashaya Laghu, Sheeta Amla Kaphapitta Shothahara, Twak recemosa Ruksha shamaka Kustagni, Raktastambana, Vrunaropana, Stambana08. Vatankura Moraceae Ficus Kashaya Guru Sheeta Katu Kaphapitta Shothahara, Twak, bangalensis Ruksha, shamaka Raktashodhaka, kshira, Vrunaropana, patra, Chakshushya phala09. Ketakipushpa Pandanaceae Pandanus Tikta, Madhura, Lagu Ushna Katu Kaphapitta Varnya, Pushpa, odorotissimus katu Snigdha shamaka Vedanastapaka, Mula Vrunaropana, Keshya , Dourgandhyahara10. Hrivera* Compositae Pluchea Tikta Guru Ushana Katu Kaphapitta Shotahara, Patra (Rasna) lanceolata shamaka Vedanashaymak, Raktashodhaka, Rasayana11. Nalika** Lauraceae Cinnamomnm Katu Tikta Laghu, Ushana Katu Kaphapitta Lekhana, Twak, (Tamala tamala madhura Ruksha, shamaka Raktashodhaka, Taila, patra) Teekshana Sleshmahara patra
    • Table 18. Showing the Chemical composition of the drugs used in Tilataila moorchhana105. Sl. Drugs Chemical composition01. Manjistha Anthraquinones manjistin, purpuroxanthin, rubiatriol, rubi coumaric acid, rubifolic acid, rubiadin, rubimallin, purprin,02. Haritaki Chebulinic acid, tannic acid, terchebin, vit C, behenic, lindeic, oleic, palmitic and stearic acids, chebulin.03. Vibhitaki Fructose, galactose, glucose, mannitol, edible oil, gallic acid, chebulagic acid, ellagic acid.04. Amalaki Ellagic acid, oleanolic, aldehyde, tannin vit C, phyllemblin, linolic acid, acetic acid, ellagic acid, phyllemblic acid and salts.05. Mustha Cyperenone, Cyperen, Cypertundone, cyperol, cyperolone, isocyperol, mustakone, rotundone, sugenol, β- sitosterol.06. Hardira Curcumene, curcumenone, curcone, curdione, cineole, curzorenone, eugenol, comphene, camphor, curcumins.07. Lodra Symposide, loturine, loturidie, colloturine08. Vatankura Leucoanthocyanin, tiglic acid, β - sisterol – a – d - glucoside09. Hrivera Kwarsitin, isoramnitin, pluchin.10. Nalika Cinnamaldehyde, Eugenol, Yuginal, fixed oil.11. Ketakipushpa Sughandita taila.Note : Hrivera* The Synonyms of Rasna mentioned in Nigantus are Hrivera, Nakuli, Gandhanakuli, Ishwarimoola,Note : Nalika** Indian Taj = Cinnamomum Tamala (Lauraceae) is known is Bengal as Naluka its leaves are known as Teja patra orTamala Patra. Brihatrayi have mentioned as only Nalika.
    • Table No 19. Showing the Pharmacaodynamics of drugs of Gandharva Hastadi Kashaya106.Sl. Name Botanical Family Part Chemical Properties Dosha name used composition Karma Rasa Guna Veerya Viapaka01. Earanda Racinus Euphorbiaceae Moola Stable oils, Madhura, Snigdham Ushna Madhura Kapha- communas Slimy Katu, Teeskshna, vatahara substance, Kashaya Sukshma Sugar, etc02. Chirubilwa Holoptela Ulmaceae Bark Friedelin, Beta- Tikta, Laghu, Ushna Katu Kapha- integrifolia sitosterol Kashaya Ruksha pittahara03. Chitraka Plumbago Plumbaginacea Root Chitranone, Katu Laghu, Ushana Katu Vata- zeylanica bark Plumbagin, etc Ruksha kaphahara04. Shunti Zingiber Scataminae Rhizome Alph- Katu Guru, Ushna Madhura Vata- officinale curcumene, Ruksha, kaphahara Beta-D- Teekshna Curcumene, etc05. Haritaki Terminalia Coberetaceae Fruit Chiulinic acid, Pancharasa Laghu, Ushna Madhura Tridoshahara chebula Tannic acid, etc. Ruksha06. Punarnava Boerrhavia Nyctaginaceae Whole Hertriacontane, Madhura, Laghu, Ushna Katu Kapha- diffuse plant Oxalic acid, etc. Tikta, Ruksha vatahara Kashaya07. Yavasa Alhagia Fabacei Whole Catechin, Madhura, Laghu Sheeta Katu Kaphahara canelorum plant Galactocatechin Tikta, Kashaya08. Musali Asparagus Liliaceae Tuberous Saponins, Sarsa Madhura Guru, Sheeta Madhura Vata- adsenden root pogenin, etc Snighda pittahara
    • Table No. 20. Showing the Drugs used for preparing of Medicated Milk107.Sl. Name Botanical Family Part Chemical Properties Dosha name used composition Karma Rasa Guna Veerya Viapaka01. Musta Cyperus Cyperaceae Tuber Cyperenone, Tikta,l Laghu, Sheeta Katu Kapha- Pitta rotundus cyperol, etc Katu, Ruksha shamaka Kashaya02. Yashtimadhu Glycyrrhiza Leguminosae Root Glycyrrhizin, Madhura Guru, Sheeta Madura Kapha- glabra Liquiritin, etc. Snigdha pittaharaTable No, 21. Showing the qualities of Takra108.English name Varga Synonym Rasa Guna Veerya Vipaka DoshakarmaButter milk Dadhi varga Amrut Madhura, Kashya, Amla Laghu, Ruksha Ushna Madhura Kapaha- vatahara Buttermilk contents per 100 gms109 – Calories – 36 Kcl. Protein – 1.8 Gms. Fat – 2 Gms. Carbohydrates – 2.89 Gms. Calcium – 0.07 Gms. Iron – 0.02 Mg. Phosphorus – 0.07 Gms Vitamin A – 102 IU. Thyamine – 0.03 Mg. Nicotinic acid – 0.01 Mg. Riboflavin – 0.1 Mg. Vitamin C – 0.9 Mg.
    • Clinical study For each and every research, there should be a methodology. Experimenting thedrug or therapy or both on a population makes clinical research and recordings are madeon the efficacy of the drug or therapy or both in the particular disease. Hence, in thissection, the researcher put forward the systemic procedure which are followed by himright form the identification of the problem to the final conclusion.Research approach In the present study the investigators objective was to evaluate the efficacy ofTakradhara in Kitibha kushta (Psoriasia). The efficacy was determined by finding out thedifference between the baseline data of the parameters to the after treatment data.Study design The study design selected for the present clinical trail, was an observational study.Reason for the selection of the study design. The results and conclusion of a clinical trail depends on the study design. Themain aim of the study was to observe the effect of takradhara in Kitibha Kushta(Psoriasis) and also it’s effect on the samprapti of Kitibha kushta.Source Of Data Patients suffering from Kitibha kushta (Psoriasis) were selected from the P.G.S &R (Panchakarma) OPD & IPD of Shri D G Melmalgi Ayurvedic College Hospital.Sample Size & Grouping The sample size for the present study was thirty patients suffering from KitibhaKushta (Psoriasis) as per the selection criteria. Patients were randomly selected in asingle group. 98 Methodology
    • Selection criteria The cases were selected strictly as per the pre-set inclusion and exclusion criteria. A. Inclusion criteria 1. Patients with classical symptoms of kitibha kushta (Psoriasis). 2. Patients of both sexes above the age of 12 years and below the age of 70 years. 3. Patients suitable for Takradhara. B. Exclusion criteria 1. Patents suffering form other systemic disorders 2. Pregnant women and lactating mother. 3. Patients below the age of 12 and above the age of 70.Duration of the study 7 days treatment and 30 days follow up.Data collection Patients were thoroughly examined both subjectively and objectively. Detailedhistory pertaining to the mode of onset of previous aliment, previous treatment history,family history, habits, Ashtavidha pareeksha, Dashavidha pareeksha and physicalexamination findings were noted. Confirmation tests to confirm the disease, and also theprevious diagnosis made on the disease were considered. Routine investigations weredone to exclude the other pathologies. 99 Methodology
    • Treatment SchedulePoorvakarma Poorvakarma of the Takra dhara involves the preparation of the Takra,preparation of the Argwadadi gana kashaya, preparation of the patients and arranging theother requirements.Requirements for preparing medicated Milk – Musta (Outer skin removed) – 60 gms. Yashtimadhu – 60 gms. Ksheera – 1 liter Water – 4 liters.Requirements for preparing Aragwadadi gana kashaya – Aragwadi gana – 500 gms. Water – 4 Liters.Other requirements – Moorchita tila taila – 50 to 100 ml. Gandharwahastadi Kwatha – 15 ml. Rasnadi Churna – 5 gms. Amalaki Jala – 500 ml. Gauze – 1 roll. Cotton – Q. S. Attenders – 2. 100 Methodology
    • Preparation of Buttermilk One liter of ksheera was taken in a clean vessel and added with 4 liters of water.In this mixture, a pottali containing Yashtimadhu and Musta (Outer skin removed). 60gms each was kept immersed. The mixture was boiled till the attainment of originalquantity of milk. The curd or buttermilk was added to milk as a fermenting agent after attainmentof swasngasheetala. First day pure curd or buttermilk was added and on the successivedays medicated buttermilk was used for fermentation. Then the vessel is well covered andkept untouched. This was done the previous day to the performance of karma. Next day, the fermented curd, was churned by adding little by little quantity ofAragwadadi gana kashaya. The churning was continued till the sneha part is removedcompletely. Thus the medicated buttermilk is prepared.Preparation of Argwadadi Gana kashaya 500 gms Yavakuta churna of Aragwadadigana dravyas was boiled in 4000 ml ofwater and reduced to 1000 ml. When it attained luck warm state it was added little bylittle to the medicated curd and churning was done. After proper churning, the medicated buttermilk, which was 2000 mlapproximately, is ready for the dhara karma.Preparation of the Patient The patient was asked to pass his natural urges prior to his entry in to thePanchakarma theatre. The procedure was done in between 09.30 to 11.00 am. Afterentering in to the Panchakarma theatre, the patient was asked to sit on the dharapati ordroni, he was then administered 15 ml of Gandharwahastadi kwatha mixed with 60 ml ofluke warm water. Then the moorchhita tila taila was applied all over the body and headfor approximately 15 minutes. 101 Methodology
    • Pradhana karma After the proper oil application to the patient the varti which is made up of gauzewas tied around his forehead. Precaution was taken while trying, that the knot of vartiremains in the temporal region of the head. Then the patient was asked to close his eyesand a piece of cotton was placed on each eye respectively. After placing the cottonproperly the eyes was tied with the help of the gauze. The medicated takra, was made intoluck warn by keeping it in the hot water and was poured into the Dharachati. Beforepouring the Takra the opening in the bottom of the vessel was closed with the help offinger, in order to prevent the flow. After filling dhara vessel up to its brim, the fingerwas released in order to make the flow on the forehead. The remaining takra was kept inthe hot water to maintain its luck warm temperature. When the flow was started a gentle oscillatory movement was given to the vesselto ensure the falling of the drava on forehead in a single stream. The oscillatorymovement was carried out with right hand and simultaneously by the left hand thephysician should be head message. When the drava looses its temperature it was replaced by the warn one. Silenceand dim light was maintained throughout the procedure. In this manner the procedure wascontinued up to 45 minutes.Paschat karma After the procedure the dharachati, Varti, the gauze and cotton was removed andthe patient was asked to open his eyes slowly. The head was washed with Amalaki jalathoroughly. After proper washing the head was whipped with clean dry cloth and Rasnadichurna was applied on the crown inorder to avoid cold or fever. 102 Methodology
    • Pathyapathya The patients were advised to follow the below listed things – 01. Not to go out in cold weather. 02. Advised to use only hot water for bathing, drinking. 03. Advised to avoid Pungent, Sour items. 04. Advised to avoid sexual intercourse, day sleep, vyayama. 05. Advised to not to take newly harvested paddy, fish, tila, masha, madya, dadhi, vartaka, pumpkin. 06. Advice to avoid vega dharana, adhyashana, krodha, shoka, loud speech, excessive reading. 07. Not to expose to dust, hot sun, wind, smoke.Methods of assessment of clinical response PASI score was considered as both subjective and objective parameters. Becauseit covers both subjective (Itching, Scaling, Erythema, and Thickness) and objectiveparameters (Area). Along with this triggering factors like Krodha, Bhaya, Chittodwega, Shoka arealso studied and results were obtained. But, they were not considered for the overallassessment of clinical response. 103 Methodology
    • Objective ParametersTable No. 22. Showing the method to assess the total PASI score. Skin sections* Itching Erythema Scaling Thickness Coverag % of Total ⊗ ⊗ ⊗ of lesion e Area* B,S,A PASI ⊗ HEAD10%B.t + + + X X 0.1 = After treatment + + + X X 0.1 = ARMS20%B.t + + + X X 0.2 = After treatment + + + X X 0.2 = BODY30%B.t + + + X X 0.3 = After treatment + + + X X 0.3 = + + + X X 0.4 = LEGS40%B.T After treatment + + + X X 0.4 = Total PASI Before Treatment Total PASI After treatment * Coverage area Score ⊗ Severity Score 0% 0 None 0 <10% 1 Mild 1 10-29% 2 30 -69% 4 Moderate 2 70-89% 5 Severe 3 90-100% 6 Maximum 4Skin sections For the PASI, the body is divided into four sections. Each section of these areas isscored by itself and then the four scores are combined into the final PASI. The four areasare – The legs, which have 40% of a person’s skin, the body (Trunk area – chest,abdomen, etc) at 30%, the arms (20%) and the head (10%). 104 Methodology
    • Area For each skin sections, measure the amount of skin involved as a percentage ofthe skin just in that part of the body (not the whole body), and then assign it a score form0 to 6.Severity The severity is measured by four different parameters – Itching, Erythema,Scaling and Thickness. Again each of these is measured separately for each skin section.These are measured on a scale of 0 to 4 from none to maximum.Totaling up the index For each skin section, add up the four severity scores multiply the total by the areascore, and then multiply that result by the percentage of the skin in that section. The severity of itching, scaling, Erythema and thickness was assessed in thefollowing manner A. Itching 01. None – No itching. 02. Mild – Itching subsides when he / she scratches. 03. Moderate – Reduction in itching by internal medicaments. 04. Severe – Reduction in itching by internal and external medications. 05. Maximum – After medicaments also the patient gets itching sometimes. B. Erythema 01. None – No Erythema. 02. Mild – Patch with reddish tinge. 03. Moderate – Patch with dull red colour. 04. Maximum – When it is bright red in colour with severe itching. 105 Methodology
    • C. Scaling 01. None – No scaling. 02. Mild – On scratching if the scales settle in pits on nails. 03. Moderate – If the scales fall on around where he scratches. 04. Severe – Scales found in his/her cloths without scratching. 05. Maximum – Scaling found on bed etc without scratching. D. Thickness – Purely subjective. The severity of krodha, bhaya, etc were assessed in following manner –OVERALL ASSESSMENT OF CLINICAL RESPONSE A. Krodha 01. None – No Krodha. 02. Mild – Gets anger but not showing outside. 03. Moderate – Shouting loudly, throughing the articles occationally. 04. Severe – Shouting loudly and making harm to others occationally. B. Shoka 01. None – No Shoka. 02. Mild – Disturbance in concentration, occational thinking of his/her problem. 03. Moderate – Always thinking about his problem with mild disturbance in sleep. 04. Severe – Not responding to others properly with complete disturbance of sleep. C. Bhaya 01. None – No Bhaya. 02. Mild – Gets occational fear by thinking about the illness. 03. Moderate – Fear causing occational disturbance in day to day activity. 04. Severe – Fear causing occational disturbance in day to day activity, sudden disturbance in sleep. 106 Methodology
    • D. Chittodvega 01. None – Zero. 02. Mild – Patient not anxious about the disease. 03. Moderate – Will be anxious, but having the belief that the disease will be cured. 04. Severe – Doesn’t have belief in any therapy and worried that the disease will not be cured.OVERALL ASSESSMENT OF CLINICAL RESPONCE 01. Complete Remission – PASI score 0 after treatment. 02. Marked improvement – Reduction in PASI score >75%. 03. Moderate improvement – Reduction in PASI score between 75% and 50%. 04. Minimal improvment – Reduction in PASI score <50%. 05. Unchanged – No reduction in PASI score.Statistical Analysis Only net affect that is baseline data i.e. before commencement of treatment i.e. onfirst day and at the end of 7 day were considered for statistical analysis. The net effectwas calculated by using paired “t” test. 107 Methodology
    • 34 patients were registered for the present study. Out of this, 4 patients wereexcluded. Due to the non-fulfillment of the objective criteria. The remaining 30 patientsof Kitibha Kushta fulfilling the subjective and objective criteria were treated. All the patients were examined before and after the treatment according to thecase sheet format given in the appendix. Both the subjective and objective changes wererecorded. The data recorded are presented under the following headings – I. Demographic data II. Data related to the disease III. Data related to over all response to the treatment IV. Statistical analysis of the clinical study.I. DEMOGRAPHIC DATA01. Distribution of Patients by Age groupsTable No.23. Showing Distribution of patients by age. Age group No. Of Patients % 10-20 3 10 21-30 10 33.33 31-40 4 20 41-50 9 30 51-60 4 20 Among the 30 patients, maximum number of patients i.e. 10 patients (33.33%)fell in between the age group of 21-30, 9 patients (30%) fell in between the age group of41-50, 4 patients fell in between age group of 31-40 & 51-60 respectively and 3 patient(10%) fell in between the age group of 10-20. 108 Observation & Results
    • 02. Distribution of patients by SexTable No. 24. Showing the distribution of patients by sex. Sex No. Of Patients % Male 21 70.00 Female 9 30.00 In the study it was observed that 21 patients were males (70%) and 9 patientswere females (30%), out of 30 patients.03. Distribution of patients by OccupationTable No. 25. Showing the distribution of Patients by Occupation. Occupation No. Of Patients % Sedentary 11 36.6 Student 4 20 Labour 10 33 Executive 5 16.66 Among the 30 patients, 11 patients (36.66%) were of sedentary, 10 patients (33%)were of labours, 5 patients (16.66%) were of executive and 4 patients (20%) were ofstudents.04. Distribution of patients by Economical StatusTable No. 26. Showing the distribution of patients by Economical status. Economical status No. Of Patients % Poor 4 20 Upper Middle class 8 26.66 Lower middle class 15 50 High class 3 10 Among the 30 patients, 15 patients were from lower middle class (50%), 8patients were from the upper middle class (26.66%) and 4 patients (20%) were from pooreconomical status and 3 patients (10%) were from high-class society. 109 Observation & Results
    • 05. Distribution of patients by ReligionTable No. 27. Showing the distribution of patients by Religion. Religion No. Of Patients % Hindu 28 93.33 Muslim 2 6.66 Christian 0 0 Others 0 0 Among the 30 patients, 28 patients were Hindus (93.33%), 2 patients wereMuslims (6.66%) and no patient were form other religions.06. Distribution of patients by Marital StatusTable No. 28. Showing the distribution of patients by Marital Status. Marital Status No. of Patients % Married 18 60 Unmarried 12 40 The maximum numbers of individual i.e. 18 patients (60%) were married andremaining 12 patients (i.e. 40%) were unmarried.07. Distribution of patients by Dietary habitsTable No. 29. Showing the distribution of Patients by Dietary habits. Dietary habit No. Of Patients % Vegetarian 15 40 Mixed 15 60 Among the 30 patients, it was found that the incidence of the vegetarians andmixed dietary habits was equal i.e. 50%. 110 Observation & Results
    • 08. Distribution of patients by AddictionTable No. 30. Showing distribution of patients by Addiction. Addiction No. Of Patients % Smoking 11 36.66 Pan chewing 6 20 Alcohol 10 33.33 Tobacco 3 10 Among the 30 patients, 11 patients were addicted to smoking (36.66%), 10patients were addicted for alcohol (33.33%) and 6 patients were addicted to pan chewing(i.e. 20%) and 3 patients (i.e.10%) were addicted to tobacco chewing.09. Distribution of patients by AgniTable No. 31. Showing the distribution of Patients by Agni. Agni No. Of Patients % Manda 10 33.33 Teekshna 7 23.33 Vishama 13 43.33 Sama 0 0 Among the 30 patients, 13 patients were having Vishama agni (43.33%), 10patients were having Manda agni (33.33%) and 7 patients were having Teekshna agni(23.33%) and interestingly no patient was with sama agni.10. Distribution of patients by KoshtaTable No. 32. Showing the distribution of patients by Koshta. Koshta No. Of Patients % Madhya 12 40.00 Mridu 8 26.66 Krura 10 33.33 Among the 30 patients, 12 patients were having Madhya koshta (40%), 8 patients(i.e. 26.66%) were having Mridu koshta & 10 patients (i.e. 33.33%) were having Krurakoshta. 111 Observation & Results
    • 11. Distribution of patients by NidraTable No. 33. Showing the distribution of Patients by Nidra. Nidra No. Of Patients % Sound 7 25.99 Disturbed 23 76.66 Among the 30 patients, 23 patients had sound sleep (76.66%) and 7 patients haddisturbed sleep (25.99%).12. Distribution of patients by Deha PrakritiTable No. 34. Showing the distribution of Patients by Deha prakrithi. Deha prakriti No. Of Patients % Vata-pitta 12 40 Vata-kapha 15 50 Pitta-kapha 3 10 Among the 30 patients, 12 patients were of Vata-pitta prakriti (40%), 15 patientwere of vata - kapha prakriti (50 %) and 3 patients were of pitta-kapha prakriti (10%).13. Distribution of patients by SatmyaTable No. 35. Showing the distribution of patients by Satmya. Satmya No. Of Patients % Rooksha 23 76.66 Snigdha 7 25.99 Among the 30 patients, majority of patients were having rooksha satmya i.e. 23(76.66%) and 7 patients were of snigdha satmya (25.99%). 112 Observation & Results
    • 14. Distribution of patients by SaraTable No. 36. Showing distribution of patients by Sara. Sara No. of patients % Pravara 2 6.66 Madhyama 26 86.66 Avara 2 6.66 It can be observed from the above table that no patient is of Pravara Sara. 26patients i.e. 86.66% were having Madhyama Sara and 2 patients (i.e. 6.66%) were havingAvara Sara.15. Distribution of patients by SahananaTable No. 37. Showing distribution of patients by Samhanana. Samhanana No. of patients % Pravara 2 6.66 Madhyama 26 86.66 Avara 2 6.66 Above table shows that 26 patients (i.e. 86.66%) were having MadhyamaSamhanana and 2 patients (i.e.6.66%) were of Pravara and Avara Samhananarespectively.16. Distribution of patients by SattvaTable No. 38. Showing distribution of patients by Sattva. Sattva NO. of Patients % Pravara 3 10.33 Madhyama 20 66.66 Avara 7 23.33 Above table reveals that maximum of patients i.e. 20 (66.66%) were havingMadhyama Satva followed by 7 patients of Avara satwa (i.e.23.33%) and 3 patients i.e.10.33% of Pravara Satva respectively. 113 Observation & Results
    • 17. Distribution of patients by Ahara shaktiTable No. 39. Showing distribution of patients by Ahara Shakti. Ahara Shakti No. of Patients % Pravara 4 13.33 Madhyama 10 33.33 Avara 16 53.33 Maximum numbers of patients i.e. 16 (53.33%) were having Avara Jarana Sakti,followed by Madhyama jarana shakti i.e. 10 patients (33.33%) and pravara jarana shaktii.e. 4 patients (13.33%) respectively.18. Distribution of patients by Vyama ShaktiTable No. 40. Showing distribution of patients by Vyayama Sakti. Vyayama Shakti No. of Patients % Pravara 9 30 Madhyama 4 13.33 Avara 17 56.77 Above table shows that 17 patients i.e. 56.77% were having avara vyayama saktifollowed by 9 patients (30%) were of pravara and 4 patients (13.33%) were of madhyamavyayama sakti respectively.19. Distribution of patients by Onset of DiseasesTable No. 41. Showing distribution of patients by Onset of the disease. Onset No. of Patients % Sudden 1 03.33 Gradual 29 96.66 Insidious 0 0 Maximum numbers of patients i.e. 29 (96.66%) were had gradual onset and 1patient 3.33% had sudden onset. 114 Observation & Results
    • 20. Distribution of patients by Dominant rasaTable No. 42. Showing distribution of patients by Dominant Rasa. Dominant Rasa No. of patients % Madhura 10 33.33 Amla 11 36.66 Lavana 1 3.33 Katu 8 26.66 Tikta 0 0 Kashaya 0 0 As shown in above table the dominant usage of Rasa in the diet of the patientswas found to be Amla (i.e. 36.66%), followed by Madhura (i.e.33.33%) and Katu (i.e.26.66%) and only 1 patient was found to have Lavana rasa satmya. (i.e. 3.33%)21. Distribution of patients by NidanaTable No. 43. Showing distribution of patients by Nidana (etiological factor). Nidana No. of patients % Viruddha Ahara 5 16.6 Mithya Ahara 12 40 Mithya Vihara 6 20 Manasika Nidana 7 25.99 In the study it was observation 12 patients i.e. 40% were taking Mithya Ahara, 7patients i.e. 25.99% were having Manasika karanas as the causative effect. 6 patients i.e.20% had Mithya vihara as the causative factor and 5 patients i.e.16.6% had ViruddhaAhara as the causative factor. 115 Observation & Results
    • 22. Distribution of patients by Viruddha aharaTable No. 44. Showing distribution of patients by Viruddha Ahara. Viruddha Ahara No. of patients % Milk + Honey 5 16.66 Milk + Fish 0 0 Milk + Onion 0 0 Milk + Rice 22 73.33 Milk + Khichadi 3 10 Out of 30 patients it was observed that, 22 patients i.e. 73.33% were taking milkwith rice, 5 patients i.e. 16.66% were using Honey with milk and 3 patients i.e. 10% weretaking milk with Khichadi.23. Distribution of patients by Mithya aharaTable No. 45. Showing distribution of patients by Mithya Ahara. Mithya Ahara No. of patients % Masha 10 33.33 Mulaka 18 60 Ati Dadhi 18 60 Meat 15 50 Sour food 5 16.66 Tila taila 2 6.66 Kullatha 22 73.33 Guda 20 66.66 Ushna & Tikshna 5 16.66 Guru 3 10 Vidahi 2 6.66 Ati Snigdha 4 13.33 116 Observation & Results
    • In Mithya Ahara maximum number of patients i.e. 22 (73.33%) patients weretaking Kullatha and 20 i.e. 66.66% patients were consuming more Guda. The excess useof Mulaka and Ati dadhi sevana was found in 18 patients i.e. 60%. 15 patients i.e. 50%patients were habituated to meat consumption and 10 patients i.e. 33.33% reported withMasha atisevana. Ushna & Tikshana & Sour foods habituation was found in 5 patientsi.e. 16.66% respectively. 4 patients i.e. 13.33% were accustomed to ati snigdha ahara and3 patients i.e. 10% patients were accustomed to Ati guru ahara. Usage of Vidahi Aharaand Tila taila was found in 2 patients i.e. 6.66% respectively.24. Distribution of patients by Mithya viharaTable No. 46. Showing distribution of patients by Mithya Vihara. Mithya Vihara No. of patients % Vegadharana 10 33.33 Divasvapa 12 40 Ratri Jagarana 8 26.6 Excessive physical works 18 60 Sheetoshna Viprayaya 4 29.66 Most common mithya vihara was found to be excessive physical work. 18patients (60%) reported with excessive physical work followed by Divasvapa 12 patients(40%), Vegadharana in 10 patients (33.33%) and Ratri Jagarana in 8 patients (26.6%). 4patients (i.e. 29.66%) were reported with Sheetoshna Viparyaya.25. Distribution of patients by Manasika NidanaTable No. 47. Showing distribution of patients by Manasika Nidana. Manasika Nidana No. of patients % Chittodwega 13 43.33 Bhaya 17 56.66 Krodha 4 13.33 Shoka 18 60 117 Observation & Results
    • The manasika Nidana Krodha was found in 18 patients i.e. 60%, Bhaya was foundin 17 patients i.e. 56.66% and Chittodvega was found in 13 patients i.e. 43.33%. 4patients i.e. 13.33% reported Shoka as a manasika Nidana.26. Distribution of patients by Family historyTable No. 48. Showing distribution of patients by Family History. Family History No. of patients % Positive 2 6.66 Negative 28 93.33 Majority of the patients i.e. 28 (93.33%) were not having family history ofpsoriasis and only 2 patients (i.e. 6.66%) reported with positive family history ofpsoriasis.27. Distribution of patients by ChronicityTable No. 49. Showing distribution of patients by Chronicity. Chronicity No. of patients % < 1 year 5 16.66 1 – 5 years 16 53.33 6 – 10 years 7 23.33 >10 years 2 6.66 The maximum number of patients i.e. 16 (53.33%) were having 1to 5 yearschronicity of the disease, followed by 7 patients i.e. 23.33% and 5 patients i.e. 16.66%were having the chronicity of 6-10 years and less than 1 year respectively. Only 2patients i.e. 6.66% reported with the chronicity of more than 10 years. 118 Observation & Results
    • 28. Distribution of patients by MedicationTable No. 50. Showing distribution of patients by Medication. Medication No. of patients % Allopathy 28 93.33 Ayurveda 2 6.66 Other 0 0 In this study, majority of the patients i.e. 29 (93.33%) had previously undergoneallopathic treatment, and only 2 patients had the Ayurvedic treatment. None of thepatients was approached with the treatment history of other systems of medicines.29. Distribution of patients by Aggravating SeasonTable No. 51. Showing distribution of patients by Aggravating Season. Aggravating season No. of patients % Winter 23 76.6 Summer 2 6.66 Monsoon 1 3.3 None 4 13.3 The symptoms aggravating season of the maximum 23 patients i.e. 76.6% waswinter followed by summer 2 patients i.e. 6.66% and monsoon 1 patient i.e. 3.33% 4patients i.e. 13.33% had no experience of seasonal variation.30. Distribution of patients by types of PsorasisTable No. 52. Showing distribution of patients by Types of Psoriasis. Types No. of patients % Plaque 27 90 Guttate 2 6.6 Erythrodermic 1 3.33 Pustular 0 0 Maximum numbers of patients i.e. 27 (90%) reported with plaque psoriasis 2patients i.e. 7.4% reported with Guttate psoriasis and in only 1 patient i.e. 3.33% reportedwith Erythrodermic psoriasis. No patient was reported with Pustular psoriasis. 119 Observation & Results
    • 31. Distribution of patients by Chief complaintsTable No. 53. Showing distribution of patients by Chief Complaints. Chief Complaints No. of patients % Shyava or Krishna varna 30 100 Kina khara sparasha 29 96.66 Parusha 29 96.66 Kandu 30 100 Srava 2 6.66 Ghana 30 100 All 30 patients (i.e. 100%) of this study were having shyava or Krishna varnata,kandu, Ghana as a chief complaint, where as 29 patients (i.e. 96.66%) were reported withKina khara sparsha and Parushata. Only 2 patients (i.e. 6.66%) were reported with srava.32. Distribution of patients by Associated complaintsTable No. 54. Showing distribution of patients by Associated Symptoms. Associated symptoms No. of patients % Agnimandya 6 20 Malabaddhata 6 20 Aswedana 4 13.33 Atiswedana 4 13.33 Shareera Guruta 3 10 Suptata 3 10 Chimchimayana 1 3.33 Toda 3 10 The associated complaints like Agni madya and Malabaddhata was found in 6patients (i.e. 20%) each. Aswedanam, Atiswedanam was found in 4 patients (i.e.13.33%)each. Shareera Guruta, Suptata and Toda was noted in 3 patients (i.e.10%) each. Only 1patient (i.e. 3.33%) reported with Chimachimayana. 120 Observation & Results
    • 33. Distribution of patients by Confirmation tests of PsoriasisTable No. 55. Showing distribution of patients by confirmation tests of Psoriasis. Signs No. of Patients % Auspitz sign 15 50 Candle grease sign 12 40 Koebner Phenomena 3 10 The Auspitz sign was positive in 15 patients (i.e. 50%) and Candle greaes signwas positive in 12 patients (i.e. 40%). Positive Koebner Phenomena was present in 3patients (i.e. 10%).34. Distribution of patients by Precipitating factorsTable No. 56. Showing distribution of patients by Precipitating factors. Precipitating Factor No. of Patients % Trauma 3 10 Sunlight 10 33.33 Emotional stress 8 26.66 Drug 1 3.33 10 patents (i.e. 33.33%) were having sunlight as a precipitating factor, 8 patients(i.e. 26.66%) were having emotional stress as the triggering factor and 3 patients (i.e.10%) had trauma as the precipitating factor and only 1 patient (i.e. 3.33%) was reporteddrug as a triggering factor.35. Distribution of patients by Site of involvementTable No. 57. Showing distribution of patients with different Site of involvement. Site of involvement No. of Patients % Head 16 53.33 Arms 19 63.33 Legs 19 63.33 Body 14 46.66 121 Observation & Results
    • Out of 30% 19 patients each i.e. 63.33% were reported with the arms and legsinvolvement respectively, 16 patients (i.e. 53.33%) were reported with head involvementand 14 patients (i.e. 46.66%) reported with body involvement.36. Distribution of patients by particular site involvementTable No. 58. Showing distribution of patients with Particular site involvement. Site of involvement No. of Patients % Only scalp 7 23.33 Only palms & soles 5 16.66 Genital 1 3.33 Out of 30 patients, 7 patients i.e. 23.33% were having only scalp involvement(Scalp Psoriasis), 5 patients i.e. 16.66% were having only palms and soles involvement(Palmo-plantar Psoriasis). Only 1 patient (i.e. 3.33%) was found with the involvement ofgenitals.Overall response of the treatmentTable No. 59. Showing Overall response of the treatment. Overall results No. of Patients % Complete remission 8 26.66 Marked improvement 7 25.90 Moderate improvement 4 13.33 Mild improvement 9 30 No response 5 16.66 After treatment, 8 patients (i.e. 26.66%) showed complete remission, 7 patients(i.e.25.90%) showed marked improvement, 4 patients (i.e. 13.33%) showed moderateimprovement and 9 patients (i.e.30%) showed mild improvement and no response wasfound in 5 patients (i.e.16.66%). 122 Observation & Results
    • Graph No. 01. Showing Distribution of patients by Age groups. Distribution of Pt.s by Age 12 10 10 9 8 No of Pt.s 6 4 4 4 3 2 0 10. - 20 21-30 31-40 41-50 51-60 No. Of Patients Age groupsGraph No. 02. Showing the distribution of patients by Deha prakriti. Distribution of Pt.s by Deha Prakriti 15 10 15 12 5 3 0 V-P V-K P-K No. Of Patients Deha PrakritiGraph No. 03. Showing the distribution of patients by onset. Distribution of Pt.s by Onset 30 25 20 29 15 10 5 1 0 0 Sudden Gradual Insidious No. of Patients Nature of Onset
    • Graph No. 04. Showing distribution of the patients by Nidana. Distribution of Pt.s by Nidana 7 5 6 12 VA MA MV MNGraph No. 05. Showing the distribution of patients by Manasika nidana. Distribution of Pt.s by Manasika Nidana Manasika Nidana Sh 18 Kr 4 Bh 17 Cv 13 0 5 10 15 20 No. of patients No. of Pt.sGraph No. 06. Showing the distribution of the patients by family history. Distribution of Pt.s by Family History 2 28 Positive Negative
    • Graph No. 07. Showing the distribution of patients by Chronicity. Distribution of Pt.s by Chronicity 20 16 15 10 7 5 5 2 0 < 1 yr 1 – 5 yrs 6 – 10 yrs >10 yrs No. of patients Chronicity in YearsGraph No. 08. Showing the distribution of patients by aggravating season Distribution of Pt.s by Aggravating season 25 23 20 No. of Pt.s 15 10 4 5 2 1 0 Winter Summer Monsoon None No. of patients Aggravating seasonGraph No. 09. Showing the distribution of patients by types of psoriasis. Distribution of Pt.s by types of Psoriasis 30 27 25 No. of Pt.s 20 15 10 5 2 1 0 0 Plaque Guttate Eryth. Pustular No. of patients Type of Psoraisis
    • Graph No. 10. Showing the distribution of patients by chief complaints. Distribution of Pt.s By chief compliants 40 30 29 29 30 30 No. of Pt.s 30 20 10 2 0 S/K Vr. KK Sp Pr Kd Sr Gh No. of patients Chief complaintsGraph No. 11. Showing the distribution of patients by associated complaints. Distribution of Pt.s by Associated Symptoms 7 6 6 6 5 No. of Pt.s 4 4 4 3 3 3 3 2 1 1 0 A B C D E F G H No. of patients Associated complaintsGraph No. 12. Showing the distribution of patients by confirmatory tests. Distribution of Pt.s by confirmatory tests 3 15 12 A B C
    • Graph No. 13. Showing distribution of patients by involvement of body Distribution of Pt.s by involvement of body parts 19 19 20 16 14 15 No. of Pt.s 10 5 0 Head Arms Legs Body No. of Patients Body PartsGraph No. 14. Showing the Overall results. Overall results 10 9 8 8 7 6 5 No. of Pt.s 4 4 2 0 CR Mr.I Mo.I Mi.I NR No. of Patients Response to treatment
    • RESULTSHEAD Out of 30 patients, 16 patients i.e. 53.33% reported with psoriasis on head. Out ofthese 16 those who reported with psoriasis only head (scalp psoriasis) was 7 (i.e.23.33%)means only 7 patients had scalp psoriasis, others i.e. 9 patients (i.e.56.25%) had theinvolvement of scalp along with other parts. Here, in the following tables only datarelated to head affliction is given in forth coming pages data related to other parts ifaffected will be given.Table No. 60. Showing the distribution of patients with different severity scorings.Sl. Symptom Mild Moderate Severe Maximum Total %01. Itching 3 4 3 6 16 10002. Erythema 7 3 1 3 14 87.5003. Scaling 5 2 6 3 16 10004. Thickness 7 6 2 1 16 100ItchingTable No. 61. Showing the distribution of patients with itching head.Sl. OPD BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 0 100 C.R. 09. 3889 4 0 100 C.R.02. 1455 3 0 100 C.R. 10. 3581 1 0 100 C.R.03. 2548 2 0 100 C.R. 11. 1486 1 0 100 C.R.04. 2924 4 0 100 C.R. 12. 267 2 2 0 N.I.05. 2173 3 1 66 Mo.I. 13. 1995 4 0 100 C.R.06. 1470 1 0 100 C.R. 14. 986 4 0 100 C.R.07. 3700 4 0 100 C.R. 15. 322 3 0 100 C.R.08. 2388 4 0 100 C.R. 16. 1467 2 0 100 C.R.ScalingTable No. 62. Showing the distribution of patients with scaling head.Sl. OPD BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 3 0 100 C.R. 09. 2388 3 0 100 C.R.02. 1455 2 0 100 C.R. 10. 3581 1 0 100 C.R.03. 1467 3 0 100 C.R. 11. 1486 1 0 100 C.R.04. 2548 1 0 100 C.R. 12. 267 3 3 0 N.I.05. 2924 4 0 100 C.R. 13. 1995 3 0 100 C.R.06. 2173 4 4 0 N.I. 14. 986 4 0 100 C.R.07. 1470 1 0 100 C.R. 15. 322 3 0 100 C.R.08. 3700 3 0 100 C.R. 16. 3889 1 0 100 C.R. 123 Results
    • ErythemaTable No. 63. Showing the distribution of patients with Erythema head.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 0 100 C.R. 08. 3700 3 0 100 C.R.02. 1455 2 0 100 C.R. 09. 2388 2 0 100 C.R.03. 1467 1 0 100 C.R. 10. 267 4 4 0 N.I.04. 2548 1 0 100 C.R. 11. 1986 1 0 100 C.R.05. 2924 1 0 100 C.R. 12. 322 1 0 100 C.R.06. 2173 4 4 0 N.I. 13. 3889 4 0 100 C.R.07. 1470 2 2 0 N.I. 14. 1995 1 0 100 C.R.ThicknessTable No. 64. Showing the distribution of patients with thickness head.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 0 100 C.R. 09. 3581 1 0 100 C.R.02. 1455 2 0 100 C.R. 10. 1486 1 0 100 C.R.03. 1467 1 0 100 C.R. 11. 322 2 0 100 C.R.04. 2548 1 0 100 C.R. 12. 267 2 2 0 N.I.05. 2924 2 0 100 C.R. 13. 1995 1 0 0 N.I.06. 2173 4 4 0 N.I. 14. 986 3 0 100 C.R.07. 3700 3 0 100 C.R. 15. 3889 2 0 100 C.R.08. 2388 1 0 100 C.R. 16. 1470 2 2 0 N.I.AreaTable No. 65. Showing the distribution of patients presented with area head.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 0 100 C.R. 09. 3581 1 0 100 C.R.02. 1455 1 0 100 C.R. 10. 1486 1 0 100 C.R.03. 1467 2 0 100 C.R. 11. 3700 3 0 100 C.R.04. 2548 1 0 100 C.R. 12. 267 2 2 0 N.I.05. 2924 2 0 100 C.R. 13. 1995 2 0 100 C.R.06. 2173 3 3 0 N.I. 14. 986 4 3 66 Mo.I.07. 1470 1 1 0 N.R. 15. 322 1 0 100 C.R.08. 2388 3 0 100 C.R. 16. 3889 4 0 100 C.R. 124 Results
    • Table No. 66. Showing the distribution of patients with Coverage area in head. Sl. Coverage area No. of patients % 01. <10% 7 43.75 02. 10-29% 4 25 03. 30-49% 3 18.75 04. 50-69% 2 12.5 05. 70-89% 0 0 06. 90-100% 0 0Total PASI score of HeadTable No. 67. Showing the distribution of patients with total PASI score of Head.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3561 0.7 0 100 C.R. 09. 3700 3.9 0 100 C.R.02. 3889 4.4 0 100 C.R. 10. 2388 3.0 0 100 C.R.03. 1455 0.9 0 100 C.R. 11. 3681 0.3 0 100 C.R.04. 1467 1.4 0 100 C.R. 12. 1486 0.3 0 100 C.R.05. 2548 0.5 0 100 C.R. 13. 267 2.2 2.2 0 N.I.06. 2924 2.2 0 100 C.R. 14. 1995 1.8 0 100 C.R.07. 2173 4.9 3.9 13.3 Mi.I. 15. 986 4.8 0 100 C.R.08. 1470 0.6 0.4 33.3 Mi.I. 16. 322 0.9 0 100 C.R.ARMS Out of 30 patients, 19 patients (i.e.41.17%) reported with psoriasis on arms. Outof these 19 those who reported with psoriasis only on arms was only 1 (i.e.5.26%).Others i.e. 18 patients (i.e.94.73%) had the involvement of arms along with other parts.Here, in the following tables only data related to arms affliction is given in forth comingpages data related to other parts if affected will be given.Table No. 68. Showing the number of patient with different severity scorings.Sl. Symptom Mild Moderate Severe Maximum Total %01. Itching 5 3 10 1 19 10002. Erythema 4 3 3 4 14 73.6803. Scaling 6 4 6 3 19 10004. Thickness 5 6 5 3 19 100 125 Results
    • ItchingTable No. 69. Showing the distribution of patients with itching arms.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 0 100 C.R. 11. 1486 3 1 66.6 Mo.I.02. 1455 2 1 50 Mo.I. 12. 2897 3 0 100 C.R.03. 2548 3 1 66.6 Mo.I. 13. 1647 1 1 0 N.I.04. 3118 3 3 0 N.I. 14. 267 2 2 0 N.I.05. 2924 4 0 100 C.R. 15. 5574 3 0 100 C.R.06. 3755 1 0 100 C.R. 16. 5609 3 0 100 C.R.07. 2173 3 1 66.6 Mo.I. 17. 2308 3 0 100 C.R.08. 1470 1 0 100 C.R. 18. 5323 2 0 100 C.R.09. 282 3 1 66.6 Mo.I. 19. 2160 1 0 100 C.R.10. 3581 3 1 66.6 Mo.I.ErythemaTable No. 70. Showing the distribution of patients with Erythema arms.Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 1 1 0 N.I. 08. 1470 2 2 0 N.I.02. 1455 2 2 0 N.I. 09. 282 3 3 0 N.I.03. 2548 4 4 0 N.I. 10. 1647 3 3 0 N.I.04. 3118 3 3 0 N.I. 11. 267 4 4 0 N.I.05. 2924 4 4 0 N.I. 12. 5574 1 0 100 C.R.06. 3755 1 1 0 N.I. 13. 2308 2 1 50 Mo.I.07. 2173 4 4 0 N.I. 14. 2160 1 1 0 N.I.ScalingTable No. 71. Showing the distribution of patients with scaling arms.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 3 2 33.3 Mi.I. 11. 1486 3 2 33.3 Mi.I.02. 1455 2 2 0 N.I. 12. 2897 3 0 100 C.R.03. 2548 4 3 25 Mi.I. 13. 1647 1 1 0 N.I.04. 3118 3 3 0 N.I. 14. 267 3 3 0 N.I.05. 2924 4 3 25 Mi.I. 15. 5574 2 0 100 C.R.06. 3755 1 0 100 C.R. 16. 5609 3 1 66.6 Mo.I.07. 2173 4 4 0 N.I. 17. 2308 2 0 100 C.R.08. 1470 1 1 0 N.I. 18. 5323 1 0 100 C.R.09. 282 2 1 50 Mo.I. 19. 2160 1 0 100 C.R.10. 3581 1 1 0 N.I. 126 Results
    • ThicknessTable No. 72. Showing the distribution of patients with thickness arms.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 1 0 N.I. 11. 1486 3 3 100 C.R.02. 1455 2 2 0 N.I. 12. 2897 3 0 100 C.R.03. 2548 4 4 0 N.I. 13. 1647 2 2 0 N.I.04. 3118 3 3 0 N.I. 14. 267 2 2 0 N.I.05. 2924 4 0 100 C.R. 15. 5574 2 0 100 C.R.06. 3755 1 1 0 N.I. 16. 5609 2 1 50 Mo.I.07. 2173 4 4 0 N.I. 17. 2308 2 1 50 Mo.I.08. 1470 2 2 0 N.I. 18. 5323 1 0 100 C.R.09. 282 3 3 0 N.I. 19. 2160 1 1 0 N.I.10. 3581 1 1 0 N.I.AreaTable No. 73. Showing the distribution of patients with area arms.Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 2 0 N.I. 11. 1486 3 3 0 N.I.02. 1455 1 1 0 N.I. 12. 2897 3 0 100 C.R.03. 2548 2 2 0 N.I. 13. 1647 3 3 0 N.I.04. 3118 1 1 0 N.I. 14. 267 4 4 0 N.I.05. 2924 2 2 0 N.I. 15. 5574 2 0 100 C.R.06. 3755 1 1 0 N.I. 16. 5609 1 1 0 N.I.07. 2173 3 3 0 N.I. 17. 2308 2 1 50 Mo.I.08. 1470 1 1 0 N.I. 18. 5323 1 0 100 C.R.09. 282 3 3 0 N.I. 19. 2160 1 1 0 N.I.10. 3581 2 2 0 N.I.Table No.74. Showing distribution of patients with Coverage area of arms. Sl. Coverage area No. of patients % 01. <10% 7 41.70 02. 10-29% 6 35.29 03. 30-49% 5 29.41 04. 50-69% 1 5.26 05. 70-89% 0 0 06. 90-100% 0 0 127 Results
    • Total PASI score of ArmsTable No. 75. Showing the total PASI score of Arms.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 2.4 1.6 33.33 Mi.I. 11. 1486 5.4 3.6 33.33 Mi.I.02. 1455 1.6 1.4 12.5 Mi.I. 12. 2897 5.4 0 100 C.R.03. 2548 6.0 4.8 20 Mi.I. 13. 1647 4.2 4.2 0 N.I.04. 3118 2.4 2.4 0 N.I. 14. 267 8.8 8.8 0 N.I.05. 2924 6.4 2.8 56.25 Mo.I. 15. 5574 3.2 0 100 C.R.06. 3755 0.8 0.4 50 Mo.I. 16. 5609 1.8 0.4 77.78 Mo.I.07. 2173 9.0 7.8 13.33 Mi.I. 17. 2308 3.6 0.4 88.89 Mo.I.08. 1470 1.2 1.0 16.67 Mi.I. 18. 5323 0.8 0 100 C.R.09. 282 6.6 4.8 27.27 Mi.I. 19. 2160 0.8 0.4 50 Mo.I.10. 3581 2.0 1.2 40 Mi.I.Body Out of 30 patients, 15 patients i.e. 50% reported with psoriasis on body surface,which include chest, abdomen, back and genitals. Out of these 15 those who reportedwith psoriasis only on body was only 2 (i.e.13.33%). Others i.e. 13 patients (i.e. 86.66%)had the involvement of body along with other parts. Here, in the following tables onlydata related to body affliction is given. In forth coming pages data related to other parts ifaffected will be given.Table No. 76. Showing the number of patient with different severity scorings.Sl. Symptom Mild Moderate Severe Maximum Total %01. Itching 5 6 3 1 15 10002. Erythema 3 4 2 3 12 8003. Scaling 6 4 3 2 15 10004. Thickness 4 7 2 2 15 100ItchingTable No. 77. Showing the distribution of patients with itching body.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 2 1 50 Mo.I. 09. 3547 1 0 100 C.R.02. 1455 3 1 66.66 Mo.I. 10. 2388 2 1 50 Mo.I.03. 2548 2 1 50 Mo.I. 11. 2368 3 1 66.6 Mo.I.04. 3118 4 4 0 N.I. 12. 2897 2 1 50 Mo.I.05. 2924 1 0 100 C.R. 13. 267 2 2 0 N.I.06. 2210 1 1 0 N.I. 14. 1995 2 2 0 N.I.07. 1470 3 1 66.66 Mo.I. 15. 2160 1 0 100 C.R.08. 3700 1 0 100 C.R. 128 Results
    • ErythemaTable No. 78. Showing the distribution of patients with Erythema body.Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 2 2 0 N.I. 07. 2173 4 4 0 N.I.02. 1455 2 2 0 N.I. 08. 1470 2 2 0 N.I.03. 2548 3 3 0 N.I. 09. 282 1 1 0 N.I.04. 3118 4 4 0 N.I. 10. 3547 2 2 0 N.I.05. 2924 1 1 0 N.I. 11. 1647 3 3 0 N.I.06. 3756 1 1 0 N.I. 12. 267 4 4 0 N.I.ScalingTable No. 79. Showing the distribution of patients with scaling body.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 3 2 33.3 Mi.I. 09. 282 1 0 100 C.R.02. 1455 2 2 0 N.I. 10. 3457 2 2 0 N.I.03. 2548 3 3 0 N.I. 11. 3581 1 1 0 N.I.04. 3118 4 4 0 N.I. 12. 1486 2 1 50 Mo.I.05. 2924 1 1 0 N.I. 13. 1647 1 1 0 N.I.06. 3756 1 1 0 N.I. 14. 267 3 3 0 N.I.07. 2173 4 4 0 N.I. 15. 5323 1 0 100 C.R.08. 1470 1 1 0 N.I.ThicknessTable No. 80. Showing the distribution of patients with thickness body.Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 3 3 0 N.I. 09. 282 2 2 0 N.I.02. 1455 2 2 0 N.I. 10. 3547 2 2 0 N.I.03. 2548 3 3 0 N.I. 11. 3581 1 1 0 N.I.04. 3118 4 4 0 N.I. 12. 1486 2 2 0 N.I.05. 2924 1 1 0 N.I. 13. 1647 2 2 0 N.I.06. 3756 1 1 0 N.I. 14. 267 2 2 0 N.I.07. 2173 4 4 0 N.I. 15. 5323 1 1 0 N.I.08. 1470 2 2 0 N.I.AreaTable No. 81. Showing the distribution of patients with area Body.Sl. OPD No. BT AT % Remarks Sl. OPD No. BT AT % Remarks01. 3569 3 3 0 N.I. 09. 282 1 1 0 N.I.02. 1455 2 2 0 N.I. 10. 3547 2 2 0 N.I.03. 2548 1 1 0 N.I. 11. 3581 2 2 0 N.I.04. 3118 3 3 0 N.I. 12. 1486 3 3 0 N.I.05. 2924 1 1 0 N.I. 13. 1647 2 2 0 N.I.06. 3756 1 1 0 N.I. 14. 267 5 5 0 N.I.07. 2173 4 4 0 N.I. 15. 5323 1 1 0 N.I.08. 1470 1 1 0 N.I. 129 Results
    • Table No. 82. Showing the coverage area of the body. Sl. Coverage area No. of patients % 01. <10% 6 40 02. 10-29% 4 26.66 03. 30-49% 3 20 04. 50-69% 1 6.66 05. 70-89% 1 6.66 06. 90-100% 0 0Total PASI scoreTable No. 83. Showing the total PASI score of Body.Sl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks01. 3569 9.0 7.2 20 Mi.I. 09. 282 1.5 0.9 40 Mi.I.02. 1455 5.6 4.2 25 Mi.I. 10. 3547 4.8 4.2 12.5 Mi.I.03. 2548 3.3 3.0 9.09 Mi.I. 11. 3581 3.0 1.8 40 Mi.I.04. 3118 14.4 14.4 0 N.I. 12. 1486 5.4 3.6 33.33 Mi.I.05. 2924 1.2 0.9 25 Mi.I. 13. 1647 4.8 4.8 0 N.I.06. 3756 1.2 1.2 0 N.I. 14. 267 16.5 16.5 0 N.I.07. 2173 18.0 15.6 13.33 Mi.I. 15. 5323 0.9 0.3 66.66 Mo.I.08. 1470 1.8 1.5 16.65 Mi.I.LEGS Out of 30 patients, 15 patients i.e. 50% reported with psoriasis on body surface,which include chest, abdomen, back and genitals. Out of these 15 those who reportedwith psoriasis only on body was only 2 (i.e.13.33%). Others i.e. 13 patients (i.e. 86.66%)had the involvement of body along with other parts. Here, in the following tables onlydata related to body affliction is given.Table No. 84. Showing the distribution of patients with different severity scoringsSl. Symptom Mild Moderate Severe Maximum01. Itching 9 4 6 102. Erythema 9 2 2 203. Scaling 12 2 5 104. Thickness 9 6 4 1 130 Results
    • ItchingTable No. 85. Showing the distribution of patient with itching legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 1455 1 0 100 C.R. 11. 2368 3 3 100 C.R.02. 2548 1 0 100 C.R. 12. 1486 1 0 100 C.R.03. 3118 1 1 0 N.I. 13. 2897 3 0 100 C.R.04. 2924 1 0 100 C.R. 14. 1647 2 2 0 N.I.05. 3755 1 0 100 C.R. 15. 267 2 2 0 N.I.06. 2210 2 0 100 C.R. 16. 5609 3 0 100 C.R.07. 2173 3 1 66.66 Mo.I. 17. 2388 3 0 100 C.R.08. 1470 1 0 100 C.R. 18. 5323 2 0 100 C.R.09. 282 1 0 100 C.R. 19. 2160 1 0 100 C.R.10. 3581 3 1 66.66 Mo.I.ErythemaTable No. 86. Showing the distribution of patients with Erythema legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 1 0 N.I. 09. 1470 2 2 0 N.I.02. 1455 1 1 0 N.I. 10. 282 1 1 0 N.I.03. 2548 1 1 0 N.I. 11. 2368 1 1 0 N.I.04. 3118 1 1 0 N.I. 12. 1647 3 3 0 N.I.05. 2924 1 1 0 N.I. 13. 267 4 4 0 N.I.06. 3756 1 1 0 N.I. 14. 2308 3 1 66.66 Mo.I.07. 2210 2 1 50 Mo.I. 15. 2160 1 1 0 N.I.08. 2173 4 4 0 N.I.ScalingTable No. 87. Showing the distribution of patients with scaling legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 3 2 33.33 Mi.I. 11. 3700 3 3 0 N.I.02. 1455 1 1 0 N.I. 12. 282 1 0 100 C.R.03. 2160 1 0 100 C.R. 13. 2160 1 0 100 C.R.04. 2548 1 0 100 C.R. 14. 3581 1 1 0 N.I.05. 3118 1 1 0 N.I. 15. 2368 3 3 0 N.I.06. 2924 1 1 0 N.I. 16. 1486 1 0 100 C.R.07. 5323 1 0 100 C.R. 17. 2897 3 1 66.66 Mo.I.08. 2210 2 1 50 Mo.I. 18. 1647 1 1 0 N.I.09. 2173 4 4 0 N.I. 19. 267 3 2 33.33 Mi.I.10. 1470 1 1 0 N.I. 20. 5609 3 1 66.66 Mo.I. 131 Results
    • ThicknessTable No. 88. Showing the distribution of patients with thickness legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 1 0 N.I. 11. 3581 1 1 0 N.I.02. 1455 1 1 0 N.I. 12. 1486 2 2 0 N.I.03. 2548 1 1 0 N.I. 13. 2388 1 1 0 N.I.04. 3118 1 1 0 N.I. 14. 2368 3 3 0 N.I.05. 2924 1 1 0 N.I. 15. 2897 3 2 33.33 Mo.I.06. 3755 1 1 0 N.I. 16. 1647 2 2 0 N.I.07. 2210 2 2 0 N.I. 17. 2308 1 0 100 C.R.08. 2173 4 4 0 N.I. 18. 5323 1 0 100 C.R.09. 1470 2 2 0 N.I. 19. 986 3 1 66.66 Mo.I.10. 282 2 2 0 N.I. 20. 322 3 1 66.66 Mo.I.Area in bodyTable No. 89. Showing the distribution of patients with area legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 1 1 0 N.I. 11. 3581 2 2 0 N.I.02. 1455 1 1 0 N.I. 12. 1486 2 2 0 N.I.03. 2548 1 1 0 N.I. 13. 2160 1 1 0 N.I.04. 3118 1 1 0 N.I. 14. 2368 1 1 0 N.I.05. 2924 2 2 0 N.I. 15. 2897 3 3 0 Mo.I.06. 3755 1 1 0 N.I. 16. 1647 3 3 0 N.I.07. 2210 2 2 0 N.I. 17. 267 4 4 0 N.I.08. 2173 3 3 0 N.I. 18. 5609 3 1 66.66 Mo.I.09. 1470 1 1 0 N.I. 19. 2308 3 1 66.66 Mo.I.10. 282 1 1 0 N.I. 20. 5323 2 1 50 Mo.I.Coverage areaTable No. 90. Showing Coverage area of legs. Sl. Coverage area No. of patients % 01. <10% 8 40 02. 10-29% 5 25 03. 30-49% 6 30 04. 50-69% 1 5 05. 70-89% 0 0 06. 90-100% 0 0 132 Results
    • Total PASI scoreTable No. 91. Showing the total PASI scoring of legsSl. OPD BT AT % Remarks Sl. OPD BT AT % Remarks No. No.01. 3569 2.0 1.6 20 Mi.I. 11. 3581 4.0 2.4 40 Mi.I.02. 1455 1.6 1.2 25 Mi.I. 12. 1486 3.2 1.6 50 Mo.I.03. 2548 1.6 0.8 50 Mo.I. 13. 2160 1.6 0.8 50 Mo.I.04. 3118 1.6 1.6 0 N.I. 14. 2368 12.0 12.0 0 N.I.05. 2924 3.2 2.4 25 Mi.I. 15. 2897 6.8 3.6 47.06 Mi.I.06. 3755 1.6 0.8 50 Mo.I. 16. 1647 9.6 9.6 0 N.I.07. 2210 6.4 3.2 50 Mo.I. 17. 267 17.6 17.6 0 N.I.08. 2173 18.0 15.6 13.33 Mi.I. 18. 5609 9.8 0.8 91.8 B.R.09. 1470 2.4 2.0 16.6 Mi.I. 19. 2308 13.2 0.8 93.94 B.R.10. 282 2.0 1.2 40 Mi.I. 20. 5328 3.2 0 100 C.R.Master chartTable No. 92. Showing total PASI scoring of the all 30 patients.Sl. OPD Total PASI BT Total PASI AT % Reduction Remarks01. 3569 14.1 10.4 26.24 Minimal02. 1455 9.7 7.2 25.77 Minimal03. 1467 1.4 0 100 Completer remission04. 2548 11.7 8.6 26.50 Minimal05. 3118 18.4 18.4 0 Unchanged06. 2924 13.0 6.1 53.08 Moderate07. 3755 2.4 1.2 50 Moderate08. 3756 1.2 1.2 0 Unchanged09. 2210 6.4 3.2 50 Moderate10. 2173 49.5 42.5 14.14 Minimal11. 1470 6.0 4.9 18.33 Minimal12. 3700 3.9 0 100 Completer remission13. 282 10.1 6.9 31.68 Minimal14. 3547 4.8 4.2 12.5 Minimal15. 2388 3.0 0 100 Completer remission 133 Results
    • Table No. 92. Showing total PASI scoring of the all 30 patients.Sl. OPD Total PASI BT Total PASI AT % Reduction Remarks16. 3581 9.3 5.6 39.79 Minimal17. 2368 12.0 12.0 0 Unchanged18. 1486 14.3 8.8 38.46 Minimal19. 2897 13.2 3.6 72.73 Moderate20. 1647 18.6 18.6 0 Unchanged21. 267 45.1 45.1 0 Unchanged22. 1995 1.8 0 100 Completer remission23. 5574 3.2 0 100 Completer remission24. 986 4.8 0 100 Completer remission25. 5609 11.6 1.2 89.66 Marked improvement26. 322 0.9 0 100 Completer remission27. 2308 16.8 1.2 92.86 Marked improvement28. 5323 4.5 0.3 93.88 Marked improvement29. 2160 5.4 1.2 79.63 Marked improvement30. 3889 4.4 0 100 Completer remissionSTATISTICAL RESULTSTable No. 93. Showing the after treatment statistical results of total PASI score ofdifferent areas.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Head total PASI 0.863 0.863 1.404 0.256 <0.001 H.S.02. Arms total PASI 0.88 0.88 1.351 0.246 <0.01 H.S.03. Body total PASI 0.376 0.376 0.662 0.120 <0.01 H.S.04. Leg total PASI 1.393 1.393 2.765 0.504 <0.01 H.S. Form the above table one can say that statistical analysis holds good for each partsof the body. Namely head, arms, body and legs. But it is more significant in head armsand legs as compare to the body. Among the significant parameters (i.e. head, arms andlegs) head and legs showed highly significant when comparing to the arms, (p <0.01.) 134 Results
    • Table No. 94. Showing the after treatment statistical results of different symptoms ofhead.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Scaling (Head) 1.1 1.422 0.259 4.247 <0.001 H.S.02. Itching (Head) 1.366 1.629 0.297 3.364 <0.01 H.S.03. Erythema (Head) 0.333 0.884 0.161 2.068 <0.01 H.S.04. Thickness (Head) 0.286 0.469 0.125 2.288 <0.01 H.S. The above table one can say that the parameters scaling head, itching head, haveshown significant difference as compared to the remaining parameters namely Erythemaand thickness.Table No. 95. Showing the after treatment statistical results of different symptoms ofarms.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Scaling (Arm) 1.066 1.436 0.262 4.068 <0.001 H.S.02. Itching (Arm) 1.166 1.234 0.225 5.068 <0.01 H.S.03. Erythema (Arm) 0.066 0.253 0.046 1.434 >0.05 N.S.04. Thickness (Arm) 1.066 1.362 0.248 4.298 <0.001 H.S. The above table shows highest significant was observed in itching compare to thescaling. But it is of no less significant in case of thickness when compared to the aboveparameters. But it is of no significance in case of Erythema. (p >0.05)Table No. 96. Showing the after treatment statistical results of different symptoms ofbody.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Scaling (Body) 0.133 0.345 0.063 2.11 >0.05 N.S.02. Itching (Body) 0.466 0.681 0.124 375 <0.01 H.S.03. Erythema (Body) - - - - -04. Thickness (Body) - - - - - 135 Results
    • Form the above table one can say that, according to the analysis; there is highsignificance in itching and no significant in the case of scaling (p >0.05). But in case ofother parameters like Erythema and thickness. 0 significance was observed as the beforeand after treatment values remained the same.Table No. 97. Showing the after treatment statistical results of different symptoms ofLegs.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Scaling (Legs) 0.766 0.817 0.149 5.14 <0.001 H.S.02. Itching (Legs) 0.833 1.019 0.186 4.478 <0.001 H.S.03. Erythema (Legs) 0.1 0.395 0.072 1.388 >0.05 N.S.04. Thickness (Legs) 0.13 0.343 0.062 2.11 >0.05 N.S. Form the above table one can say that, there is high significance in the parameterslike itching and scaling as compared to the remaining parameters like Erythema andthickness, which are of no significant.Table No. 98. Showing the a after treatment statistical results of total PASI of all theparts.Sl. Parameter Mean S.D. S.E. t-value p-value Remarks01. Total PASI of all the parts 3.65 3.519 0.642 5.685 <0.001 H.S. Total PASI includes (head total PASI + arms total PASI + body total PASI + legstotal PASI). After treatment the total PASI score of all the parts showed highly significantresults as compare to the before treatment. (p <0.01).Table No. 99. Showing the after treatment statistical results of Manasika bhavas.Sl. Parameters Mean S.D. S.E. t-value p-value Remarks01. Krodha 0.333 0.884 0.161 2.068 <0.05 H.S.02. Bhaya 1.1 1.322 0.241 4.564 <0.001 H.S.03. Shoka 1.2 1.063 0.194 6.185 <0.001 H.S.04. Chittodvega 0.733 1.048 0.194 3.77 <0.001 H.S. 136 Results
    • Form the above table one can say that, significant results are obtained in theparameters like shoka and bhaya as compared to the chittodvega and krodha, whichshows less significant than the above said parameters.OVERALL CONCLUSION All the parameters except Erythema arms, scaling body, Erythema legs, showshighly significant (p <0.05). 0 significance was observed in Erythema body and thicknessbody. Among the highly significance parameters total PASI, shoka, thickness head,itching arms and scaling legs shows highly significant than others. (By comparing tvalues). The net mean effect of PASI is more with more variations. But the parametersErythema legs, the net mean effect is less with less variation. (By comparing means andS.D.) 137 Results
    • Acharya charaka explained long back any hypothesis / principals if to be provedmust be discussed thoroughly form all angles. If the hypothesis is formed properly it has to be tested and observed by variousmethods and eventually the results are obtained. A hypothesis gets established as aprinciple if the reasoning given is satisfactory otherwise it remains as it is. Discussion improves the knowledge and discussion with shastra becomes basicestablishment of the concept. Thus, the discussion is the most essential phase of anyresearch work. Keeping this as a view the discussion will be made on the followingheadings – 01. Discussion on Disease entity. 02. Discussion on Therapeutic regimen. 03. Discussion on Plan of study. 04. Discussion on Observations. 05. Discussion on Clinical response to the treatment. 06. Discussion on Probable mode of action of the therapy.DISEASE Kitbha kushta of Ayurevda closely resembles the clinical symptoms of psoriasis.As per the nature of the disease, this is a chronic recurrent dermatosis. The primary lesionis a epidermal papule and the papule is pink in colour of various intensity. The freshlesions are brighter and older ones are darker. The papules are flat and have rough surfacecovered with silvery white, microlamular scales, which scrap off easily. At first thepapules have a regular round countour and a diameter of 1-2 mm of each, latter theyspread peripheral after attaining a size with an intensive itching sensation of the skin. Ifwe consider the above symptoms, they closely resembles the symptoms of Kitibha kushtaand also the researchers those worked on skin disorders have co-related Kitibha kushtawith psoriasis. 138 Discussion
    • It is one among the most important skin disorder, because of its frequentpersistent and or recurrence and tendency to disable in proportion of those it affects. Theestimated prevalence in India is 1.5 to 3.5 % in the general population. It may occur onboth sexes. More common in third and fourth decade of life. It usually follows anirregular chronic course marked by remission and exacerbation of unpredictable onsetand duration. Factors that may leads to more lesions include drug reactions, respiratoryinfections, cold weather, emotional stress, surgery and viral infections. Psoriasis (Kitibha kushta) is not only a somatic but also a disease of psychologicalimportance since stress, tension and anxiety aggravate the course of the disease. Regarding the prognosis of the disease, Madhavakara said, if the kushta is due todwidoshaja, then it is yapya. It is true till today in spite of rapid advancement in modernscience like physiology, molecular biology, genetic immunology and clinical medicinethe disease still remains recurrent oriented. Keeping the above facts and also the extensive research works, which is going onin our science in this particular disease, it was decided to study, the effect of takradharakarma in Kitibha Kushta (Psorasis). Enormous research works had been carried out in thefield of Panchakarma in order to prove the efficacy of therapies such as vamana,virechana, basti, etc and even they are proved to be effective. Since Psoriasis involvesboth mind and body, Aragwadadi gana kashaya takra dhara was selected for the researchpurpose and also there was no research work was done previously on this particularkarma and on this particular disease. Hence, an attempt was made to know the efficacy ofthe particular treatment modality in the disease Kitibha kushta (psoriasis). 139 Discussion
    • SHAREERA When we look in to the Shareera (Anatomy) of twak, it was observed that Kitibhakushta (Psoriasis) is a disease caused by abnormal keranitinization. As twak is said to beone of the main seat of vata dosha, its abnormal clinical manifestation can be observed onthe twak in the form of different clinical manifestations like Vaivarya, Rukshata, etc.NIDANA As there is no specific Nidana mentioned in the texts for kitibha we hadconsidered the samanya Nidana mentioned for kushta under – a. Aharaja b. Viharaja c. Achara & d. Other nidanas like Chikitsasambandhi sankramika, etc.Rasa sambandhi Excessive and regular intake of food articles which are predominance of Amlaand lavana rasa act in two ways – a. They cause dosha dushti. b. They cause rakta dushti. The resultant kushta is a combined effect of both. It is evident form the statementof the Charakacharya that excessive intake of Amla rasa causes vilayana and pitta vriddhiand also acts as ubhaya hetu. The same is true with lavana rasa also.Viruddha ahara sambandhi According to Acharya Charaka viruddha ahara influences on the equilibriumstatus of dosha, dushya, mala and srotas. These may become responsible factors for themanifestation of the disease. 140 Discussion
    • The exact role of some of the nidanas mentioned such as papakarmas, gohatya,etc in the causation of kushta is difficult to understand and analyse. Vagbhata consideredthese nidanas as Adrushta karmaja vyadhi hetus. Manasika karanas like adhika chinta shoka, bhaya and krodha, etc acts as avyanjaka (precipitating) hetu because of papa karma. This view is also supported by thecontemporary sciences as the intense stress of the life in concentration camps maytemporarily suppress some psychosomatic skin disorders, which may later recur in severeform. This psychosomatic mechanism may be implicated in delayed reactions toprolonged stress. Because of repeated papa karma (Kaya, Vak, Manasa) which inturn leads toManovaishamya i.e. altering the normal functions of manas. These altered functions ofmanas like chinta, shoka, bhaya, etc leads to vataprakopa thereby precipitating thedisease condition.SAMPRAPTI, SADHYASADHYATA & CHIKITSA While describing the samprapti, it was said that the pathophysiology of kitbhakushta could be discussed according to the Nidana. By the above-mentioned Nidana,prakupita vata due to margavarodha carry vitiated pitta, kapha, and lasika in tiryaga sirasand loading them in udakadhara, raktadhara and mamsadhara twachas. If vitiatedshleshma is predominant with sneha, sheeta and picchhila gunas they intern vitiate kleda.On the other hand, if pitta is predominant with its gunas like sneha and drava, then alsokleda gets accumulated. The accumulated kleda results in srotavarodha leading to vatavriddhi. Due to this, twacha becomes shyava varna at the same time, due to the ushnaguna of pitta, the dravamsha of kleda escapes through sweda which inturn leads toghanibhuta kleda in twacha. This affects in parushata, kharasparsha of twacha, which arethe chief complaints of kitibha kushta. 141 Discussion
    • In Ayurveda, the prognosis depends on age, sex, immuno status and mental status.Madhavakara stated that, the kushta which are dwidoshaja are yapya. So as kitibha kushtais vata kaphaj it is yapya. On the contrary modern science explains above fact thatbecause of its recurrence it requires persistent treatment and after that also the remissioncannot be denied. The course of Kitibha kushta is not uniform with periods of excerbations andrecurrences, which varies form days to week, to months to year. Therefore, themanagement requires a continuous care approach to control the symptoms, to preventexacerbations, relapses and avoiding triggering factors. Again the course and severity ofkitibha kushta varies form patient-to-patient, season-to-season over the years. Thenumber of guidelines has been developed, but no specific therapy to fulfill the need of thepatient in modern medical care exists. Ayuredic approach to a disease is definitely psychosomatic in nature. For example– Kushta is due to disrespect given to the guru, bramhana, doing papa karmas, etc and thetreatment approach of all these diseases includes – a. Daiva vyapashraya b. Yukti vyapashraya c. Satwavajaya It shows the integrated approach i.e. psychosomatic approach of our acharyastowards the diseases. Ayurveda emphasized more medical care than symptomatic cure, for the radicalcure shodhana is indicated in kitibha kushta. Specifically in vata pradhana kushta there isan indication of Virechana, niruha and anuvasana basti. In kapha pradhana kushtavamana can be given. 142 Discussion
    • Takra Dhara, which is proven therapy in may psychological as well as manysomatic problems, had a definite role in kitibha kushta (Psoriasis), which ispsychosomatic in nature. Acharya sushruta emphasized that Nidana parivarjana is must in the managementof disease. That is to say “Prevention is Better than Cure”. Thus, it is essential to avoid allphysical, psychological and triggering factors.DISCUSSION ON THERAPEUTIC REGIMEN Takra dhara karma is delt in detail in dhara kalpam a book in Malyalam literature.Great Ayurvedic scholars such as Vaidyaratnam P. S. Warier, Ashtavaidyan VayaskaraN. S. Moos, etc have translated it into English long back. After thorough insight of thesebooks Argwadadi gana takra dhara karma was selected. Though, there is no direct indication of Takradhara karma in Kitibha kushta(psoriasis), considering its utility in dhatu shaithilyata and all kinds of Dosha kopa, it wasselected as a therapeutic regimen. Because dhatu shaithilya and dosha kopa is normallyseen in all kinds of kushtas and also our ancient acharyas like Charaka, Sushruta,Vagbhata, Bhavamishra, etc had explained the utility of takra lepana and kashaya seka indifferent kushtas. Considering this one as a guideline (Shastram Jyotir Prakasharthm…|)the expanded version of takralepa and kashaya seka was studied as takradhara. Bhavamishra explained seka as sukshma dhara. (Sekastu Sukshma dharabhi: . . .)Hence, one cannot deny that there is no reference of the word Dhana in our classics. Textbooks such as Dharakalpam, Ayurvedic treatments of Kerala, Chikitsasangraham, etc have explained Dhatritakrotthadhara in detail. In this present studyAragwadadi gana was used in the place of Amalaki considering the reference in Chikitsasamgraha and Ayurvedic treatments of Kerala that according to the disease condition thekashaya can be changed and used for the Dhara purpose. So Aragwadadi gana kashayawas selected and used for dharakarma which is indicated in all kinds of kushta. 143 Discussion
    • Many of the drugs in Aragwadadi gana are having vata kapha nashaka, krimighna,kandughna action and some of the drugs are having kaphapitta shamaka and vishaghnaaction. Both kapha pitta shamaka and vata kapha shamaka actions are justified in terms ofKitibha kushta, because according to Charaka Kitibha kushta is due to the vitiation ofvata and kapha and according to Sushruta it is due to vitiation of vata pitta. While purchasing the drugs in the place of Kakajangha, Kakamachi was used.Instead of black variety of Sahachara white variety was taken and in the place of bigvariety of Badara small variety was taken due to their non-availability. Daily before to Dhara, Gandharvahastadi kwatha 60 ml with luke warm water wasgiven in order to eliminate the dosha utklesha which usually occurs during the course ofdhara. Though it is having slight anulomana action, it was selected because the drugswhich are their in the kashaya are not having kushtahara properties. This justifies that itmay not have contributed in the reduction of symptoms. But it action on the symptomscannot be denied completely. For Abhyanga (Oil application) purpose on head and body moorchhita tila tailawas selected. Though the text advices taila which is good for the particular disease, it wasdecided to use moorcchita tila taila in order to prove the particular effect of dhara inKitibha kushta. The moorchhita tila taila dose contain some of the kushtahara drugs likeManjishta, Yashtimadhu, etc, but their concentration in taila are minimal. Hence, theycannot exhibit any action over the disease. In the text it is mentioned that the minimum time duration for performing dharakarma is 25 minutes and the maximum time duration is 75 minutes. In the present study45 minutes was fixed for the dhara purpose. Though it is mentioned in text that the timeduration for performing dhara karma is to be started from least and ended at themaximum time. In the present study standard 45 minutes time duration was followed andno complications were observed. 144 Discussion
    • The following Observations were made during the Therapeutic regimen – If the fine powder is used i.e. fine powder of Yasti and Musta for preparing medicated milk, it was observed that the fine powder was hampering the curd formation. It may be due to the interference of fine power with the fermentation process. Hence, Yavakuta churna was used for preparing the medicated milk. It was observed that if the fermenting agent (curd or buttermilk) was added to cold milk the curd was not formed properly. Hence, the fermenting agent was added always when the milk was in lukewarm state. It may be due to cold environment or the hampered growth of lactic acid bacillus in cold milk. During the course of treatment brightness of face, complete remission of hair fall was noticed on some patients. By this it is proved that dhara is useful in Keshadinam Shauklyam & Oja kshayam which are the conditions indicated for Takradhara. Sound sleep was observed on majority of the patients during the dhara procedure. It may be due to sedative effect of dhara means we are making the patient to concentrate on one point, closing the eyes with guaze and the calm environment of dharagraha. During the course of treatment some patients developed cold. For them the treatment was stopped for 2 to 3 days and started once again. At that time the precaution was taken and lukewarmness of buttermilk was maintained properly throughout the procedure. 145 Discussion
    • Discussion on plan of the study A. Selection of the patients – The patients of both sexes were selected for the clinical trial between the agegroup of 14-60 years. The patients were selected irrespective of duration of the disease.Total 34 patients were reported, but only 30 patients who had fulfilled the inclusioncriteria were taken for the study. B. Laboratory investigations – The selected patients were subjected to laboratory investigations like Hb, TC, DC,AEC, ESR, Urine for albumin and sugar. C. Diagnosis and confirmation – The disease was diagnosed as Kitibha kushta based on symptomatology describedin Charaka samhita, Sushruta samhita, Ashtanga hridaya etc, it is added by previousdiagnosis made by the contemporary practitioners, as most of the patients come afterundergoing contemporary treatment. Confirmation was made by Auzpit sign, Candlegrease sign and Kobners phenomenon. D. Availability – Patients were availed form different sources such as medical camps, throughadvertisement and OPD and IPD of D.G.M.A.M.C.H. & R.C., Gadag. E. Grouping – The selected patients were placed in the single group irrespective of age, sex andchronicity of the disease. 146 Discussion
    • Discussion on ObservationsAge It was observed from the clinical study, that the age incidence of the disease wasmaximum in the patients of age group 20-40 years. It holds well the explanation given incontemporary science that onset of psoriasis is most common in the second to fourthdecades of life.Sex In this clinical study, among 30 patients 22 patients i.e. 73.33% were males,which is supporting the observation of modern science i.e. prevalence rate is more inmales than in females. The probable reason may be that the males are more exposed todifferent types of contacts and environments. So they may be more affected by viruddhaahara and vihara due to conditions i.e. hostel, business, etc which are the main causativefactor of Kushta.Religion A distributed incidence among Hindus and Muslims was seen in this study showsa greater prevalence was in Hindus 28 patients i.e. 93.33% and 2 patients i.e. 6.66% fromMuslim community. The greater incidence may be due to more population of Hindus inand around this area.Diet It was observed that equal incidence of diet (i.e. vegetarian and mixed) was found.The study showed there is no specific relation between diet and disease. It may be due tothe random selection of the patients. 147 Discussion
    • Economical status Socio-economical status showed 23 cases i.e. 76.66% were form middle classsociety. As number of cases included in the study was limited. Hence, It is not worthy togive conclusion and it also may be due to the random selection of the patients.Occupation The incidence of Kitibha kushta was more in the people who were habituated tosedentary life style. The high percentage ratio (36.6%)was found in above said life style.It may be due to the excessive concentration over the disease by the sedentary people andintern develops shoka, chinta, etc which are the triggering factors of psoriasis.Marital Status Maximum number of individuals (60%) were married. In this particulargeographical sect, as soon as the age of 18/21 years is crossed the individuals getsmarried. As the study is based on based on age of 14 years, it is quite natural to havemore number of patients who were married.Koshta The result of the present study showed that the most of the patients were havingKrura and Mridu koshta. It may be due to the desha. The geographical area of the studywas being Jnagala desha, naturally the people will be having dominancy of vata and pittadosha. Krura and mridu koshta are having dominancy of vata and pitta dosharespectively.Onset Majority of the patients were having gradual onset of Kitibha kushta (96.66%).Because the causative factors like Viruddha and mithya ahara vihara are just like garavisha (slow poison) it is obvious that it acts slowly. 148 Discussion
    • Addiction Smoking, Alcohol, Pan chewing, Tobacco, was found in almost all the patients.Here, alcohol intake and smoking precipitate the disease. This view supports thecontemporary science view.Prakriti In the present study, it was observed that vata pitta prakriti (40%) as well as vatakapha prakriti (50%) patients were dominant. This is possible because Kitibha kushta is avata kapha dominant disorder and this particular geographical sect (Jnagala desha) is alsovata pitta dominant in nature.Sara (86.66%) of patients were having madhyama Sara. Acharya Charaka explainedsara with a view to determine the measurement of the strength of an individual. In theclassics it has been said that madhyama and avara sara are more prone to diseases. It isalso remarkable that no patient was observed having pravara sara.Samhana Most of the patients (86.66%) were of madhyama samhana. Madhyama samhanaindicates moderate body compactness and strength. If the person is strong enough thenthe viruddha, mithya, ahara, viharas can not affect him. Madhyama samhana and avarasamhana people are usually affected by the above said things.Satva Majority of patients were of madhyama satva (66.66%) followed by (23.33%) ofavara satva. Satwa bala decides the severity and the prognosis of disorder. Acharyacharaka has stated that the people with madhyama and avara satva are more vulnerable todiseases, which is supported by present study. 149 Discussion
    • Satmya Most of the patients (76.66%) were belonged to ruksha satmya and most of thepatients were having madhura, amla rasa satmya which is reflective of the nature of thediet.Jarana shakti The study showed that (53.33%) patients were having avara jarana shakti. It isdue to agni mandya which is the prime cause for almost all the diseases. Causative factorssuch as viruddha, mithya ahara, etc doesn’t affect if digestive power (agni) is good.Vyayama shakti Majority of the patients were having avara vyayama shakti (56.77%) followed bypravara vyayama shakti (30%). Vyayama shakti is determined on the basis of anindividual ability to perform work. Charaka has very rightly stated that one who doesexercise daily remains unaffected by the diseases.Nidana Ahara Masha and mamsa atisevana, sour food, kulattha, guda, dadhi atisevanawere noted in one or other patients. They may be the cause for vitiating the vata andkapha which are the prime causitive factors of kitibha kushta. Vihara Vega dharana, divaswapna, ratri jagarana, adhika atapa sevana, sedentaryhabits were observed in one or other patients and in turn viharas tends to vitiate vata andkapha. Then intern causes kitibha kushta. 150 Discussion
    • Mansika Hetu Emotional disturbances were found in all patients in one or other form likekrodha, bhaya, shoka or chittodvega. It may be due to the self-detachment from thefamily and the society, which is resultant of the disease.Triggering factors Physical trauma, exposure to hot sun light, withdrawal of cortico steroids havebeen observed as triggering factors in most of the patients. The above findings suggeststhe hyper responsiveness of the skin.Poorva roopa It was observed that most of the patients were having kandu, vedana, rukshata,daha, raga, vaivarnya, tandra, aswadana, etc. All the poorva roopas explained in theclassics were found in one or the other patients.Roopa It was observed from that chief complaints like kandu, shyava or Krishna varna,khina khara sparsha, parusha, ghanatwa were found in 96.66% cases in various gradesand associated complaints like agnimandya, malabaddhata, toda, chimachimayana,gourava were found in many patients.Family historyOut of 30 only two patients (6.66%) has the family history of psoriasis. It may be due tothe small sample size and random selection.Sleep Most of the patients (76.66%) complained of disturbed sleep. This may be due totheir complaints and psychological disturbances. 151 Discussion
    • DISCUSSION ON CLINICAL RESPONSE TO TREATMENT 01. Overall PASI (Psoriasis Area severity Index) score – Overall PASI score was calculated in the following manner. Before treatmentresponse of each patients was calculated first, then after treatment response of each ofthem was calculated with the help of statistics. (Paired t-test). The total PASI score of each individual was calculated in the following manner. a) Head (Ihead + Ehead + Shead + Thead) X Ahead X 0.1 = Total head. b) Arms (Iarms + Earms + Sarms + Tarms) X Aarms X 0.2 = Total Arms. c) Body (Ibody + Ebody + Sbody + Tbody) X Abody X 0.3 = Total body. d) Legs (Ilegs + Elegs + Slegs + Tlegs) X Alegs X 0.4 = Total legs.(I – Itching, E – Erythema, S – Scaling, T – Thickness, A – Area.) Finally the total PASI of each patient is- Total head + Total arms + Total body + Total legs. This PASI score will rangefrom 0 (No psoriasis) to 96 (covered head-to-toe, with complete itching, redness, scalingand thickness) After calculation the over all response was made in the following manner.Over all effect of the treatment was assed as complete remission (PASI score 0 aftertreatment). Best improvement (Reduction in PASI score >75%) Moderate improvement(Reduction in PASI score between (75%-50%) Minimal improvement (Reduction inPASI score<50%) and unchanged No reduction in PASI score). Before treatment the total PASI score of 30 patients was 11.7. After treatment itwas reduced to 4.25. The net reduction rate was 7.45. 152 Discussion
    • DISCUSSION ON HEAD AFFECTED PATIENTS OF PSORIASIS Out of 30 cases, 16 cases (i.e.53.33%) were reported with the psoriasis on head.Out of these 16, those who reported psoriasis only on head (scalp psoriasis) was 7(i.e.23.3%). Itching head was present in all the 16 patients (i.e.100%). After treatmentcomplete remission of itching was observed in 14 cases (i.e.87.5%), moderateimprovement was noticed in 1 (6.25%) case and no improvement was found in 1case(i.e.6.25%). Totally 95.6% reduction in itching was observed. Scaling head was found in all the 16 cases (i.e.100%). After treatment completeremission was observed in 14 (87.5%) cases and no reduction in the symptoms wasobserved in 2 (12.5%) cases. Totally the therapy provided 82.5% reduction in symptom. Erythema head was found in 14 cases (i.e.87.5%). After treatment completeremission of Erythema of head was observed in 11 (78.57%) cases and no improvementwas observed in 3 (21.42%) cases. Totally the therapy provided 64.28% reduction insymptom. Thickness head was observed in all the 16 cases (i.e.100%). After treatment 13(81.25%) patients got complete remission of symptoms and no response was found in 3(18.75%) cases. Totally the therapy provided 61.90% reduction in symptom. Out of 16 cases, complete reduction in area was found in 11 (68.75%) cases,minimal reduction and no reduction was found in 1 (6.25%) and 3 (18.75%) patientsrespectively. Totally 81.25% reduction in area was found in head. After treatment the total PASI score of head showed, complete remission in 13(81.25%) cases, minimal response in 2 (12.5%) cases and no reduction in 1 (6.25%)patient. 153 Discussion
    • DISCUSSION ON ARMS AFFECTED PATIENTS OF PSORIASIS Out of 30 patients, 19 patients were reported with psoriasis in arms i.e. 63.33%. Itching in arms was present in all the 19 (100%) cases. After treatment completeremission of itching was observed in 11 (57.89%) cases, moderate improvement wasnoticed in 5 (26.3%) cases and no improvement was found in 3 (15.78%) cases. Totallythe therapy provided 74.46% reduction in symptom. Scaling in arms was found in all the 19 cases i.e. (63.33%). After treatmentcomplete remission was observed in 6 (31.5%) cases, moderate, minimal and noreduction in the symptom was observed in 1,5 and 7 (5.26%), (26.3%) and (36.84%)cases respectively. Totally the therapy provided 36.63% reduction in symptom. Erythema in arms was found in 14 cases (i.e.73.68%). After treatment completeremission of Erythema was observed in 1 (7.14%) case, moderate improvement wasnoticed in 1 (7.14%) case and rest 12 (85.7%) cases not responded to the treatment.Totally the therapy provided 5.71% reduction in symptom, which is very minimal. Thickness in arms was observed in all the 19 cases (i.e.100%). After treatment 3(15.78%) patients got complete remission of symptom, 2 (10.52%) patients observed withmoderate improvement and no response was found in 14 (73.68%) cases. Totally thetherapy provided 13.5% reduction in symptom. Out of 19, cases complete reduction in area was found in 3 (15.78%) cases,moderate reduction in 1 (5.26%) case, no reduction was found in 15 (74.94%) patients.Totally 18.42% reduction in area was found in arms, which is very minimal. After treatment the total PASI score of arms, showed complete remission in 4(21%) cases, best improvement in 2 (10.52%) cases, moderate improvement in 3 cases(15.78%), minimal improvement in 8 (42.18%) cases and no improvement in 2 (10.52%)patients. 154 Discussion
    • DISCUSSION ON BODY AFFECTED PATIENTS OF PSORIASIS Out of 30 patients, 15 patients i.e. 50% were reported with psoriasis on bodysurface, which includes trunk area, abdomen, back, genitals, etc. Itching in body was present in all the 15 cases (i.e.100%). After treatmentcomplete remission of itching was observed in 4 (26.66%) cases, moderate improvementwas noticed in 7 (46.66%) cases and no improvement was found in 4 (26.66%) cases.Totally the therapy provided 50% reduction in symptoms. Scaling in body was found in all the 15 cases (i.e.100%). After treatmentcomplete remission was observed in 2 (13.33%) cases, minimal and no reduction in thesymptoms was observed in 2 (13.33%) and 1 (6.66%) cases respectively. Totally thetherapy provided 13.33% reduction in symptom, which is very minimal. Erythema in body was found in 12 cases i.e. 80%. There is no reduction inErythema of body after treatment was observed and the pretreatment & post treatmentvalues remained as the same. Thickness of lesion in body was found in all the 15 cases i.e. 100%. No reductionin Thickness of lesion in body after treatment was observed and the pretreatment & posttreatment values remained same. After treatment there is no reduction in area of the body was observed and thepretreatment & post treatment values remained the same. After treatment in total PASI score of body, minimal improvement was noted in10 (66.66%) cases, moderate improvement was observed in 1 (6.66%) case and noreduction was found in 4 (26.66%) cases. It is due to the reduction values in itching,scaling and total PASI calculation, which is calculated after adding the values of itching,scaling, Erythema and thickness. 155 Discussion
    • DISCUSSION ON LEGS AFFECTED PATIENTS OF PSORIASIS Out of 30 patients, 20 patients (i.e.66.66%) were reported with psoriasis in legs. Itching in legs was present in all the 19 cases (i.e.95%). After treatment completeremission of itching was observed in 13 (68.42%) cases, moderate improvement wasnoticed in 2 (10.52%) cases and no improvement was found in 4 (21.66%) cases. Totallythe therapy provided 71.42% reduction in symptom. Scaling in legs was found in all the 20 cases (i.e.100%). After treatment completeremission was observed in 7 (35%) cases, moderate reduction was found in 2 cases,minimal and no reduction in the symptom was observed in 3 (15%) and 8 (40%) casesrespectively. Totally the therapy provided 25.71% reduction in symptom. Erythema in legs was found in 15 cases (i.e.75%). After treatment mild andmoderate reduction was observed in 1 (6.66%) case each, no reduction was found in 13(86.66%) cases. Totally 11.11% reduction in Erythema in legs was noted, which is veryminimal. Thickness of lesion in legs was found in all the 20 cases (i.e.100%). Aftertreatment complete remission was observed in 1 (5%) case, moderate reduction wasobserved in 2 (10%) cases and mild reduction was noted in 1 (5%) case. No reductionwas observed in 16 (80%) cases. Totally 16.2% reduction in thickness of lesion in legswas noted. Out of 20 cases moderate reduction in area was found in 3 (15%) cases and noreduction was found in 17 (85.00%) cases. Totally 12.5% reduction area was found inlegs which is very minimal. 156 Discussion
    • After treatment the total PASI score of legs, showed that, complete remission in 1(5%) case, best improvement in 2 (10%) cases, moderate improvement in 5 (25%) cases,minimal and no improvement in 4 (20%) cases. In 7 cases (i.e.23.33%) the lesions were found in all over the body parts. (i.e.head, arms, body, legs.) The results were not shown because, it was discussed under theparticular part affected. Out of 30 patients, bhaya was found in 16 (53.33%) cases after treatment,complete remission was found in 12 (40%) cases, moderate improvement was noted in 1(3.33%) case and no reduction was found in 3 (10%) cases. Out of 30 patients, 5 (16.66%) patients got affected with krodha, after treatmentcomplete reduction was found in 3 (10%) cases, moderate reduction was found in 2(6.66%) cases. No case was remained un-responded. Out of 30 patients Shoka was found in 18 (60%) cases, after treatment 16(53.33%) cases got relieve completely and 2 (6.66%) patients got moderate relief. Out of 30 patients Chittodvega was found in 14 cases (46.66%), after treatmentcomplete reduction was observed in 13 (43.33%) cases and 1 (3.33%) case respondedmoderately.OVERALL RESULT Out of 30 patients complete remission was observed in 8 (26.66%) cases, markedimprovement was found in 7 (25.90%) cases, 4 (13.33%) cases were respondedmoderately and 9 (30%) responded mildly. No response was found in 5 (16.66%) cases. 157 Discussion
    • OVERALL DISCUSSION ON RESULTS The statistical results showed that, therapy was very effective in reducing totalPASI score. It may be due to the variation in results i.e. the patients who got affected withpsoriasis on head especially scalp psoriasis and palmo-plantar variety of psoriasis wereresponded well. At the same time the patients who got affected with psoriasis on bodyand other parts of arms and legs (except soles and palms) did not responded well. This isthe reason for reduction in total PASI score. Though the overall response of treatment in body, arms and legs (except palmsand soles was not good, but the therapy provided considerable amount of reduction initching and scaling. Though the results were shown according to the different sites involvement, oneshould not assume that the lesions were present only on that particular site of theparticular patient. Because, some of the patients had two sites involvement viz. head andbody. Some of them had three site involvement viz. head, arms and body and some ofthem had all the four sites involvement viz. head, body, arms and legs. In order to emphasis the efficacy of the therapy in that particular site the resultswere given according to the site affliction. Because the statistical analysis showed highlysignificant results in all the parameters irrespective of the sites affected. Out of all the 30 cases, some of the cases reported with the particular siteinvolvement viz. scalp, palm, soles, genitals, etc. They have included under the concernpart affliction for eg. Scalp affected patients were included under head affected patientsand their after treatment results were also shown according to the parts which includesthe above said sites. 158 Discussion
    • PROBABLE MODE OF ACTION Ayurevdic approach to any disease is psychosomatic in nature. In Kitibha kushta(Psoriasis) there are somatic symptoms like kandu (itching), Ghana (thickness), Parusha(Dry) and Psychological symptoms like anxiety, stress, depression, and etc are present, soit is considered as psychosomatic disorders in which both mind and body are affected. Sothis aragwadadi gana takra dhara helps in regulating the vitiated shareerika and manasikadoshas. For better understanding the probable mode of action of takara dhara in kitibhakustha (psoriasis) can be discussed in the following headings. 01. Medicinal effect 02. Procedural effectMedicinal effect The medicines which are used in takradhara karma are having vata kapha haraproperties. Kitibha kushta being vata kapha in nature might have got responded to thetreatment, which contains exact antagonistic medicinal properties to the disease. “Aushadham Veerya Pradhanavat |” The veerya of the different medicines usedin takra dhara might have entered through four tiryag gami dhamanis which graduallyramify to hundred and thousands of branches. The network of this dhamanis spread allover the body and their exterior orifices are attached to the root of hair. It is through theseorifices the veerya is absorbed into the body rather than the medicine themselves.Through these dhamanis the veerya is circulating all over the body there by causingsamprapti vighatana of the disease. 159 Discussion
    • Acharya Sushruta explained, the pitta, which is located in skin, is spoken asBhrajakagni, in as much as it enables the digestion and utilization of substances used forabhyanga, pariseka, avagaha, lepana, etc. Dalhana commenting on above and saysbhrajakagni is located in Avabhasini twacha (i.e. 1st layer). Commenting on VagbhataSutra 12th chapter 14th shloka, Arunadutta says Bhrajakagni performs deepana andpachana of substances used for abhyanaga, lepana, pariseka, etc. Takra dhara is a kind ofpariseka. Hence, the medicaments used in it will be absorbed in the first layer of twachai.e. Avabhasini and getting digested (deepana) and metabolized (pachana) by the powerof bhrajakagni. After the digestion and metabolism, the veerya of the medicaments whichare used in dhara spreads all over the body, through tiryag gami dhamanis and exhibitstheir action all over the body. The therapeutic effect is attributed to the medicaments viz. medicated buttermilk,which exchange through the fine pores present over the scalp and forehead. The modern physiology and biochemistry says that it is possible to produce acertain amount of absorption by the application of substances conveyed in the fattyvehicles (Lovatt Evan’s Physiology). Here the aragwadadi gana kashaya is employedthrough the buttermilk, which also contain some amount of fat in it. It is true that fordhara purpose the fat removed buttermilk is used, then also it may contain some amountof fat in molecular form. With this molecules the substances may enters through the skinpores, which is presented in the scalp and might have exhibit their action. There are three possible roots for absorption. The pilosebaceous follicles playsome part in absorption of many compounds. The trans-follicular absorption, route ofpenetration is through the follicular pores to the follicles and then to the dermis via 160 Discussion
    • sebaceous gland. The permeability of the cells of the sebaceous glands is greater than thatof granular layer of the epidermis. In this way the substances which are used intakradhara karma absorbed and entered in the blood through and remove pathology.Procedural effect Imbalance of prana, udana and vyana vayu, sadhaka pitta and tarpaka kalpha canproduce stress and tension which are the usual triggering factors of the psoriasis.Takradhara re-establishes the functional integrity between these three subtypes of doshasthrough its mechanical effect. Agnya chakra (the space between the two eyebrows) is the seat of pituitary andpineal gland. As we know the pituitary gland is one of the main gland of the endocrinesystem and exhibits its action on skin, etc. Takradhara stimulates it by its penetratingeffect, which decreases the brain cortisones and adrenalin level, Synchronizes the brainwave (alpha wave) and strengthens the mind which is usually disturbed in psoriasis. By takradhara, patient feels relaxation, both physically and mentally. Relaxationof the frontalis muscle tends to normalize the entire body activity and achieves a decreaseactivity of sympathetic nervous system with lowering of heart rate, respiration, oxygenconsumption, blood pressure, brain cortisones and adrenalin levels, muscle tension andprobably increase in alpha brain waves. It strengthens the mind and spirit and thiscontinues even after the relaxation. Corresponding to different levels and powers ofconsciousness there are nerve plexus and glands in human organisms. Special stimulationof different nerve plexus, glands and brain cells accompanies mental functions ofdifferent levels. Takradhara which contain many kushtahara property drugs maystimulate the endocrine, nervous and immune system and there by it may reduces diseasepathology. 161 Discussion
    • In Kushta, dhatus are involved and dhatu shaithilyata takes place due to vitiateddoshas. It is clear from our texts, that the dhatu kshaya will leads to ojo kshaya and alsothe ojas is getting kshaya due to kopa, shoka, etc which are the triggering factors ofpsoriasis. Reduction in chittogvega kopa, shoka are taking place due to takradhara, whichin turn over comes the oja kshaya. It is stated in the benefits of takradhara that it is besttherapy for ojokshaya. Hence, it is having definite role in samprapti vighatana of Kitibhakushta (Psoriasis). 162 Discussion
    • A SPECIAL CASE SHEET FOR KITIBHA KUSTHA (PSORIASIS) Post Graduate studies and research centre, (Panchakarma) Shri. D.G.M Ayurvedic Medical College, GadagGuide: - Dr G.Purushottamacharyulu M.D.(Ayu) Scholar: P. ChandramouleeswaranCo-Guide:- Dr S.H. Doddamani. M.D.(Ayu)1. Name of the patient _________________________ SL. No O.P.D. No2. Father’s / Husband’s Name ___________________ I.P.D. No3. Age ______ yrs, Place of Birth _______________4. Sex M F Education __________________5. Marital Status M ( ) UM ( )6. Religion H. ( ) / M ( ) / C ( ) Others ( )7. Occupation Labour ( ) Student ( ) Executive ( ) Sedentary ( )8. Economical status P ( ) / LM ( ) / UM ( ) / R ( )9. Address ________________________ E-mail ID _________________ _________________________ Phone No :______________ _________________________ Pin. : ___________________ D M Y D M Y10. Date of schedule initiation Completion11. Result Well Moderately Mildly Not Responded Responded Responded Responded CONSENT I am fully educated with the disease and treatment there by I got satisfied. Iaccept for medical trail on me happily. Signature of Patient
    • BA. Pradhana Vedana Vruttanta Avadhi Before AfterShyava or Krishna varnaKina khara sparshaParushaKandu (Itching)Srava (exudate)Ghana (thickness)B. Anubandhi vedana Vruttānta Avadhi Before AfterLoss of Appetite (Agni Mandya)Irregular bowel habits (Malabaddhata)Over sweating (Ati Sweda)Absence of Sweating (Asweda)Heaviness of the body (Shareera Guruta)Numbness (Suptata)Formication (Chimchimayana)Pain (Toda)C. Adhyatana vyadhi vruttānta a) Onset of skin lesion Sudden ( ) Gradual ( ) Insidious ( ) b) Site of onset Scalp ( ) Trunk ( ) Upper Extremity ( ) Lower Extremity ( ) D. Chikitsa vruttanta: (If any) New Case ( ) Treated ( ) Under Treatment ( ) Previous Medication: Allopathy ( ) Ayurveda ( ) Others ( ) Response: No ( ) Mild ( ) Moderate ( ) Good ( ) Drugs used: (If any) E. Purva vyadhi Vruttanta: (If any) F. Kula Vruttanta: History of Psoriasis in family ( )
    • CG. Vayaktika vruttanta :1 Ahāra Vegetarian ( ) Non Vegetarian ( )2 Vihāra Nature of work : Hard ( ) Moderate ( ) Sedentary ( )3 Agni Samāgni ( ) Mandāgni ( ) Teekshāgni ( ) vishamāgni ( )4 Kostha Mrudu ( ) Madhyama ( ) Krura ( )5 Nidra Prākruta ( ) Alpa ( ) Ati ( ) Diwāswapna ( )6 Vyasana None ( ) Tobacco ( ) Smoking ( ) Alcohol ( )7 Artava Regular ( ) Irregular ( ) Menopause ( ) Samanya PareekshaA. Asta sthāna Pareeksha : B. Vital examination1 Nadi /Min 1 Heart Rate /min 2 Mala 2 Resp. rate /min3 Mootra 3 Blood Pressure mm of Hg4 Jihwa 4 Body Temp /F5 Shabda 5 Body weight Kgs.6 Sparsha7 Druk8 AkrutiC. Dasha vidha Pareekshā :1 Prakruti V ( ) P ( ) K ( ) VP ( ) VK ( ) PK ( ) Sama ( )2 Sāra Pravara. ( ) Madhyama. ( ) Avara ( )3 Samhanana Pravara ( ) Madhyama. ( ) Avara ( )4 Pramana Pravara ( ) Madhyama. ( ) Avara ( )5 Sātmya Ekarasa. ( ) Sarva rasa ( ) Vyamishra ( ) Rooksha satmya ( ) Snigda satmya ( )6 Satva Pravara ( ) Madhyama ( ) Avara ( )7 Ahara Shakti a) Abhyavaharana shakti P ( ) M ( ) A ( ) b) Jarana shakti P( )M( )A( )8 Vyayam Shakti Pravara ( ) Madhyama ( ) Avara ( )9 Vaya Bala ( ) Yuva ( ) Vrudda ( )
    • DD. Sroto Pareeksha : Observed Lakshanas.1. Rasavaha srotas2. Rakta vaha srotas3. Mamsa vaha srotas4. Sweda vaha srotas5. Pranavaha srotas6. Annavaha srotas7. Udakavaha srotas8. Medavaha srotas9. Asthivaha srotas10. Majjavaha srotas11. Sukravaha srotas12. Pureeshavaha srotas13. Mutravaha srotas14. Artavavaha srotas15. Manovaha srotasE. Vishesha pareeksha of twachā (Special examination of skin)Character of lesionArea Localized ( ) Generalized ( )Size Small ( ) Large ( )Area of skin Scalp ( ) Elbow( ) Palms ( ) Soles ( ) Trunk ( ) Back ( ) Knee ( )affected Arms ( ) Legs ( ) Generalized ( )Colour Bright red ( ) Red ( ) Dull red( ) Pink ( ) Bluish Brown ( )Surface Dry ( ) Moist ( ) Greasy ( ) Scaly ( )Borders Round ( ) Polycyclic ( ) Irregular ( ) Demarcated ( )Texture Oedamatous ( ) Rough ( ) Smooth ( )Pattern Linear ( ) Annular ( )Associated with Pain ( ) Itching ( ) Burning ( ) Others ( )Shape of lesionMacule B A Papule B A Plaque B AHypo pigmented Scaly ErythematousHyper pigmented Accuminate Silvery ScaleErythematous Dome shaped
    • EI. Nidana :A. Ahara HetuHoney + Milk Milk + FishMilk + onion Kichadi + MilkRice with milk Ati dadhi sevanaTila taila ati sevana Kulattha ati sevanaMamsa ati sevana Guda ati sevanaMoolaka ati sevana Ushna & Teekshna aharaGuru ahara ati sevana Vidahhi ahara ati sevanaExcessive sour food intake Ati snigda sevanaB. Vihara HetuVega dharana DivaswapnaRatri jagarana Sheeta Ushna viparyayaExcess physical workC. Manasika HetuChittodvega KrodhaBhaya ShokaD. Triggering factorsTrauma SunlightEmotional stress DrugsII. Purva rupas :Slno Laxana Before After Sl.no Laxana Before After1 Adhika Sweda 6 Kledata2 Asweda 7 Shareera guruta3 Atislakshnata 8 Aruna Varna4 Kandu 9 Vivarnata5 Kharata 10 Suptata
    • FIII. Rupas : Before After Lakshanas Treatment Treatment 1 Shyava / Aruna /Asita / Krishna Varna 2 Kina khara sparsha 3 Parusha 4 Sravi 5 Vruttam 6 Ghana 7 Kandu 8 Snigda / Ruksha 9 Asweda10 Matsyashakalasannibham11 Vruddimanti12 Guruni13 Druda14 Punah:prasavati15 Prashantate Punha punah UtpadyateGradings : Normal -0 Mild-1 Moderate-2 Severe-3IV. SampraptiV. Samprapti ghataka’s1 Dosha 6 Srotodusti prakar2 Dusya 7 Adhistana3 Ama 8 Sanchar sthana4 Agni 9 Roga marga5 Srotas 10 Vyadhi swabhavaVI . Upashaya : Anupashaya :VII . Vyadhi vinischaya :
    • GVIII. Upadrava :IX . Sadhyasadhyata : Sukha sadhya ( ) Kastha sadhya ( ) Yapya ( )X . Laboratory Investigations : Sl. Name of the test Values 1 ESR /1st hour 2 Hb% Gm% 3 Total count RBC Per cm WBC Per cm 4 Differential count N E B M L 5 AEC (Absolute Oesinophil Count) Per cm 6 Urine for albumin and sugarXI. Chikitsa: Takradhaara Dainamadiana Neerikshana DAY Time of performance Duration
    • HXII. Objective Parameters PASI SCORING Skin sections* Itching Erythema Scaling Thickness Coverage % of Total of lesion Area* B,S,A PASI HEAD10%B.T + + + × x 0.1 = After treatment + + + × x 0.1 = ARMS20%B.T + + + × x 0.2 = After treatment + + + × x 0.2 = BODY30%B.T + + + × x 0.3 = After treatment + + + × x 0.3 = LEGS40%B.T + + + × x 0.4 = After treatment + + + × x 0.4 = Total PASI Before Treatment Total PASI After treatment *Coverage Score 0% 0 Severity⊗ Score <10% 1 None 0 10-29% 2 Mild 1 30-49% 3 Moderate 2 50-69% 4 Severe 3 70-89% 5 Maximum 4 90-100% 6Overall Assessment of Clinical Research 01. Complete Remission – PASI score 0 after treatment. 02. Marked improvement – Reduction in PASI score >75%. 03. Moderate improvement – Reduction in PASI score between 75% and 50%. 04. Minimal improvment – Reduction in PASI score <50%. 05. Unchanged – No reduction in PASI score. Guide’s signature Investigators signature (Dr. G. Purushottamacharyulu) (P.Chandramouleeswaran)
    • I The severity of itching, scaling, Erythema and thickness was assessed in thefollowing manner A. Itching 01. None – No itching. 02. Mild – Itching subside; when he / she scratches. 03. Moderate – Reduction in itching by internal medicaments. 04. Severe – Reduction in itching by internal and external medications. 05. Maximum – After medicaments also the patient gets itching sometimes. B. Erythema 01. None – No Erythema. 02. Mild – Patch with reddish tinge. 03. Moderate – Patch with dull red colour. 04. Maximum – When it is bright red in colour with severe itching. C. Scaling 01. None – No scaling. 02. Mild – On scratching if the scales settle in pits on nails. 03. Moderate – If the scales fall on around where he scratches. 04. Severe – Scales found in his/her cloths without scratching. 05. Maximum – Scaling found on bed etc without scratching. D. Thickness – Purely subjective.The severity of krodha, bhaya, etc were assessed in following manner – A. Krodha 01. None – No Krodha. 02. Mild – Gets anger but not showing outside. 03. Moderate – Shouting loudly, throughing the articles occationally. 04. Severe – Shouting loudly and making harm to others occationally.
    • JB. Shoka 01. None – No Shoka. 02. Mild – Disturbance in concentration, occational thinking of his/her problem. 03. Moderate – Always thinking about his problem with mild disturbance in sleep. 04. Severe – Not responding to others properly with complete disturbance of sleep.C. Bhaya 01. None – No Bhaya. 02. Mild – Gets occational fear by thinking about the illness. 03. Moderate – Fear causing occational disturbance in day to day activity. 04. Severe – Fear causing occational disturbance in day to day activity, sudden disturbance in sleep.D. Chittodvega 01. None – Zero. 02. Mild – Patient not anxious about the disease. 03. Moderate – Will be anxious, but having the belief that the disease will be cured. 04. Severe – Doesn’t have belief in any therapy and worried that the disease will not be cured.
    • CONCLUSION Based on the observation made in the study the following conclusion can bedrawn – Takradhara is a modification of the Shirahseka procedure, which comes under the type of Moordhni taila. The word “Dhara” is available in our classics (Sekastu Sukshma Dharabhi: | B.P.). Considering utility of takralepana and kashaya seka in kushta, the improvised study was conducted was conducted in the name of takradhara. No severe side effects were observed in the study, through some of them complained of running nose, etc. Though statistical analysis of after treatment results of total PASI score showed highly significant. It was observed that the procedure was highly effective in scalp and palmo-plantar variety of psoriasis. Reduction in symptoms like scaling and itching was found in all most all the patients. No reduction or mild reduction was observed in Erythema of arms, body and legs. Maximum reduction in Erythema was found in head. Maximum reduction in thickness of lesion was found in head comparing to arms and legs. In body it was very minimal. In the body the affected area was not reduced after the treatment. Overall treatment response was good in head while comparing to other parts. In head affected patients, the therapy provided complete remission in almost all the cases, but in some cases it doesn’t even had a minimal impact. 163 Conclusion
    • Significant reduction was found in triggering factors like bhaya, krodha, chittodvega, etc. During follow up period the results attained seemed to wear out in body completely, minimal in arms and legs. But results lasted throughout the follow up period in the head affected patients.LIMITATIONS OF THE STUDY 01. The sample size was very small to generalize the result.SUGGESTIONS FOR FUTURE STUDIES ⇒ The study should be conducted in a large sample. ⇒ The study should be conducted for a longer duration so as to know the lasting of the clinical effects. ⇒ The study should be conducted along with the shodhana procedures. 164 Conclusion
    • SUMMARY The dissertation work entitled “Evaluation of the efficacy of the takradhara inKitibha Kushta (Psoriasis)” consists of seven parts. They are 1. Introduction 2. Objectives 3. Review of literature 4. Methodology 5. Results 6. Discussion 7. Conclusion. The introduction highlights on aim of Ayurveda, importance ofPanchakarmas, psychosomatic approach to treatment of Kitibha kushta, Dharakarma,Takradhara and Kitibha kushta. The objectives part describes the need for the study,previous studies on Takradhara, title of the present study and the objectives of the presentstudy. Review of literature part covers the historical view on Takradhara karma andKitibha kushta, Nirukti and Paribhasha of Takra, Dhara and Kitibha Kushta, Shareera ofTwak (Rachana and Kriya), description of Takradhara procedure in particular anddescription of Kitibha kushta. Methodology part contains review of the properties andchemical composition of the drugs used, methodology of the clinical study, procedures ofTakra dhara karma and the parameter for clinical assessment. The results part containdemographic data, data related to the disease, data related to the overall response to thetreatment, statistical analysis of the clinical parameters. Discussion part consists of theheadings Discussion on disease, therapeutic regimen, plan of the study, observations, andclinical response to the treatment, probable mode o action. Conclusion part contains theconclusions of the present study and suggestions for future study. 165 Summery