Issue : 01 DOI : 10.5281/zenodo.8147277

INTERNATIONAL

JOURNAL

DIAGNOSTICS

AND

RESEARCH

Volume : 01

Page 23

Corresponding author : Dr.Nidhi Kevalsingh Gaharwar

Article Info : Published on : 02 /01/2024

Abstract

Psoriasis is a chronic disease in which the immune system becomes overactive causing skin cells to multiply too

quickly. It is skin disease that causes a rash with itchy, scaly patches, most commonly on the knees, elbows, trunk

and scalp. In Allopathy and Ayurveda many drugs and herbs have proven efficacy in psoriasis but integrated

treatment is more effective than any other. We report about integrated treatment in 30 years old female patient

with Palmoplantar psoriasis presented with itching, pain and fissuring symptoms on palm and feet. The treatment

protocol was adopted as per modern pathophysiology and Ayurvedic samprapti and patient cured completely

within 3 months of the treatment and have not reported any recurrence even after 2 years of follow up

Keywords : Palmoplanter Psoriasis, Panchtiktaghrith guggulu, Gandhaka rasayana, Mahatiktaka ghrita

ISSN No. : xxxx-xxxx

Volume : 01

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FOR PATHOLOGY AND RADIODIGNOSIS

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INTERNATIONAL JOURNAL OF DIAGNOSTICS AND RESEARCH

An Integrated Approach to Diagnose and Treatment of Palmoplanter Psoriasis

- A case study

Dr.Nidhi Kevalsingh Gaharwar

, Dr.Satyendrakumar R.P. Singh

P.G. Scholar Dept. of Rognidan Evum Vikruti Vigyan CARC Nigdi ,Pune, Maharashtra ,India.

Associate ProfessorDept. of Rognidan Evum Vikruti Vigyan CARC Nigdi ,Pune, Maharashtra ,India.

Cite this article as : - Dr.Nidhi Kevalsingh Gaharwar (2024) ;An Integrated Approach to Diagnose and Treatment of Palmoplanter Psoriasis

- A case study ; Inter.J.Dignostics and Research 1(2),23-28, https:/doi.org/10.5281/zenodo.10451134

Introduction:

Psoriasis is a chronic disease in which the immune

system becomes overactive causing skin cells to

multiply too quickly. Patches of skin become scaly

and inflamed most often on the scalp, elbow, knees

but other parts of the body can be affected as well.

Scientist do not fully understand what causes

psoriasis but they know that it involves a mix of

genetics and environmental factors[1]. Types of

psoriasis: [1]

1. Plaque psoriasis -this is the most common kind

and it appears as raised, red patches of skin that

are covered by silvery white scales the patches

usually develop in a symmetrical pattern on the

body and tend to appear on the scalp, trunk,

limbs, especially the elbows and knees.

2. Guttate psoriasis- This type usually appears in

children or young adults and look like small,

red dots, typically on the torso or limbs

outbreaks are often triggered by an upper

respiratory tract infection such as strep throat.

3. Pustular psoriasis- In this type pus filled bumps

called pustules surrounded by red skin appear it

usually affects the hands and feet but there is

form that covers most of the body.

4. Inverse psoriasis - This form appears as smooth

red patches in folds of skin such as beneath the

breasts or in the groin or armpits rubbing and

sweating can make it worse.

5. Erythrodermic psoriasis - This is a rare but

severe form of psoriasis characterized by red,

scaly skin over most of the body it can be

triggered by a bad sunburn or taking certain

medications such as corticosteroids

erythrodermic psoriasis often develops in

people who have a different type of psoriasis

that is not well controlled and it can be very

serious.

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6. Nails psoriasis - Nail psoriasis is even more

common in people who have psoriatic arthritis.

having symptoms pitting of nails, tender painful

nails separation of nail from bed.

7. Psoriatic arthritis - psoriatic arthritis is a

condition where you have both psoriatic and

arthritic. In more than 80% of cases, people had

psoriasis for an average of 12 yrs before getting

psoriatic arthritis. About 90% of people with it

also have nail changes[2].

Diagnosis: skin biopsy

Most of the time psoriasis can be diagnosed just by

examining the skin. But for the confirmed diagnosis

and to rule out other causes of symptoms such as

eczema or cutaneous lupus a skin biopsy may be

performed.

Aim: To encourage integrated approach in Psoriasis

for its early management.

Case Study:

Patient Information: A 30-year-old female

homemaker had been diagnosed as Palmoplantar

psoriasis and was treated by a dermatologist from

where the patient was taking allopathic treatment

(Methotrexate -once in week or 2-4 times in week,

Etanercept - injected twice a week upto 12 weeks ,

Emollient )from 3 years with regular follow-ups.

Topical and systemic immunosuppressive therapy

was resulted in symptomatic relief from this

treatment. Personal history revealed that the patient’s

general health was good. All the blood tests (routine

tests) were within a normal range. No concomitant

illness was found associated. However, due to a

recurring pattern caused by the unknown aggravating

factors, the patient discontinued allopathic treatment

and consulted to our clinic.

Clinical findings

The patient presented with erythematous plaques on

the palm and feet (sole). The affected skin was found

with a deep painful fissures. The patient was

suffering from intense itching and burning sensation

on palm and feet. At the time of the case

presentation, no signs of psoriatic arthritis and nail

bed psoriasis were found.

Fig 1 - Photographs of affected areas before and

after one month of treatment

General examination

Body temperature (97.6 °F), Pulse (88/min), and

Blood Pressure (118/86) were within normal limit.

Systemic examination

In systemic examination, respiratory and

cardiovascular system found normal. The patient was

restless due to itching and burning sensation over

psoriatic lesions.

Asthavidha pariksha ;

Nadi (pulse) – Pittakaphaja;

Mala (stool)– Sandra-picchila, bowel habit was

regular;

Mutra (urine) – Prakrita;

Jivha (tongue)– Shveta-picchila, Sama (coated);

Shabda – Prakrita;

Sparsha (touch)– Ushna;

Drika (vision) – Prakrita;

Aakriti – Madhyam (medium built).

Nidana panchaka :

Nidana – Viruddhahara sevana (simultaneous use of

milk and salty snacks) and Raktadushtikar Ahara-

vihara (excessive use of salty food, sour food like

pickles, curd and sitting a long time in direct

sunlight);

Samprapti –

Dosha – Pitta, Kapha and Rakta;

Dushya – Rasadhatu, Raktadhatu and Mamsadhatu;

Agni – Mandagni; Aam – Jatharagni and Dhatvagni

janya;

Strotasa – Rasavaha, Raktavaha and Mamsavaha;

Adhisthana – Twaka; Rogamarga – Bahya;

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Vyadhi Swabhava – Chirakari (chronic);

Sadhyasadhyata -Kricchrasadhya (difficult to treat);

Poorva roopa – Abhyantara daha (feeling of

warmth), Kandu (itching), Mukhapaka (mouth ulcers)

sometimes and Mandagni (anorexia);

Roopa: Jwara (fever), Trishna (thurst), Daha (burnin

g sensation), Kandu, Tvakavaivarnyata (in present

case, the affected skin was found with a deep painful

fissures on palm and feet.), Balahani (generalised

weakness);

Upashaya :Bahyashita; sparsha and Abhyanga (impr

ovement on wet cold sponging and oil application)

Anupashaya – Ushna sparsha (increased symptoms

on work in hot and humid climate).

Diagnostic assessment :All routine blood tests were

within a normal range (CBC, LFT, KFT, Blood

glucose test ,Lipid profile etc is within a normal

range). The patient was not ready for tissue biopsy

due to unaffordable cost. Therefore, based on clinical

presentation, distribution of the skin damage, the case

diagnosis was confirmed as palmoplantar psoriasis.

Therapeutic Interaction :

All previous oral and topical (Allopathic)

medications were stopped. In this case, an integrated

approach has been taken into consideration.

According to Ayurveda samprapti, the involvement

of pitta and kapha dosha ascertained by observing

the clinical presentation such as Daha (burning

sensation), Kandu (itching), Raktavarnata (redness),

and the nature of skin lesions.

Vitiated pitta and kapha dosha found involved in the

pathological progress. The details of the internal and

external medications prescribed have been mentioned

in table no. 1

Table 1 - List of internal and external medications

with dose, adjuvant, and duration.

Sr.

No.

Formulation

Dose, frequency

and time

Adjuvant

Duration

Injection Kenacort

(Triamcinolone Acetonide)

40mg IM -Abbott pharma

Weekly once

upto 1 month

and then in after

15 days upto 2

months

—

3 Month

Panchtiktaghrith

guggulu (Tablet)

1 gm (2 tablets)

twice daily, after

meal

Lukewarm

water

3 Month

Gandhaka rasayana

(Tablet)

250 mg (2

tablets) twice

daily, after

breakfast

Lukewarm

water

3 Month

Mahatiktaka ghrita

2 gm (4

capsules), once

daily on an

empty stomach

at early morning

Warm

water

3 Month

Mahamanjishthadi Kwath

20 mL of kwath,

twice daily after

meal

50 mL of

normal

water

3 Month

Urtiplex Lotion with

Gammascab Lotion

(charaka pharma)

Topical

application at

night

–

3 Month

Immupsora oil (charaka

pharma)

Twice a day,

Topical

application

–

3 Month

Dr Reckeweg R65 Psoriasis

Drops

15 drops twice a

days before food

1/2 cup of

water

Next 9

months

Strict dietary plan

Restricted use of

salt, sour food

items, curd, old

butter, milk and

sweet products,

meat and fish,

overeating etc.

Fast-food and

soft or Hard

drinks strictly be

avoided

–

2 Years

Timeline

In the present case, all the treatment was continued

for 3 months and follow up has been taken for one

year. Pathyahara (A strict dietary plan) continued for

two years after along with the active treatment to

check the recurrence of psoriasis.

Follow up and outcomes

The Follow-ups details with timeline, treatment

protocol, and periodic clinical outcome have been

mentioned in Table 2. The psoriatic lesions with all

its signs and symptoms cured. No adverse events

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witnessed during the treatment. Photographs of

affected areas before and after the one month of

treatment is shown in Figure 1. The patient kept only

on a strict dietary regimen for two years but no

recurrence observed.

Table 2 - Follow-up history and clinical outcomes.

Timeline

Dates

Treatment plan

Periodic clinical outcomes

Onset of

treatment

02/05/2021

As per Table 1

Integrated treatment started.

Follow-up

09/05/2021

As per Table 1

Subjective improvement in

signs and symptoms. Itching

reduced.

Follow-up

16/05/2021

As per Table 1

Subjective changes in signs

and symptoms. Itching and

burning reduced.

Follow-up

23/05/2021

As per Table 1

Significant improvement in

symptoms i.e., very minimal

itching and burning sensation

left now

Follow-up

06/06/2021

As per Table 1

No itching and burning

sensation.

Follow-up

20/06/2021

As per Table 1

Fissures on hand cured

completely

Follow-up

04/07/2021

As per Table 1

Fissures on feet cured

completely.

Follow-up

18/07/2021

As per Table 1

Recovered completely. No

relapse in any sign and

symptom.

Follow-up

10/04/2022

Homeopathic

treatment along

with dietary

regimen

continued

No relapse in any sign and

symptom.

Follow-up

30/04/2023

Only dietary

regimen

continued

No recurrence found. No

relapse in any sign and

symptom.

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[3]. Among different types

of psoriasis, palmoplantar psoriasis is the form of

psoriasis where itching, pain and fissuring symptoms

on palm and feet were observed. Being an

autoimmune disease, it is quite difficult to treat.

Therefore, one can opt for integrated treatment

approach for its early management.

In present case, the patient was following the excess

use of salty and sour food items, old butter and curd,

spicy food, simultaneous use of milk products and

salty snacks, etc. The patient was taking modern

medications without sidestepping the causative

factors as par Ayurveda. Therefore, temporary relief

had observed with a relapsing pattern during the

previous treatment. Thus, in the present case, the

strict dietary regimen (Pathya) has been advised as

the mitigating intervention along

with integrated medicines.

The ongoing pathological changes were attenuated

and corrected followed by integrated medications

such as Injection 1. Kenacort 40mg Intramuscular, 2.

Panchtiktaghrith guggulu (Tablet), 3. Gandhaka

rasayana (Tablet), 4. Mahatiktaka ghrita, 5.

Mahamanjishthadi kwath, 6. Urtiplex Lotion with

Gammascab Lotion, 7. Immupsora oil, 8. Dr

Reckeweg R65 Psoriasis Drops, 10. Strict dietary

plan.

1. Kenacort 40mg IM- It contains triamcinolone as

its active component a steroid medicine. It is

used to relieve symptoms like itchy, red and sore

patches on the skin. This medicine is also used in

the treatment of psoriatic arthritis, an

autoimmune disease, characterized by red

patches of skin with silvery scales and swelling,

stiffness, and pain in the joints.

2. Panchtiktaghrith guggulu (Tablet)- is an

Ayurvedic supplement that can help enhance

healthy skin. The tablet aids maintaining the

healthy digestive functions of body. It can

effectively improve the strength of bones and

joints assuaging inflammation.[4]

3. Gandhaka rasayana (Tablet)- This formulation is

most valuable in treating all types of infections

owing to its potent antibiotic trait. It is mainly

used to treat skin disorders, bleeding disorder,

enhance skin complexion and immunity.[5]

4. Mahatiktaka ghrita- Is a medicated ghee used for

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5. Shaman chikitsa. Ghee has

‘sukshmasrotogamitwa’ action hence can subside

doshas from Rasa, Rakta, Mamsa, Meda and also

nourishes the skin. Various active.

6. phytoconstituents extracted in the Mahatiktaka

ghrita work synergistically to cure psoriasis,

possibly through the liposomal drug delivery

system.[6]

7. Mahamanjishthadi (Herbal fermented liquid)- It

purifies and improve the quality of blood as it

possesses anti-bacterial, mild laxative and

diuretic properties hence beneficial in treating all

types of skin disorders like eczema, urticaria and

psoriasis.[7]

8. Urtiplex lotion - It cools and soothes skin,

support anti-allergic action, helps relieve itching,

helps reduce flare-ups which helps to reduce

burning and intense itching immediately.[8]

9. Gammascab lotion- It belongs to class of

medications called anti parasitic drugs. it used to

treat skin disease marked by itching and small

raised red spots infestation with lice. In the

present study Gammascab lotion has been

applied with Urtiplex lotion to overcome the

superadded infection. Scratching a rash, break the

skin and lead to a superadded infection which is

more serious and difficult to treat.[9]

10. Immupsora oil - It is a comprehensive topical

formulation for psoriasis. Neem oil, karanj oil,

haridra oil, yashtimadhu and kumari effectively

help in the dry, itchy, scaly skin of psoriasis. It

also exhibits antiseptic and anti-inflammatory

properties.[10]

11. Dr. Reckeweg R65 psoriasis drops- Its

homeopathy medication helps manage skin

conditions such as psoriasis and dryness. This

medicine is being used to avoid recurrence.[11]

12. Strict dietary plan- The intake of Viruddha

ahara (the unwholesome dietary practices) is one

of the important causative factors in the

etiopathogenesis of skin diseases. The patient

should avoid Viruddha ahara for better treatment

response, speedy recovery, and to avert the

recurrence in chronic skin ailments as Nidan-

Parivarjan said to be the first line of treatment.

The promising outcomes in the present case are a

combined effect of all the Ayurveda, allopathy and

homeopathic medicines, also pathya sevana (a strict

diet plan), and regular follow-ups by the patient. The

possible mechanism and role of integrated medicines

in the Samprapti-vighatana (counteracting the

pathophysiology) of psoriasis have seen.

Patient perspective

The patient shared her perspective about

the Integrated treatment in her local (Marathi)

language. She had severe itching, burning sensation,

and stress at the time of presentation, while she was

free from all the signs and symptoms at the end of

treatment and also recurrence has not seen till now

even after two years of follow up.

Conclusion

In the present case, the treatment protocol was

adopted as per Ayurvedic samprapti and modern

pathophysiology the treatment response was observed

much earlier as compared to previous treatment. No

recurrence reported after the end of active treatment.

The importance of a wholesome diet as a health

promoter is also revalidated. The external and

internal medications help to correct the complex

pathophysiology of psoriasis like chronic diseases.

Altogether, integrated treatment led to speedy and

substantial recovery from a chronic case of psoriasis.

Informed consent

Consent of the patient was obtained for the

photographs and before reporting the case report for

publication.

References

1. Psoriasis types, symptoms and causes -

https://www.niams.nih.gov/health-topics/psoriasis

2. https://www.webmd.com/skin-problems-and-

treatments/psoriasis/psoriasis-types

3. Guruprasad C. Nille and Anand kumar Chaudhary

-Potential implications of Ayurveda in Psoriasis: A

clinical case study. J Ayurveda Integr Med. 2021

Jan-mar; 12(1): 172-177. Published online 2021

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Volume : 01

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Feb 3. Doi: 10.1016/j.jaim.2020.11.009PMCID:

PMC8039350 | PMID: 33546993

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8

039350/

4. Shastri A., editor. Bhaishajya ratnavali of Shri

Govind Das, chapter 54, verse 365-370.

Chaukhambha prakashan; varanasi: 2012.p. 914

5. Shastri L., editor. Yogratnakar, uttarardh;

Rasayanadhikar: verse 1-8. Chaukhambha

prakashan;Varanasi: 2010.pp. 501-502.

6. Tripathi B.,editor .Charaka samhita of agnivesha,

chikitsasthan; kushtha chikitsa: chapter 7, verse

144-150. Chaukhambha surbharti prakashan;

varanasi: 2013. pg.327-328

7. Joshi Y. G., editor. Kayachikitsa chapter 13,

Kushtha sau sampada Shyam kopdrekar pune

sahitya vitaran 273, shanivar peth, Pune: 2017 pg

164-166.

8. https://www.charak.com/product/urtiplex-anti-

itch-lotion/

9. https://www.apollopharmacy.in/otc/gamascab-

lotion-100ml

10. https://www.charak.com/product/imupsora-oil/

11. https://www.reckeweg-india.com/product-

details/R65-63.html

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DOI : 10.5281/zenodo.10451134

Dr. Nidhi Kevalsingh Gaharwar Inter. J.Digno. and Research

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