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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 90-96

Management of Vipadika (~Plantar Psoriasis) in Ayurvedic prospect


1 Department of Kayachikitsa, Chaudhary Brahm Prakash Ayurved Charak Samsthan, Najafgarh, New Delhi, India
2 Department of Kayachikitsa, ITRA, Jamnagar, India
3 Department of Shalakya Tantra, Akhandanand Ayurved College, Ahmedabad, Gujarat, India

Date of Submission29-Sep-2021
Date of Decision22-Oct-2021
Date of Acceptance24-Nov-2021
Date of Web Publication29-Jun-2022

Correspondence Address:
Jitendrakumar Nathabhai Varsakiya
Department of Kayachikitsa, Chaudhary Brahm Prakash Ayurved Charak Samsthan, Najafgarh, Khera Dabar, New Delhi - 110 073
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AYUHOM.AYUHOM_47_21

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  Abstract 


Plantar psoriasis accounts for 3%–4% of all psoriasis cases and produces significant functional and social disability. Plantar psoriasis is a variant of psoriasis that characteristically affects the skin of the soles with features, i.e.,; hyperkeratotic, pustular, or mixed morphologies. Many of the skin disorders in Ayurveda have been described under the heading of Kushtha (group of skin diseases) and Kshudra Kustha. Vipadika (Plantar psoriasis) is one of the diseases which has been included under the heading of Kshudra Kushtha. In classics, clinical features of Vipadika are cracks (Sphutana) either in palms or soles or in both with pain. A 42-year-old male patient visited our outpatient department with complaints of scaling and fissure of skin of bilateral soles, with bleeding from cracks for 6–8 months. Examination and history lead to a diagnosis of Vipadika (Plantar psoriasis). This case was managed with Virechana Krama (~therapeutic purgation), followed by Shaman Chikitsa (pacifying therapy) with internal administration of Guduchi Churna 2 g twice a day after meal with luke warm water, Panchvalkal Kwath once 4 ml morning empty stomach, with Panchvalkal Kwath wash in sufficient quantity, Triphala Churna Avchurnan (topical dusting of powder) and local application of Jatyadi tail along with Pathya (wholesome regime), and Apathya (unwholesome regimen) for 4 months. The effect of the therapy was assessed by the signs and symptoms before and after the treatment. The treatment modalities showed relief in patient's signs and symptoms. Hence, Ayurveda procedures and medicaments are promising in the management of Vipadika (~Plantar psoriasis).

Keywords: Plantar psoriasis, Tinospora cordifolia, vipadika, virechana karma


How to cite this article:
Varsakiya JN, Goyal M, Kathad D, Dhaniya A, Kumari R. Management of Vipadika (~Plantar Psoriasis) in Ayurvedic prospect. AYUHOM 2021;8:90-6

How to cite this URL:
Varsakiya JN, Goyal M, Kathad D, Dhaniya A, Kumari R. Management of Vipadika (~Plantar Psoriasis) in Ayurvedic prospect. AYUHOM [serial online] 2021 [cited 2022 Aug 17];8:90-6. Available from: http://www.ayuhom.com/text.asp?2021/8/2/90/348862




  Introduction Top


Planter psoriasis is a chronic skin disease which mainly affects palms and soles. Lesions are well defined erythematous, plaque. Sometimes, the involvement is diffuse. When the massive silvery white or yellowish scales which in contrast to the lesions get spread to other parts of the body, they become difficult to remove.[1] Plantar psoriasis affects individuals of all ages, while plantar pustulosis has an average age of onset between 20 and 60 years of age. Gender specificity is unclear in plantar psoriasis, although plantar pustulosis shows a clear predilection for females, with a female-to-male ratio of 8:2. Although the incidence has not been determined, the plantar variant of psoriasis comprises 3%–4% of all cases of psoriasis, which affects 2%–5% of the population.[2]

In Ayurveda, it has been mentioned that Kushtha is Raktaja Vyadhi.[3],[4],[5] Vipadika described under the Kshudra Kushtha and Vatapradhana Vyadhi. Due to a lack of hygiene, excessive walking, etc., vitiation of Vata Dosha affects Rakta Dhatu in the foot leads to scaling of the skin of soles and palms (~Pani-padasputanam) and severe pain (~Tivra Vedanam).[6] Hypertrophy of epidermal layer of the palms and soles, usually of a more or less horny and plate-like character, is well defined in Ayurveda as Vipadika and Plantar psoriasis is in the contemporary science.[7] In the present case study, a patient suffering from Vipadika has been treated with Virechana Karma (~therapeutic purgation), followed by administration of drugs such as Guduchi Churna, Panchvalkal Kwath with Panchavalkala Kwath wash, Triphala Churna Avchurnan, and local application of Jatyadi Tail. The details are described hereafter.


  Case Report Top


A 42-year-old male patient came to Kayachikitsa outpatient department in September 2019 with complaints of gradual onset of cracking, scaling, and hyperpigmentation of skin of bilateral soles and bleeding from cracks for 6 months. There was severe itching and pain which was continuous throughout the day. The patient had developed pus and watery discharge in cracks along with bleeding. The lesions were bilaterally asymmetrical and over the soles, instep, and sides of feet were involved. Scales and cracking were not present at other sites except soles. Distal sole and toes were involved. The condition was progressive and creating anxiety to the patient. Gradually, he developed difficulty in walking after a few months of onset of complaints. The patient had no any past history of diabetes mellitus, hypertension, thyroid disorder, or any chronic illness.

Treatment history

The patient had taken allopathic treatment from February to August 2019 including steroids internally and topically but did not get relief.

Clinical findings on examination

General examination

On Examination of the patient, pallor was absent; tongue was coated. The patient was usually preferred salty and spicy vegetarian diet with variable appetite and habitual alcoholic. His bowel habits were irregular with complaints of constipation. He had disturbed sleep, and his frequency of micturition was 6–7 times in the day time and 1–2 times in the night.

Evaluation of lesions is based on the following criteria

  1. Size of scales and fissures – Small and large various sizes of scales are present
  2. Number of scales and fissures – Multiple scales are present over bilateral sole region
  3. Discharge – Watery and serous discharge
  4. Pigmentation– Blackish pigmentation over center of sole
  5. Pain-Present.


Diagnosis

The diagnosis of Vipadika is made for Plantar psoriasis.

Therapeutic focus and assessment

Before administration of the drugs, Virechana Karma was done. For this purpose, during first 3 days, 2 g of Haritaki Churna + Shunthi Churna 2 g for Deepana (~stomachic) and Pachana (~digestant) was administered twice in a day with lukewarm water before meal. On 4th day, after assessing the status of the patient for Abhyantara Snehana (~internal oleation therapy) Panchtikta Ghrita starting from 30 ml early morning on empty stomach with lukewarm water given and was observed for Sneha Jeerna Lakhshana, and accordingly for next 7 days, the dose of Ghee was given in increased pattern till the patient achieved proper Snehana features such as unctouness of skin and feces, feeling of hunger, and thirst at the right time. After completion of Abhyantara Snehana, for next 3 days, Sarvang Abhyanga (~therapeutic massage) with Jatyadi Taila and Vashpa Swedana (~therapeutic fomentation) was done daily. During all this period, the patient was kept on normal diet with precautions to avoid excessive oil or heavy food items. On the next day, after massage and fomentation in the morning, Virechana Yoga (Triphala Kwath 100 ml, Munakka Kwatha 100 ml, and Trivrat Avleha 40 gm) was given. With 17 Vegas of Virechana, Madhyam type of Shudhi was done at the day of Virechana. The patient was advised Samsarjana Krama (~post therapy dietetic regimen for revival) according to Shuddhh (~cleansing) i [Table 1].
Table 1: Details of Virechana procedure

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After proper Shodhana (~Bio-cleansing), administration of drugs – Guduchi Churna 2 g twice a day after food with lukewarm water, Panchvalkal Kwath 40 ml empty stomach in the early morning, also Panchwalkal Kwatha was given for local wash. The patient was advised Triphala powder for local Avchurnan (~pouring), and local application of Jatyadi Tail was advised for 3 months [Table 2].
Table 2: Posology of drugs given

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  Results and Outcomes Top


In this case report, result was assessed on the bases; effect of therapy shown the changes in clinical features before and after treatment includes follow-up in scaling of skin, fissure, pain, hyperpigmentation as seen in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8] [Table 3]. After near about 4 months of treatment, the patient had no recurrence till the month of August 2021.
Figure 1: Before treatment left foot image

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Figure 2: Before treatment right foot image

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Figure 3: After Virechana left foot

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Figure 4: Right foot after Virechana

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Figure 5: Left leg after 2 months of therapy

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Figure 6: Right leg after 2 months of therapy

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Figure 7: Right foot after 4 months of therapy

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Figure 8: Left leg after 4 months of therapy

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Table 3: Assessment of therapy on clinical features before and after treatment

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  Discussion Top


Vipadika (~planter psoriasis) is mentioned under the umbrella of Kshudra Kustha as Vata Kaphatmak Vyadhi (~diseases caused by Vata-Kapha) in the Ayurveda texts. According to signs and symptoms, it can be correlated with plantar psoriasis. Although Kushtha Roga is Tridoshaja, they are prone to Pitta and Rakta Dushti (~vitiation of doṣha responsible for regulating body temperature and metabolic activities and blood). Hence, the line of treatment should be to remove vitiated doṣa responsible for regulating body temperature and metabolic activities from the body and cleansed the Rakta Dhatu (~blood structural components of the body). The main line of treatment described for Kushtha is repeated Shodhana (~bio-purification),[8] to ensure the complete eradication of the disease. In this study, Virechana Karma (~therapeutic purgation) was considered as it has less complications and better effects in the management of Pittaja Roga (~disease caused by vitiation of Doṣha responsible for regulating body temperature and metabolic activities.

Effect of Virechana Karma (~therapeutic purgation)

Shodhana Karma is advocated in any chronic disease to flush out the excess Doshas from the body, and small amount of left over Dosha is managed by Shaman Chikitsa. Virechana is one of the Shodhan Chikitsa (bio-purification) mainly done in the Pitta and Rakta Dosha predominant disorders, executed as Srotovishudhi (cleansing of body channels), which lead to eliminate various toxins and inflammatory markers out of the body. As like in water-filled pond, aquatic creatures and plants die after the removal of water from it. The same happens in Virechana. The Pitta and Rakta Dosha predominant disorders vanish after the elimination of Pitta Dosha from body.[9] Furthermore, a study reveals that Shodhana process helps in removing the free radicals (oxidants) present in the microcirculatory channels of the body; in addition, Virechana Karma increases the bio-availability of drugs by opening channels and by improving the nutritional assimilation, which leads to the proper effect of administered drugs and helps to manage the illness.[10],[11]

Probable mode of action of Guduchi Churna (Tinospora cordifolia Miers)

Guduchi was described extensively in Ayurvedic literature for various purposes. It has Tikta (bitter), Kashaya (astringent) Rasa (taste), Laghu (light), Snigdha (unctuous) Guna (properties), Ushna (hot) Veerya (potency), and Madhura (sweet) Vipaka.[12] In Madanpal Nighantu, it is mentioned in Haritakyadi Varga[13] and in Aushadhi Varga in Kaideva Nighantu.[14] Both the treatise mentioned its role in Kushtha. Later, its Kushtha Hara properties were established experimentally, where this exerts antileprotic activity in a combination formulation.[15] Oral administration of stem decoction of this herb uses to consume in Twaka-Vikara (skin disease) in folk medicine of Dehrabaar Kolaras community of Shivpuri district of Madhya Pradesh.[16] In psoriasis, deregulation of immune system is majorly involved, which causes the rapid inflammation and cell growth of epidermal layer of skin. Guduchi among its several other properties possesses immunemodulating, antioxidant, and anti-inflammatory properties also. Signaling mechanism of the novel (1, 4)-alpha-D-glucan (RR1) isolated from T. cordifolia was observed as immunostimulator for macrophages.[17] Alcoholic and aqueous extracts of this also have immunomodulating effects.[18] In one study, it had been demonstrated that Guduchi extracts remarkably to attenuate the symptoms and processes underlying psoriasis-like dermatitis in mice.[19] Antioxidant property of this plant is due to an arabinogalactan polysaccharide and phenolic compound (epicatechin).[20] Ethanolic extract of this plant is capable of restoring a normal level of lipid peroxidation, enzymatic, and nonenzymatic antioxidants in the case of N-nitroso diethyl amine-induced liver cancer in rats.[18]

Probable mode of action of Panchvalkal Kwath

Panchavalkala, i.e., group of barks of five trees – Vata (Ficus bengalensis L.), Ashwatha (Ficus religiosa L.), Udumbara (Ficus glomerata Roxb.), Plaksha (Ficus lacor Buch-Ham.), Parish (Thespesia populenea Soland. ex corea) has Kashaya (astringent) predominant Rasa and Sheeta (cold) Guna (properties). Kashaya Rasa is Twak Prasadaka (soothing effects on skin), Vrana Shodhaka (ulcer cleaning), and Ropaka (healing effect).[21] The Pharmacological action of Panchavalkala (Bark) is found to have anti-inflammatory, analgesic, and antimicrobial properties.[22] Previous researches define that tannins compound present in Udumbara and Nyagrodha are antioxidants and purify the blood along with anti-inflammatory actions. They helped to decrease the swelling with their mode of action. The flavonoids and phytosterols are analgesics and anti-inflammatory, thus they help in reducing the pain. Tannins also proved to possess antimicrobial property which could have reduced the discharge.[23] Hence, these constituents within the Panchavalkala Kwath may help in the regression of signs and symptoms.[24]

Probable mode of action of Triphala powder

Triphala, a well-recognized and highly efficacious polyherbal Ayurvedic medicine consisting of three myrobalan fruits, i.e.,; Terminalia chebula (Haritaki), Emblica officinalis (Amalaki), and Terminalia bellerica (Bibhitaki) have plethora of health benefits, is a mainspring of gastrointestinal tract and revitalizing treatment. Furthermore, it is most popular herbal remedy which “cleanse” by promoting bowel movement. Early research on Triphala has found that the formula to be conclusively effective for several clinical uses such as appetite stimulation, anti-inflammatory, reduction of hyperacidity, antioxidant, immunomodulating, adaptogenic, radioprotective effects, hypoglycemic, antibacterial, antimutagenic, antineoplastic, chemoprotective, and prevention of cavity.[25] Polyphenols in Triphala modulate the human gut microbiome and thereby promote the expansion of beneficial Bifidobacteria and Lactobacisllus while inhibiting the expansion of undesirable gut microbes. The bioactivity of Triphala is elicited by gut microbiota to get a spread of anti-inflammatory compounds.

Topical application of the ashes of this myrobalan combination with Saindhava Lavan (Potassium Nitras or Nitricum) is used in syphilitic ulcers to remove the exudations from the ulcer.[26] Dermal application of Triphala extract (10% weight/weight) has shown its healing effects in both clean uninfected and infected wound in rat. Mechanistic studies showed that the Triphala ointment reduced the bacterial counts, decreased the Matrix metalloproteinases expression, and enhanced wound closure with improved levels of collagen, hexosamine, uronic acid, and super oxide dismutase at all time points studied.[27] Several research papers validate the ethnomedicinal claims that Triphala displays free radical-scavenging, antioxidant, anti-inflammatory, antipyretic, analgesic, antibacterial, antimutagenic, wound-healing, anticarcinogenic, antistress, adaptogenic, hypoglycaemic, anticancer, radioprotective, chemoprotective, and chemopreventive properties.[28] Triphala has potential antioxidant property, and it acts as a skin-protective ingredient by re-building skin structural proteins and stimulating selective youth genes.[29]

Probable mode of action of Jatyadi Tail

Jatyadi Taila is a Polyherbo-mineral Ayurvedic preparation which is used for topical application on many skin problems like scalds. Among 20 ingredients of Jatyadi taila some are rhizome of Haridra (Curcuma longa L.), stem of Daruharidra (Berberis aristata DC.), Leaf of Jatipatra (Jasminum aurichulatum Vahl.), whole plant or leaf of Patola (Trichosanthes dioica Roxb.), leaf of Neem (Azadirachta indica L.), root of Yashti madhu (Glycyrrhiza glabra L.), root of Manjishtha-(Rubia cordifolia L.), stem bark of Lodhra (Symplocos racemosus Roxb.), root of Shweta Sariva (Hemidesmus indicus R. Br.), etc.[30] All these have bitter and astringent predominant dominant taste, which perform Pitta Shamaka, Rakata Shodhaka, and Vrana Hara properties. Pharmacologically active constituents of these ingredients are rutin, quercitin, glycyrrhizin, sitosterol, curcumin, berberin, gallic acid, lupeol, karanjin, etc., which is helpful in wound healing.[31],[32],[33],[34] In Ayurveda, Jatyadi Taila possesses antimicrobial activity, which is a particularly used as a wound healer.[35]


  Conclusion Top


For the present case report, Ayurvedic diagnosis of Vipadika is made for plantar psoriasis. This is the uniqueness of Ayurveda treatment that Shodhana Purvaka Shaman therapy has definite result in such type of skin diseases. Cleansing therapy is not only cure the ailment but also it prevents the disease recurrences. This case study showed promising results of Ayurveda remedies to manage such type of ailments with improvement in quality of life.

Patient viewpoint

“I feel much better after getting Ayurvedic treatment for my scales and fissure over bilateral soles. Although this disease does not produce any other systemic malfunctions, it was creating psychological as well as social problems to me. I had to use steroids and spent much time and money to restore skin to a more normal or youthful appearance, but it did not work. Also due to scale and fissure, I had difficulty in walking, unable to join my duty since 2 year. Now, I have joined my duties and much thankful to Ayurveda.”

Patient consent

An informed written consent was obtained from the patient for reporting this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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