An Ayurvedic Approach to Vipadika (Palmoplantar Psoriasis): A Case Study

Ayurveda includes all the skin diseases under the broad name Kushta (Skin Diseases). There are 18 types of skin diseases were described in Ayurved Samhitas. Out of which 11 are Kshudra Kushta. Vipadika (Palmoplantar psoriasis) is one of them. Different Acharyas have given different presentations of signs and symptoms of Vipadika. According to Ashtang hridaya, Panipadsputana (Cracks over palms and soles), Tivra Vedana (severe Pain), Manda Kandu (Mild Itching), and Sarag Pidika (Red-colored Macule) are the symptoms of Vipadika. This skin disease hampers day-to-day activity and depresses patients because of cosmetic issues. This case was about a woman of age 55 years having Itching on the plantar aspect of both feet, cracks over soles, burning sensation, and pain during walking. There was no previous history of any systemic disease. The patient had not undergone any surgical procedure. The patient used to eat pickles twice a day on daily basis. At the first follow-up, the burning sensation was reduced. Then the cracks, itching, and Case Study Biswas et al.; JPRI, 33(38A): 267-273, 2021; Article no.JPRI.71113 268 pain during walking reduced with consecutive follow-ups. Raktmokshan (Leech therapy) was planned after every 15 days. Total treatment was about 3 months with a follow-up of 15 days. With this treatment protocol, the patient got completely relieved from all parameters.


INTRODUCTION
Skin diseases are considered nonserious type diseases. The seriousness and awkwardness can only be felt by the sufferer. In this era, the presentation has got enormous importance. Thus, Skin is the first thing observed by others.
Skin diseases are not responsible for Mortality but the cosmetical issue affects the patient at the mental level. Researches show that the patient with skin diseases had greater impairment in mental health as compared with patients having Diabetes mellitus, Hypertension, Asthma, joint pain, Epilepsy, etc. Billions of money are spent on the cosmetical issue every year. Ayurveda includes all the skin diseases under the broad name Kushta. There are 18 types of Kushta described in Ayurved Samhitas [1]. Out of which 11 are Kshudra Kushta. Vipadika is one of them. Different Acharyas have given the different presentations of signs and symptoms of Vipadika. According to Ashtang hridaya, Panipadsputana (Cracks over palms and soles), Tivra Vedana (Intense pain), Manda Kandu (Mild itching), and Sarag Pidika (Red-colored macules) are the symptoms of Vipadika [2]. According to Acharya Charak crack and severe pain are the symptoms of Vipadika [3]. According to Sushtrutacharya, Itching, Burning sensation, Pain present especially on pada (sole) are the symptoms of Vipadika [4]. Critics of Sushruta have told Padadari (cracks over sole) and Vipadika are the same. In Vipadika there is the involvement of Tridosha (basic constitution) but Vata is predominantly vitiated [5]. This case is about 55 year's old lady with Vipadika. There was no previous history of any systemic disease and Surgeries. The patient was good before 2 years. After that, she had cracks, Burning sensation, Pain, and reddish macules over her palms. But these symptoms got subsided after taking medicines from allopathy and Homeopathy. She didn't know which treatment gave her results. Before 1 year she had the same symptoms on both plantar aspects of the foot. She had consulted for various treatments available but of no use.
In this case, Leach therapy and Ayurvedic medication from Ayurved texts was prescribed to break the pathogenesis. As texted, Kushta Dirgharoganam, the treatment was given for 3 months. [6] 2. CASE PRESENTATION Patient information: A 55-year-old lady came to OPD of Dirghayu Ayurved Chikitsalay and Panchkarma centre, Ramnagar, Wardha from post-Arvi with the following chief complaints. The patient had cracks on both the soles for 1 year. A burning sensation for 1 year, Itching from 1 year, the patient had Insomnia due to itching from 7 -8 months, Pain during walking from 3 months, and Constipation since 2-3 months  Table: 1.
Differential Diagnosis: Palmoplantar psoriasis, Tylosis (Palmoplantarkeratoderm), and Dermatitis are the diseases that have the same pictures in the patient and get confused during the treatment. [7] While treating the diseases it is important to find out the difference between these diseases Table 4, which is useful for the further line of treatment Treatment: Treatment was given in two ways internal medication which includes Hingwadi vati, Arogyavardhini vati, Aragwadhakapila, Gandhak rasayan, Raktapachak kadha and Local application Karanj tail is used along with the leech therapy. Each Follow up was plan after 15 days to analyzed the subjective and objective criteria after For the first 30 days line of treatment is different Table 5.

OBSERVATION AND RESULTS
The result was observed after Each follow-up of 15 days and pre and post-treatment after analyzed the subjective and objective criteria of the Patient. After the complete treatment for 90 days, the condition of the patient after each follow up is a follows: Table 6.
After a complete treatment assessment score is 0, it shows that the patient has 100 % relief in Cracks, burning sensation, itching, and pain. Pictures of the sole of both feet also show significant relief during the treatment and after the treatment [ Fig. 1] [Fig. 2] [Fig. 3]

DISCUSSION
As a cosmetic purpose, many skin diseases have their unique importance, but in this case, along with the cosmetic involvement patient had difficulty in daily activity due to severe pain in both the soles. She was unable to walk properly and had insomnia due to pain and nocturnal itching. She had taken medicine from allopathy and homeopathy but still didn't get the result so, she came to OPD for Ayurvedic treatment. This case ofVipadika, treated with Hingwadi vati, Arogyavardhini Vati, Gandhak rasayan, Raktapachak kadha, Kandughna kadha and karanj tail for local application.
Aragwadhakapila: It contain Argwadha (Cassia fistula) and Kampillak (Mallotus philippensis) Cassia fistula is best as mild laxative [6] which excretes Pitta and toxins. Mallotus philippensis is also useful as laxative and in various skin diseases to remove he toxins [18].

Jaloukavachran:
According to Acharya Sushruta, although there are four Doshas in body. When Raktadhatu (Blood) is expelled out of the body it carries vitiated Pitta (Bile) along with it. Raktmokshan (Blood letting) cause Prasad manas ( normalization of physiology of manas or whole body with senses), it prevents Raktaj rogas(formed due to Blood vitiation) like skin doshas [19]. Jaloukavacharan(Leech therapy) is best for diseases of pittaj manifestations [20]. Daha(Burning) was the associated symptom in this patient.
In this case of Vipadika (Palmoplantar psoriasis), The overall symptoms namely cracks, burning sensation, pain, and itching get subsided by Classic treatment of Ayurveda. Here the work is predominantly on Raktavaha strotas. In classics, it is stated that before starting treatment the strotas should be cleaned to ensure fast absorption of drugs [27][28]. For this purpose, Hingwadi vati is administered which is use as appetizer and helps in cleansing Strotas. Arogyavardhini is administered for 45 days. It mainly works on Pitta. Raktapachak kadha and Kandughna kadha is given to pacify the Rakta related symptoms like burning sensation and itching. Local application of Karanja tail pacifies the local symptoms immediately. It soothes the affected area and relieves from pain and itching. Leech therapy improves the condition fast where Rakta and Pitta doshas are involved [29][30].

CONCLUSION
Skin diseases are very hard to treat and line of treatment is not fixed in each patient so this study can be taken as the primary protocol to treat the patients of Vipadika as it shows good result in cracks, burning sensation, pain, and itching and gets complete relief within 90 days with no side effect. Further research can be carried out on Series of cases with the same protocol for confirmation of the drugs. Also, this can be used in other skin diseases having the same symptoms.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline patients consent and ethical approval has been collected and preserved by the authors.

ACKNOWLEDGEMENT
Authors are thankful to Dr. Vaishali Kuchewar Dean MGACH & RC for providing such opportunity also thankful to Dr. Priti Desai, Dr. Shweta Parwe, Dr. Punam Sawarkar and all other peoples who knowingly and unknowingly helped me in making manuscript.