J R.A.S. Vol. IX, No. 3-4, pp. 124-134

'Herbal Treatment (Siddha) for Psoriasis (A report on clinical research with speciaJ focus on

HistopathologicaJ aspect)

K.K. Rao', J.R. Krishnamurthi 2, B.M.V. Shetty 3, Pandiyarajan* and G. Velucfiamy*

Received on 18th December, 1986

Psoriasis ti chronic non infectious/non Contagious disease known for its recurrent episode is one with which the patient litis to bear on long term basis. First time in the history of management < f Psoriasis a simple, single Siddha herbal preparation coded as 777 oil was introduced at Central Research Institute (SitlU.a), Madras. This drug has given encouraging results on more than 100 cases of proven psoriasis. The pathogenesis, the histopathological

findings, before and after treatment are discussed in detail with focus on the Clini-cal resultj obtained. 30 cases chosen for

'Paper presented in the International Con-ference on Indigenous system of medicine at Madras (Jan. 1986).

1. Assistant Research Officer (Pathology). 2. Hon. Consultant 3. Hon. Consultant 4. Lab. Technician 5. Assistant Director fneharge Central

Research Institute (Siddha) Madras-110016.

exclusive histopathological analysis and also the follow up studies done on these cases are also included in this paper.

Introduction

Psoriasis, a notoriously chronic auto-somal dermatosis, well known for its coursc of remission and exacerbation without any specific reason has knowlcd-gcably no cure in any of the existing modes of therapy. This unsighty condi-tion of skin has been successfully cured with a Siddha drug of herbal origin intro-duced by Dr. J.R. Krishnamurthy fo r the first time as treatment to Psoriasis. With continuous study for more than 5 years conducted at Central Research Institute for Siddha, Madras, by a team of doctors, the gratifying results are confir-med beyond doubt. This paper records the details of study covering both clinical and laboratory findings with special

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HERBAL TREATMENT (SIDDHA) FOR PSORIASIS

rcfcrence to histopathological aspects which is taken as the confirmatory measure. Pathogenesis of Psoriasis :

In Psoriasis there is manifold increase in normal number of basal cells of epi-dermis. In association with normal cells of hyperplasia there is enhanced meta-bolism and accentuated synthesis and degradation ofnucleo proteins resulting in an elevated excretion of nucleic acid metabolites such as uric acid.

There is an increased vasculature in sub-epidermis that is essential to support the increased rate of cell division. The cytologic, histologic and histochcmical allevation are known to be the result rather than the reason. Clinically it is characterised by sharply defined dry scaly erythematous patches covercd with adhe-rent silvery white micaceous scales nlTccl-ing extensor surface of the body. Prominent Features for A Microscopic Diagnosis of Psoriasis arc :

Marked parakeratosis on the surface responsible for the abnormal scaling with collections of neutrophils in and beneath the horny layer (Micro absccss of Munric).

Acanthosis of Epidermis with elonga-tion of retc pegs to nearly uniform levels ending in club shaped expansion. The epidermal plate over the bulbous and oedematous dermal papillae inter-digita-ting with rete pegs.

Dilated rigid capillaries in these papillae accounts for the bleeding on lift-ing the scale. Spares Collection of lymphocytes and histocytes in upper dermis especially in the papillae.

In any case all these above said fea-tures may not be typically present but still a positive diagnosis can be made by the presence of most of them. A super-imposed exfoliative dermatitis is fre-quently present. Again the above histo-logy is often modified by trauma, infec-tion and therapy. Materials and Methods

Cases for this trial arc sciectcd from the out-patient section of Central Research Institute (Siddha). Most of them ere long standing psoriatics with a duration ranging from 5 years to 30 years. The diagnosis is based on the clinical methods of Siddha and Allopathic methodology. a. The classical distribution over

extensor surface. B. The (silvery) scaly appearance which

when removed reveal the bleeders. c. Recurrent episodes during particular

season as well as the chronicity. d. Nail changes and e. Total absencc of itching are taken

into account for confirming the con-dition clinically.

Laboratory Parameters Adopted arc : 1. Urine Examination Routine (To rule

out diabetes and renal pathology).

125

K.K. RAO et al 2. Haemogram (complete) to rule out

anaemia. 3. Blopd chemistry for excluding

diabetes. 4. Serology—For confirming STD

RA test to confirm Psoriatic Arthritis 5. Skin scraping study—To rale out

tuberculosis and leprosy. 6. Biopsy for confirmation (vital para-

meter) 7. Photographs for periodic assessment.

From the cases registered for trial after thorough screening it was confir-med that this disease is prevalent in both sexes and no age is spared (Table I & II).

Biopsy was performed from an appro-priate site of lesion taking care to include a small area of adjacent normal skin both before and after treatment. The standard procedure of routine histopathology was followed in studying Hacmatoxylin and Eosin stained section of formalin fixed paraffin embedded tissue.

Biopsy and photograph arc taken before starting the treatment. Photo-graph alone is repeated at the end of 3 weeks for assessment and comparison. By the end of sixth week the patient recovers almost totally. The biopsy and photographs are again repeated. The patients are instructed to report if there-is any sign of exacerbation or recurrence. Treatment Given :

A Siddha herbal preparation coded as

777 oil was given internally at a dose of 5 ml twice a day. The same oil is u ced externally also over the lesions. The drug 777 oil is prepared from the leaves of Veipalai (Wrightia iinctoria R. Br.). Though Vetpalai is a known herb for many skin diseases, (Ref. Wealth of India, Vol. X) , this introduced for the first time as treatment to Psoriasis. The method of preparation of the oil is also different from the usual literary procedures. Details of the Drug Basic Ingredient : Leaves of Vetpalai Base used : Coconut oil Method of prepa- : Exposure to Sun-ration light Dose administered : 5 ml twicc daily

internally. Gentle application over the fesion snd ex-posure to sunlight preferably in the morning is ad-vised.

The various a5pects of this prepara-tion, namely the 777 oil were studied along with the clinical trial, the details of which are as follows : Phaimacological Aspect

Pharmacological aspects such as analgesic, anti-inflammatory and anti-pyretic properties were tested on albino rats and mice and significant

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HERBAL TREATMENT (SIDDHA) FOR PSORIASIS

anti-inflammatory and analgesic activities were noted with this coded preparation.

1. Analgesic activity — Chemical writhing *'-.*•• Significant of 777 oil and hot plate method results noted.

2. Anti-inflammatory — Caragenine induced Significant activity of 777 Oil paw oedema activity in the

doses of 1.5 nil/kg 3 ml/kg and 6 ml/kg orally.

3. Anti-pyretic study Brewer's yeast induction pyrexia in rats

No anti-pyretic effect noted. (Ghosh et al, 1984)

Toxicity Studies Ho adverse effects were seen on most

of the patients with the scheduled clinical doses. About 2% were allergic to 777 oil and developed intense itching and burnirg. They were withdrawn from the trial.

Toxicity studies (acute and subacute)

conducted on animals too, did not show any significant changes on HPE and studies in the vital organs of animals tested. A, dose of 10 ml/kg body weight on test animals showed toxicity clinically but HPE & studies did not show any change in the vital organs of even these animals. (Kalavathy K. Rno ct al, 1985).

Microbiological Activity Antifungal and ) . ° V on patients Antibacterial S. aureus S. albus S. Citrcus

1 > Agar dilution assay method

0.8% and abuvc

Significant inhibition of growth noted (Hamcaveni ct al 1984}

Photochemical C hanges Tested with the sample at various

stages to assess the efficacy of exposure to sunlight. Result

Definite chemical changes improving

the efficacy of drug, confirming its eficct of exposure to sunlight. (Alam & Anandan, ct al, 1984-85). Instructors given to patients on 777 oil treatment :

During the trial a specific diet patter^ 127

K.K. RAO et al Tablc-I

Distribution of psoriasis eases according to age & sex Sex

Age in years Male Female

No. % No. % Below 10 years 10—20 years 2 0 - 3 0 years 30—40 years 40—50 years 50—60 years 60—70 years 70 years & above

22 — 8

Tuble-Il Clinical presentation and laboratory findings of follow up cnscs

— • — —

— 1 12.5 1 4.54 2 25 2 9.09 2 25 T 31.S2 2 25 8 36.36 1 12.5 4 1S.I8 — . —

_ — _

Male Female

I. Clinical Presentation A. Auspitz's Sign 22 8 B. Koebncr's Phenomenon 22 8 C. Nail Changes 6 2

II. Stool Examination A. Hookworm 5 3 B. Roundworm 3 1 C. SS. Larva 4 —

III. Precipitating Causes A. Alcohols 6 — B. Focal Sepsis 4 2

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HERBAL TREATMENT (SIDDHA) FOR PSORIASIS

that includes high protein and less fat was adopted uniformly. In addition they were instructed to observe the following practice : 1. Soap in any form should not be used. 2. Common skin allergens such as fish,

brinjal, tomato were totally avoided. 3. Besan or green gram flour only is

allowed for bathing purpose. 4. Advised to avoid wearing synthetic

materials.

5. High protein and low fat diet is recommended.

6. Advised to expose themselves to sun-light after applying oil preferably in the morning for a short time. Duration of treatment was fixed as

six weeks. Cases which fail to show any response within the target period was taken as No relief entity. Commence-ment of response was noted in all cases by sccond week, (Table-Ill).

Response to Treatment No response Disappearance of scales alone Disappearance of scalcs -f erythema Disappearance of scalcs Disappearance of erythema Transformation of papular macular lesion Total clcarancc of all the above said feature and reversion of skin to near normal/normal

No relief Mild relief. Moderate relief. Marked relief.

Complete relief.

Tabk-III Classification of Psoriasis cases according to commencement of response

Four Five

Duration in week

Cases Responded

Duration in week Male Female Duration in week No. % No. 0/ / o

One 6 2 7 . 2 7 1 1 2 . 5 Two 10 4 5 . 4 5 3 3 7 . 5 Three 6 2 7 . 2 7 4 5 0

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K.K. RAO et al Observation and Disci ssion

100 patients were tried as the results were encouraging from the beginning. Almost all the cases showed definite response though not 100%. After con-firming its efficacy on 100 cases, 30 cases were taker, for Histopathological studies with its periodic biopsy and photograph exclusively. Clinical improvement obser-ved (ref. Photograph) in the extent and

severity of the "extensive lesion is as important as microscopic changes in evaluating progress under treatment.

Greater value is to be given to epi-thelial changes. A basis of assessment from a subjective plan of grading epider-mal and inflammatory changes before and after on a three plus ( + + + ) and single plus ( + ) was attempted but was found to be of limited appreciation in practice.

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HERBAL TREATMENT (SIDDHA) FOR PSORIASIS

The follow'ng was adopted as direct evidence of improvement : a. Reduction in Parakeratosis. b. Diminished heights of rate ridges.

c. Reduction in the number of inflam-matory cells, (rcf. Photograph & Slides). In a disease so prone to natural

remission and exacerbation in its course any conclusion on progress has to be tempered with a due measure of caution.

Follcw up studies en patents treated with 777 o i l :

Recurrence is t he^o i r s t . problem left unanswered in Psoriatics. With conti-nuous research for more than 4-5 years, significant postponement of recurrence was noted among psoriatics treated with 777 oil. Recurrence seems to be more common among men than in women. Emotional upsets, over work, tension, exposure to dilferent climatic condition focal sepsis & viral infection—all these seem to precipitate subsequent attacks.

Before Treatment After Treatment 2-11-82 7-3-83

Epidermal change : Note the reduction in Parakeratosis 1 3 1

1 , t K . K . R A O et al

Tab!e-IV Results of Treatment

No. of cases according to sex Results Male Female

No. % N o . % Complete relief 7 31.81 2 25 Marked relief 8 36.36 2 25 Moderate relief 4 18.18 2 25 Mild relief 1 4.54 — — No relief — — — — LAMA 2 9.09 2 25

Table-V ••; - -

•Follow up studies on Psorlaslvcascs treated with 777 oil

S. No. Period of No. of eases Duration Response Follow up Reported with of

Recurrcncc Treatment I. End of 1 year 3 cases 4 weeks Complete relief

2 cases 6 weeks Complete relief 2. End of 2 years 2 cases 4 weeks Complete relief

2 cases 8-10 weeks Complete relief 2 cases. 3 weeks L A M A (Refused

to undergo subse-quent biopsies).

3. End of 3 years 18 cases 6 weeks Complete relief 4. End of 4 years 1 case 4 weeks Complete relief •The severity of the lesion was very much minimised in all the cases followed and also subsequent attacks af te r 777 oil therapy were postponed.

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HERBAL TREATMENT (SIDDHA) FOR PSORIASIS

Among these 30 cases followed and assessed histopathologically, 18 cases did not get any recurrence for 3 years conti-nuously. 2 cases reported only after 4 years with minimum flare up. 3 cases had their usual exacerbation every year during winter season. These patient themselves admitted that th i severity of the lesion is minimised after 777 oil treat-ment. 3 cases reported afier 2 years. Among 4 cases left, 2 patients refused to undergo subsequent biopsy and grouped under LAMA cases. 2 patients who reported with recurrence stayed for more than 6 weeks (8-10 weeks). These cases had focal sepsis (dental canics) and the relapse took little longer to gel cleared. (Rcf. Table-V). Conclusion

it is evident from our tr ial ' that 777 oil help", in postponing the subsequent attacks. Even when there is rccurrcncc the severity and extent of the lesion is

very much minimised. Added advantages of this drug are its easy availability, cost and no adverse reaction even on the long run. his disease where particularly steroi js the one and only drug of choice, this herbal preparation has given reason-ably good results and also a psychological boost to patients who have been subjected to anticular disfigurement and mental harassment. Acknon lodgement

The authors acknowledge the scrvicc rendered by members of various sections such as Clinical (Siddha), Pharmacy and Pharmacology, Pathology and Bioche-mistry that has helped in reviving the response to therapy. Our thanks arc due to Dircclor, C.C.R.A.S , for conducting this trial at C.R.I. (S), Madras, and also for the financial assistance. Wc lh«ink Mr. Sivanandam, Statistician for his help.

REFERENCES Anderson J.R.

Anonymous

Boyd William

Lever W.F. Mcqueen, A.

1971 Text book of Pathology VII Edn. Chapt. XI Page 1625-26.

1976 Wealth of India, Raw Materials Vol. X CSIR , New Delhi. Page 588-90.

1949 Text book of Pathology VIII Edn. Chapt. 46 The Skin' Page 1406-7.

1987 Histopathology of Skin. IV Edn. 1945 Muirs Text book of Pathology,

Chap. 27. The skin, Page 1056. 1 3 3

K.K. RAO et al

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134