# Introduction roper Shodhana Karma brings Roga Apunarbhavatwam 1 ; that means the disease never reoccur. If we speak practically, reoccurrence of disease can be delayed for longer period .Shodhana Karma helps in detachment of Doshas from their root. Panchakarma is also referred as penta-biopurificatory process. Virechana Karma is one among Panchakarma; by which orally administered drug acts on internal Dosha, especially Pitta Dosha and expel them out of the body through Guda. Virechana is the prime treatment for Pittaharana and Amashayagata Pitta 2 . Psoriasis is a common chronic skin disorder of autoimmune origin. The exact cause of the condition is not known. But it is believed that the main culprit behind the pathology may be the autoimmune response of T-lymphocytes and neutrophils which causes the over production of healthy skin cells which rapidly moves to the outermost layer of the skin in days causing a build-up of thick, scaly patches on the skin surface. It is also believed that genetic factor also plays an eminent role in this condition. In modern medicine, the mild form of this condition is managed by topical agents like corticosteroids, moisturisers etc. Moderate condition is managed by phototherapy. For severe conditions systemic agents like methotrexate, ciclosporin, hydroxyl carbamide etc. are used. Still the condition is usually reoccurred within months. The word Psoriasis is from the Greek word ps?ra meaning "itch", psoriasis is a chronic, noncontagious disease characterized by inflamed lesions covered with silvery-white scabs of dead skin 3 .Normal skin cells mature and replace dead skin every 28-30 days. Psoriasis causes skin cells to mature in less than a week. Because the body cannot shed old skin as rapidly as new cells are rising to the surface, raised patches of dead skin develop on the arms, back, chest, elbows, legs, nails, folds between the buttocks, and scalp 3 . Psoriasis is considered mild if it affects less than 5% of the surface of the body; moderate, if 5-30% of the skin is involved, and severe, if the disease affects more than 30% of the body surface 3 . From the available studies, the prevalence of psoriasis in India ranges from 0.44 to 2.8% 4 . In another study it is found that point prevalence of psoriasis is 8% # 5 .The same study has described that among the psoriasis patients, the ratio of male to female was 1.1:1. Highest prevalence was noted in the age group of 21-30 and 41-50 years 5 . # II. # Definition Psoriasis is a non-infectious chronic inflammatory disease of the skin, characterised by welldefined erythematous plaques with silvery scale with predilection for the extensor surface and scalp and a chronic fluctuating course 6 . # III. # Types of Psoriasis Dermatologists distinguish different forms of psoriasis according to which part of the body is affected, how severe symptoms are, how long they last, and the pattern formed by the scales. The most common one is chronic plaque psoriasis (50%); the most common sites of involvement in descending order of frequency were the palms and soles (33%) and scalp (20.8%); nearly 4.1% presented with erythroderma 5 . Plaque psoriasis 7 -the most common type. Lesions are well demarcated, red with dry, with a silverywhite scale. The elbows, knees and lower back are commonly involved. Other sites of predilection include scalp, nails, flexures and palms. Guttate psoriasis 7 -commonly seen in children and adolescents and may follow a streptococcal sore throat. Erythrodermic psoriasis 7 -skin becomes universally red or scaly. As in other forms of erythroderma temperature regulation becomes problematic with hypothermia or hyperthermia. Pustular psoriasis 8 -there are two varieties; generalised form and localised. It is characterized by blister-like lesions filled with non-infectious pus and surrounded by reddened skin. Generalized pustular psoriasis can make life-threatening demands on the heart and kidneys. Palomar-plantar pustulosis (PPP) causes large pustules to form at the base of the thumb or on the sides of the heel. In time, the pustules turn brown and peel. In Ayurveda, psoriasis can be correlated to many varieties of Kushta; such as Sidhma Kushta, Ekakushta, Kitibha Kushta, Mandala Kushta etc. due to similarity of signs and symptoms. The present case is correlated to Sidhma Kushta. Acharya Charaka explained Sidhma under Mahakushta. Sushruta and Vagbhata Acharya described it under Kshudra Kushta. In this case study, Sweta (whitish), Tamra (coppery), Alabu Pushpa Varna (pinkish) and Rajo Brushtam Vimunchati (peeling of skin) features of Sidhma were found. It is Vatakapha predominant disease. In every Kushta, Dooshana of Sapta Dravya (Tridosha, Twak, Rakta, Mamsa and Lasika) occurs. Kushta is difficult to cure, but in classics repeated Shodhana Karma has been advised without harming Prana of Shareera 9 . In Vata predominant condition Sarpipana is administered. In Pitta predominant cases Raktamokshana and Virechana are done. Whereas in Kapha dominant condition Vamana Karma is followed 9 . # Aim To evaluate the effect of Virechana Karma in Psoriasis. # Objective To evaluate the effect of Virechana Karma with Manibhadra Churna in Psoriasis. # Place of Study This case study was done in the department of Panchakarma, MVR AMC, Parassinikadavu, Kannur. IV. # Case Study a) Presenting complaints A 42 year old male patient c/o itching overhead, behind the ears, nails, lower back and legs since 2 years and while itching he gets whitish powder. # b) History of presenting complaints Patient was apparently normal before 2 years; gradually he developed itching over his head. He has consulted a dermatologist and has taken modern medicine. He got symptomatic relief. After 2months, again itching was started on head and leg associated with severe burning sensation on chest. Again he has taken modern medicine for the same and got relief. But all the symptoms were remitted as soon as the medicines were stopped. So he has planned to take Ayurveda treatment for the same. # c) History of previous illness Nothing # Results During Snehapana itching, roughness of lesion and scaling were reduced. After Virechana Karma Samyaka Shudhi Lakshana was achieved; symptoms such as itching, erythema, scaling, thickness, candle grease sign, Koebner's phenomenon and Auspitz sign were not found. The weight of the patient was also reduced.0 After the follow up period of 6 months the patient was fine and reoccurrence of the disease was not found. So all the Shamana medicines were stopped. One more follow up was planned again after 6 months. Patient was fine and no reoccurrence of the condition was happened. # Signs & Symptoms # Discussion Kushta is noted as Dush Chikitsya due to Prasarana Bhava. Raktadhatu is the main reason for Prasarana Bhava. Pitta and Rakta are Ashraya-Ashrayee Bhava; hence Virechana Karma can bring best result. In the present case study, the patient is Dushchardya too. So Virechana Karma was planned. Agni was deranged in the patient. So Deepana -Pachana Karma before Snehapana was advised. Panchakola Churna was taken 5gm with half glass of Takra; which is Shreshta Pachana and Deepana Dravya. Thus, internal Ama Pachana was brought out and Jadharagni was kindled. For external Rukshana purpose, Udwartanam with Nimba Churna and Aragwadha Churna was done. Nimba (Azadiractaindica) and Aragwadha (Cassia fistula) are anti-fungal, anti-bacterial and anti-pruritic drugs. Udwartana helped in the exfoliation of dead tissues. Arohanakrama Snehapana with Aragwadha Mahatiktaka Grita was given for 7days. Samyak Snigdha Lakshana such as Vata Anulomata, Agni Deepti, Snigdha Vit, Twak Snigdhata was obtained. In order to pacify Kapha and promote easy evacuation of Doshas with stools, 3days Vishrama Kala was planned. In these 3days Abhyanga with Psoricure oil and Bashpa Sweda were done. Next day Virechana was administered with Manibhadra Churna 50g in lukewarm water at 8am. It is the drug of choice for Virechana in Kushta. Samyak Virechana Lakshana was obtained. After Virechana Karma Samsarjana Krama has followed for Prakruti Prapta Purusha. # VII. # Conclusion The present case study showed that classical way of Virechana Karma with Manibhadra Churna is effective in Psoriasis. All the symptoms of psoriasis were totally reduced. Vyadhi Harana, Agni Vridhi, Laghutwa, Indriya Prasada and Twak Prasada were also obtained. No untoward effect was got during and after the treatment. After Samsarjana Karma, the patient has obtained his Prakruti. The effect of Virechana with Manibhadra Churna in Psoriasis -A Case Study 5![Shamana therapy ? Panchatikta Guggulu Grita 10ml ( B/F, Morning only) ? Psoricure oil ( External application) weekly once ? Avipatti Churna 15g with hot water (weekly once, night only) All the medicines were prepared as per classics in the pharmacy of MVR AMC, Parassinikadavu, Kannur. n) Assessment Criteria of Virechana Aantiki Shudhi -Kaphantam Vaigiki Shudhi -20 Vega Laingiki Shudhi -Laghutwam, Indriya Prasada, Agni vardhana, Kramat Vit, Pitta, Kapha and Anila Pravrutti. Manika Shudhi -3 Prastha V.](image-2.png "5 )") 1![Fig. 1: BT & AT](image-3.png "Fig. 1 :") The effect of Virechana with Manibhadra Churna in Psoriasis -A Case Study2) Desha3) ScalingBhumi -Jangalam Deha -SarvashareeraScoreSymptoms3) Bala0No scalingRogibala -Madhyama Rogabala -Madhyama1Mild scaling from some lesion4) Kala2Moderate scaling from someKshnadi -SharadkalalesionVyadhyavastha -Vyakta 5) Analam -Vishamagni 6) Prakruti -Pittakapha3 4Severe scaling from some lesion Severe scaling from all lesion7) Vaya -Youvanam8) Satwam -Madhyama4) Thickness9) Satmyam -Sarvarasa 10) Koshta -KrurakoshtaScore 0Symptoms No thicknessi) Systemic examination RS -Normal CVS -S 1 S 2 heard P/A -Soft, non-tender1 2 3Mild thickness Moderate thickness Very thickj) Skin examination4Very thick with in durationGeneral inspection of skin -lesion present on scalp, ears, nails, lower back and legsd) Personal History B -constipated, irregular 5) Candle grease signSkin colour -pinkishM -6 to 7 times per day ScoreSignInspection of lesion -plaque, symmetrical, hardA -decreased 0Absentsurface, well demarcatedS -disturbed1ImprovedPalpation -roughness, scaly lesion Koebner's phenomenon -positiveDiet -mixed Addiction -tea (~10 times/day) 2 PresentAuspitz sign -positive Candle grease sign -positive6) Auspitz sign e) Family History Positive family history ScoreSignk) Diagnosis On the basis of detail clinical history and examination, the present case was diagnosed as Plaque Psoriasis.f) General Examination BP -130/90mmHg Pulse -83/min RR -16/min 0 1 2Absent Improved Presentl) Assessment CriteriaHR -83/min Ethical approval: A written consent was taken from the1) ItchingScore 0 1Symptom No itching Mild itchingTemp. -97.4 0 F patient. Weight -72Kg Height -165cm BMI -26.45Kg/m 2 g) Ashtashana Pareeksha m) Treatment protocol 1) Rukshana Chikitsa (Abhyantara and Bahya) ? Panchakola Churna (5g) with Takra for 5days (B/F, twice daily)2Moderate itchingNadi -Sadharanam ? Udwartana with Nimba Churna and Aragwadha3Severe itchingMutram -Anavilam Churna2) ErythemaMalam -Badha Jihwa -Upaliptam 2) Snehana Karma (Abhyantara and Bahya) ? Snehapana with Aragwadha Mahatiktakam Grita inScore 0 1Symptoms No erythema Mild erythemaDrik -Prakruta Aarohanakrama Matra until Samyak Snigdha Sparsha -Anushnasheeta Shabda -Spashta Akruti -Madhyama Lakshana has obtained. In this case for 7days ( 30ml, 60ml, 90ml, 120ml, 150ml, 170ml, 200ml ). ? Abhyanga with Psoricure oil and Bashpa Sweda for2 3 4Erythema without oedema Erythema with oedema Erythema with oedema and blisters3days h) Dashavidha Pareeksha 3) Shodhana Karma 1) Dooshya Dosha -Vatakapha Dhatu -Rasa, Rakta, Mamsa ? Virechana with Manibhadra Churnam (50g) with lukewarm water, given at 8am. 4) Samsarjana Karma Mala -Sweda ? Peyadi and Rasa Samsarjana Krama administeredfor 8 Annakala (5days) ## Acknowledgement Special thanks to Dr. Shaiju Kumar, Department of PG Studies in Panchakarma, MVR AMC, Parassinikadavu, Kannur. * Charaka Samhita of Agnivesha (Ayurveda Dipika, Chakrapanidatta, comme, Sanskrit), Sutrasthana 16/20. Varanasi: Choukambha Surabharati Prakashan Acharya Jadavji Trikamji editor 2005 97 * Charaka Samhita of Agnivesha (Ayurveda Dipika, Chakrapanidatta, comme, Sanskrit), Sutrasthana 20/16. Varanasi: Choukambha Surabharati Prakashan Acharya Jadavji Trikamji editor 2005 115 * Psoriasis in India: Prevalence and pattern SDogra SYadav Indian J Dermatol Venereol Leprol 76 2010 * Epidemiological pattern of psoriasis, vitiligo and atopic dermatitis in India: Hospital-based point prevalence SornaKumar SChitra Nayak Indian Dermatology Online Journal 2014 * Davidson's Principles and Practice of Medicine NicholasABoon NickiRColledge 2006 1287 Churchill Livingstone Elsevier Limited * Davidson's Principles and Practice of Medicine NicholasABoon NickiRColledge 2006 1288 Churchill Livingstone Elsevier Limited * Davidson's Principles and Practice of Medicine NicholasABoon NickiRColledge 2006 1289 Churchill Livingstone Elsevier Limited * Chikitsasthana 7/40, 41. Varanasi: Choukambha Surabharati Prakashan Charaka Samhita of Agnivesha (Ayurveda Dipika, Chakrapanidatta, comme, Sanskrit) Acharya JadavjiTrikamji 2005 452