Rupoid Psoriasis on Hands: A Case Report

Rupia derives its etymological roots from the Greek word “Rhupos,” meaning dirt. “Rupioid” describes distinct, cone-shaped plaques with dense, dark, lamellate, and adherent crusts on the skin, resembling oyster or limpet shells. Rupioid psoriasis, a morphological subtype of plaque psoriasis characterised by hyperkeratotic lesions, is a prevalent dermatological condition affecting approximately 2.5% of the global population. Given its autoimmune nature, psoriasis lacks a definitive cure. Its clinical features are similar to those observed in Kitibha Kushtha, a type of MahaKushtha (major skin disease) in Ayurveda. The treatment approach involves purificatory therapies alongside internal medicine. This case report details a 46-year-old male patient who presented with symptoms of rupioid psoriasis for eight years. The patches thickened and gradually darkened to a blackish hue. The itching intensified gradually. The intervention included purificatory therapies, emesis, and purgation, followed by internal medicine and topical application. The combination of purificatory therapies, followed by external and internal administration of Ayurvedic formulations, proved highly effective in managing the patient’s KitibhaKushtha (rupioid psoriasis).

Ayurveda, Emesis, Internal medicine, Psoriasis, Skin disease

A 46-year-old male healthcare provider presented to the institutional outpatient department complaining of hard, crust-like skin lesions and wounds on both forearms, accompanied by itching for eight years. The condition gradually spread to his hands, trunk, and back. The patches turned a blackish hue, and the itching worsened, particularly at night. The patient initially consulted a homeopathy clinic without relief. He subsequently attended the dermatology department of a tertiary hospital, where a biopsy was recommended. Due to the patient’s refusal of histopathology, a diagnosis of rupioid psoriasis was made based on clinical presentation. The patient received treatment with methotrexate, cetirizine, and folic acid, along with topical steroids, for three months under the care of a dermatologist, providing temporary relief. New lesion formation ceased during treatment, but the condition relapsed upon cessation of medication. He then sought care at an Ayurvedic hospital. The patient had no significant past history of rupioid psoriasis or other skin problems, and no family history was reported. He maintained a mixed diet (vegetarian and non-vegetarian), experienced sleep disturbance due to itching, and had no harmful habits (Vyasan). On examination, the patient’s vital signs were normal. His pulse was 80 beats per minute and regular, with a blood pressure of 120/90 mmHg (Vata Kaphaj). Respiratory rate was 18 breaths per minute, and temperature was normal (98.2°F). Ashtavidha Pariksha (eight diagnostic tools) revealed normal findings except for Malabaddhata (constipation); his tongue (Jivha) was Saam, and his skin (Sparsha) was Khar with Raktawarna. He also exhibited Kshudhamandya (impaired digestion). Dermatological examination revealed multiple, well-demarcated, raised, black lesions with thick, lamellate, and adherent crusts on both hands. The diagnosis was made by comparison with other conditions exhibiting similar features [Table/Fig-1].

Assessment criteria: The Psoriasis Area Severity Index (PASI) score [Table/Fig-2] was used to assess severity [1]. The scale ranges from 0 to 4, representing no severity to maximum severity. The body is divided into four sections: head (H) (10% of the skin), arms (A) (20%), trunk (T) (30%), and legs (L) (40%). Each section is scored individually, and the scores are combined to determine the final PASI score. For each section, the percentage of skin area involved is estimated and graded from 0 to 6. Based on erythema, induration, and desquamation, the patient initially scored 4 on the PASI scale.

Treatment: Treatment commenced with Gandhak Rasayan, Avipathikar Churna, Vetapalai Oil, and Padachira Ointment, along with Panchatikta Ghrita and Trikatu Churna as preparation for Shodhan Karma. Shodhana Chikitsa (purificatory therapy) involved sequential Vamana (emesis) and Virechana (purgation) as part of Purvakarma, Pradhankarma, and Paschatkarma. Purgation was performed 20 days after emesis.

Follow-up and outcome: Following Vamana, erythema, induration, and desquamation scores reduced to 1, 2, and 2, respectively. After Shodhan, Shaman Chikitsa was administered [Table/Fig-3]. A second follow-up after Vamana and Virechana showed further reduction to 0 for these symptoms [Table/Fig-4,5]. Pre-Shodhana procedures, formulations, doses, drugs, and properties are detailed in [Table/Fig-6,7,8 and 9]. Vamana involved 2600 mL intake and 3200 mL output with nine vega; Virechana resulted in expulsion of Pitta dosha with twenty-four vegas [Table/Fig-10].

[Table/Fig-4]:

a) presence of darker lesions on forearms; b) 1^st Follow up image showing no lesions only scars remain; c) On 2^nd Follow-up showing healed lesions and scars.

Rupioid psoriasis is a unique form of psoriasis characterised by distinctive lesions. Unlike other psoriasis types, it presents with cone-shaped, thick, crusted black lesions, and patients exhibit periods of remission. Few infectious aetiologies are relevant to the differential diagnosis of rupioid presentations. These include syphilis, HIV, scabies, histoplasmosis, Rupioid Psoriasis (RupP), and reactive arthritis. Diagnosis is based on Kushta symptoms. Eka Kushta presents with dry skin and lesions covering the entire body. KapalaKushta features black, hard, dry plaques resembling an earthen pot. Kitibha Kushtha presents with black-brown lesions that are hard to the touch, similar to wounds. Based on these symptoms, this case was diagnosed as Kitibha Kushtha, correlating with rupioid psoriasis due to similar signs and symptoms. Ayurvedic research has addressed erythrodermic psoriasis, plaque psoriasis, and scalp psoriasis using Shodhan Karma [2,3]. However, no case studies specifically address rupioid psoriasis treated with Shodhan and Saman Chikitsa in Ayurveda. Therefore, based on the presented findings, the diagnosis was Kitibha Kushtha and Shodhan followed by Shaman Chikitsa was recommended.

Shodhan Chikitsa: Before purificatory therapies, Purva karma improved digestion. Pradhan karma, involving Vamanopag Dravyas (drugs used in emesis therapy), works at a microcellular level, aiding detoxification, improving immunological function, and preventing recurrence. After Shodhan Karma, Dhoomapan was administered via Aguru (Aquilaria agallocha Roxb) stick in each nostril for five minutes. Sansarjana Karma (post-detoxification diet) was prescribed for five days. The post-Vamana and Virechana dietary regimen enhanced Jatharagni (digestive capacity), replenishing Jatharagni in the stomach and intestines and gradually enhancing acid and alkaline secretions. The regimen included Vilepi, Akrita Mamsarasa, Peya Krita Yusha, Akrita Yusha, and Krita Mamsaras.

In Virechana, the drug properties facilitated expulsion of morbid factors via the anal route due to the predominance of Jala, Prithvi Mahabhuta, and Adhobhaga Prabhava.

Internal medicine included Panchatikta Ghrita (Snehapan) containing Patol (Luffa acutangula), Neem (Azadirachta indica), Vyaghri (Solanum xanthocarpum), Vasa (Adhatoda vasica), Guduchi (Tinospora cordifolia), and ghee. It acts as a digestive stimulant, cleanser of bodily channels, blood purifier, antipruritic, anti-dermatitis agent, and complexion enhancer [4]. Gandhak rasayan, a widely recommended formulation for skin diseases, possesses antibacterial, antiviral, and antimicrobial properties. Purified sulphur reduces infection and alleviates itching, improving skin complexion and aiding digestion. Sulphur is administered orally and topically as a blood purifier, mitigating burning sensations (Daha) and itching (Kandu). The formulation is Raktashodhak (blood-purifying), Vranaropak (wound-healing), Twachya (skin-friendly), and Krumighna (antiparasitic), reducing infection and alleviating Raag (redness) and Pidika (eruption) [5].

Topical application: Padachira Ointment moisturises and softens the skin. Vetapalai oil possesses Kushthaghna (skin disease reducing) properties, being antibacterial, antiviral, anti-inflammatory, antifungal, and antimicrobial. It manages itching, pruritus, and psoriasis, improving digestion, skin complexion, and acting as a painkiller and wound healer. All constituents hydrate the skin and exhibit Tridosha (three humours reducing) properties [6]. Skin powder possesses antiviral, antibacterial, and antifungal properties, treating skin diseases, reducing infection and itching, and lessening Daha (burning sensation) and Kandu (itching). It is also blood-purifying, wound-healing, skin-friendly, and antiparasitic [7].

Rupioid psoriasis correlates with Kitibha Kushtha, a Maha Kushtha subtype. Effective treatment involves Shodhana procedures (Vamana and Virechana), followed by Shaman Chikitsa, including Gandhaka Rasayan and topical application of Vetapalai oil, Padachira ointment, and skin powder. The synergistic effect of Shodhana Chikitsa and Shaman Aushadhi yielded improved outcomes.

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