Psoriasis Treatment In Ayurveda

Skin is the largest organ of the body and it protects our body from the outer environment. Skin’s health is affected by the external environment (weather changes) or internal environment (unhealthy diet, lifestyle, stress, etc.). The changes in the character of skin reflects the different internal diseases. Psoriasis is an autoimmune chronic inflammatory disease which is non-infectious in nature. Ayurveda has explained skin diseases under the heading Kushta Roga which is further divided into Maha Kushta (Major skin diseases) and Kshudra Kushta (Minor skin ailments) based on the severity of the disease. Kushta Roga is explained as Ashtamahagada (one among the 8 serious diseases) and a disease caused due to overnutrition which is why it is difficult to treat. Psoriasis is explained as ‘Kitibha Kushta’ in Ayurveda. Although initially Kapha and Vata Doshas are vitiated along with few Dhatus (tissues), later all the Doshas and Dhatus become involved.

Causative factors of Psoriasis

There are 4-fold causative factors of Psoriasis.

1. Diet factors
   • Viruddhahara sevana (Incompatible foods) – Use of food substances having contradictory properties such as milk with sour fruits / salty snack, intake of yoghurt at night, etc.
   • Raktadushtikara Ahara (Food that vitiate the blood when taken in excess) – Too much intake of fish, salty food, citric fruits and their juices, other sour food items like yoghurt, pickles, sauces, etc.
   • Guru Anna sevana (Intake of heavy to digest food) - Excess intake of yoghurt, red meat, bakery products, etc.
2. Lifestyle factors
   • Atapa Sevana – Excess Sun bathing
   • Sheeta Maruta Sevana – Expoure to excess cold breeze
3. Mental factors
   • Mental stress increases Rajas Guna of the mind which are predominant of fire and air elements. This starts a chain reaction in the body, increases Vata Dosha and causes dryness, thinning and shrinking of the Srotas(micro-circulatory channels) which carries nutrition to the skin. Thus, skin moisture is dried up.
   • Emotional stress like anger affects the skin. During emotional outburst there is increase of blood flow to the skin because of increase of Pitta / heat in the body. We can notice that our face turns red when we are angry, this explains the connection between emotions and skin.
   • Physical stress like excess exercise, body strain or too much of physical work also causes increase of Vata in the body thereby drying out the skin moisture and making the skin rough.
4. Other factors
   • Genetic factors
   • Environmental factors such as stress, infections, mechanical trauma, sunburn, side effects of medicines such as beta-blockers, metabolic factors like calcium deficiency, hormonal changes such as in pregnancy.

Repeated indulgence in the above said unhealthy diet or lifestyle will lead to sluggish liver function that will increase of Pitta and Kapha Dosha in the body along with formation of Ama (endotoxins). This Ama is circulated to the skin thereby reducing the skin immunity and causing skin break outs.

The components involved in pathogenesis -

• Dosha involved: Kapha Vata predominant Tridoshas
• Dushya (Tissues vitiated): Rasa (Lymph), Rakta (Blood), Mamsa (Muscle tissue)
• Agnidushti (Nature of vitiation of digestive and metabolic fire): Jataragni and DhatwagniMandhya (Low digestive and metabolic fire)
• Srotodushti (Type of vitiation in micro-circulatory channels) – Sanga (Obstruction)
• Srotas (Micro-circulatory channels vitiated) – Rasavaha & Raktavaha Srotas (Channels carrying lymph and blood)
• Adhishtana (Seat of manifestation) – Twak (Skin)
• Rogamarga (Disease pathway) – Bahya (External pathway)
• Vyadhi Swabhava (Disease nature) – Chirakari (Prolonged)
• Sadhyasadhyata (Curability) – Krichrasadhya (Difficulty to treat)

Indulgence in causative factors hampers the digestive fire and leads to imbalance in Tridoshasalong with the Dhatus (tissues) mainly Rasa (Lymph), Rakta (Blood), Mamsa (Muscle tissue) and Lasika (Water component of the body). This leads to imbalance in Anna Rasa (digested food) leading to Ama (endotoxin) formation. The vitiated tissues especially lymph and blood along with endotoxins gets obstructed in the skin leading to appearance of lesions associated with burning sensation & itching all over the body causing psoriasis.

Premonitory symptoms –

• Daha - Feeling of warmth,
• Kandu - itching,
• Mukhapaka - mouth ulcers,
• Mandagni – Low appetite,

Symptoms –

• Jwara - Fever,
• Daha - burning sensation,
• Trishna - thirst,
• Asveda – absence of sweating,
• Tvakvivarnata - Discoloration of skin,
• Parushata –Dryness,
• Khara Sparsha –Roughness,
• Ghanatwa – Hardness of skin,
• Aruna – Krishna Varna - variable shades of red color of skin or blackening of affected part,
• Matsya shakalopama - skin surface covered with large silvery scales like the fish,
• Matsya shakalopama - skin surface covered with large silvery scales like the fish,
• Balahani - generalized weakness,
• Mahavastu – Broad lesion

Increase of symptoms on exertion and in hot humid weather, decrease of symptoms upon wet cold sponging and oil application can be noticed.  

Clinical types of Psoriasis and their Dosha dominance

• Plaque Psoriasis - Vata
• Guttae Psoriasis – Pitta Kapha
• Flexural Psoriasis – Pitta
• Erythrodermic Psoriasis – Pitta
• Pustular Psoriasis – Kapha Pitta
• Nail Psoriasis – Kapha
• Psoriatic Arthritis – Vata

Treatment principles in psoriasis –

Ayurveda treatments addresses the root cause of the diseases and aims at elimination of aggravated Doshas thereby reducing the size and number of lesions, restoring normal skin colour and boosting immunity through the following 5 ways.

1. Nidana Parivarjana
2. Dipana-Pachana
3. Snehana & Swedana
4. Shodhana
5. Shamana
6. Rasayana

   External treatments –

   Administration of oral medicines only are not sufficient to correct the metabolic problems occurring in all the systems of the body and deliver significant amount of herbs to the skin tissue. That is why there is a need for local application of medicines as they bring about effective changes because they stay in contact with the skin for a longer duration of time. For any herb to penetrate into the deeper cells, that is to get best pharmacological effect of the medicine at cellular level, an appropriate carrier is important. Lipid and lipid soluble substances like ghee and oil have a free passage across the cell membrane because of their Yogavahi (catalyst) properties. That is why application of medicinal ghee / oil and the use of Takradhara are effective in alleviating the symptoms of psoriasis. The keratin layer acts as a herbal medicine reservoir which then diffuses into the skin’s deeper layers gently over the period of time. Hence, Lepa application mixed with buttermilk, local application of medicinal oil or ghee will be effective for a longer period of time as it serves as a lubricant and while maintaining the elasticity of the surrounding skin, it reduces the formation of fissures within the plaques. It also reduces the scales on the psoriatic plaque’s surface. The herbs used in Lepa / herbal oils or ghee aid in the healing of lesions because of their wound cleansing and wound healing property. They also help to reduce itching because of their antimicrobial property.

    

   Single herbs beneficial in psoriasis

   Compound formulations recommended in psoriasis

    

   1. Nidana Parivarjana: Avoidance of causative factor

      This is first step towards treatment of any disease. Until the causative factor is removed, the disease pathogenesis cannot be stopped. So the patient should avoid indulgence in causative factors, such as too much of sun exposure, overstrain, intake of contradictory food items, excess intake of sour and salty food items, red meat, fish and intake of yoghurt at night.

   2. Dipana: Pachana

      Administration of Aviapthikar and Trikatu churna or Panchakola churna to help increase the digestive fire and eliminate the endotoxins thereby reduce sliminess and heaviness of theDoshas so they can be easily dislodged. Once the Ama are eliminated, then

   3. Snehana and Swedana: Oleation & Sudation

      Snehana: Oleation

      It is of two types – Internal and External. Internal oleation is in the form of Snehapana (oral intake of medicinal ghee) and external oleation is in the form of Abhyanga (Ayurveda oil massage).

      • Snehapana (Internal oleatiion) with medicinal ghee such as Guggulu Tiktaka Ghrita / Maha Tiktaka Ghrita is recommended. Warm medicinal ghee is administered along with addition of rock salt and dry ginger powder in increasing dose to the patient every day for a period of 5 to 7 days based on the age, digestive fire, disease symptoms, physical strength, etc. Ghee lubricates the skin, softens the Doshas and regulates bowel movement. Adding rock salt to the ghee helps to pacify Vata dosha and adding dry ginger powder to the ghee helps reduce Kapha Dosha. Also, as the above-mentioned ghee are bitter in taste, it helps to reduce Kapha Doshas and has healing properties as well.

      • Abhyanga (Oil massage) produces unctuousness, thereby helping reduce dryness, roughness, itching and discoloration of skin. Abhyanga with Nimbadi oil, Mahamarichyadi oil or Yashtimadhu oil is generally recommended as Nimbadi oil has anti-microbial property and Yashtimadhu oil is unctuous in nature. Mahamarichyadioil is used when there is increased thickness of the skin and itching.

      Swedana: Sudation

      Toxins are eliminated from the body in 3 forms – urine, feces and sweat. As the psoriasis patient does not sweat because of the nature of the disease, toxin accumulation becomes more in the body. Hence Swedana procedures are beneficial because they induce sweating thereby helping eliminate the toxins from the body.

      • Vashpa Swedana: Steam bath where the patient is made to sit inside the steam chamber (with his head and neck outside of the chamber) after Abhyanga to induce sweating on the whole body.
      • Nadi Swedana: Passing the medicated steam vapors over the affected part on the skin, that is skin lesions through a tube connected to a vessel which contains boiling water along with herbs such as Nirgundi, Neem, Curcuma, Dry ginger, Dashmool and Camphor. The therapeutic properties of the herbs used in Nadi swedana and the warmth of the steam vapor helps to reduce inflammation, thickening and discoloration of skin. It also repairs the damaged skin tissue and makes the skin soft. It removes toxins thereby relieving pain and stiffness in psoriatic arthritis.

      Snehana and Swedana help in balancing Vata Dosha. The medicinal ghee / oil used in oleation has properties such as unctuousness, heaviness and smoothness which are the opposite to the properties of Vata. Steam is hot in nature which is opposite to the coldness property of Vata. Unctuous steam (use of water to generate steam vapor) is beneficial for the dry and rough nature of Vata.

   4. Shodhana Chikitsa: Detoxification treatments

      When the psoriasis is chronic and Doshas are greatly increased in the body, ShodhanaChikitsa will be the first and foremost choice. The five types of detoxification procedures are recommended for psoriasis based on the Doshas vitiated, strength of the patient, number of skin lesions (whether local or whole body) and chronicity of the disease.

      • Vamana: Therapeutic emesis

        When the psoriasis is chronic and Doshas are greatly increased in the body, ShodhanaChikitsa will be the first and foremost choice. The five types of detoxification procedures are recommended for psoriasis based on the Doshas vitiated, strength of the patient, number of skin lesions (whether local or whole body) and chronicity of the disease.

      • Virechana: Therapeutic purgation

        When aggravated Pitta & Kapha are localised in Vata region and when the person has a moderate physical & mental strength, Virechana is the choice of treatment. The Virechana medicines have the property to cleanse the microcirculatory channels thereby improving the nutrient flow through them thus nourishing the skin. The Virechana medicines have hot potency, penetrating action, minuteness property and quick spreading nature hence remove excess Doshas and Ama through increased bowel movement. Virechana is less stressful than Vamana because Pitta Dosha and blood are related (Blood is liquid because of the heat of Pitta). And as vitiated blood is the primary cause of psoriasis, Virechana will be more beneficial than Vamana.

        Acharya Susrutha has recommended Nitya Virechana in psoriasis which is a mild, non-aggressive form of purgation on a daily basis. This helps in the management of psoriasis by eliminating Ama and excess Doshas from the body and its prevention by reversing the pathogenesis. Daily intake of Avipathikar churna or Trivrit or Aragvadha is recommended for this purpose. By virtue of the qualities of these herbs, they penetrate into the deeper channels and remove the obstruction in the them which is the main pathology involved. Also, the properties of the herbs helps in liquefaction of the fatty blockages in the channels and expel them along with the increased Doshas through the stools from the alimentary tract by virtue of their purgative nature without causing irritation to the anus or intestines. They also help in dilatation of the micro circulatory channels and act at the cellular level.

      • Basti: Medicated enema

        When Vata Dosha is aggravated greatly in the body and patient has low physical and mental strength, Basti is recommended. Basti is considered the safest among the Panchakarmas and is suitable for all ages.

      • Raktamokshana: Blood letting

        Siravyadhana (Venesection) and Jalukavacharana (Leech therapy) are recommended in Ayurveda texts although in present day it is not easily accepted by patients. It is the best method to remove vitiated blood from the body and as it addresses the root cause of the disease it is considered as an effective method in the treatment of psoriasis.

      • Nasya: Nasa medicationMental stress / depression is one of the factors caused by psoriasis which also exacerbates psoriasis creating a vicious cycle. Nasya helps in removing excess Kapha and Vata Doshas from the mind thereby helping manage stress effectively. As the functions of different parts of the body are dependent on one another, Nasya which helps restore the health of the microbiome in the nasal epithelium will also coordinate with the gut microbiome and enhance immunity. In other words as the Doshas are present all over the body, helping regulate the Doshic balance at one part of the body will also bring about Dosha regulation in other parts of the body too thus beneficial in the management of psoriasis.
   5. Shamana Chikitsa (Pacification treatments)

      Shamana Chikitsa is more important when the body is weak and Doshas imbalance is minimal. Shamana Chikitsa helps activate the Agni, normalize digestive functions and restore equilibrium of Doshas that are vitiated in the body without disturbing the other Doshas which are already in balance. It can be classified into 2 types – External and Internal. Application of oils, ointments and pastes, etc come under external treatment whereas intake of herbs such as Khadira, Manjishta, Aragwadha, etc come under internal treatment. The increased Doshas should be balanced by the appropriate use of both these treatments. Ayurveda recommends the use of Khadira for internal use and Aragwadha for external use in all skin problems.

      • Khadira has Kapha – Pitta balancing properties and contains astringent and cold properties. It also has quercetin which reduces the release of histamine and tannins which is a vasoconstrictor. Thus, it helps combat the inflammatory autoimmune response when used in combination with ghee. As ghee is unctuous it helps counteract the extreme skin dryness in psoriasis. Thus, Khadira Ghrita is beneficial in reducing itching.

      • Aragwadha also has Kapha – Pitta balancing properties and it is a mild purgative too. It is cold, bitter, sweet, soft and unctuous that is why when used externally it helps counteract dryness and roughness of the skin. It has anti-oxidant, wound healing, anti-microbial and anti-itching properties.

      • Lepa: Application of herbal pastes

        Herbal pastes mixed with fermented gruel or yoghurt are applied on the skin lesions. Different types of pastes like Vidangadi lepa, Pathyadi lepa, Tutthadi lepa, Jivantyadilepa, Dhatryadhyolepa are recommended in Ayurveda texts. Lepa helps scraps out the toxins and aid in removal of hyperkeratinisation. It helps in blood purification as well. From Ayurveda perspective the pastes that are locally applied on the skin will reach the deeper tissues through the skin pores and the microcirculatory channels that transport the sweat. The Lepa also imparts properties such as minuteness and penetrating nature in the channels, thereby deblocking the impediment in those channels and allowing the toxins to flow out through sweat. This action clears the microcirculatory channels due to the heating, penetrating and minuteness properties. The different ingredients of the Lepas have pungent and bitter taste mainly.

        • Pungent taste dilates the microcirculatory channels thus stops uncontrolled proliferation of cells which causes hyperkeratinisation.
        • Bitter tastes have blood purifying, anti-inflammatory, anti-pruritic properties. It is also pacifier of Kapha Dosha and is easy to digest. It scraps out toxins and excess Kapha from the body which might be helpful in the management of hyperkeratinisation that leads to scaling.
        • Penetrating property of Lepa brings about scrapping of toxins and balances Kapha and Vata.
        • Hot potency of the herbs used in Lepa has Vata – Kapha balancing properties and acts quickly at minute channels.
      • Siddhartaka Snana Churna: Bath powder.

        This is a medicinal compound powder which is recommended mainly for bathing in psoriasis and other skin diseases. It has ingredients such as Musta, Madanaphala, Triphala, Karanja, Daruhardira, Aravadha, etc which have wound healing, anti-inflammatory, skin complexion promoting properties. You can mix the powder with lukewarm water and use it for scrubbing on the body or apply on the affected part as a Lepa (unction). And when the paste dries up, gently rub it and wash it off with water at room temperature.

      • Taila Lepana: Local application of herbal oil / ghee

        Topical application of Jivantyadi Yamaka or Tiktaka ghrita on the skin lesions.

      • Takradhara: Pouring of medicated buttermilk

        Takradhara is prepared by mixing buttermilk with decoction of Musta and Amalaki. This liquid is poured on the body and scalp in the form of continuous thin stream. Lactic acid present in buttermilk is a good vehicle for transdermal absorption of herbs. Also it helps to moisturize the skin and lessen the appearance of thickening of the skin. The probiotic bacteria in buttermilk help restore the health of skin microbiome in psoriasis thereby improving the skin health and function. Buttermilk has all 5 tastes (except salty taste) with predominance of sour taste and has hot potency hence balances Vata and Kapha Doshas. Scales are produced in psoriasis because the cells divide faster than normal. The ascorbic content of Amalaki used in Takradhara inhibits cell proliferation thus reducing scale formation on skin.

      • Kshalanam – Washing

        Cleansing the affected skin lesion with decoction prepared from neem leaves, Amalaki and Mung bean is effective because of the anti-microbial property and it reduces excess moisture from the skin lesion in case of Kapha dominant psoriasis like pustular psoriasis.

      • Shirodhara: Pouring of warm medicinal oil on forehead

        This generates a tranquilizing effect by regulating brain waves thus helping in relaxation. Shirodhara also stimulates the Marmas on the head which are the vital energy of the body and improves blood circulation to the brain thereby helping reduce stress and anxiety and improving emotions and behaviour as well. If a person has scalp psoriasis then medicinal buttermilk is poured on the forehead in a rhythmic manner.

      • Amalaki (Phyllanthus emblica)
      • Haridra (Curcuma longa)
      • Daruharidra (Berberis aristata)
      • Guduchi (Tinospora cordifolia)
      • Manjishta (Rubia cordifolia)
      • Sariva (Hemidesmus indicus)
      • Karanja (Pongamia glabra)
      • Chakramarda (Cassia tora)
      • Neem (Azadirachta indica)
      • Tulsi (Ocimum sanctum)
      • Medicinal powders – Manjishtadi churna, Mustadi churna, Triphaladi churna
      • Medicinal ghee preparations - Panchatiktaka ghrita, Mahatiktaka ghrita, Guggulutiktakaghrita
      • Herbal tablets - Arogyavardhini vati, Kaishora guggulu, Triphala guggulu
      • Herbal decoctions - Mahatiktaka Kashaya, Patolakaturohinyadi Kashaya, Mahamanjishtadi Kwath
      • Herbal liquids – Aragwadharishta, Khadirarishta
   6. 1. Oral administration of medicinal ghee in Vata predominant psoriasis,
      2. Vamana in Kapha dominant psoriasis and
      3. 1. Saama / Nirama Avastha (Presence or absence of Ama),
         2. Navina / Jirna (Acute / chronic),
         3. Manobalavardhaka / Sharirabala vardhaka (need for improvement of mental tolerance or physical strength),
         4. Involvement of Doshas – Vata Kapha / Kapha / Vata / Pitta,
         5. Vyadhi Pratyanika / Rasayana (Management of psoriasis / Rejuvenation for preventing recurrence)Virechana & Raktamokshana in Pitta predominant psoriasis.Rasayana: Rejuvenation & Immune promotion

            As psoriasis is a chronic inflammatory disease with involvement of more than one Dosha and Dhatu, repeated Shodhana treatments are necessary because of the excess aggravation of Doshas and involvement of deeper tissues and prolonged nature of the disease. Repeated Shodhana will be based on the severity of the disease, strength of the patient and predominance of Doshas. Repeated Shodhana method explained in the classical text books of Ayurveda are – Vamana once in 15 days, Virechana once in a month, Raktamokshana once in 6 months, Nasya once in 3 days. Ashtanga Hridaya, one of the classical text books of Ayurveda explains about the need of Rasayana after Shodhana treatment. Only after elimination of endotoxins along with vitiated Dosha through Shodhana, Rasayana is recommended for enhancing the health of deteriorated Dhatus, boosting immunity and reducing disease recurrence. This is because the body becomes clean after Sodhana just like a clean cloth obtained by washing soiled cloth. Now this clean cloth is ready to absorb any colour that it is dipped into. In the same way, body will be ready to receive the Rasayanabenefits after Shodhana. However, if Rasayana is done without Shodhana, then it is like colouring a soiled cloth, which will look soiled even after colouring with best colours.

            Manibadra guda is the best Rasayana in psoriasis. It is in linctus form which imparts maximum effect of the formulation on the patient. The ingredients of this herbal formulation such as Haritaki, Amalaki, Vidanga, Trivrit have both Shodhana and Rasayana properties. It is prepared in jaggery base. Initially while taking this formulation the patient may have increased bowel movement and loose stools (Shodhana effect) but later the bowel movement will normalize in frequency and consistency.

            The suitable treatments are planned based on the following criteria’s –

         Acharya Charaka has explained the different treatment principles based on Dosha involvement.

Ahara Vihara: Diet and lifestyle recommended

Thus, psoriasis can be effectively managed with Ayurveda treatment.

Reference:

1. Ch.Sa.Ch.St. Chapter 7, Sloka number 22
2. Su.Sa.Ch.St. Chapter 9, Sloka number 43