The Gerson Institute of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayurveda) Medical Director, Jupiter Medical Center Dept. of Integrative Medicine Division of Education and Research

Jupiter Medical Center at The Calcagnini Center for Mindfulness
1210 S. Old Dixie Highway, Jupiter, Florida 33458, Suite M-117.2

 

Lake Mary Clinic and Panchakarma Facility: at 635 Primera Blvd. Lake Mary, Florida 32746

 

 Telephone: (561) 263-MIND (6463); option #2 or (561) 510-3833

The Ayurvedic Approach to Psoriasis (Ekakushtha)

Definition


According to Samkhya darshan, the skin is one of the five jnanendriyaadhisthana (sense organs) and is the organ of sparsha tanmatra—the fundamental energy of the sense of touch. As every high school student learns, the skin is the largest and heaviest organ in the human body. It is a deceptively complex organ and plays a vital and generally under-appreciated role in physical and mental health—until a problem arises. Besides acting as an effective barrier against the entry of microorganisms, it play important roles in temperature regulation, immunity, excretion of wastes, and synthesis of Vitamin D. Any form of skin damage can result in diverse health problems.


Incidence/Prevalence

Psoriasis is one of the most common dermatologic diseases, affecting slightly more than 2% of the US population (7 million people) and approximately the same worldwide. It is a common, chronic and non-infectious skin disease characterized by circumscribed scaly patches with particular predilection for the scalp and extensor surface of body. It usually occurs before the age of 40, most commonly between the ages of 15 and 25 years; it affects men and women almost equally. It is outcome of rapid skin cell proliferation, characterized by the absence of sweating, severe itching, dryness of the skin, and white silvery scales. In the Charaka Samhita (c. 200 B.C.) the symptoms of Ekakushtha are very similar:


अस्वेदनं महावास्तु यन्मत्स्यशकलोपमम्| तदेककुष्टं

asvedanaṃ mahāvāstu yanmatsyaśakalopamam| tadekakuṣṭaṃ,

Asvedana - Absence of sweating mahavastu - Extensive localization and Yanmatsya shakalopamam – Resembles the scales of fish.

Etiology/Risk Factors


The etiology (cause) of psoriasis is still poorly understood, but there is clearly a genetic/epigenetic predisposition. It has been found in large surveys that one third of patients have a positive family history. The strong genetic influence may result from a single dominant gene with poor penetrance or a number of genetic and epigenetic influences. Other factors such as local trauma, general illness, smoking, chronic indigestion, excessive alcohol and stress are also involved, so the cause of psoriasis is best regarded as being multifactorial. Psoriasis can be a very persistent complaint. It does not kill but it causes great deal of unhappiness, low self-esteem, social withdrawal, and depression. Hence, psychological aspect of psoriasis is equally important in both the etiopathogenesis and management of psoriasis.
In Ayurveda, psoriasis most closely resembles a condition known as Ekakushtha. In modern medicine, the focus is on suppressing the symptoms of psoriasis because the cause is not clearly understood. Ayurveda, in contrast, regards psoriasis as a difficult disease to cure but nonetheless curable in some cases. In the Ayurvedic understanding of psoriasis, Vata, Kapha and Pitta/Rakta vitiation are the major contributing pathological factors in its manifestation. Although ekakushtha is considered as a disease of bahya roga marga (the exterior pathway), the initiation of pathogenesis is from the kostha (alimentary canal). Although there are differences of opinions among the Ayurvedic scriptures regarding the details of the disease, all agree without exception on the prominent role of diet in the early pathogenesis of ekakushtha. One possible modern interpretation of this is that epigenetic influences can activate the genetic mechanism for this disease. However applying the usual samshamana (gentler) principles of treatment of Kushta according to nidana and samprapti, will inevitably result in only partial cure
and/or recurrence. Therefore, as I will detail below samshodana (“radical”) treatment in the form of Vamana (therapeutic vomiting), Virechana (purgation therapy), and Vasti (herbalized enemata) Karmas in conjunction with proper internal medication is considered as the best line of effective treatment.

Modern View of Etiopathogenesis of Psoriasis


Psoriasis is considered to be largely a disorder of keratinization. The basic observed defect is rapid progression from basal cell to horny cell of epidermis in psoriatic lesion (3-4 days instead of 28 days in normal skin). There is evidence that both hormonal and immunological abnormalities are involved at a cellular level. The raised concentrations of inflammatory metabolites of arachidonic acid in psoriatic skin are related to the clinical changes. Recent study suggests that dysfunction of T cells is the primary event and that hyperkeratosis of the epidermis occurs secondarily. Additional inductive factors include irritants, injury, sunlight, infection, and drugs (e.g., lithium, β-blockers, calcium antagonists).

The inflammatory aspect of psoriasis is physically evident by the redness of psoriatic plaques. The biochemical basis for this inflammation stems from several immune modulators including various cytokines released from keratinocytes and other proteins involved in the inflammatory response, which are increased in psoriasis at both local and systemic level. These inflammatory mediators most likely play a crucial role in the pathogenesis of psoriasis.

Among the interleukins (ILs), IL-1, IL-6, IL-7 and IL-8 are upregulated in psoriatic skin. In addition, IL-15, which reduces keratinocyte cell apoptosis, is also elevated. Other factors, which cause the inflammation seen in psoriatic skin, include neutrophil activating peptide-1/Il-8, intercellular adhesion molecule-1, HLA-DR, tumor necrosis factor-a, interferon-g, macrophage migration inhibitory factor, pituitary adenylate cyclase activating polypeptide (PACAP). All of these inflammatory factors exert specific effects on T cells, endothelial cells, macrophages and neutrophils, which in turn produce the immunogenic inflammatory response seen in psoriasis. As a result, psoriasis is now considered by modern medicine to be an autoimmune disease mediated by a T-helper type 1 cell response to an as-of-yet unidentified antigen.

Ayurvedic Samprapti (Etiopathogenesis) of Ekakushtha (Psoriasis)


Ayurveda believes that vitiation of Vata and Kapha doshas by dietary and lifestyle transgressions play a key causative role in the genesis of this chronic skin disease. In addition, ama (viz. endogenous metabolic waste products), a variety of exogenous environmental stressors, and genetic/epigenetic factors also play significant role in the patho-physiology of psoriasis. The vitiated doshas and malas with and without ama, in turn, adversely affect the skin (tvak) and blood tissues (rakta dhatu).

The vitiated Vata and Kapha doshas also adversely affect the jala mahabhautic components (watery elements) of the affected skin region. This causes the affected skin to appear whitish or coppery color (Kapha), scaly and thin (Vata). In the samprapti of psoriasis, the disturbed Vata both (a) dries the water element of skin and (b) promotes abnormally rapid proliferation of skin tissue. The vitiated Kapha Dosha and accumulated malas also produces itching.
The blood, which is vitiated by Vata, Kapha and malas subverts the normal healing process and later on, it is permeates and can become deeply rooted in different tissues. This is supported by the recent published findings that people with psoriasis or psoriatic arthritis, both inflammatory conditions, are more susceptible to a number of other conditions including obesity, heart disease and diabetes. (Lønnberg, AS, et.al., Association of Psoriasis With the Risk for Type 2 Diabetes Mellitus and Obesity, JAMA Dermatol. Published online April 27, 2016. doi:10.1001/jamadermatol.2015.6262.)

Treatment


Modern medicine currently (2016) offers many suppressive treatments but because of its chronic recurrent nature psoriasis is a challenge to control chemically. The newest agents are called “biologics” and the ones you may have heard of (on television ads) include: Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Stelara (ustekinumab), among many others. Conventional treatment also include PUVA and corticosteroids. But all these therapies have serious side effects--liver and kidney failure, bone marrow depletion etc. and, in the best case scenario, they only suppress the symptoms and do not cure the disease. For this reason the Ayurvedic approach is clearly superior.


The Ayurvedic Treatment of Ekakushtha (Psoriasis)


Though the treatment of psoriasis is constantly evolving, the Ayurvedic holistic model advocated twenty centuries ago remains the core. In this connection, the biopurificatory measures of vamana, virechana and basti karmas (therapeutic emesis, purgation, and enemata) are the key to its treatment.
To summarize, treatment consists of Samshodhana Chikitsa in the form of a modified Panchakarma regimen which can include vamana (therapeutic physician-supervised vomiting), virechana (purgation), and basti (a series of medicated enemata). Whether one or all of these procedures are used depends on the careful assessment of roga- and rogi-pariksha by the physician. Internal medications are given at the conclusion of samshodhana.
If Vamana is included in the treatment protocol, it is generally done prior to both virechana and basti.

VAMANA


The Vamana Protocol comprises three stages:
 Purva Karma (preparatory procedure)
 Pradhana Karma (main procedure)
 Pashchat Karma (post procedure)


1) Purva Karma of Vamana: a] Deepana – Pachana, b] Snehana and c] Abhyanga – Svedana.


Deepana and Pachana can be achieved in many ways. Administration of Trikatu powder, Panchakola powder, Pippali, Pippalimoola, Chitraka, Ginger root, Ativisha, and Hingu, are most commonly used. Dosages range from 1/4-1/2 teaspoon BID or TID for 3 days.


Snehana (oleation) before Vamana procedure is performed by Abhyantara Snehapana (internal oleation therapy). Abhyantara Snehapana is acheived by administering pure cow’s Ghee (or other oil) in small but increasing dosages over 3-7 days. A typical regimen begins with one ounce in early morning and increases daily by one ounce each succeeding day. After observing of Samyaka Snigdha Lakshana (symptoms of proper internal oleation: oiliness of skin, passing stool containing fat, feeling of aversion of ghee), patients are either given Sarve Abhyanga or instructed to perform self-Sarve Abhyanga (total body oil massage) with an appropriate oil (e.g. dashmoola oil, bakuchi oil, bala oil, vranashodaka oil, etc) for three days. On those same three days, Svedana is given by sarvanga bashpa sveda (fomentation done by using steam applied to whole body) or by avaghaha sweda (hot herbalized bath) either once or twice daily for 3 days by using Dashamoola decoction in either case. During these 3 days, moderate quantity of liquids and a warm diet (unspiced) which is non-complex and non-sticky is given. However for the evening meal preceding the morning of Vamana, patients are given kichadi made from black gram, sesame oil and rice along with milk and or curd. Then, on the fourth morning, Vamana Dravya is administered.


2) Pradhana Karma (main procedure viz. Vamana therapy)


Patients must come for treatment with an empty stomach the morning of the Vamana day. Before administration of Vamana (emesis) Drug, patients are asked to consume cold milk or water until akantha pana (full stomach). Depending on individual requirements, some patients are also given peya + ghee. Pulse, blood pressure, respiration and temperature are recorded. As mentioned in classics, Vamana drug is administered between 6:00 and 8:00 am. The classic vamana dravya is a mixture of Madanaphala (seed powder of Randia dumentorum), Vacha (Acorus calamus), Saindhava Lavana (rock salt), and honey, in a 4:2:1:1 proportion. This is modified as per the patient.

For collecting vomitus, a bowl is positioned in front of the patient, who is in a kneeling position. The urge to vomit is often spontaneous without any effort or straining. The urge may be excited if necessary by opening wide the lips, the palate, the throat and by tickling the throat with two well-manicured fingers. This induces the gag reflex followed by vomiting.
The number of vegas (i.e. motions) after administration of the vamana dravya are counted until the sign of proper vamana is reached: the appearance of a small amount of Pitta (bile) in the vomitus.


3) Pashchat Karma (Vamana post-procedure: dietetic restrictions)


The time period from the completion of Vegas, till the patient reached his normal diet is crucial and the specific management that has to be taken at this juncture is known as Paschat Karma (“after” care). After the completion of Vamana patients are kept on Samsarjana Krama (special dietetic regimen) modified according to the intensity of the vamana procedure. Patients are generally all advised to take rest and eat an individualized peyadi samsarjana krama (thin rice gruel) for 3 to 5 days. On the 5th day a normal diet is resumed.


VIRECHANA


The Virechana Process also comprises three stages, which are as follows:
 Purva Karma (preparatory procedure)
 Pradhana Karma (main procedure)
 Pashchat Karma (post procedure)


1) Purvakarma of Virechana


The procedures are essentially the same as for Vamana Purva Karma but if Virechana was preceded by Vamana, the Purva Karma can often be abbreviated. Deepan-Pachana dravyas, external Abhyanga, and Abhyantara Snehana are given simultaneously for three days. On the morning of the 4th day, the Virechan Dravya is given.


2) Pradhana Karma (main procedure viz. purgation therapy)


Before administration of Virechana (purgation) Drug, Abhyanga (massage) by ‘Dashmoola oil’ and Svedana (fomentation) by ‘Dashamoola decoction’ is carried out by sarvanga bashpa sveda or by avaghaha sweda on the morning of Virechana day. Pulse, blood pressure, respiration and temperature are recorded. Patients have an empty stomach. As advised in the texts, Virechana drug is administered in the mid-morning between 9:30 and 10:30 a.m. on empty stomach. The usual virechana dravya is eranda taila (castor oil) or eranda taila + Haritaki but many other ‘Virechana Yogas’ (purgative formulations) are also used (i.e. trivrit, snuhi, icchabhedi rasa).
The number of vegas (i.e. motions) after administration of the virechana dravya are counted until the sign of proper purgation is reached: stopping of purgation on its own, passing of stool with mucus in the last one or two motions, feeling of lightness in the body.


3) Pashchat Karma (post procedure of dietetic indication)


As with Vamana, the time period from the completion of Vegas (bowel movements) to the time when the patient regains normal agni and strength is crucial and known as Paschat Karma (post-care). After the completion of Virechana (purgation), patients are again given Samsarjana Krama consisting of initially thin and gradually heavier rice gruel for 3 to 5 days. Normal diet is then resumed.


BASTI
Ayurveda enumerates over thirty types of bastis classified according to site of administration (i.e. rectum, urethra, vagina, wounds), internal or external (i.e. back, eyes, chest), function (detoxifying, nourishing, secretory, for infertility, etc), frequency, or duration (8-, 15-, or 30-day regimen).


The type of bastis used in Panchakarma are pakwashaya gata bastis, which are alternating niruha and anuvasana (decoction-based and oil-based, respectively) and which follow the yoga basti schedule (eight consecutive days of alternating anuvasana and niruha basti).


The Basti Process also comprises three stages, which are as follows:
 Purva Karma (preparatory procedure)
 Pradhana Karma (main procedure)
 Pashchat Karma (post procedure)


1) Purvakarma of Basti Karma


As with all panchakarma procedures proper purva karma preparatory measures are essential for effective therapy. Every day, the patient is instructed to have a light breakfast approximately one hour prior to arriving at the clinic. The basti purva karma procedures are external Abhyanga and Bashpa Swedana which are given every morning for three days. These procedures serve to dilate the srotas (channels) and facilitate the removal of ama from and the delivery of medicinal substances to the tissues. On the morning of the 4th day, the 1st basti treatment commences.


2) Pradhana Karma (main procedure viz. vasti therapy)


The patient is positioned in the left lateral position (lying on the left side with the left leg extended and the right leg flexed at the knee and drawn up towards the chest). The basti temperature should be near body temperature (95-100F) to increase absorption by the colonic mucosa. The oil (anuvasana) or decoction (niruha) is drawn up into a rectal syringe and introduced into the rectum through a lubricated thin rubber catheter (usually #8). It is then removed and the patient instructed to turn into the prone position (“face down”) and lie quietly for pratygamana kala (retention time) of 1000 seconds (16.6 minutes); after the first 5 minutes any position can be assumed as long as patient remains lying (i.e. “face up” or on one side).


The patient is then instructed to sit on the toilet to evacuate any fecal and residual basti matter, but not to sit longer than five minutes. After basti pratyagamana (expulsion of basti), the patient is instructed to not to eat for 2 hours and then eat only a light, warm, liquidy meal (e.g. dal soup with rice, fresh fruit juice, yogurt, etc). Oily, heavy, and flesh foods are to be avoided as is daytime sleep during the basti sequence.


Other dietary measures include: Avoid excessive salt, red chilies, chilli powder, fried foods, candy, chocolate, pastries, left over food, alcohol, and dairy taken with fruit.


Oral medications


Ayurvedic medications which are used in the treatment of ekakushtha (psoriasis) include:


Arogyavardhini Rasa. 250 mg 2x daily after meal with plain water for next 4 weeks
Kaishora Guggulu. 250 mg 2-3x daily after meal with warm water for next 2 months
Rasamanikya (an arsenic and mica containing medicine) 125 mg after meal 1-2x daily with ghee and honey for one month


Dosages and combinations of the following plant based medicines are at the physician’s discretion:

Kakamachi (Solanum nigrum)
Neem (Azadirachta indica)
Guduchi (Tinospora cordifolia)
Haridra; Turmeric (Curcuma longa)
Manjistha (Rubia cordifolia)
Musta (Cyperus rotundus)
Saptaparna (Alstonia scholaris)

 

Modes of Action of Various Components of Treatment

Deepana and Pachana herbs due to Ushna, Laghu Guna ( hot and light property) of panchakola, pippali, pippalimool, chitrak, ativisha, hing, etc. enhance the digestive capacity and metabolic activity of the cells and facilitates the easy digestion of ghee or other oil during Snehapana (intake of unctuous ghee) which follows.


Snehapana (internal oleation therapy) which precedes Virechana procedure is effective to adsorb toxic materials so they can be easily evacuated from body. It is prerequisite procedure which is carried for 3-7 days based on the tolerance of patient and manifestation of signs of proper internal oleation (oiliness of skin, passing stool containing fat, feeling of aversion of Ghee). Sneha dravyas like ghee prevent the obstruction of srotasmi (subtle channels) as doshas and ama pass from Shakha (periphery) to Kostha (gastrointestinal tract). Lipid soluble toxic substances pass from the peripheral tissues, through the intestinal wall, to the unctuous ghee environment in the intestinal lumen—from where they can be eliminated. Consuming ghee in increasing quantities for several days is helpful in extracting lipid soluble toxic substances from the tissues.


Abhyanga- Svedana (whole body external oleation and massage and sudation therapy). After obtaining symptoms of proper internal oleation, which appear after 5th day of ‘Snehapana’, patients are administered Abhyanga and Bashpa Svedana. Abhyanga (whole body external oleation) softens morbid humours. Svedana liquefies the morbid doshas in the srotasmi (micro channels) and renders their transport from periphery to central gastrointestinal tract easy. From there, doshas can be expelled from the body by normal eliminative functions.

Virechana (Purgation). Oleation therapy and sudation therapy administered for the purpose of Virechana liquefies morbid doshas, bringing them from Shakha to Koshtha wherein they are naturally eliminated just by gently stimulating the local eliminative organ (viz. colon). Besides eliminating Pitta and Kapha doshas, the main seat of Vata (i.e. Pakvashaya) is also purified thereby making Virechana Karma a truly Tridoshahara procedure.

Vamana (Therapeutic Vomiting). Vamana is a procedure in which Doshas (waste products or toxins) are eliminated through upper channels i.e. mouth. Specifically, Kapha and Pitta Dosha brought centrfugally to Amashaya (stomach and duodenum) from peripheral tissues by the specific preoperative procedures and then eliminated by inducing the emesis. Kapha disorders and associated Pitta disorders or diseases originating or relocated to sites of Kapha will be relieved either permanently or for a long period of time. Vamana also eliminates Kapha Dosha from the respiratory passages and helps to prevent the initiation of diseases due to Kapha and Pitta. Additionally, many Ayurvedic herbal medicines are administered by mouth, where they first reach Amashaya (the stomach)--the main seat of Kapha. Digestion of food also begins here. If there is accumulation or aggravation of Kapha in Amashaya, the digestion of food or medicine cannot proceed properly. Through Vamana Karma, Amashaya Shuddhi (cleansing of stomach) occurs, so the digestion of drug and food takes place properly.

Basti (Herbalized Enema) is highly useful as both a detoxification procedure and a route of delivery of medicine. The active principles of the Niruha Basti drugs are likely absorbed by active transport mechanisms as they are mainly water soluble. In contrast, Anuvasana Basti and other oil-based Bastis contain are lipophilic emulsions facilitating direct absorption into the perirectal venous system and general circulation. All the cells/tissue in the body are interconnected. Basti by eliminating morbid content of large intestine will impact other tissues and promote health of the entire organism. Recent research demonstrates a definite relation between the brain of the central nervous system and the gut’s brain (our “second” brain). 

Samsarjana Krama (post-procedure dietetic regimen). After the completion of Shodhana (purification) procedures such as Vamana or Virechana, normal diet should not be given immediately as the Agni (digestive fire) is extinguished due to the intensely reducing procedures. A normal diet would be beyond its capacity to digest. The purpose of Samsarjana Krama is to gradually re-ignite the intentionally reduced Jatharagni (digestive fire) and re-establish optimum bowel functioning.

Internal Medication. Kaishora Guggulu is an excellent herbal formulation which corrects the function of stomach and intestine, reduces inflammation, and is inherently detoxifying. The ingredients of Kaishora Guggulu are Tinospora cordifolia Willd., Emblica officinalis Gaertn., Terminalia bellirica Gaertn., Terminalia chebula Rets., Commiphora mukul Hook., Zingiber officinale Roscoe, Piper nigrum L., Piper longum L., Embelia ribes Burm f. Operculana turpethum Linn. and Baliospermum montanum Willd. It has anti-bacterial, anti-inflammatory, anti-oxidant, anti-microbial property which helps in treating wounds. It is natural blood purifier therefore, corrects Raktadushthi (vitiation of blood).
Arogyavardhini Rasa is a formulation promotes digestive fire, up-regulates liver function, clears body channels and has laxative action which helps to eliminate toxins out of the body; therefore it is highly recommended for all skin disorders. Rasamanikya is an Ayurvedic medicine used in the treatment of Vata and Kapha disease (i.e. psoriasis, fever, asthma, bronchitis, joint disease, and polycystic diseases of various organs. It contains heavy metal and mineral ingredients (arsenic trioxide and mica) hence should only be taken under strict medical supervision of an experienced vaidya.


The other medicines listed in the Oral Medication section are beyond the scope of this article to describe but are all very effective and commonly used.


CONCLUSION. Psoriasis is a multifactorial heredo-inflammatory disease that is triggered by some uncharacterized local and/or systemic factors. There is evidence that both hormonal and immunological mechanisms are involved at a cellular level and possibly a psychological component. The Ayurvedic treatment approach focuses on the removal pro-inflammatory mediators and toxic physical wastes, restoring homeostasis to aggravated doshas and correction of Agni (digestive fire) and metabolism which can eliminate the condition.

Basti is a highly useful as both a detoxification procedure and a route of delivery of medicine. The active principles of the Niruha Basti drugs are likely absorbed by active transport mechanisms as they are mainly water soluble. In contrast, Anuvasana Basti and other oil-based Bastis contain are lipophilic emulsions facilitating direct absorption into the perirectal venous system and general circulation. All the cells/tissue in the body are interconnected. Basti by eliminating morbid content of large intestine will impact other tissues and promote health of the entire organism. Recent research demonstrates a definite relation between the brain of the central nervous system and the gut’s brain (our “second” brain).