Dr. Ravi Shankar.B

From:

Dr. Ravi Shankar.B

1st year M.S. (Ayu.)

Department of PG Studies in Shalya Tantra

Govt.AyurvedicMedicalCollege,

BANGALORE.

To

The Registrar

RajivGandhiUniversity of Health Sciences,

Bangalore

Karnataka.

THROUGH:

The Principal and Head of the Department

PG Studies in Shalya Tantra,

Govt.AyurvedicMedicalCollege,

Bangalore.

Respected Sir,

Sub: Submission of completed proforma for Registration of subject

for Dissertation.

*****

I request you to kindly register the below mentioned subject against my name for the submission of the dissertation to the Rajiv Gandhi University of Health Sciences, Bangalore for partial fulfillment of M.S (Ayurveda).

Title of the Dissertation:-

“EFFICACY OF SHIRISHA TWAK LEPA IN THE MANAGEMENT OF KITIBA w.s.r. TO PSORIASIS” – A CLINICAL STUDY.

Herewith, I am enclosing completed proforma of synopsis for registration of subject for dissertation.

Thanking you,

Yours faithfully,

Place: Bangalore[Dr. Ravi Shankar.B]

Date:

1

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE-II

COMPLETED PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTION:-

1 / NAME OF THE CANDIDATE
AND ADDRESS: / DR. RAVI SHANKAR.B
1ST YEAR M.S. (AYU.)
DEPARTMENT OF PG STUDIES IN SHALYA TANTRA
GOVT.AYURVEDICMEDICALCOLLEGE,
BANGALORE.
2 / NAME OF THE INSTITUTE / GOVT.AYURVEDICMEDICALCOLLEGE,
BANGALORE.
3 / COURSE OF THE STUDY IN SUBJECT / AYURVEDA VACHASPATHI
1ST YEAR M.S. (AYU.)
SHALYA TANTRA
4 / DATE OF ADMISSION TO THE COURSE / 22-12-2009
5 / TITLE OF THE DISSERTION / “EFFICACY OF SHIRISHA TWAK LEPA IN THE MANAGEMENT OF KITIBA w.s.r. TO PSORIASIS” – A CLINICAL STUDY

1

6Brief resume of the intended work.

6.1Need of the Study:-

Psoriasis is a common, chronic, skin disease characterized by well defined, slightly raised, dry, Erythematous macules with silvery scales and typical extensor distribution.

Comparing the features of Psoriasis & Kitiba lakshanas as per Susrutha Samhita, Charaka Samhita and Ashtanga Sangraha. Both the diseases can be correlated to each other.

It is estimated that 2-3% of world population suffer from Psoriasis. Among them 35% of the people suffer from moderate to severe forms of Psoriasis.

In the year 2008, National Psoriasis foundation did a survey of 426 Psoriasis sufferers, among them 71% reported that the disease was causing significant problem in day to day life.

Patients with Psoriasis often experience a diminished quality of life. Itching and pain can interfere with basic functions such as self care, walking and sleep. Psoriasis affects quality of life similar to other chronic diseases as HT, DM & Depression.

The disease Kushta causes discolouration of the skin, which is the cause of social stigma, brings down the cosmetic value of a person, hampers the persona. More than physical suffering, patient suffers Psychologically.

Complications in Psoriasis are infrequent, the condition which can cause complicated Psoriasis are joint involvement (Psoriasis Orthopathica) which can cause disability, even crippling.

Treatment for Psoriasis in Allopathy is more palliative than curative. The First line of treatment for a majority of skin disease is topical application which holds good in Psoriasis too. The topical application such a Coal Tar, Dithranoll & Cortico steroids are the drugs of choice.

Among them, tar is messy to apply, has a strong odor and can stain skin and clothing, folliculities is the commonest side effect and to get a desired result it has to be combined with photo therapy.

Whereas Anthralin (Dithranoll) is highly irritant, should be used cautiously and is not suitable for Psoriasis of Head, Neck, Flexures and Genitalia.

Topical Steroids can become less effective if used repeatedly for a long time. Long term use produce side effects such as, stretch marks, thinning of skin, skin colour changes. Relapse of the disease is more common with withdrawal of treatment probably as they act mainly by slowing epidermal cell division.

With the limitations of these Allopathic procedures a more skin friendly, non- irritative, long lasting, easily available, economical and a potent therapeutic agent is the need of the hour.

Many efforts have been done to treat Psoriasis / Kitiba in Ayurvedic line of treatment using different modalities, like Prachhanana, Siravyada and Jaloaka which are not so friendly or easily acceptable by patient, which needs direct supervision by a Physician.

Lepa one among the Bahya pradana upakrama which could be easily employed with effective results. As it is the first line of treatment for Kushta, according to Susruta many Lepas like Aragvada Patra lepa, Aragvada Kshara Lepa, have been tried in Kitiba. Results have shown moderate to good response as high as 40% and 60%, but no total cure was observed in any of the studies. In the literary review Shirisha twak lepa was found to be potent with Vranahara, Vishahara, Shothahara, Varnya, Thridoshahara properties. Considering these factors the present study shall be taken up to evaluate the efficacy of Shrisha twak lepa in management of Kitibha Kustha. In this regard another group of study, the management of the Kitibha with Aragwada patra lepa shall be taken up which has been already established in the previous study with a success rate of 60%.

6.2 Review of literature:-

Nidana & Samprapthi:-

ÍqÉjrÉÉWûÉUÉcÉÉUxrÉ ÌuÉvÉãwÉÉSè aÉÑÂÌuɬÉxÉÉiqrÉÉeÉÏhÉÉïÌWûiÉÉÍvÉlÉÈ xlÉãWûmÉÏiÉxrÉ uÉÉliÉxrÉ uÉÉ urÉÉrÉÉqÉ aÉëqrÉkÉqÉïxÉãÌuÉlÉÉå aÉëÉqrÉÉlÉÑmÉÉæSMü qÉÉÇxÉÉÌlÉ uÉÉ mÉrÉxÉÉÅpÉϤhÉqÉvlÉiÉÉå rÉÉã uÉÉ qÉeeÉirÉmxÉÔwqÉÉÍpÉiÉmiÉÈ xÉWûxÉÉ NûÌSï uÉÉ mÉëÌiÉWûÎliÉ iÉxrÉ ÌmɨÉvsÉãwqÉÉhÉÉæ mÉëMÑüÌmÉiÉÉæ mÉËUaÉ×½ÉÌlÉsÉÈ mÉëuÉ×¬É ÎxiÉrÉïaaÉÉÈ ÍxÉUÉÈ xÉÇmÉëmɱ xÉqÉÑ®ÕrÉ oÉɽ qÉÉaÉï mÉëÌiÉ xÉqÉliÉ̲ͤÉmÉÌiÉ rÉ§É rÉ§É cÉ SÉåwÉÉå ÌuÉͤÉmiÉÉã ÌlɶÉUÌiÉ iÉ§É iÉ§É qÉhQûsÉÉÌlÉ mÉëÉSÒpÉïuÉÎliÉ LãuÉÇ xÉqÉÑimɳÉxiuÉÍcÉ SÉãwÉxiÉ§É iÉ§É cÉ mÉÌUuÉ×Ì¬Ç mÉëÉmrÉÉmÉëÌiÉÌ¢ürÉqÉÉhÉÉã ÅprÉliÉUÇ mÉëÌiÉmɱiÉã kÉÉiÉÔlÉÍpÉSÕwÉrÉlÉç ||1 (Ni. Ch 5. Slo 3. p. 494)

Indulgence in unhealthy improper foods and activities, especially food which are hard for digestion, incompatible, unaccustomed, uncooked & unhealthy, persons who have consumed fats for oleation therapy, who has vomited just then, who indulge more in physical activities & copulation, who consumes meat of animals of domestic and of marshy region along with milk constantly, who immerses himself in water immediately after getting fatigued by exposure to heat, he who suppresses the bolts of vomiting, suddenly be these activities pitta, kapha become aggravated, then vata associating with these become increased/aggravated moves through the siras, spreading sidewards conveys (pitta and kapha) to the exterior parts all over the body, such of the area in which these are deposited, there mandala (patches) develop on the skin, if not treated goes inside by vitiating the dhatus.

ÍqÉjrÉÉWûÉUÌuÉWûÉUãhÉ ÌuÉvÉåwÉåhÉ ÌuÉUÉåÍkÉlÉÉ |

xÉÉkÉÑÌlÉlSÉuÉkÉÉlrÉxuÉWûUhÉɱÉæ¶É xÉãÌuÉiÉæ ||

mÉÉmqÉÉÍpÉÈ MüqÉÉïÍpÉÈ xÉkÉÈ mÉë£üÉlÉæuÉåËUiÉÉ qÉÉsÉÉÈ |

ÍxÉUÉÈ mÉëmɱ ÌiÉrÉïaaÉÉxiuÉasÉxÉÏMüÉxÉ×aÉÉÍqÉwÉqÉç ||

SÕwÉrÉliÉÈ vsÉjÉÏM×üirÉ ÌlɶÉUliÉxiÉiÉÉã oÉÌWûÈ |

iuÉcÉÈ MÑüuÉïÎliÉ uÉæuÉhrÉï SÒ¹ÉÈ MÑüü¹qÉÑcÉÎliÉ iÉiÉç ||

MüÉsÉålÉÉåmÉåͤÉiÉÇ rÉxqÉÉiÉç xÉuÉïÇ MÑüwhÉÉÌiÉ iɲmÉÑÈ |2 (Ni. Ch 14. Slo 3-5. p.235)

Indulgence in unsuitable foods activities, especially the incompatible, abusing the ascetics, committing murder, usurping the properties of others and such other sinful acts pertaining to the present life, effects of actions of past life all together cause aggravation of malas (doshas), these doshas invading the tiryakgata siras, vitiate the twak, lasika, asrk (blood), and amisa (muscle) making them loose, then spread

outwards causes discoloration of the skin, after a long time of negligence and produce

kushta . It is called so because it makes the entire body ugly. (by mutilation).

Lakshana:-

rÉiÉç xÉëÌuÉ uÉרÉÇ bÉlÉqÉÑaÉëMühQÒû iÉiÉç ÎxlÉakÉM×üwhÉÇ ÌMüÌOûpÉÇ uÉSÎliÉ |1 (Ni. Ch 5. Slo.14 p.496)

Kitiba Kushta:- In this skin patch is exudative round thick has severe itching, is octous and black.

vrÉÉuÉÇ ÌMühÉZÉUxmÉvÉï mÉÂwÉÇ ÌMüÌOûpÉÇ xqÉ×iÉqÉç |3 (Chi. Ch 7. Slo.22. p.127)

Kitiba is blackish rough like a coin & chaise.

AxuÉãSÇ qÉixrÉÇvÉMüsÉxÉ̳ÉpÉÇ ÌMüÌOûpÉÇ mÉÑlÉÈ |

¤ÉÇ ÌMühÉMüUxmÉvÉï MühQÒûqÉimÉÂwÉÉÍxÉiÉqÉç ||2 (Ni. Ch 14. Slo. 22. p.237)

Skin not sweating, resembles the scales of fish, dry, producing sound while scratching, rough, itching, course, and black are the features of kitiba.

Chikitsa:-

iÉ§É mÉÔuÉïÃmÉãwÉÔpÉrÉiÉÈ xÉÇvÉÉåkÉlÉqÉÉxÉãuÉãiÉç | iÉ§É iuÉMç xÉÇmÉëÉimÉã vÉÉåkÉlÉÉsÉãmÉlÉÉÌlÉ. vÉÉãÍhÉiÉ mÉëÉmiÉã xÉÇvÉÉåkÉlÉÉsÉãmÉlÉ MüwÉÉrÉmÉÉlÉ vÉÉåÍhÉiÉÉuÉxÉãcÉlÉÉÌlÉ qÉÉÇxÉmÉëÉmiÉã vÉÉåkÉlÉÉsÉãmÉlÉ MüwÉÉrÉmÉÉlÉ vÉãÍhÉiÉÉuÉxÉãcÉlÉÉÍU¹qÉljÉmÉëÉvÉÉÈ| cÉiÉÑjÉïMüqÉïaÉÑhÉmÉëÉmiÉÇ rÉÉmrÉqÉÉiqÉuÉiÉÈ xÉÇÌuÉkÉÉlÉuÉiÉ¶É iÉ§É xÉÇvÉÉåkÉlÉÉcNûÉåÍhÉiÉuÉxÉãcÉlÉÉccÉÉåkuÉï pÉssÉÉiÉÍvÉsÉÉeÉiÉÑ kÉÉiÉÑqÉɤÉÏMü aÉÑaÉÑsuÉaÉÑÂiÉÑuÉUMüZÉÌSUÉxÉlÉÉrÉxM×üÌiÉ ÌuÉkÉÉlÉqÉÉxÉãuÉãiÉç mÉgcÉqÉÇ lÉæuÉÉããmÉ¢üqÉãiÉç ||4 (Chi. Ch 9. Slo 6. p.104)

During premonitory stage purificatory therapies both upward & downward should be administered, when the disease is localized in the skin purificatory therapies and application of paste externally are to be done, when it spreads to raktha dhatu then purificatory therapies, external applications, drinking decoctions, blood letting are necessary, when it spreads to mamsa then purificatory therapy, external applications, drinking decoctions, blood letting, use of Arista’s, manta, and prasha (avaleha) should be adopted. When the doshas has attained the 4th quality, (meda dhatu) become yapya and if patient is self controlled and faithful in adhering to treatments, then he should be treated with purificatory therapies, blood letting, and recipes prepared from either ballataka, silajatu, dhatu makshika, guggulu, agaru, tuvaraka, khadira, asana or Ayuskrti should be used. When the disease has attained 5th quality then no treatment should be administered.

rÉã sÉãmÉÉÈ MÑü¹ÉlÉÉÇ rÉÑerÉÉliÉã ÌlÉWïûiÉÉxÉëSÉãwÉÉhÉÉqÉç |

xÉÇvÉÉåÍkÉiÉÉvÉrÉÉlÉÉÇ xÉ±È ÍxÉ̬pÉïuÉãiiÉãwÉÉqÉç ||3 (Ni. Ch 7. Slo 52-53 p.129)

The medicaments applied externally exhibits quick effect after the impurity of blood is eliminated and thus the seat of morbidity is evacuated.

vÉæUÏwÉÏ iuÉMç mÉÑwmÉÇ MüÉmÉÉïxrÉ UÉeÉuÉפÉmɧÉÉÍhÉ |

ÌmÉ¹É cÉ MüÉM qÉÉcÉÏ cÉiÉÑÌuÉïkÉÈ MÑü¸ÉlÉÑssÉãmÉÈ ||3 (Chi. Ch 7. Slo 96. p.133)

Bark of sirisa, flower of cotton plant, leaves of aragvadha and kakamachi make 4 types, of Kushta alleviating paste.

Modern view on Psoriasis:

Psoriasis considered to be a constitutional disorder currently suspected to be auto immune in origin, cause not exactly known, believed to have a genetic component brought on by stress viz., anxiety, mental trauma, fever, physical injury, digestive upsets etc.Streptococcal infection, presence of diabetes and purines in the diet are other precipitating factors.

Clinical features:-

Clinically Psoriasis exhibits itself as dry, well defined macules, papules & plaques of Erythema with layer of silvery scales, the lesions are slightly raised above the surface of the skin.

Typical distribution is extensor; the areas commonly affected are the scalp, back of elbows, front of knee, legs and lower part of the trunk. Nails, palms and soles may also be affected in average case, but mucous membranes may be rarely involved.

Diagnosis:-

Diagnosis of Psoriasis is clinical based on cardinal morphological lesions of Psoriasis characterized by erythematic scaly eruptions, single or multiple disposals primarily on the extensor surface of the body.

1. The candle grease sign (tache-de-bouge)
2. Auspitz sign

being positive.

May be supplemented by histo-pathological examination which reveal -

a) Parakeratosis b) Regular elongation of the rete ridges with thickening of their lower portion. c) Micro abscesses in stratum cornium.5 (p.253-256)

Treatment:

In the year 2008, 3 new treatment options i.e., ladder pattern was accepted for the treatment of Psoriasis.

1. Topical applications like Taconic as first line of treatment.
2. Xtrac velocity excimer laser system emits light intensity beam of UV light to treat moderate and severe Psoriasis.
3. Biological drugs to treat moderate to severe and Psoriatic arthritis.6

Abbreviations:

Chi-Chikitsa,

Ni-Nidana,

Slo-Sloka,

p.-page.

Previous work done:-

1. Sachin patil : Management of Kitiba by Aragvadha patra lepa- a clinical study Rajiv Gandhi University of Health Sciences, Bangalore, 1999.

6.2Objectives of Study:

1. To evaluate the efficacy of Shirisha twak lepa in the management of Psoriasis.
2. To evaluate the efficacy of Aragvadha patra lepa in the management of Psoriasis.
3. To statistically analyse the efficacy of Shirisha twak lepa by comparing the efficacy of Aragvadha patra lepa in the management of Psoriasis.

7Methodology:-

7.1Source of Data:-

Patients suffering from Psoriasis shall be selected from OPD & IPD of Sri. Jayachamarajendra Institute of Indian Medicine, Bangalore.

7.2Method of Collection of Data:-

40 patients suffering from Psoriasis with the features of itching, erythema, induration and desquamation shall be selected for the study.

Inclusion Criteria:-

Psoriasis patients complaining of the features of itching, erythema, induration, and desquamation.

Exclusion Criteria:-

Patient’s with other systemic disease.

Pregnancy

Patients with other skin diseases.

Patients below the age of 16 years and above the age of 70 years.

Study design:-

40 Patients who fulfill the diagnostic criteria will be selected and divided into 2 Groups namely Group A and Group B with 20 patients in each Group.

Methodology in Group A:-

Patients of the Group A shall be treated with lepa of Sheresha twak once daily for a period of 30 days. Observations shall be made and recorded before treatment. The changes with the treatment shall be observed and recorded on 10th, 20th and 30th day in the proforma of Case Sheet prepared for the study.

Methodology in Group B:-

Patients of the Group B shall be treated with lepa of Aragvadha patra once daily for a period of 30 days. Observations shall be made and recorded before treatment. The changes with the treatment shall be observed and recorded on 10th, 20th and 30th day in the proforma of Case Sheet prepared for the study.

A period of 90 days shall be fixed for observation regarding the recurrences in cases where total relief was observed.

The observations regarding recurrences if any, shall also be recorded in the proforma of Case Sheet.

Assessment Criteria:-

Subjective-Itching

Objective-Erythema

Induration

Desquamation

The Objective features shall be studied as per PASI scoring. The changes in the parameters shall be statistically analysed and conclusion shall be drawn.

7.3`Investigation:-

- Nil-

7.4Ethical Clearance:-

Ethical Clearance shall be obtained by the Ethical Committee.

8.BIBLOGRAPHY:-

1. Sushrutha. Sushrutha Samhitha- Text, English Translation, Notes, appendeces and Index by KR. Srikantamurthy. 2nd ed. Varanasi: Choukhambaha Orientalia; 2004. vol.1. pp. 650
2. Vagbata. Ashtanga Sangraha-Text, English Translation, Notes and Indeces by KR. Srikantaurthy. 5th ed. Varanasi: Choukhambaha Orientalia; 2005. vol.2. pp. 615
3. Agnivesha. Charaka Samhita-Text with English Translation by PV Sharma. 7th ed. Varanasi: Choukhambaha Orientalia; 2005. vol.2. pp. 871
4. Sushrutha. Sushrutha Samhitha-Text, English Translation, Notes, appendeces and Index by KR. Srikantamurthy. 1st ed. Varanasi: Choukhambaha Orientalia; 2002. vol.3. pp. 503
5. PN. Behl, A Agarwal, Govinda Srivastava. Practice of dermatology. 9th ed. NewDelhi : CBS Publishers and Distributors; 2002. vol.1. pp. 526
6. www. ehealthmd.com/library/psoriasis/pso_treatment, 14-4-2010. p. 1

9 / Signature of the Candidate
10 / Remarks of the Guide
11
11.1 / Name
Designation of the Guide / Dr. R. Vijaya sarathi. M.D.(Ayu)
Professor,
Dept. of PG Studies in Shalya Tantra,
Govt.AyurvedicMedicalCollege
Bangalore
11.2 / Signature
11.3 / Name and Designation of the Co-guide
11.4 / Signature
11.5 / Head of the Department / Dr. B.A.Venkatesh. M.D.(Ayu)
Professor and HOD
Dept. of PG Studies in Shalya Tantra,
Govt.AyurvedicMedicalCollege
Bangalore
11.6 / Signature
12 / Remarks and Signature of the Principal

1