|Year : 2012 | Volume
| Issue : 2 | Page : 224-229
Clinical efficacy of Shodhana Karma and Shamana Karma in Mandala Kushtha (Psoriasis)
Gunjan Mangal1, Gopesh Mangal2, Radhey Shyam Sharma3
1 Lecturer, Department of Swasthavritta, Sri Shirdi Sai Baba Ayurvedic College, Renwal, Jaipur, Rajasthan, India
2 Lecturer, Post Graduate Department of Panchakarma, National Institute of Ayurveda, Jaipur, Rajasthan, India
3 Vice Chancellor, Rajasthan Ayurveda University, Jodhpur, Rajasthan, India
|Date of Web Publication||29-Dec-2012|
Lecturer, P.G. Department owf Panchakarma, National Institute of Ayurveda, Madhav Vilas Palace, Amer Road, Jaipur - 302002, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
In India an estimated 0.8% of the population is suffering from Psoriasis. It is a papulo-squamous disorder of the skin, characterized by sharply defined erythemato-squamous lesions. It is chronic and is well known for its course of remissions and exacerbations. The exact etiology is still unknown. This condition is comparable with Mandala Kushtha in Ayurvedic system of medicine. Shodhana procedures are reliable to control the disease. Forty patients, fulfilling the inclusion criteria, were selected and randomly divided into four groups with 10 patients in each group. In Group A, Vamana and Virechana was administered once during the trial period. In Group B, Vamana and Virechana followed by Dermo-care in the dose of 5 g twice a day for the period of 2 months. In Group C, only Dermo-care was administered. In Group D, Tab. Neotrexate (Methotrexate) 7.5 mg/week was given under the supervision of dermatologist. Marked improvement was observed in 10% of the patients in Group B. Moderate improvement was observed in 20% of the patients in Group A, 90% in Group B, and 80% in Group D. Mild improvement was observed in 80% of the patients in Group A, 100% in Group C, and 20% in Group D.
Keywords: Mandala Kushtha, Psoriasis, Shamana, Shodhana, Vamana, Virechana
|How to cite this article:|
Mangal G, Mangal G, Sharma RS. Clinical efficacy of Shodhana Karma and Shamana Karma in Mandala Kushtha (Psoriasis). AYU 2012;33:224-9
| Introduction|| |
In Ayurveda all skin diseases are categorized under "Kushtha0". Mandala Kushtha a type of Maha Kushtha is a chronic of Kushtha. Even if it is cured relapses are common. Mandala Kushtha is stated to be Tridoshaja with the dominance of Kapha Dosha. The description and characteristic features of Mandala Kushtha are nearer to Psoriasis. Hence, Mandala Kushtha can be compared with Psoariasis.
Psoriasis is chronic and well known for its course of remissions and exacerbations. Modern medical science treats psoriasis with spiraled (P) and ultraviolet A (UVA) therapy PUVA, corticosteroids, and antimitotic drugs. But these therapies are associated with serious side effects like liver and kidney failure, bone marrow depletion, etc. ,
Panchakarma therapy of Ayurveda has attracted attention of the people worldwide as it is an unique sort of treatment of various chronic, auto immune, hormonal, degenerative disorders, etc., where other sorts of treatments have no satisfactory answer. Acharya Charaka has highlighted the role of Panchakarma therapy by stating that the disease treated by Shodhana will never recur, whereas the treatment with Shamana therapy may recur in due course of time. 
In addition, if Shamana drugs are administered after proper course of Shodhana, then it provides additional relief and thus helps in eradicating the diseases completely.
Vamana Karma is the best measure for Kapha Dushti, whereas Virechana Karma is indicated not only for Pitta Dosha but also in Kapha and Rakta Dushti.
Jeemutaka (Luffa echinata) is selected for Vamana instead of Madana Phala (Randia spinosa) as it is specially indicated in Kushtha Roga. 
Considering all the above, it has been planned to evaluate comparative efficacy of Vamana, Virechana and Shamana Yoga (Dermo-care) [Table 1] in Mandala Kushtha (Psoriasis).
| Materials and Methods|| |
An open prospective clinical trial.
Patients suffering from Mandala Kushtha fulfilling the inclusion criteria were randomly selected from the Out-Patient Department (OPD) and the In-Patient Department (IPD) section of National Institute of Ayurveda, Jaipur and Girdhara Hospital and Research Centre, Jaipur. Total 47 patients were registered in the trial, out of which 40 patients were completed course of treatment.
- Patients aged between 12 and 60 years.
- Patients having the clinical features of Mandala Kushtha (Psoriasis).
- Patients aged below 12 and above 60 years.
- Patients with leprosy, tuberculosis, paralysis, and malignant diseases.
- Pregnant women and lactating mothers.
- Patients with systemic disorders viz. uncontrolled hypertension, cardiac problems, diabetes mellitus, etc.
- Patients who are on steroids.
Plan of study
Registered patients were equally categorized in to four groups (10 in each group).
Group A: Vamana and Virechana
Group B: Vamana and Virechana followed by administration of Dermo-care (Anubhuta Yoga)
Group C: Only Dermo-care
Group D: Tab. Neotrexate (Methotrexate 7.5 mg/week)
Posology and duratrion of treatment
- The trial drug, Dermo-care [Table 1] - For the present clinical research work, a hypothetical indigenous herbo-mineral compound is prepared in Churna (powder) form was administered 5 g after meal, twice a day with potable water for a period of 2 months.
- Standard control drug, Tab. Neotrexate (Methotrexate) 7.5 mg/week (2.5 mg for three times at 12 hourly - 8 pm-8 am-8 pm/week) with potable water for 2 months. The drug was administered under the supervision of a dermatologist.
- Follow up was done for 2 months at regular interval of 15 days.
- Koshtha Pareeksha was done with Triphala Churna (10 g) in morning with luke warm water for 1 day.
- Deepana, Pachana with Panchakola Churna (5 g) twice a day for 2 days or till appearance of Nirama Lakshana.
- Snehapana : Panchatikta Ghrita was administered for the purpose of Snehapana orally.
- Abhyanga and Swedana – Sarvanga Abhyanga by Dashamoola Tail and Sarvanga Swedana by the Dashamoola Kwatha was done.
- Patients were asked to drink Ksheera (milk) till Akantha Purana is obtained. Approximately 2-3 l is needed to observe the signs and symptoms of Akantha Purana.
- Administration of Jeemutaka Phala (12 fruits) Kwatha with 2 g of Vacha (Acorus calamus), 1 g of Saindhava (Rock salt) and 30 g of Madhu (Honey) as Vamana Yoga.
- About 2-3 l of Vamanopaga Dravya i.e. Yashtimadhu Phanta (hot infusion of Glycerrhiza glabra) was given, followed by administration of Lavanodaka (rock salt water).
- Dhoompana was done with Dashamoola Churna through the mouth for 3-4 puffs.
- Vamana Karma was followed by Samsarjana Karma as per the type of Shuddhi.
This is same as Vamana Karma except that Koshtha Pareeksha, Deepana-Pachana, and Kaphotkleshakara Ahara, which is not done in Virechana Karma, whereas Abhyanga and Swedana were done for 3 days.
The Virechana Yoga [decoction made up of 15 g each of Aragvadha (Cassia fistula), Draksha (Vitis vinifera), Haritaki (Terminalia chebula) +4 g Katuki Churana (Picrorhiza kurroa) +30 ml Eranda Taila (castor oil) +2 tablets of Abhayadi Modaka] was given in empty stomach at 8-10 am.
Paschat Karma, same as Vamana Karma except Dhoomapana. 
Criteria for assessment of results
Psoriasis Area and Severity Index  (PASI) score was considered for both subjective and objective parameters.
Totaling up the index
For each skin section, add up the three severity scores and multiply the total by the area score, and then multiply that result by percentage of the skin in that section.
The severity of PASI Parameters (scaling, erythema, and induration) and other parameters were assessed in the following manner.
The severity of Kandu (itching), Mandal Rupa (oval/round patches), Krodha (anger), Shoka, and Chinta (anxiety) was assessed in the following manner:
| Observations|| |
Maximum patients were in the age group of 20-30 years and 65% were males, 87.5% belongs to Hindu community, 85% were married and have primary level education, 55% patients had sedentary type of work, 80% were from urban area, 25% have chronicity of more than 5 years and 90% have negative family history of Psoriasis. Majority of patients, (72.5%) were taking allopathic treatment and 12.5% were taking Ayurvedic treatment. 62.5% patients have irregular bowel habits. 50% patients have Samyak Nidra and 35% have Alpa Nidra. Majority of the patients (97.5%) have gradual onset of the disease. 65% patients have Viruddha Ahara with 30% patients taking milk with Amla and Lavana Rasa. Milk with fish is reported in 7.5% and milk with onion in 10%. Chinta was the major Manasika Nidana reported by 55% patients followed by Krodha in 42.5%, and Shoka in 27.5% patients. A total of 70% reported aggravation of symptoms in winter season, 85% each have presented with the lesions o n the legs and torso, 82.5% had lesions on arms, and 75% had lesions on head. 7.5% had lesions on palm and sole and 5% had lesions on scalp. Nobody was observed to have lesions on genitals. Nearly 80% have presented with the plaque type of psoriasis, 10% having guttate psoriasis, and only 5% each having erythrodermic and pustular psoriasis. Nearly 90% have candle grease sign positive whereas Auspitz sign and Koebners phenomenon were found in 62.5% and 10%, respectively.
Sweta-Rakta Varna (faint reddish white) was observed in 87.5%, Sukla Rom-Raji Santanini (pervaded with white hairline/scale) in 85%, Kandu (itching) in 100%, Sukla Picchala Srava (thick white and slimy discharge) in 15%, Utsana Mandala (raised patches) in 87.5%, and Ananonya Sansatat Mandal (patches joined with each other) in 62.5% patients. Anubandhi Vedana like Ati Sweda (over sweating) in 2.5%, Asweda (absence of sweating) in 10%, Shareera Guruta (heaviness of the body) in 40%, Malabaddhata (constipation) in 50%, Agni Mandya (loss of appetite) in 37.5%, Suptata (numbness) in 2.5%, and Toda (pain) in 10% patients.
| Results|| |
In leg total PASI [Table 2], torso total PASI [Table 3], arm total PASI [Table 4], head total PASI [Table 5] statistically significant results were noted in all the four groups.
|Table 2: Pattern of clinical improvement in leg total PASI in patients of all the four groups|
Click here to view
|Table 3: Pattern of clinical improvement in torso total PASI in patients of all the four groups|
Click here to view
|Table 4: Pattern of clinical improvement in arm total PASI in patients of all the four groups|
Click here to view
|Table 5: Pattern of clinical improvement in head total PASI in patients of all the four groups|
Click here to view
Marked improvement in total PASI was observed in the patients of Group B is (82.70%) and Group D (79.58%), which are both statistically highly significant. Moderate improvement was observed in Group A (58.29%) and Group C (53.70%), which is statistically significant and highly significant, respectively [Table 6].
|Table 6: Pattern of clinical improvement in total PASI in patient of all the four groups|
Click here to view
On comparing the effect in all groups; it is clear that the patients from Group B showed maximum percentage relief as compared with other groups. Groups B, C, and D were statistically highly significant.
Moderate improvement in Kandu was observed in the patients of Group B (61.11%) and Group D (65.62%), which is statistically significant and highly significant, respectively. Mild improvement was observed in Group A (33.33%) and Group C (37.95%) and are mildly significant and highly significant, respectively.
On comparing the effect on all groups, it is clear that the patients from Group D showed maximum percentage relief as compared with other groups. Group C and D were statistically highly significant.
Moderate improvement in Mandala Rupa was observed in the patients of Group B (63.33%) and Group D (55.17%), which is statistically highly significant. Mild improvement was observed in Group A (35.48) and Group C (29.62%), which is statistically insignificant and highly significant respectively.
Moderate improvement in Krodha was observed in the patients of Group B (57.08%) and Group C (67.00%), which is statistically insignificant. Mild improvement was observed in Group A (42.00%) while minimal improvement in Group D (22.22%), which is significant and insignificant respectively.
Moderate improvement in Shoka was observed in the patients of Group A (54.64%), Group B (71.67%), and Group C (60.00%). Group A is statistically significant while Groups B and C both are insignificant.
Moderate improvement in Chinta was observed in the patients of Group B (61.08%), Group C (55.55%), and Group D (66.66%). Group B is statistically highly significant whereas Groups C and D are moderately significant. Mild improvement was observed in Group A (41.32%) and is insignificant.
Overall effect of therapy
- In Group A, moderate improvement was observed in 20% patients whereas mild improvement was observed in 80% patients.
- In Group B, marked improvement was observed in 10% patients whereas moderate improvement was observed in 90% patients.
- In Group C, mild improvement was observed in 100% patients.
- In Group D, moderate improvement was observed in 80% patients whereas mild improvement was observed in 20% patients.
No one was observed to have improvement/controlled or minimal/no response toward therapy in any group [Table 7].
After 1 month, 0%, 0%, 28.5%, 10% and after 2 months 25%, 20%, 40%, 37.5% recurrence was found, respectively in A, B, C, D groups.
| Discussion|| |
Changes in life style, irregularities in dietary habits became major issues in current scenario and are responsible in manifesting a number of ailments. Significance of lifestyle and diet, etc., have been well recognized in Ayurvedic classics and emphasis a following the guidelines on Dinacharya, Rutucharya in eradication of various diseases can be readily observed in them. ,,,,,
Deepana and Pachana
Panchakola Churna increases the Agni and then helps in Ama Pachana.
Snehapana with Panchatikta Ghrita as a Purvakarma subsides the symptoms like Rukshata, Daha, etc., Similarities in chemical and physiological nature in Ghrita and human cell membrane intensifies the penetration of Sneha (Panchatikta Ghrita) in to deeper tissues causing partial rejuvenation of cell, smoothing of vitiated Dosha (stagnated metabolic wastes).
Vamana and Virechana
Soothened Doshas will get liquefied and reaches to Koshtha by Swedana, which can be easily eliminated by the action of Vamana and Virechana.
Thus it is clear that the toxins or nitrogenous waste materials that are collected in lower intestinal cells are removed by Virechana and thus cleansing the lower passage and rejuvenating each and every cell of lower GIT.
These Shodhana (Vamana and Virechana) probably may leads to certain endogeneous changes in the body responsible for the alleviation of psoriatic pathological process.
Dermo-care (Kalpit Yoga)
Most of these drugs have following properties - Kushthaghna, Krimighna, Rakta Shodhana, Kandughna, Amapachana, Medhya, Rasayana, Kaphaghna, Twachya, Yakriduttejaka, Agni Vardhak, and also Tridoshaghna. The synergistic actions of Tikta and Kashaya Rasa dominant herbs and minerals are likely to check the etio-pathogenesis of Mandal Kushtha (Psoriasis) and arrest its progress.
| Conclusion|| |
Vamana and Virechana along with Dermo-Care proved more effective to control erythema of leg and arm; induration of leg, torso, arm, and head; scales of leg, torso, and head; coverage area of torso and arm; Mandal Rupa and Shoka. Only Dermo-Care is more effective to control Krodha. Neotrexate (Methotrexate) is more effective to control erythema in torso and head; scales in arm; coverage area of leg and head; Kandu and Chinta. Shodhana independently have shown much better results than the patients treated with Shamana therapy (Dermo-care yoga). Neotrexate (Methotrexate) independently have shown much better results than the patients treated with Shodhana alone or Shamana therapy (Dermo-care) alone. Shodhana followed by Shamana therapy have shown better results than the patients treated with Shodhana, Shamana therapy or modern medicine alone.
| References|| |
|1.||Meffert J. Psoriasis. Available from: http://emedicine.medscape.com/article/1943419-overview. [Updated on 2012 Aug 6]. |
|2.||Anthony S, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al. Eczema, psoriasis, cutaneous infections, acne, and other common skin disorders in Harrison's Principles of Internal Medicine. 17 st ed. New York: McGraw Hill Publication, McGraw-Hill Medical; 2008. p. 517. |
|3.||Agnivesha, Charaka, Dridhabala, Charaka Samhita, Sutra Sthana, 16/20, edited by Vaidya Jadavaji Trikamji Aacharya, 1 st ed. Varanasi: Krishnadas Acadamy; 2000. p. 97. |
|4.||Ibidem. Charaka Samhita, Siddhi Sthana, 11/12. |
|5.||Hemadri, Commentator. Astanga Hridaya, Sutra Sthana 16/19, Varanasi: Krishna Das Academy; 1995. p. 247. |
|6.||Govindnath Sen, Bhaisajya Ratnavali, edited by Kaviraj Shri Ambikadatt Shastri, Kushtha Rogadhikara 54/257, 15 th ed. Varanasi: Chaukamba Sanskrit Sansthan; 2002. p. 633. |
|7.||Agnivesha, Charaka, Dridhabala, Charaka Samhita, Sutra Sthana, 24/18, edited by Vaidya Jadavaji Trikamji Aacharya,1 st ed. Varanasi: Krishnadas Acadamy; 2000. p. 125. |
|8.||Feldman SR, Krueger GG. Psoriasis assessment tools in clinical trials. Ann Rheum Dis 2005;64 65-8. |
|9.||Kaviraj Atridev Gupt, Ashtanga Hridaya, Sutra Sthana, 2/48, 1 st ed. Varanasi: Choukhamba Sanskrit Sansthan; 2005. p. 26. |
|10.||Agnivesha, Charaka, Dridhabala, Charaka Samhita, Sutra Sthana, 5/13, edited by Vaidya Jadavaji Trikamji Aacharya,1 st ed. Varanasi: Krishnadas Acadamy; 2000. p. 38. |
|11.||Ibidem. Charaka Samhita, Chikitsa Sthana, 7/4-8;450. |
|12.||Ibidem. Charaka Samhita, Nidana Sthana, 5/6;217. |
|13.||Sushruta, Sushruta Samhita, Chikitsa Sthana, 9/2, edited by Kaviraj Ambikadutta Shastri. 12 th ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2001. p. 629. |
|14.||Kaviraj Atridev Gupt, Ashtanga Hridaya, Nidana Sthana, 14/1-3, 1 st ed. Varanasi: Choukhamba Sanskrit Sansthan; 2005. p. 271. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]