Ayurvedic Management of Kitibha Kushta w.r.t. Guttate Psoriasis- A Single Case Study

Guttate psoriasis is a type of psoriasis that presents over the upper trunk and proximal extremities, it is small (0.5 to 1.5 cm in diameter) lesions; it is found frequently in young adults. As per its clinical features we will compare with Kitibha Kushta. The life time prevalence is approximately 2% of individuals with psoriasis. Many treatment modalities have been adopted in medical sciences, but it is having various side effects. So here in this case by using Shodhan, Shaman and Bahirparimarjan chikitsa we successfully treated the case of Kitibha kushtha. It is a single case study, A 22 year male patient approached to Kayachikitsa OPD having complaint of multiple small red lesions over the chest, abdomen, and back region also on both upper limbs and Itching over them since 2 years.The patient was treated with Shodhan and Shaman Chikitsa. Patient got 90% result in chief and associated complaints and during and after the completion of therapy there is improvement in the quality of life of the patient. After Shodhana and Shaman Chikitsa patient got satisfactory relief in symptoms. 136 * Corresponding Author: Vishakha Bindalkar PG scholar, Department of Kayachikitsa, Mahatma Gandhi Ayurved College Hospital and Research centre, Salod(H), Wardha.. Email id vishakha.bindalkar@gmail.com Vishakha Shashikant Bindalkar et.al., Ayurvedic Management of Kitibha Kushta w.r.t. Guttate PsoriasisA Single Case Study Published online in http://ijam.co.in ISSN No: 0976-5921 Patient had recurrent history of Tonsillitis. No any family history was present regarding psoriasis or any dermatological disorders. Disturbed sleep due to the i t c h i n g a n d t h e r e i s l a c k o f a p p e t i t e . Ashtavidha Pariksha was within normal limit but only mala was asamyak due to irregular bowel habits, jivha was saam and sparsha was kina khara sparsha and parusha with ruksha pidika. On Examination, all vitals of the patient were within normal limit. Pulse rate 80permin regular and vata pittaj, Blood pressure was 130/80mmHg. Respiratory rate was 18 per min, temperature was 98o f. Examination of Skin A.Inspection • Size shape – Erythematous small lesions over abdomen, chest, back region and both upper limbs. • Color – Red • Thickness – 0.8 to 1.2 mm thick • Lesion Small red blisters like lesion. • Palpation :• MoistureDryness • Temperature – Warmth to touch • Texture – Rough Diagnosis Kitibha kushtha (Guttate Psoriasis) Treatment Plan given • ShodhanVaman,Virechan. • Shamana aushadhi along with Bahirparimarjan chikitsa for 4 months in three follow up. Table no.1:Shodhan chikitsa by following the purvakarma, pradhankarma and pschyat karma. Paschyat Karma After obtaining Samyaka Vamana Lakshana and Samyaka Virechana Lakshana Dhoomapan was given with stick made of Aguru for 5 minutes by each nostril. Then patient was advised to follow the Sansarjana Karma for five days. Sansarjana Karma [9] was given in the form of Peya, Vilepi, Akrita Mudga Yusha, Krita Mudga Yusha for 5 days. Picture no. 1: Small red blisters like lesion over abdomen, chest, back region and both upper limbs. Procedure Medicine Dose Duration Route Deepan pachan Trikatu churna 3 gm bd before meal with luke warm water for 3 days Oral Snehapana Panchatikta ghrita Starting from the 30ml in the increasing order upto the180ml. (empty stomach at morning time with lukewarm water) For 7 days Oral


Introduction
Guttate psoriasis ( Also known as eruptive psoriasis) is a type of psoriasis that presents as small (0.5 to 1.5 cm in diameter) lesions over the upper trunk and proximal extremities; it is found frequently in young adults. (1,2 ) The term "guttate" is used to described the drop like appearance of skin lesion. Guttate psoriasis is classically triggered by a bacterial infection, strongly associated with a streptococcus bacterium and typically occurs 1-2 weeks after an episode of tonsilitis; usually an upper respiratory tract infection. (3) Guttate psoriasis can affect any area of skin and appears as little red blisters that are tear drop in shape. This type of psoriasis accounts for about 2% of individuals with psoriasis. Current research is limited in identifying the best treatment for guttate psoriasis. Commonly used regimens include topical tar and UVB phototherapy, anthralin and topical steroids. (4) In Ayurved all types of skin diseases are included under the Kushtha. Acharya charak mentioned it in Ashtamahagad (difficult to treat). (5) Acharya charak described kushtha rogadhikar in which he classified Kushtha in to two major types; Mahakushtha (Major skin diseases) and Kshudra kushtha (Minor skin diseases). (

Case report
A 22 years male patient came with chief complaint of multiple small red lesions over the chest, abdomen, back region also on both upper limbs and Itching over them since 2 years.
Patient had recurrent history of Tonsillitis. No any family history was present regarding psoriasis or any dermatological disorders. Disturbed sleep due to the i t c h i n g a n d t h e r e i s l a c k o f a p p e t i t e . Ashtavidha Pariksha was within normal limit but only mala was asamyak due to irregular bowel habits, jivha was saam and sparsha was kina khara sparsha and parusha with ruksha pidika. On Examination, all vitals of the patient were within normal limit. Pulse rate 80permin regular and vata pittaj, Blood pressure was 130/80mmHg. Respiratory rate was 18 per min, temperature was 98 o f.

Grading -PASI (Psoriasis Area Severity Index) Score
Within each area, the severity is estimated by three clinical sings: Severity parameters are measured on the scale of 0 to 4, from none to maximum. The body is divided into four sections [head (H) (10 % of a person's skin); arms (A) (20%): trunk (T) (30%); legs (L) (40%)]. Each of this area is scored by itself, and then the four scores are combined into the final PASI. For each section, the percent of area of skin involved, is estimated and then transformed into a grade from 0 to 6.

Discussion
Guttate psoriasis is a type of psoriasis that appears as little red blisters which is tear drop in shape. The small lesions over the upper trunk and proximal extremitie. In Ayurved as per its clinical features it can be correlated with the Kitibha kushtha. The predominant doshas in Kitibha kushtha are Vata and Pitta dosha. It is the vyadhi of raktavahastrotas, having sampraptighatak vata and kapha dosha, twak, lasika, rakta and mamsa. (10) The shodhan and shaman chikitsa are described in samhitas for the management of Kushtha. (11) Among the shodhan vaman is the best chikitsa for the kushtha followed by virechan karma as it eliminates the kapha and pitta sequentially from the body. In the present study shodhan, shaman and bahirparimarjan chikitsa was given to the patient. The treatment schedule was started by following the sequence of puvakarma, pradhan karma and paschyat karma. In purva karma, deepan -pachana dravya were given which are agnivardhak and amapachak. For that Trikatu churna was used, it was given for 3 days. After that Snehapan was given with the Panchatikta ghrit for 7 days. For the purposre of Abhyantar snehan, it causes the Vatashamana. For the Abhyanga the Marichyadi tail was used for the purpose of bahyasnehan, it reduces the dryness, provides the moisturization body, improves  It also removes the strotorodha (obstraction in the strotas).

Action of Snehapana -Panchatiktaghtrit
The ingredients of Panchatikta are tikta rasa, ruksha and laghu guna. It acts mainly on kled, meda, lasika,rakta, pitta and kapha which helps in balancing the vitiated dosha and dhatu. It has properties like Deepan, Pachan, Strotoshodhak, Raktashodhak, Raktaprasadak, Kushtaghna, Kandughna and Varnya. (12) The Ghrit has lipophilic action helps to carry drugs to the target organs, it enters to its cellular level and delivers to mitochondria and nuclear membrane. It maintains the normal texture of skin.

Action of Abhyanga with Marichyadi tail
For the purpose of abhyanga or Bahyasnehana (external oleation) the Marichyadi tail is used. The most of dravyas of Marichyadi tail are have properties like katu, tikta, kashay rasa and ushna virya which does the shaman of Kapha and Vata dosha. Its snighdha guna reduces the rukshatva, kharatva and parushata. It has properties like Raktashodhan, Kushtaghna and Kandughna. The nature of tail is Sukshmagamitva means it helps drugs to go into the minute channels and does the proper absorption. The Kashay rasa of these dravyas helps to reduce the Kleda. (13) Marichyadi tail has antiseptic, antifungal, anti-inflammatory, antimmuno modulatory property. The Marichyadi tail is effective in the Symptoms of kitibha kushtha due to these properties.

Action of Vaman karma
Vaman does the elimination of the prakupit doshas mainly kapha and pitta from the koshtha. The vamanopaga dravyas, such as Madanphal churna, Vacha churna, Pippali churna, Saindhav, Madhu, Yashtimadhu phanta having properties like ushna, Tikshna, Vyavayi and Vikasi it enhances the absorption rate and helps to reach at Hriday. It moves from hriday to the Dhamani to all Sthul and Sukshma strotas. It acts on the microcellular level which removes all the toxins from the body. There is the predominance of the Agni and Vayu mahabhutas.
Vamak dravyas has the urdhwabhagahar prabhav which causes the elimination of doshas from the upward direction i.e, from the mouth. This therapy is very effective for the elimination of aggravated doshas.

Action of Virechan karma
The Virechan dravyas which are having properties like Ushna, Tikshna, Sukshma, Vyavayi, Vikasi it reaches to the heart due to their potency it enters into the all over dhamanis and circulates throughout the sthula and sukshma strotas. Then it does the liquefaction of the dosha sanghat due to its Agneya guna. This Doshasanghat gets chhinnabhinna and circulates through out the strotas and didn't get sticks any where because the Snehan was done in the purvakarma, as like honey not sticks to the vessel which is coated by oil. This doshasanghat passes through the minute capillaries and moves towards the koshtha and ultimately reaches to the amashay. The virechan drug has the predominance of the Jala and Prithvi mahabhuta, so it acts as a Adhobhagahara prabhav. It does the elimination of the vitiated dosha from the guda marga. (14) Action of Vetapalai oil Vetapalai oil having Kushthaghna, anti-inflammatory, antibacterial, antiviral, antifungal, anti-microbial, antioxidant properties. It is indicated in treatment of skin disease, itching, pruritus, psoriasis. It improves the skin complexion, relieves pain and efficient in wound healing. All the contents are Vata, Pitta, Kapha Shamak (pacifies the Tridosha), Twachya (which improves complexion). It moisturizes and soothes the skin. (20)

Action of Atrisor cream
Atrisor

Action of Atrisor moisturizer
Atrisor moisturizer contains Narikel tail (Cocos nucifera L.), Nimba (Azadirachta indica A Juss.), Haridra (Curcuma longa L.), Manjishtha (Rubia cordifolia L.) and shweta indrajao (Wrightia tinctoria Roxb. R. Br.). It reduces the inflammation of the skin and itching associated with psoriasis, this relieving itchy, flaky and dry skin. Atrisor moisturizer restores moisture in the skin and helps in keeping the skin soft and supple. It prevents further dryness and exacerbation of the lesion. (23) The Erythema (Redness), In-duration (Thickness), Desquamation (Scaling) and Itching of the lesion was very severe before treatment, but the improvement was seen after the treatment of patient with Shodhan, Shaman and Bahirparimarjan chikitsa. There is significant result in the Erythema (Redness), In-duration (Thickness), Desquamation (scaling) and Itching. The PASI scale was considered. Before treatment the PASI score was 19.8. After 2 months it was 2.4, after 4 months it was 0.8, after 6 months it was reduced to 0. In the present case study the patient got the 90% relief in the symptoms after following the Shodhan (Vaman and Virechan), Shaman (Internal medications) and Bahirparimarjan chikitsa.

Conclusion
The Guttate Psoriasis can be correlated with Kitibha Kushtha, which is a type of Kshudra Kushtha. From the above case study it can be concluded that the Kitibha Kushtha can be successfully treated with the Shodhan (Vaman and Virechan), Shaman (Internal medications) and Bahirparimarjan Chikitsa (External application). As it is a single case study, it is recommended to conduct the research study on more number of patients to prove the effectiveness of the treatment modalities.