Abstract
Introduction
Palmo-plantar Psoriasis is a non-infectious chronic inflammatory disease of the skin bounded to the palm and soles in extent. In Ayurveda, all skin diseases are recounted under a single rubric i.e., Kushtha (skin diseases); PPP (Palmo-plantar Psoriasis) may be correspondent with Vipadika (one of the Kshudra Kushtha described in Ayurveda), based on its clinical sign & symptom.
Objectives
The role of Ayurvedic regimen in Palmo plantar psoriasis.
Methodology
Here we are presenting a case of 68-year-old man with a long 8-year history of pruritic rashes on his both palms and soles which was diagnosed as Palmo-Plantar Psoriasis (Vipadika) and successfully managed with simple Ayurveda medicines, external application of Jivantyadi Yamaka, external washing with Triphala decoction and 3 sitting of Jalaukavacharana (Leech Application).
Result
The patient reported a significant improvement in the complaints of itch and rash, on the scale and erythema of the palms and soles in a span of about 3 weeks.
Conclusion
We, therefore, recommend the treatment of Palmo –plantar Psoriasis starting with leech application along with oral and external Ayurveda medication, and results can be seen.
Keywords: Palmo-plantar psoriasis, Vipadika, Kshudrakushtha, Jalaukavacharana (leech application), Case report
1. Introduction
Healthy skin is a mirroring of general healthiness. Skin, the largest organ of the body is also considered elegant in society. Any disease related to the skin not only affects the patient semantically but also muddles the rational and collective health of the forbearing, as the mien of the patient may be mortifying. Palmo-plantar psoriasis (PPP) (L 40.3) is a common chronic immune-mediated, inflammatory, proliferative, non-communicable disease of skin influencing people who are genetically predisposed with habitat having a crucial role in pathogenesis [1]. The prevalence of Psoriasis imprecisely ranges between 2 and 3% worldwide [2]. In India, the prevalence of psoriasis also varies from 0.44 to 2.88% [2]. There are many treatment manners accessible but since its chronic relapsing nature [3], Palmo-plantar psoriasis is a challenge to treat. Modern medical science treats psoriasis with PUVA (Psoralen plus ultraviolet-A radiation) along with corticosteroids and immuno-modulators [4]. The treatment alternatives accessible in modern medicine are associated with side effects with recurring setbacks [5] (see Table 1, Table 2, Table 3)
Table 1.
Treatment protocol.
| S.no. | Medicine | Dose | Anupana | Schedule | Duration of Medicine | Leech Application | Time |
|---|---|---|---|---|---|---|---|
| 1 | Avipattikar churna | 5 g | Lukewarm water | Twice a day before food | 02/05/22 to 21/05/22 | 04/05/22 | 25min |
| 2 | Guduchi churna | 3 g | Lukewarm water | Twice a day before food | 06/05/22 | 25min | |
| 3 | Haridra khanda | 10 g | Lukewarm milk | Twice a day after food | 08/05/22 | 25min | |
| 4 | Arogyavardhini vati | 2 tablets of 500 mg | Lukewarm water | Thrice a day, after food | |||
| 5 | Jivantyadi yamaka | For external application | - | - | 02/05/22 to 30/05/22 | ||
| 6 | Decoction ofTriphala Kwatha | For external application | - | - | 02/05/22 to 30/05/22 | ||
Table 2.
Assessment criteria for clinical features and observations.
| S.No. | Clinical features | Score | BT | AT | FU |
|---|---|---|---|---|---|
| A | Sphutan (Scaling of skin) | 4 | 2 | 0 | |
| 1 | Insignificant dryness at the foot/palms | 0 | |||
| 2 | Roughness is present when touching | 1 | |||
| 3 | Excessive roughness presents and leads to itching | 2 | |||
| 4 | Excessive roughness presents and leads to slight cracks | 3 | |||
| 5 | Roughness leads to cracks and fissures | 4 | |||
| B | Kandu (Itching) | 3 | 2 | 1 | |
| 1 | No itching | 0 | |||
| 2 | 1-2 times a day | 1 | |||
| 3 | Frequent itching | 2 | |||
| 4 | Itching disturbs the sleep | 3 | |||
| C | Pani-padasphutana (Fissures/cracks) | 4 | 1 | 0 | |
| 1 | No cracks | 0 | |||
| 2 | Cracks on the palm or sole only | 1 | |||
| 3 | Cracks on palm and soles | 2 | |||
| 4 | Cracks on complete foot and complete hand | 3 | |||
| D | Vedana (Pain) | 3 | 2 | 1 | |
| 1 | No pain | 0 | |||
| 2 | Mild pain of easily bearable nature; comes occasionally | 1 | |||
| 3 | Moderate pain, but no difficulty | 2 | |||
| 4 | Appears frequently and requires some measures for relief | 3 | |||
| 5 | Pain requires medication and may remain throughout the day | 4 | |||
BT-Before treatment.
AT- After treatment (at the time of discharge).
FU-Follow Up (after 1 month of discharge).
Table 3.
| Sr.No | Constituent | Function |
|---|---|---|
| 1 | Bdellins | Anti-inflammatory inhibits plasmin |
| 2 | Hyaluronidase | Antibiotic action |
| 3 | Hirustastin | Analgesic and Anti-inflammatory |
| 4 | Eglins | Anti-inflammatory |
| 5 | Acetylcholine | Vasodilator |
| 6 | Hinstamine-Like | Vasodilator |
| 7 | Ghilantens | Analgesic and Anti-inflammatory |
| 8 | Eglin C, | Analgesic and Anti-inflammatory |
| 9 | Guamerin And Piguamerin | Analgesic and Anti-inflammatory |
| 10 | Tryptase Inhibitor | Analgesic and Anti-inflammatory |
| 11 | Kinins | Analgesic, relive itching |
But according to Ayurveda, it's unfurling because of the inapt way of living such as dietary patterns and tensity. Ayurveda treatments are nature-based and devoid of side effects and the chances of relapse are low. Hence, it is a need of time to search out a safe and effective medicine for the complete cure of psoriasis, and here comes the role of Ayurveda. Acharya Charaka mentioned that all skin diseases (Kushthas) are Tridoshaja (Bodily Humors) in nature [6]. Palmo-plantar psoriasis is one such disease that can't be correlated exactly with any disease mentioned in Ayurveda but to a certain extent based on its symptoms, it can be correlated with Vipadika (AAB-90-Charaka) which is one of the types of Kshudra Kushtha (Minor skin diseases) [7]. It involves predominantly Vata and Kapha dosha [8] (bodily humor), vitiation of Rakta Dhatu (blood) and is characterized by Pani-Pada Sphutan (Fissure in palm and soles) and severe pain (Teevra Vedana) [7]. Acharya Vagbhat added another sign of red patches over the palm and sole [9]. Palmoplantar Psoriasis (PPP) remains a difficult dermatologic disorder to treat, even in the age of biologics. This condition causes significant morbidity that can interfere with a patient's ability to work and carry out routine activities. We present a case of Palmo-plantar Psoriasis in which a patient has shown an excellent response by combining of Ayurvedic oral medication, external application, and Leech Application proving the novelty of evidence.
2. Patient information
A 68-year-old man came to the OPD of All India Institute of Ayurveda, New Delhi on 02/05/2022 with a long 8-year history of pruritic rashes on both his hands and legs and was previously diagnosed as “eczema” by an outside physician. He used triple antibiotic ointment in the past without any significant improvement before he visited Ayurveda hospital. He had no significant family history, past medical and psychological history.
3. Clinical findings
On examination, scaly, ill-defined erythematous plaques on the soles and palms were noted. To confirm a case of Palmoplantar Psoriasis differential diagnoses were made-
3.1. Differential diagnosis
Differential diagnosis.
| Palmoplantar Psoriasis | Dyshidrotic Eczema | Allergic contact Dermatitis |
|---|---|---|
| Itching-moderately itchy. Scratching results in bleeding | Itching-mild to moderate. Scratching results in oozing |
Very itching, scratching results in oozing |
| Nail changes-typical | Nail changes-variable | Nail changes-variable |
| No vesicles | Deep-seated pruritic vesicles. | Pruritic vesicular eruption |
| Smoking history | Not relatable | Not relatable |
3.2. Differential diagnosis as per ayurveda
Vipadika (Palmo-Plantar Psoriasis) can be differentiate from Padadari [10] as per Doshik dominance, symptom, cause and affected areas. Vipadika caused by Vata-Kapha where Padadari is due to only Vata. Ruja (pain), Srava (discharge), Kandu (itching) are seen in Vipadika where only Ruja (pain) seen in Padadari. Both hands and feet are affected in Vipadika where only the foot is affected by Padadari.
4. Diagnostic assessment
The investigations were done before starting the treatment which included Absolute Eosinophil Counts (AEC)- 913 cells/μL and immunoglobulin E (IgE)- 1000 IU/ml.
5. Therapeutic intervention and timeline
5.1. Application of Leech therapy
Primarily a Leech was placed on the affected site of the palm and sole and observed for two minutes (to allow the leech to suck the blood from the site), a wet cotton Gauze was placed over the body of the leech to provide moisture to the leech. After 15 minutes, the leech detached from the site after sucking the blood. A piece of cotton gauze was placed over the site of the bite to avoid further bleeding of the affected part. This procedure was performed for three sittings without any complications.
5.2. Ayurvedic medication
The patient was first put on Leech therapy with Ayurvedic oral medication (Table no.1) and cleaning with the decoction of Triphala along with the daily external application of Jivantyadi Yamaka (Herbal Medicated Ghee) to the palms and soles.
6. Outcome & follow up
The patient was under close observation in the In-Patient Department of All India Institute of Ayurveda, for eight days and no side effect was reported.
The patient noted a good improvement since there was a reduction in the scaling of the skin, itching, and erythema on his palm and sole and a significant reduction in Absolute Eosinophil Counts (AEC) from 913 cells/μL (5/5/2022) to 534 cells/μL (9/5/2022) and further to 108 cells/μL (31/5/2022) indicating significant decline (88.2%) in AEC. Similarly, the immunoglobulin E (IgE) levels declined from 1000 IU/ml to 992 IU/ml further to 820 IU/ml over the same duration.
At the time of discharge, the patient reported a significant improvement in the complaints of itch and rash of his palms and soles, and a substantial improvement in the scale and erythema of the palms and soles was observed on examination, and complete relief after 1 months follow up (Table no.2) Even after one-month visit and telephonic communication during 2 months’ follow-up no side effect was reported by the patient.
7. Discussion and conclusion
Palmoplantar psoriasis remains a debilitating skin disorder. The present case report of a patient who was misdiagnosed in allopathy as a case of eczema and remained on treatment for long eight years without any noticeable benefits, was diagnosed as a case of Palmoplantar psoriasis (PPP) which can be correlated with Vipadika described in Ayurveda as one of the Kushtha (Skin Disease). Looking into the age, Bala (Strength) of the patient and severity of the sign and symptoms, Nitya Mridu Virechana was planned by giving Avipattikar Churna as it is mentioned in the classics that Alpaalpa Punah: Punah: Shodhana [11](repeated little by little cleansing) in the context of Kushtha, and Shodhana should be done with due care of Prana (vitality) as it is mentioned for Shodhana (purification) application in Kushtha – “Bahusho Anurakshata Pranan” [12] (with due care of vitality). Considering the Rakta (vitiation of Rakta) and Pitta Dushti (vitiation of Pitta) and to provide immediate relief from suffering, Raktamokshana with Jaloukavacharana was done.
The patient was first exposed to three sittings of Leech Application to suck out the vitiated blood and additionally oral Ayurveda medicines, external application of Jivantyadi Yamaka and external washing with Triphala decoction (Table no 1). Leech saliva is rich in both analgesics and anti-inflammatory actions (Table no.3). Jivantyadi Yamaka [13] (medicated ghee) is a special Ayurvedic medicine where two fats are used in the preparation. Here sesame oil and cow ghee are used as a base. Thus, this herbal preparation contains oil soluble and water soluble phytoactive principles of medicinal herbs and some standard oral Ayurveda medicines like Avipattikar Churna [14], Guduchi churna [15] & Arogyvardhani Vati. [16] All are Raktashodhak (blood purifier) and Pittarechak (eliminating the excess of pitta) and Mala Shodhaka (eliminating metabolic wastes). All of these are assumed to be causative factors for palmoplantar psoriasis. In Ayurveda Haridra Khanda [17] is one of the well-known formulations to treat allergic manifestation, as the clinical presentation of the patient was with rashes and raised AEC, hence it was also used. One can see Fig. 1 and observe clear improvements in clinical conditions between 4/5/22 to 30/05/22 - in about 3 weeks. Based on the findings of this study, our recommendation for treating Palmoplantar Psoriasis is to initiate the use of leech application in conjunction with oral and external Ayurveda medication. Positive results have been observed with this approach. Although, the benefit of leech applications has been reported in situations of nevus of Ota [18] and Vicharchika [19] but no reference could be located in the literature where in leech application is done in Vipadika. Therefore, the present case report may be the first time on the subject.
Fig. 1.
Application of leech.
7.1. Strength of the study
Given the challenging nature of treating skin diseases, this study could serve as a treatment protocol for patients with palmoplantar psoriasis, as it has demonstrated positive outcomes in alleviating symptoms such as cracks, pain, itching, and disfiguration, with no reported side effects. Further research can be carried out with a series of cases with the same treatment plan for confirmation, and this can also be adopted in other skin diseases having the same features. The treatment is affordable and accessible in terms of cost.
8. Patient perspective
The patient expressed great contentment with a treatment that was cost-effective and required less time. Features like scaling, itching, cracks, and pain, have shown marked relief making the patient socially and semantically confident.
Author contribution
Concepts, literature search-SK, HS, HK Design- SK, HS, HK, Application of Leech- HS, HK, Manuscript preparation- HS, HK Manuscript editing- SK, AK, Other.
Source of funding
None.
Conflict of interest
None.
Acknowledgements
The authors thank Director All India Institute of Ayurveda, New Delhi for support.
Footnotes
Peer review under responsibility of Transdisciplinary University, Bangalore.
Appendix.
Mode of Action of internal medicines.
Internal medicines, their contents and mode of action.
| S.No. | Medicine | Contents | Mode of Action |
|---|---|---|---|
| 1 | Arogyavardhini vati | Loha (Calcined iron) Abhrak (Biotite mica), Tamra (Incinerated copper), Shilajit (Asphaltum), Guggul (Commiphora wightii), Indian bdellium-tree, Chitrak (Plumbago zelaynica), and Kutki (Picrorhiza kurroa), Triphala, Kajjali, Nimba Patra Swaras. (Neem leaves’s juice) | These drugs have Pachak (Digestive), Dipak (appetizer), Vishaghna (Antitoxic), and Jantughna (Antimicrobial) effects. It is mentioned as the best medicine for skin diseases. |
| 2 | Guduchi Churna | Guduchi (Tinispora cordifolia) | It is anti-inflammatory, antioxidant, hepatoprotective, antiallergic, and immunomodulatory activities. Guduchi is known for its detoxifying, rejuvenating, immune-supporting properties. |
| 3 | Haridra khanda | Haridra (Curcuma longa) Shunthi (Zingiber officinale) Maricha (Piper nigrum) Pippali (Piper longum) Twak (Cinnamomum zeylanica) Ela (Elettaria cardamomum) Tamala patra (Cinnamomum tamala) Vidanga (Embelia ribes) Trivrita (Operculina turpethum) Haritaki (Terminalis chebula) Bibhitaki (Terminalia bellirica) Amalaki (Emblica officinalis) Nagkesara (Mesua ferrea) Musta (Cyperus rotundus), Sugar | All the drugs have properties to control the allergic condition and improve Vyadhikshamatva (immunomodulatory). |
| 4 | Avipattikar churna | Shunthi (Zingiber officinale), Maricha (Piper nigrum), Pippali (Piper longum), Haritaki (Terminalia chebula), Vibhitaka (Terminalia bellerica), Aamalaki (Emblica officinalis), Musta (Cyperus rotundus), Vidanga (Embelia ribes), Ela (Amomum subulatum), Patra (Cinnamomum tamala), Lavanga (Syzgium aromaticum), Trivrit (Operculina terpethum) and Sharkara (Sugar candy), salt (Vida Lavana), | Antacid, Appetizer, Carminative, Digestive, Stimulant Antioxidant, Anti-inflammatory. |
| 5 | Jivantyadi yamaka | Jivanti, Neem, Karela, Triphala, Giloy | It has antipruritic and soothing action which helps to promote healing of lesions. It is also an antioxidant, which is used in many skin infections and helps the body to get rid of harmful blood toxins responsible for various diseases. |
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