An integrated approach of psoriasis in the light of Siddha and Ayurveda – A clinical case

Psoriasis is a chronic autoimmune skin disease in which there is an accelerated turnover of skin cell growth. This is one of the challenging conditions in dermatology where the treatment remains a conundrum. The symptoms get relapsed once the medicine/ treatment is withdrawn. An integrated approach of Siddha and Ayurvedic treatments renders the relapse of this condition deferred. We report an integrated approach in a 31-year-old male patient diagnosed with Psoriasis Vulgaris (PASI -18.3) and suffered for a duration of 20 years. The patient had lesions in the chest, abdomen, back of trunk, shoulder, knees, and scalp. He was treated with integrated Siddha and Ayurvedic modalities of treatment for a period of consecutive 40 days and was followed up without a treatment for a period of 1 year. No recurrence was observed after the complete resolution of lesions which occurred within 41 days of treatment. reported after three months of treatment. The importance of diet is highlighted. This study has unraveled possible effective treatments with long-lasting relief for psoriasis with an integrated approach.


INTRODUCTION
soriasis is a chronic, non-communicable, autoimmune inflammatory skin disease that causes a lot of negative repercussions on a patient's quality of life.It can occur in any age group (1,2).The aetiology remains unclear, but it could be a genetic predisposition superimposed with etiology (3).Other causes include environmental factors such as infections, alcohol misuse, cigarette smoking, medications, psychological stress, sunshine, and physical trauma.It affects men and women equally and girls at an earlier age.Two age groups of incidences are observed that include 16-22 years and 57-62 years (4).Skin lesions include red scaly plaques, well demarcated with sharp delineated edges and more or less symmetrical distribution.Stress is a major contributing and deteriorating factor.
In Siddha, it is termed as venparusethil/ sethiluthirnoi/ kalanjagapadai (5).Enormous medicines are available to treat this condition whereas in Ayurveda, Takradhara is a special Panchakarma therapy in which medicated buttermilk is processed with medicinal herbs and is used for external therapy.Butter milk is poured as a continuous stream over the parts of the body.It is of three types namely, Sarvanga Takradhara which deals with the procedure implicated all over the body; Ekanga Takradhara is a procedure dealt with a particular region of the body and Shiro Takradhara is performed over the head of the body (6,7).Bashpa Sweda is the process which produces perspiration in the body and removes stiffness, heaviness, and coldness of the body (8).Due to the chronic and cyclic nature of psoriasis, an integrated treatment approach has been adopted in this study.

Patient information
A 31-year-old male patient reported on 15 th November 2021 with the complaints of erythematous plaques present on chest, abdomen, back of trunk, shoulder, knees, and scalp, itching and scaling.The Psoriasis Area and Severity Index (PASI) score was 18.3 and there was no associated comorbidity.For the past 20 years he was suffering from the above condition and underwent allopathy medications for 15 years with regular follow ups.Topical and immunosuppressive medications provided symptomatic relief.On withdrawal of medicines the symptoms flared up.Due to recurrence patients withdrew the allopathy medication and consulted concomitant siddha and ayurveda treatment.

Clinical findings
On examination, the skin lesions were diagnosed as Kalanjagapadai (psoriasis).The PASI score was 18.3.

Prognostic characteristics
As per the study conducted by Sharma et al., psoriasis was recovered without a relapse for a period of 60 days by ayurvedic treatment (9).In this study, the skin lesions reduced and showed an expeditious recovery in 40 days of integrated treatment.The patient was strictly advised to avoid sour taste foods and nonvegetarian foods till the course of treatment.P

Follow up and outcome
Patients diagnosed as having Kalanjagapadai (psoriasis) were treated with Siddha medicines both internally and externally (Table 1).Itching was completely reduced after 15 days of treatment.The scaling reduced after 25 days of treatment.Erythematous plaques disappeared after 30 days of treatment.As per Table 2, the PASI score was 0 after the course of treatment.No adverse events occurred during the treatment period.Patient was followed up for about 1 year.

Intervention adherence and tolerability
Since the patient comes weekly once for OPD and through video consultation thrice a day helped in facilitating intervention adherence and tolerability.No adverse and unanticipated events occurred.The consent was obtained from the patient for the publication of photographs in scientific articles.

DISCUSSION
Psoriasis is an autoimmune disease where genetic and environmental factors have a significant role.Moreover, cytokines, inflammatory cascade, and keratinocytes play an important role in the pathogenesis of psoriasis.Being an autoimmune disease and a recurrence in nature, it is quite difficult to treat.So, an integrated approach was adopted to facilitate an expeditious recovery.
The treatment embodied internally, T.Parangipattai choornam, Manjalnoi kudineer choornam, Shaya choornam and seven sittings of takradhara with Baspa Sweda.The literature evidence clearly stated that the Parangipattai chooranam is indicated for all types of skin diseases (10).As per the study conducted by Deepa et al., the anti-inflammatory activity of poly herbal ingredients of PPC is highlighted (11,12).Manjalnoi kudineer choornam is also a polyherbal formulation in which each ingredient expresses the anti-inflammatory effect (13)(14)(15)(16).Another poly herbal formulation, Shaya choornam is known for many vital effects including anti-inflammatory and health promoting effect (17) prevents the recurrence of psoriasis.
Takradhara is a direct indication of psoriasis as it was implicated as an external procedure (4) whereas Bhaspa Sweda eliminates the waste product from skin and gives softness to the skin (8).Therefore, these internal and external therapies facilitated a meteoric recovery of chronic psoriasis in 40 days.
The diet plays an important role in psoriasis.As per the study conducted by Garbicz et al., a vegetarian diet balances potassium deficiency.Increased potassium intake may cause an increase in the synthesis of cortisol, which has an anti-inflammatory effect (18).Therefore, non-vegetarian diets are avoided.Maria et al., spelled out that amino acids are increased up-to 20-fold in psoriatic lesions (19,20) while sour-tasting foods contain amino acids.Hence these foods are restricted during treatment.

Limitations of the study
Since this case report is based on a single case which shows a positive outcome and hence it cannot be generalized.Further clinical trials can be conducted on a larger scale to assess the efficacy of this treatment.

CONCLUSION
In this case, the treatment response was observed much earlier when compared to conventional treatment.The importance of diet is accentuated.This integrated approach facilitated an expeditious recovery from chronic psoriasis.Chronic and cyclic nature of psoriasis can be subjected to Siddha treatment modality which does not respond to conventional treatment.

Table 2 :
Psoriasis Area Severity Index (PASI) after the treatment