Case presentation kitibha Kushtha

Dr.Mahendra Prasad Yadav
SDM college of Ayurveda, Hassan, Karnataka

1. Case presentation Presented by Dr. Mahendra Pd. Yadav Final Year PG Scholar Guided by Dr. Prakash L. Hegde Professor & HOD Department of Dravyguna SDM College of Ayurveda and Hospital, Hassan

2. Identification Detail Name : XYZ IPD no : 27200 Age : 32 years DOA : 21/12/2018 Sex : Male DOD : 31/12/2018 Place : K.R.Pete , Mandya

3. Chief complains c/o of flaky reddish white lesions all over the body including scalp along with itching and peeling off of the greyish skin since 3 years .

4. ASSOCIATED COMPLAINTS: Loss of weight since 1 month. shivering since 1 month

5. Vedana Vruttanta (History of present illness) A male aged 32 years complaints of flaky reddish white lesions all over the body including scalp along with itching and peeling off of the greyish skin since 3 years. He consulted many allopathic physicians but got only temporary relief. Since 1 year, he observed spreading of lesions to both the hands and later to abdomen and legs associated with severe itching followed by peeling off of greyish skin

6. Poorva Vyadhi Vruttanta (History of past illness and treatment ) No known case of DM and HTN No history of major surgery Kula Vruttanta (Family History) No any specific diseases

7. Vayaktika Vruttanta ( Personal history ) Functional history Bowel- passes hard stools Appetite- decreased Micturition- normal Sleep- disturbed

8. Personal History Diet – veg Daily dietary routine 9:30am Breakfast Chapati,Uppitu.Chitrana . 2:00 pm - Lunch - Rice, Ragi mudde 8:00 pm – Dinner – Mude,Rice . 9.30-10.00- sleep Addiction: – he is not addicted to alcohol, nicotine and other addictive substance. Occupation :- Farmer Socio-economic history:- Middle class Treatment History:- Taken allowpathy medicine

9. Astha-vidha Pariksha 1. Nadi Kapha Vata ++ 2. Mala Hard 3. Mutra Frequency per day - N Gandha - N Rupa - N 4. Jihwa Normal texture and color 5. Drik Intact 6. Shabda NAD 7. Sparsa Roughness skin 8. Aakriti Average

10. Dashavidha Parikshya 1. Prakriti Kapha ++ vata + 2. Vikriti vata 3. Sattwa Madhyama sattwa 4. Satmya Madhyama satmya 5. Ahara shakti Madhyama 6. Vyayama shakti Avara 7. Sara Ashthi sara 8. Samhanana Madhyama 9. Agni Madhyama 10. Vaya Madhya vastha

11. General examination G.C. – Ill B.P. – 110/70 mmHg Pulse – 80/min, with regular rhythm and normal volume Temp. – Normal Respiration – 20/min J A o C C O D

12. Systemic examination Chest – Clinically NAD VS – S 1 + S 2 + S m P/A – NAD

13. SAMPRAPTI GHATAKA Dosha :Vata(Vyana vayu),Pitta(Bhrajaka pitta )Kapha(Kapha). Dhatu : Rasa, Rakta,Mamsa . Upadhatu : Tvacha Agni : Jataragni , dhatwagni mandya ( Rasa,rakta,mamsa ) Srotas : Rasa, rakta , mamsa Srotas dushti prakara : Sanga Udbhava sthana : Amashaya,Pakvashaya Sanchara sthana : Sarvasharira Adhisthana : Twak , rakta , mamsa , lasika Vyakta sthana : Twak Roga marga : Bahya Swabhava : Chirakari Sadhyasadhyata : Krichsadhya

14. DIAGNOSTIC ASSESSMENT Differential diagnosis- Ekakushta - – there will be mahavastu (large lesions). Sidhma - there will be Shweta varna , tamra varna (coppery whitish lesions), tanu (thin). Kitibha - there will be shyavata (blackish brown in colour), kinakhara sparshata (rough in touch like scar tissue), parushata (hard to touch). Psoriasis - there will be red patches of skin covered with thick, silvery scales with typical features of erythema, desquamation. Final diagnosis- Kitibha ( psoriasis)

15. TIMELINE DATE TREATMENT MEDICINE 22-12-2018 to 23-12-2018 Deepana pachana Agnitundi vati,chitrakadi vati , panchakola phanta 24-12-2018 to 27-12-2018 Snehapana Panchatikta ghrita 30-12-2018 Virechana Trivrut lehya 11-01-2019 Jalaukavacharana -

16. THERAPEUTIC INTERVENTION Deepana pachana for 2 days S.N. MEDICINE DOSE TREATMENT 1 Agnitundi vati (1 vati =125g) 2-2-2 (30 minutes before food) 22-12-2018 to 23-12-2018 2 Chitrakadi vati (1 vati =125g) 2-2-2 (20 minutes before food) 22-12-2018 to 23-12-2018 3 Panchakola Phanta 50ml-50ml-50ml (10 minutes before food) 22-12-2018 to 23-12-2018

17. Bahirparimarjana chikitsa for 2 days S.N. TREATMENT TREATMENT DATE 1 Sarvanga parisheka with Panchavalkala kwatha 22-12-2018 to 23-12-2018 2 Manjishtadi lepa over ubhaya janu sandhi 22-12-2018 to 23-12-2018 3 777 oil for all over the body 22-12-2018 to 23-12-2018

18. PROCEDURE DOSE TREATMENT DATE Snehapana 30ml 24-12-2018   70ml 25-12-2018   120ml 26-12-2018   140ml 27-12-2018 Shodhananga Snehapana in arohana karma with Panchatikta Ghrita for 4 days Panchakarma procedures PROCEDURE MEDICINE TREATMENT DATE Sarvanga abhyanga, sarvanga nadi sweda Nalpamaradi taila for abhyanga 28-12-2018 to 30-12-2018 Virechana Trivrut lehya 30-12-2018

19. DISCHARGED ON 31-12-2018 Samsarjana karma Peyadi karma 31-12-2018 to 6-1-2019 FOLLOW-UP AFTER 10 DAYS Jalaukavacharana near ubhaya gulpha sandhi - 11-1-2018

20. Discharge medications MEDICINE DOSE ANUPANA DURATION Nimbadi guggulu ( 1 guggulu =250g)   1-0-1 (5minutes after food) Koshna jala 10 days Gandhaka rasayana (1tab=250g) 1-1-1 (10 minutes after food) Koshna jala 10 days Arogyavardhini vati (1 vati =125g) 1-0-1 (15 minutes after food) Koshna jala 10 days Manibhadra guda 0-0-10g (30 minutes after food) Koshna jala 10 days Patola katurohinyadi Kashaya 30ml-30ml-30ml (15 minutes before food) With equal quantity of koshna jala 10 days 777 oil FOR EXTERNAL APPLICATION 10 days

21. Follow-up medications MEDICINE DOSE ANUPANA DURATION FOLLOW-UP AFTER 10 DAYS Gandhaka rasayana (1tab=250g) 1-0-1  (10 minutes after food) Koshna jala 14 days Guggulu tiktaka ghrita 5g-0-5g (10 minutes before food) Koshna jala 14 days Chitrakasava 30ml-30ml-30ml (15 minutes before food) Koshna jala 14 days Ashwagandha churna 6g at 6a.m-6g at 6p.m Ksheera 14 days Triphala churna 0-0-15g (30 minutes after food) Koshna jala 14 days Eladi taila For External Application 14 days

22. FOLLOW-UP AFTER 14 DAYS Guggulu tiktaka ghrita 5g-0-5g (10 minutes before food) Koshna jala 15 days Maha manjishtadi Kashaya 30ml-30ml-30ml (15 minutes before food) Koshna jala 15 days Ashwagandha churna 6g at 6a.m-6g at 6p.m Ksheera 15 days Eladi taila For external application 15 days Eladi soap For bathing 15 days Cap. Puritin 1-0-1 (10 minutes after food) Koshna jala 15 days

23. BEFORE TREATMENT

24. AFTER TREATMENT

25. DISCUSSION Initially to remove the amapachana , agni deepana was done. Snehapana was planned with Panchatikta ghrita as tikta dravyas are drug of choice in twak vikaras . Virechana was planned for dosha shodhana based on satva and bala of the subject. Jalaukavacharana was done to remove the sthanika doshas of b/l lower limbs. Suitable shamanoushadhi was planned for shesha dosha nirharana . Rasayana was planned to prevent recurrence.

26. CONCLUSION Shodhana is very much necessary in expelling out the doshas from the body. S hodhana especially virechana helps remove the root cause of the disease and prevents from recurrence. Here an attempt has been made to show the importance of panchakarma in kitibha kushta ( psoriasis).

27. KUSHTA INTRODUCTION Skin that covers the major part of the body when it is diseased causes social stigma. It is important to maintain the health of skin in order toward off various skin diseases explained under the heading of ‘ Kushta ’. Any disease in Ayurveda is managed with Shodhana , Shamana & Rasayana chikitsa . The same is true for Kushta . It is important to understand the concept, indication and appropriate use of these to get optimum results

28. Kustha is a condition in which different body organs , dhatus , updhatus , are destroyed & contempted . One which produces discolouration over skin region is said to be kustha . During the lapse of time, it makes the entire body look ugly. TYPES MAHAKUSHTA- 7 KSHUDRA KUSHTA-11 TOTAL- 18

29. MAHAKUSHTA : Kapala - vataj Udumbar - pittaj Mandala - kaphaja Rishayajihava - vata-pittaja Pundarika - pitta- kaphaja Sidham - vata-kaphaja Kakanaka - tridoshaja

30. KSHUDRA-KUSTHA Ekakustha - vata-kapha Charmakhaya - vata-kapha Kitibha - vata-kapha Vaipadika - vata-kapha Alsaka – vata-kapha Dadrumandala - pitta- kapha Charmadala - pitta- kapha Pama - pitta- kapha Visphota - pitta- kapha Shataru - pitta- kapha Vicharchika - kaphaja

31. DOSHA-DUSHYA DOSHA: Vata Pitta Kapha DUSHYA : Twak Rakta Mamsa Lasika

32. DOSHA LAKSHANA VATAJ : rokshyam , shosha , shoola , sankochana , parushayam , khara bhava , harsha , shayav aruna . PITTAJA : daha , raga, parisarava,paka,visaragandhi , angapatana . KAPHAJA : shwetaya , shataya , kandu , utsedha , gaurav , sneha , kleda .

33. SAPTADHATVASHRAYA KUSTHA LAKSHANA TWAK : - Toda, vaivarnyam , rukshatwa RAKTA : - sweda , swapa , swayathu . MAMSA : - Sphota in pani & pada , kledata in joints . MEDSA : - Kounyam & gatikshaya for angas , dalana of angas . ASTHI & MAJJA :- Nasa bhanga , netra raga, swarakshaya , krimis in kshatas . SHUKRA :- Swadara paktya badhanam (A.H.Ni.14 )

34. SAMANAYA CHIKITSA All kustha are tridosaja so they should be treated by knowing there doshobala , abala & lakshnas . First do samana in those kusthas having there increased doshas than treat apradhan doshas

35. DHATU-GATANUSARA CHIKITSA Twak parapte - Shodhanam , Alepanam . Shonit parapate - Shodhanam , Alepanam , Kashayapanam , Shonitavasechanam . Mamsa parapate - Shodhanam , Alepanam , Kashayapanam , Shonithavasechanam , Arishtapana , Mantraprayoga .

36. Medas parapte Shodhanam , Shonithavasechanam , Bhallathaka , Shilajatu , Dhatumakshikam , Guggulu , Agaru , Tuvaraka . From Asthi onwards- Asadhaya . Rest of all dhatugata condition of kustha should be considered incurable and left untreated . ( Su.Chi 9/6)

37. CHIKITSA SUTRA Vata - Sarpi Kapha - Vamana Pitta - Raktamokshana, Virechana Chardana - Pakshatpakshat . (15 – 15)days Virechana - Masanmasan .(1 – 1)month Rakta mokshanam - Shashte shashte masya . (6 – 6)months. Nasya - Triratrat triratrat . (3 – 3)days. ( Su.Chi . 9/43) ( As.Hr.Chi . 19/96)

38. SNEHANA Abhyantara snehana : with Panchtiktaka ghrita Mahatikataka ghrita etc. Bahya snehana : with Yastimadhu taila Marichayadi taila Nalpamaradi taila etc.

39. SWEDANA Mridu sweda and ushana jala snana is indicated: Like: Parisheka Nadi sweda VAMANA Vamana Yogas : Kutajaphala , Madhanaphala,Yastimadhu churna + Patola and Nimba rasa Sheetha rasa kashaya with madhu + yastimadhu churna .

40. VIRECHANA VIRECHANA YOGAS: Trivrut , Danti & Triphala with souveeraka , tushodaka , alodana & sidhu . Manibhadra guda .

41. NASYA Kapha pradhana kushta with krimi anubandha . Saindhava , Danti , Maricha , Pippali , Karanjaphala , Vidanga – Vairechanika dhumapana with Manashilla , Jyotishmati , Hartala etc.

42. RAKTAMOKSHANA Kushta ( Sthira , Katina and Mandala) – Nadi & Prastara sweda Rub with Kurcha Rakta nirharana with Srunga / Alabu / Jalouka .

43. BASTI Acc. To Bruhattrayi Niruha & Anuvasana basti is contraindicated in kustha . ( Ch.Si 2 /14), ( Su.Chi . 35/21), ( As.Hr.Su . 19/4-6) If there is excess of vata even after shodhana – we can give anuvasana with sneha – made of madanaphala , madhuka , nimba , kutaja , patola (CH.Chi.7/47-47).

44. SHAMANA YOGAS There are innumerable shamana yogas mentioned for kushta in the form of churna , Vati Taila Ghrutam etc It is important to know when to use how to get good results.

45. GHRITA : Vatakushta - Ghrita prepared of Meshasringi , Guduchi , D wipanchamuli . Pittakushta - Ghrita prepared of Dhava , Aswakarna , Kakubha , Palasa , Pichumarda , Parpataka , Madhuka , Lodhra

46. Kaphajakushta - Ghrita prepared of Aragwadha , Nimba , Saptaparna , Chitraka , Maricha , Vacha , Kushta , Bhallataka , Abhaya , Vidanga

47. In pitta & Rakta - Tikta Ghritas externally & internally. Eg : Tiktashatpalak ghrita (Ch.Chi.7/140-143) Mahatiktaka ghrita (Ch.Chi.7/144-150) Mahakhadira ghrita (Ch.Chi.7/152-156) Khadira , nimba , darvi ghrita (Ch.Chi.7/135)

48. TAILAS : Vatakushta - Taila prepared of meshasringi , guduchi , dwipanchamuli . Kaphajakushta - By taila of priyala,sala,aragwadha , nimba , saptaparna , chitraka , maricha , vacha , kushta , bhallataka , abhaya , vidanga . Sarvakushta - By bhallataka taila , tuvaraka taila etc . (Su.Chi.9/7)

49. KASHAYA : Sonitha prapta & Mamsa prapta . Tikta kashayas - For kaphaja , pithaja & Raktaja kushtas . Eg : Laghu Manjishtadi , Madhyama Manjishtadi , Brihat Manjishtadi Kashayas , Patolamuladikwatha

50. CHURNA : Mustadi churna (Ch.Chi7/65-67) Triphaladi churna (in numbness of skin) (Ch.Chi.7/68,69) Swarnamakshika churna with gomutra (Ch.Chi.7/70-72) Somraji churna Bakuchi churna

51. ARISTHA , ASAVA: In Mamsa prapta kushta . Eg : Khadirarishta , Madhwasava , Kanakabindwarishta , Triphalasava Madvaasava in kustha & kilasa Kanakavinduristha Triphalasava Kashayas made of rasanjan , aragavadha patra , kutaja , patola mula , nimba bark, khadirsara , triphala .

52. ALEPANA : Twak prapta , Shonita prapta , Mamsa prapta (Su.Chi.9/6) Eg : Eladilepa , Kushtadilepa , Lodhrabijadilepa , Mamsyadilepa etc.

53. LEPAS : Sidhma nasak lepa (Ch.Chi.7/117,118) Mandala kustha nashak taila (Ch.Chi.7/122-127) Pittakusthan nashak lepa (Ch.Chi.7/130,131) Vidangadi lepa Dadrurvaadou durvadi lepa ( Chakradatta ) Manashiladi lepa etc.

54. VATI : Aarogyavardhini vati (R.RS.) Saptasama gutika Triphala gutika Gandhaka rasayana etc.

55. GUGGULU PREPARATIONS: Amrita guggulu Ekavimsatika guggulu Panchatiktaghrita guggulu etc

56. KSHARA PRAYOGA: Kushtas where sastra karma is contraindicated. In Sparsanendriyanasa Nipatya After visravana (Ch.Chi.7/54)

57. SNANOPYOGI DRAVYAS : Siddharthaka snana churna Darvi kwatha Patola Nimba Khadirasara Karanja Aragwadha ( Ch.Chi7/129,130)

58. RASAYAN YOGAS: Medo prapta kushta Navayasa rasayana ( chakradatta ) Brahmiaadi rasayan Chitraka rasayan Bhallataka rasayan Tuvarak rasayan ( Ah.Chi.19/53) For All kushtas Eg : Tuvarasthi , Bhallataka , Bakuchi , Chitrakamulam , Silajatu ( Ah.Chi.19/53)

59. CONCLUSION Selection of chikitsa for kushta depends on predominant of doshas Repeated shodhana is essenstial for bahu doshavastha other than trying to eliminate it all at once since it weakens the patient

60. In excessive vata aggravated condition, basti chikitsa can be adopted Nasya is indicated in kapha pradhana kushta and dhumapana in kushta affecting jatrurdhwa If doshas are in alpavastha we can treat with shaman line of treatment.