Management of Erythrodermic Psoriasis through Ayurveda



 

Vikraman Syamala Abhilesh, BAMS1 ; Changuli Krishna Bhat Prathibha, MD (Panchakarma)1 ; Puthanmadom Venktramana Sharma Anandaraman, MD (Panchakarma), PhD2

Perm J 2021;25:20.221

https://doi.org/10.7812/TPP/20.221
E-pub: 08/11/2021

ABSTRACT

Case Presentation: Psoriasis is a noninfectious chronic inflammatory skin disorder, characterized by well-defined erythematous plaques with silvery scales. In an ayurvedic perspective, we can compare this disease with Kitibha Kushta (a type of skin lesion) because most of its signs and symptoms mimic that of erythrodermic psoriasis. A 23-year-old patient diagnosed with psoriasis presented with erythematous overlapped patches all over the body, Auspitz sign, and pain associated with occasional itching sensation. After assessing the dosha involvement, proper Shodhana (purification therapy), Shamana (pacifying therapy), and Rasayana (rejuvenation therapy) were adopted and a reduction in erythema, itching, scaling, pain, and lesions were seen, along with a swingeing decrease of PASI, DLQI, and VAS scores from 37.4, 11, and 07 to absolute zero.

Conclusion: Even though erythrodermic psoriasis is very difficult to treat, a thorough assessment of pathogenesis, proper shodhana (purification) and rasayana (rejuvenation therapy) proves to be effective. This gives further scope, similar to a structured clinical trial in the disease.

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease characterized by erythematous patches associated with silvery scales, itching, burnt skin appearance, and in some cases pustules or blisters.1 The disease not only causes physical deformity but can also cause severe social stigma to a person and affects one’s quality of life.2 Social exclusion, discrimination, and stigma are psychologically devastating for individuals suffering from psoriasis and their families.2 According to various data published so far, the prevalence of psoriasis varies between 0.09% and 11.43%, which makes this disease a serious problem, with at least 100 million individuals affected around the globe.1 There is no definite treatment available for psoriasis, but different treatment modalities, such as internal medications, topical creams, phototherapy, and biologics, are available.1 They are found to bring symptomatic relief, but the long-term use of these medications can cause systemic and local side effects as well as toxicity. According to Ayurvedic literature, psoriasis can be compared with either Ekakushta,3 Sidhma Kushta, or Kitibha Kushta,4 which are of Vata-Kapha in origin. For the elimination of doshas, repeated shodana (purification) is necessary,5 which is explained in classics as the main line of treatment and after shodana for enhancing the deteriorated dhatus (bodily tissues); rasayana prayoga is ineluctably explained.6 Different rasayana prayogas are mentioned for this purpose, but the complete efficacy of the drug is attained only if the medicine is consumed as explained in classics.7 Manibhadra Guda is a drug having both purgative as well as rasayana properties. According to the market need and to increase the shelf life of the drug, Manibhadra guda is prepared either in Avaleha (linctus) form or in granules form.7 This case reports an incidence of psoriasis that was cured using the classical approach described above.

CASE PRESENTATION

A 23-year-old male student presented with erythematous patches, scaling, pain, itching, and roughness of skin over the whole of trunk and the upper and lower limbs since 1 month.

The patient was apparently normal before 3 years. In July he noticed small pimples on the dorsal aspect of the trunk. He ignored the condition, but, because there was an increase in the number of pimples, he consulted an allopathic physician and took medication for more than 1 month. Symptomatic relief was achieved as the pimples disappeared. By later November the condition reappeared with much more intensity. He consulted a homeopathic physician, took medication, and found temporary relief. By February 2016, the condition reappeared, but this time instead of pimples the patient experienced reddish skin patches with scaly lesions, cracked lips, severe itching, and bleeding spots when scales was removed. He consulted another allopathic physician who advised topical applications, but the condition spread from back to his hands, legs, end front of trunk. Unsatisfied with the treatment, he consulted another allopathic physician, who diagnosed the condition as Erythematous psoriasis via skin biopsy. Medications were prescribed for 1 month, and the patient achieved a complete remission of the disease for a year. In January 2018, the symptoms started to reappear, so he came to our hospital for a better and permanent cure. Detailed examination revealed that the symptoms were aggravated on exposure to sunlight, and the patient was unable to do his daily routine. The personal history of the patient reveals regular intake of red meat, maida products, and excessive intake of sour and spicy food, which may have attributed to the condition. No other specific causative factor was found relevant in the present condition.

PRESENTING CONCERNS/CLINICAL FINDINGS

Clinical Findings

  • Lesion type: scaly raised patches (Kinavat Sparsham)
  • Configuration: irregular
  • Color: red (Arunna Varnam)
  • Texture: rough (Khara Sparsham)
  • Symmetry: symmetrically distributed
  • Distribution: ventral and dorsal aspect of trunk, hands, and legs (Sarva Shareeram)
  • Nails: unaffected
  • Mucosa: unaffected
  • Swelling: absent

Investigations

Blood routine and liver function test results were within the normal limits.

Skin Biopsy

Biopsy was taken prior to the visit to our hospital, which confirmed the case as psoriasis.

Assessment

Parameters

Parameters such as the Psoriasis Area Severity Index (PASI), Dermatological Life Quality Index (DLQI), and visual analogue scale) (VAS) score to assess pain were also evaluated prior to admission. Primary findings were: PASI, 37.4; DLQI, 11; VAS, 07.Based on the manifested symptoms and clinical findings, the case was diagnosed as Kitibha Kushta, which is characterized by reddish patches, indurated, itching, and scaling. The lesions showed remission and relapsing time intervals comparable to those of Kitibha Kushta.

THERAPEUTIC INTERVENTION

The interventions were done after ascertaining the dosha involved. The involved dosha were Vata and Kapha. It is elicited based on the presenting complaints like severe itching, pain, scaling, and dryness. The treatment was accomplished in 3 different phases:

  1. Shamana (pacifying treatment; Table 1)
  2. Shodana (purification treatment; Table 2)
  3. Shodana Rasayana (rejuvenation treatment; Table 3)

First Phase: Shamana Chikitsa (Pacifying Treatment)

The internal and external medications administered in order to bring a pacifying action are listed in Table 1. The patient was advised to avoid curd, fish, black gram, brinjal, ladies’ finger, sour, spicy food, fried items, etc. in the diet.

Table 1. Shamana medications

Sl No. Formulation Ingredients Dose Adjuvant Duration
  Guduchyadi Kashayam Decoction prepared of Tinospora cordifolia (WILLD.) HOOK.F. & THOMS. Prunus puddum (WALL.) ROXB. EX BRANDIS. Azadirachta indica A. JUSS. Coriandrum sativum L. Pterocarpus santalinus L.F. 20 mL; thrice daily before food 60 mL boiled and cooled water Day 0-2
  Kaisora Guggulu Hand-made pills prepared out of Emblica officinalis, Terminalia bellarica, Terminallia chebula, Commiphora mukul, etc. 1; thrice daily before food With hot water Day 0-2
  Vilwadi Gulika Hand-made tablets prepared out of Aegle marmelos (L.) CORREA EX.SCHULTZ, Ocimum sanctum, Pongamia pinnata (L.), Valeriana wallichi DC., etc. 1; thrice daily, after food   Day 12-13
  Histantine tablet Ayurvedic proprietary medicine in the form of tablet made out of Nardostachys jatamansi DC, Inula racemosa HOOK.F, Picrorhiza kurrora ROYLE EX BENTH, Acorus calamus L., Curcuma longa L., Cuminum cyminum L., etc. drugs 1; thrice daily after food   Day 12-13
  External application of Jeevantyadi yamaka and thiktakam ghritam Ghee prepared out of Leptadenia reticulate (RETZ.) WIGHT & ARN, Rubia cordifolia L. Berberis aristata DC, Mallotus philippensis (LAM.) MUELL.-ARG, Colchicum luteum BAKER, etc. drugs Once a day   Day 15-24
  Application of eladi gana choorna over head Powdered drugs prepared out of Elettaria cardamomum MATON, Amomum subulatum ROXB., Hydnocarpus laurifolia (DENNST.) STEUM., Saussurea lappa C.B.CL., Callicarpa macrophylla VAHL. etc. drugs Once a day   Day 15-24
  Vajrakam kashayam Decoction of drugs made of Adhatoda vasica NEES, Tinospora cordifolia (WILLD.) HOOK.F. & THOMS, Trichosanthes dioica ROXB., Solanum xanthcarpum SCHRAD & WENDL, Pongamia pinnata (L.) PIERRE etc. drugs 20 mL; thrice daily before food 60 mL boiled cooled water Day 24-38
  Manibhadra Guda (jaggery based herbal preparation) Jaggery based preparation of powders of Embelia ribes BURM.F., Emblica officinalis GAERTN., Terminalia chebula RETZ. & WILLD, Operculina turpethum (L.) S. MANSO Etc 1 and half table spoon, at bedtime   Day 24-38
  Liv 52 Ayurvedic proprietary medicine made of Capparis spinosa L., Cichorium intybus L., Solanum nigrum L., Terminalia arjuna (ROXB.) WIGHT & ARN etc. drugs 1; twice daily after food   Day 24-38
  Sarivadyasavam Self-fermented liquid made of Hemidesmus indicus (L.) SCHULT, Cyperus rotundus L., Symplocos racemosa ROXB. Ficus benghalensis L. Ficus religiosa L. Hedychium spicatum BUCH.-HAM., Prunus cerasoides D.DON, Coleus vettiveroides K.C. JACOB etc. drugs 25 mL; thrice daily after food   Day 26-38
  Dushivishari gulika Hand-made pill prepared out of Piper longum L., Scindapsus officinalis SCHOTT., Cymbopogon martini (ROXB.) WATS, Nardostachys jatamansi DC., Symplocos racemosa ROXB., Elettaria cardamomum MATON, Tribulus terrestris L., Oroxylum indicum (L.) VENT., Glycyrrhiza glabra L., red ochre, etc. 1; thrice daily after food   Day 26-38
  External application of Tiktaka ghṛtam (medicated ghee) Trichosanthes dioica ROXB., Azadirachta indica A. JUSS., Picrorhiza kurroa ROYLE EX BENTH., Berberis aristata DC,. Cissampelos pareira L., Alhagi pseudalhagi (BIEB.) DESV., Fumaria indica PUGSLEY, Andrographis paniculata (BURM.F.)WALLICH EX NEES., Holarrhena anthrice dailyysenterica (ROTH.)A.DC., Piper longum L. etc., herbs processed with ghee Once daily   Day 25-45

Second Phase: External Therapies and Shodhana Chikitsa (Purification Therapy)

Vamana (emesis), Virechana (purgation), and Raktamokshana (bloodletting) was planned for the purification of the body. As a part of the preoperative procedure, pachana (carminative therapy) using kashaya dhara (pouring of medicated decoction over the body), oleation therapy (both internal and external), and sudation therapy were performed. The entire course of the treatment is listed in Table 2.

Table 2. Shodana therapies

Sl. No. Procedure Medication Dose Duration
1. Kashaya dhara (pouring of medicated decoction over the body) Decotion made of Cassia fistula L., Curcuma longa L., Hemidesmus indicus (L.) SCHULT Approx. 5 L/d Day 0-2
Decotion made of Emblica officinalis GAERTN., Terminalia bellerica ROXB., Terminalia chebula RETZ. & WILLD. Day 12-13
Decotion made of Cassia fistula L., Curcuma longa L., Hemidesmus indicus (L.) SCHULT Day 26-32
Decotion made of Ficus racemosa L., Ficus religiosa L., Ficus bengalensis L., Santalum album L. Day 35-37
2. Snehapana (internal administration of medicated ghee in increasing dose) Ghee prepared out of Tribulus terrestris L., Solanum melongena L., Desmodium gangeticum (L.) DC., Aegle marmelos (L.) CORREA EX. SCHULTZ Cedrus deodara (ROXB.) LOUD, etc. Starting with 30 mL on first day and increased to 230 mL on the fifth day. Day 3-7
Ghee prepared out of Tribulus terrestris L., Solanum melongena L., Desmodium gangeticum (L.) DC., Aegle marmelos (L.), CORREA EX. SCHULTZ, Cedrus deodara (ROXB.) LOUD etc. Starting with 30 mL on first day and increased up to 210 mL on the fifth day. Day 14-18
Ghee prepared out of Tribulus terrestris L., Solanum melongena L., Desmodium gangeticum (L.) DC., Aegle marmelos (L.) CORREA EX. SCHULTZ, etc. Starting with 30 mL on first day and increased to 210 mL on the fourth day (final) Day 39-42
3. Abhyanga (whole body oil massage) and steam fomentation Terminalia chebula RETZ. & WILLD., Emblica officinalis GAERTN., Cyperus rotundus L. oil, etc.   Day 8-9
Ghee prepared out of juice of Emblica officinalis GAERTN, Cassia fistula L., Curcuma longa, etc. Day 43-45
4. Vamana (emesis therapy) Medicine mix with paste of purified Randia dumetorum LAM, Acorus calamus L., rock salt, honey, etc. Approx. 15 g in a single dose made to drink Day 9
5. Raktamoksham (bloodletting) Siravyadha (venesection) using syringe needle 60 mL blood was removed Day 14
50 mL blood was removed Day 23
6. Utsadana (powder massage)<!--Para Run-on--> Ghee prepared of juice of Emblica officinalis GAERTN, Cassia fistula L., etc. mixed with powder of Curcuma longa   Day 19-20
Rubia cordifolia L., Vateria indica L., Hemidesmus indicus (L.), SCHULT, bee’s wax, oil, etc. Day 23-25
7. Virechana (purgation therapy) Manibhadra guda prepared of Embelia ribes BURM.F, Emblica officinalis GAERTN, Terminalia chebula RETZ. & WILLD. Jaggery, etc. 50 g of manibhadra guda mixed with 50 mL of juice of Vitis vinifera L. Day 21
Manibhadra guda prepared of Embelia ribes BURM.F, Emblica officinalis GAERTN, Terminalia chebula RETZ. & WILLD. Jaggery, etc. 30 g Day 33
Manibhadra guda prepared of Embelia ribes BURM.F, Emblica officinalis GAERTN, Terminalia chebula RETZ. & WILLD. Jaggery, etc. 60 g of manibhadra guda mixed with 50 mL of juice of Vitis vinifera L. Day 45

Third Phase: Rasayana Prayoga of Manibhadra Guda (Rejuvenation)

In skin disorders, shodana for elimination of vitiated doshas and rasayana chikitsa for retaining the normalcy of doshas and dhatus is necessary. Manibhadra guda is an excellent combination of herbs for purgation in skin diseases having rasayana guna; hence, it acts as shodana rasayana (Table 3). In classics the quantity of the drugs and the time period for the consumption of the medicine is explained. One pala (48 g) each of powdered Vidanga sara (de-husked Beeja), Amalaki, Hareetaki, 3 pala (144 g) of powdered Trivrut should be mixed with 12 pala (576 g) of Guda. According to Sahasrayoga, the medicines should be pounded for a period of 5 Nazhika (120 minutes).

Table 3. Ingredients and rasapanchaka of dravyas in manibhadra guda

SL No Dravyas Botanical name Part used Rasa Guna Veerya Vipaka Karma
1 Vidanga Embelia ribes BURM.F. De-husked Beeja Katu, Kashaya Lagu, Rooksha, Theekshna Ushna Katu Deepana, Vishahara, Krimihara, Kushtahara
2 Amalaki Emblica officinalis GAERTN Phala Lavana varjita pancha rasa Guru, Rooksha Sheeta Madhura Tridoshahara, Kushtahara, Vayastapana, Rasayana
3 Hareetaki Terminalia chebula RETZ. & WILLD. Phala Lavana varjita pancha rasa Laghu, Rooksha Ushna Madhura Tridoshahara, Kushtahara, Anulomana, Rasayana, Hrudya,
4 Trivrt Operculina turpethum (L.) S. MANSO Moola Katu, Tiktha Laghu. Rooksha, Theekshna Ushna Katu Kapha Pitta Hara, Rechana, Krimihara
5 Guda Jaggery   Madhura Laghu, Snigdha Ushna Madhura Agnideepana, Tridoshahara

For the treatment of this case, Manibhadra Guda was prepared according to classical reference. In the market, the ingredients Amalaki and Hareetaki are available as dried phala, Vidanga as Beeja and Trivrut as dried moola. Dehusking of the Vidanga Beeja was done in order to obtain the sara (essential part) that was needed for the preparation. After that all the ingredients were separately powdered and filtered using a sieve of appropriate mesh size. The solidified guda was powdered and mixed with other drugs. This sample was then pounded for about 4 hours until it became a homogenous mixture. The mixture of medicine thus prepared was in a wet powder consistency that possessed a blend taste of sour and sweet. The total mixture was then weighed and divided for 30 days, which gave a measurement of approximately 28 g per day. It was then packed in 30 different sachets and was given to the patient to be consumed for a period of 1 month on an empty stomach.

Follow-Up and Outcomes

There was arrest in the progression of erythematous patches, scaling, and itching during the time of discharge itself. On the first follow-up there was complete absence of scales, and occasional itching was present. By the second follow-up the patient was completely cured of the condition with no patches, scales, or itching. During the time of snehapana, factors such as scaling, itching, and number of patches increased, but all these parameters showed marked reduction after shodana karma. The PASI score and the DLQI score explain this stupendous change. Photographs were taken during and after the treatment for records.

Outcome measures (Assessment before and after treatment)

  • Itching: severe to subsided
  • Scaling: severe to subsided
  • Thickness: severe to subsided
  • Redness: moderate to subsided.
  • PASI: 37.4 to 00.
  • DLQI: 11 to 00.
  • VAS: 07 to 00.

DISCUSSION AND CONCLUSION

The disease Kushta (skin diseases) is one among the Ashtamahagada (8 great disorders) and santarpanajanya vyadhi (diseases of over nutrition). The vitiation of the tridoshas and saptha dhatu (bodily tissues) occurs in kushta. Ayurveda explains mainly 18 types of skin diseases under 2 categories named Maha Kushta (major skin diseases) and Kshudra Kushta (minor skin diseases), based on severity in their manifestations. Each one among the major categories is further explained in detail with the dosha involvement and skin appearances. Because of the prolonged nature of the disease along with the involvement of the deeper dhatus and predominance of doshas, Shodhana is the first and foremost line of treatment in Kushta. Repeated Shodana, depending on the predominance of doshas and strength of the patient, is to be done, as per the advice put forward by acharyas. The disease psoriasis is mainly compared with either Eka kushta, Sidhma Kushta, or Kitibha Kushta, which are of Vata-Kapha in origin. The scaly, rough, erythematous patches associated with severe itching are the characteristic features of Kitibha Kushta, and the case was diagnosed as it is.

In this present case the dosha involvement was assessed by specific features of dosha involvement that is Vata and Kapha, which produces severe itching, scaling, and erythematous patches. In the contemporary system of medicine this is referred to as erythrodermic psoriasis. Because the person has already done skin biopsy, no further investigations other than blood investigation were done in terms of western biomedicine.

The treatments adopted were purely based on the Ayurvedic principles. In bahudosha avasta (excessively aggravated doshas) Shodhana is the main line of treatment. Because kushta is a bahu dosha avasta vyadhi and repeated shodana is the treatment principle told in classics, we have adopted the same here also. For the elimination of Vata dosha, sarpi pana (ghee intake) was done, Kapha dosha was eliminated through emesis, and purgation was done for the elimination of the same. Also, during the course of treatment patient complained of pain over the flanks, which was managed with the application of unctuous drugs. It indicated that the pain was due to vata dosha, which might have been vitiated due to continuous shodana. After the shodana procedure, to remove the excess doshas and to bring about a rejuvenating effect to body shodana rasayana was administered with Manibhadra guda prayoga. This case highlights the importance of assessments of doshas, and the measures to be adopted accordingly will help us to manage the diseases, irrespective of however chronic it is.

In Ashtanga Hridaya, kushta chikitsa chapter, rejuvenation is explained after purification therapy. From this it is easily understood that Shodana karma is very much essential before Rasayana prayoga. The samshodana karma produces an effect of detoxification of the body and the mind. Acharya compares this detoxified body and the healthy mind to a clean cloth that is ready to absorb the color in which it is been dipped, unlike a soiled cloth, which looks soiled even after coloring with the best colors. Therefore, the use of Manibhadra guda helps in imparting the maximum effect of the formulation over the patient.

As per the current practice, Manibhadra guda is manufactured in the form of lehya (linctus), which is contrary to its preparation, as explained in the classics. During the preparation of lehya, the drugs come in constant contact with fire. Properties such as sara (to flow) guna and the drava (liquidity) guna of guda are lost because of the action of agni. Therefore, the lehya does not yield the desired effect of shodana. According to acharya susruta, sara guna is one of the inevitable properties of a purgative drug. This is mainly done in order to increase the shelf life of the preparation.

In the classical preparation of Manibhadra guda, the medicine does not encounter with agni (fire); therefore, the inherent qualities of the drugs such as sara guna and drava guna are preserved. Therefore, the administration of this rasayana helps in the repeated Shodana without hampering the strength of the patient. This medicine is said to be consumed for a period of 1 month for its full action to take place, making the medicine satmya to the patient. Therefore, along with rasayana guna of the dravyas, an added benefit of shodhana is also obtained. Thus, it is possible that a new concept of Shodana rasayana is explained.

While looking into the drugs used in the preparation of Manibhadra guda, it is possible to classify the drugs into 2 essential groups: those drugs having the shodana effect (which are kushtahara) and those that are rasayana in nature. While considering the drug Vidanga, Acharya Susruta has explained this as an inevitable drug for the preparation of various medicines for Kushta. Amalaki and Hareetaki are both drugs having kushtahara effect. These 2 drugs are also considered to be good rasayana dravyas. Drug Trivrut is considered as an excellent virechana (purgative) drug according to classics. In Charaka kalpa stana acharya explains that trivrut can be used along with many other drugs in order to cure a lot of diseases. This can be corelated to the rasayana effect of the drug. Therefore, while summarizing all the above facts it can be concluded that Manibhadra guda can act as a very good Kushtahara and rasayana medicine.

In this diagnosed case of kitibha kushta, based on the dosha analysis, vata kapha hara line of treatment was adopted. Both internal and external purification along with wholesome diet and rasayana therapy were found to be effective in the termination of the disease. The adopted treatment modalities were completely based on Ayurvedic principles. All other associated signs and symptoms resolved completely with no signs of relapse.

The entire course of treatment for the patient was up to 45 days of hospital treatment and 1 month of rasayana prayoga. When the patient started to consume manibhadra guda, he was having an increased bowel activity of about 8-9 vegas (bout), which was loose in nature, for about 1 week. As days passed, the bowel urge kept on reducing, and during the final days of having manibhadra guda, his bowel activity was reduced to 2 per day (morning and at night), and the nature of bowel was normal. The patient has attained precisely 82.67% of relief during the time of discharge. The silvery scales, redness, itching was reduced. When the patient came for his first follow-up visit, there was complete remission of the disease. Parameters such as PASI, DLQI, and VAS Score was calculated to be 0. Here we can say that the shodana effect of the medicine helped to expel the residual morbid doshas from the body, whereas the rasayana effect helped to bring back the normalcy of the doshas.

PHOTOGRAPHS

The photographs of lateral aspect of the body (Figure 1), anterior trunk (Figure 2), and anterior aspect of the lower limbs (Figure 3) of the patient was collected at the time of admission, at the time of discharge and at the first follow up. They are as follows:-

tpj20221f1

Figure 1. Lateral aspect of body.

tpj20221f2

Figure 2. Anterior aspect of body.

tpj20221f3

Figure 3. Anterior aspect of lower limbs.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Author Contributions

V.S.A. participated in patient care, drafting, literature review and submission of the final manuscript; P.V.S.A. participated in direct patient care, review and editing of the manuscript; C.K.B.P. participated in review and editing of the manuscript; all authors have given final approval of the manuscript.

Funding

None

Author Affiliations

1Department of Panchakarma, Amrita School of Ayurveda, Vallikavu, Kerala

2Department of Panchakarma, All India Institute of Ayurveda, An autonomous organization of Ministry of AYUSH, Government of India Mathura Rd, Gautampuri Awas, Sarita Vihar, New Delhi, Delhi, India

Corresponding Author

Puthanmadom Venktramana Sharma Anandaraman, MD (Panchakarma), PhD (dr.ananthramsharma@gmail.com)

Informed and Photographic Consent

Written consent was obtained from the patient for publication of this case report.

References

1. World Health Organization. Psoriasis; 2016. Accessed July 27, 2018. www.who.int

2. Mattei PL, Corey KC, Kimball AB. Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI): The correlation between disease severity and psychological burden in patients treated with biological therapies. J Eur Acad Dermatology Venereol 2014 Mar;28(3):333-7. Accessed July 19, 2018. http://www.ncbi.nlm.nih.gov/pubmed/23425140

3. Patel JR, Bhatted S. A comparative study on Vamana Karma with Madanaphala and Krutavedhana in Ekakushtha (Psoriasis). Ayu 2011 Oct;32(4):487–93. Accessed July 19, 2018. http://www.ncbi.nlm.nih.gov/pubmed/22661842

4. Navoday Raju N, Kamalakar PS, Deepika S, Tripathy TB. Management of kitibha kushta (psoriasis): A case study. Int J Res Ayurveda Pharm 2017 Mar;8(1):72-76. Accessed July 27, 2018. www.ijrap.net

5. Vagbhata. Chikitsasthana. In: Ashtanga Hridayam with commentaries of Ayurveda Rasayana by Hemadri and Sarvanga Sundara by Arunadatta, Vaidya HP, editor. Varanasi: Chaukamba orientalia: 2010; 19/96; p 718.

6. Mehta C, Dave A, Shukla V. Comparative effect of Navayasa Rasayana Leha and Medhya Rasayana tablet along with Dhatryadhyo Lepa in Ekkushtha (psoriasis). AYU (An Int Q J Res Ayurveda 2013 Jul-Sep;34(3):243. Accessed July 19, 2018. http://www.ayujournal.org/text.asp?2013/34/3/243/123103

7. Bismi HB, Sharma AR, Prathibha CK. Manibhadraguda shodhana rasayana in psoriasis, best practices in Panchakarma by group of authors. Wardha: Datta Meghe Institute of Medical Science: 1st Edition: 2017; p 79-92.

Keywords: Ayurveda, Manibhadra Guda, Psoriasis, Shodhana, Vamana

Abbreviations: PASI = Psoriasis Area and Severity Index; DLQI = Dermatological Life Quality index; VAS = Visual analogue Scale

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