1. INTRODUCTION:

Psoriasis is a T- cell mediated autoimmune non contagious chronic dermatological ailment with significant physical as well as psychological consequences^1,2. Approximately 125 million people worldwide and 10 million Indian people suffer from psoriasis every year³. Possible reason for its onset would be stress, various infections, intestinal dysbiosis and excess use of antibiotics and other chemotherapies⁴. Psoriasis affects patient’s social life leading them to emotional stress and lack of confidence⁵. Due to this, high expenditure on anxiety disorders along with psoriasis keep it underexplored and untreated properly^6,7. Despite of the current inventories in the novel therapies for psoriasis, the prevalence of the cases is high worldwide^8,9.

According to WHO, approximately 80% population of the developing countries use traditional medicines for the primary health issues and chronic diseases¹⁰. While dealing with the psoriasis with the Ayurvedic modalities, use of cow urine can also be used for the management of psoriasis¹¹. Various topical herbal formulations are now being developed where cow urine can also be used for the management of psoriasis¹². we present the two case reports which were treated with cow urine distillate (CUD) also known as Gomutra arka in Ayurveda and therapeutic purgation (Virechana) which responded in short duration. The alone use of CUD for treating psoriasis is not yet tested. Also, its effect after therapeutic purgation is also a topic of research. The present study is a small footstep in the same direction. Though robust conclusion cannot be established through such limited data, the furthermore studies on large sample size are warranted.

2. MATERIAL AND METHODS:

The case report is designed according to the CARE case report guidelines.

2.1 Case 1

2.1.1 General information and past history:

23 years old male patient visited Out-Patient Department (OPD) of Kayachikitsa Department, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi on 12/6/2019 presenting with discoid erythematous scaly lesion below right knee anteriorly in the past 3 months. Also, he was suffering from multiple erythematous scaly lesions at occipital and bilateral temporal regions of head for 8 years. He had no history of psoriasis or major illness in family. He was diagnosed as a case of psoriasis by private dermatologist of Varanasi and was prescribed allopathic medication. Patient took oral prednisolone 5mg once a day along with topical corticosteroids for 5 years. Initially he got improved for about 2 years but later but didn’t get satisfactory improvement. Instead of relief, within one month of leaving medications, new lesion appeared below right knee for which he decided to try Ayurvedic treatment. He was frustrated with his disease and looking little depressed.

2.1.2 Clinical Findings:

On examination, his physique and general condition seemed fair with stable vitals. His appetite was normal and sleep was poor. He was afebrile (36.8ºC) with blood pressure-112/76mmHg, pulse rate-84/min, respiratory rate-20/min and weight-47kg. On systemic examination, central nervous system was normal. Cardio-respiratory system did not show significant findings. Gastrointestinal and urogenital systems were normal too.

2.1.3 Investigations:

Hematological investigation revealed hemoglobin - 13.1 gm/dL, platelets- 4.57lakhs/uL, total leukocyte count- 10020/uL. Renal function test and liver function test were normal. His C- reactive protein level was raised.

2.1.4 Diagnosis:

Clinical features and past history was suggesting presentation of Plaque Psoriasis. Also, Grattage test was positive at the lesions of leg region and head region. Patient was advised for skin biopsy but he refused and insisted for medication for initial. Thus, the final diagnosis was considered as a case of Plaque Psoriasis on the basis of clinical findings.

2.1.5 Treatment:

After proper counseling about disease, he was given oral cow urine distillate (Gomutra Arka) 10ml diluted in 1 glass of water twice a day for two months. Along with that, he was restricted for dairy and products in diet.

2.2 Case 2

2.2.1 General information and past history:

55 years old male patient visited same Kayachikitsa OPD on 27/9/2019. He was presenting with the multiple indurated discoid erythematous plaques on head, abdomen and back trunk region for about 12 years. Also, he was suffering from recurrent episodes of belching and heaviness in abdomen for last 6 months. He had no history of any other major past illness. He was diagnosed as a case of psoriasis from Dermatology OPD of Sir Sunderlal Hospital, Banaras Hindu University, Varanasi in 2012. He was thus taking treatment for about 8 years but despite of medication; he was going through episodic phases of remission and relapse of psoriatic lesions 3-4 times in a year. For last one years, he wasn’t getting relief and some new psoriatic plaques started appearing he added. Thus, he was referred to Kayachikitsa OPD of Sir Sunderlal Hospital on his personal request.

2.2.2 Clinical Findings:

On examination, he had moderate built with fair general condition. He had good appetite but sleep was disturbed. He was afebrile (36.2º C) with blood pressure - 128/86 mmHg, pulse rate - 92/min, respiratory rate - 22/min and weight - 72kg. On systemic examination, central nervous system, cardio-respiratory system and didn’t reveal any significant findings. On abdominal examination, it was distended with tympanic notes. No palpable organomegaly seen; no signs of ascites were observed. Urogenital system found normal too.

2.2.3 Investigations:

Routine hematological investigations were normal. Renal and liver function tests were normal. C reactive protein level was raised.

2.2.4 Diagnosis:

Patient was referred case of psoriasis and was diagnosed as plaque psoriasis on the basis of clinical features and skin biopsy.

2.2.5 Treatment:

He was given therapeutic purgation (Virechana therapy) as per scheduled below (Table 1) completed in 2 weeks. Virechana was done by giving Trivritta Avaleha (50gm) orally as main medicine and dried grapes’ decoction (1 litre) as Anupana. Patient was feeling light after Virechana. Total 16 Vegas (~episodes of motion) were observed during the therapy indicating moderate shuddhi. His vitals were stable with no sign of dehydration. His pulse rate was 92/min and blood pressure was 112/74mmHg. Later he was advised to take oral cow urine distillate (CUD) 10ml diluted in 1 glass of water twice a day for two months. He was also restricted for dairy and products in diet as above case.

Table 1: Procedure of Therapeutic purgation (Virechana)

Preparatory phase
Day	Morning Schedule (melted Cow ghee with tolerable hot water at 6am)	Evening Schedule
1^st	30 ml CG PO with HW	Light diet (khichadi / dal-chawal / roti)
2^nd	60 ml CG PO with HW	Light diet
3^rd	90 ml CG PO with HW	Light diet
4^th	120 ml CG PO with HW	Light diet
5^th	150 ml CG PO with HW	Light diet
6^th	Snehana (Whole body Massage with luke warm mustard oil) followed by Sarvang Swedana (steaming).	Light diet
7^th	Whole body Massage with luke warm mustard oil followed by steaming	Hot liquid diet at evening (Kadhi / Dal / Tomato soup)
Main procedure
8^th	Whole body massage and steaming as above; followed by Therapeutic purgation.
Post-operative phase
9^th	Therapeutic purgation, No meal	Peya (thin gruel of rice)
10^th	Peya	Peya
11^th	Vilepi(thick gruel of rice)	Vilepi
12^th	Vilepi	Akrut yusha
13^th	Krut yusha (semi liquid preparation from lentils)	Krut yusha
14^th	Krut mansa rasa	Normal regular diet

CG- Cow ghee; PO- Per Oral; HW- Hot Water

3. FOLLOW UP AND OUTCOMES:

Cow urine distillate (CUD) was given at each follow up. CUD was given for 2 months and assessment was done upto 3 months in both the cases. CUD was given after therapeutic purgation in case 2. Case 1 was given additional session of counselling for 15 min at each follow up. Both the cases were called for follow up every 15 days later. Both the cases showed improvement at each follow up. Assessment was done on the basis of Psoriasis Area Severity Index (Table 2) at one month interval of treatment. CBC, LFT and RFT were within normal range throughout the treatment period indicating the safety of medicine. CRP level was raised in both cases before treatment came to normal range within 2 months (Table 3).

Table 2: Psoriasis Area Severity Index (PASI) score both cases at each follow up

Hospital Visit and Follow up	Case 1 -PASI	Hospital Visit and Follow up	Case 2- PASI
12/6/2019 (BT)	9.5	27/9/2019 (BT)	21.6
11/7/2019 (F1)	6.2	28/10/2019 (F1)	14
12/8/2019 (F2)	2.8	28/11/2019 (F2)	8.8
13/9/2019 (F3)	0.6	27/12/2019 (F3)	1.8

BT Before Treatment, F1- Follow up 1, F2- Follow up 2, F3- Follow up 3

Figure 1 Psoriasis cases before and after treatment

Table 3: Timeline of the psoriasis cases

Case 1		Case 2
Years	Clinical events and interventions	Years	Clinical events and interventions
2011	Onset of disease	2007	Onset of disease
2014	Diagnosed as Psoriasis	2012	Diagnosed as Psoriasis
2014 to 2018	underwent allopathic medications for 5 years	2012 to 2019	underwent allopathic medications for about 8 years
March 2019	New lesion appeared on right lower limb	Early 2019	Onset of GI complaints
12/6/2019First visit	Severity of lesions: Head-Erythema (+++), Scaling (++++), Induration (++++) Lower limb- Erythema (+++), Scaling (+++), Induration (++++)	27/9/2019 First visit	Severity of lesions: Head-Erythema (++++), Scaling (+++), Induration (++); Trunk- Erythema (++++), Scaling (++++), Induration (++++); Other complaints: Abdominal distension and heaviness, Belching
27/3/2019 Last visit	Severity of lesions: Head-Erythema (nil), Scaling (nil), Induration (+); Lower limb- Erythema (nil), Scaling (+), Induration (nil)	27/12/2019 Last visit	Severity of lesions: Head-Erythema (nil), Scaling (nil), Induration (nil); Lower limb- Erythema (+), Scaling (+), Induration (+)

DISCUSSION:

Psoriasis is a chronic autoimmune dermatosis seeking long term therapy and which is very difficult to treat due to its recurrent relapsing behavior¹³. In Ayurveda, cow urine has been described to have anti dermatitis property¹⁴ and also it possesses Rasayana property which exhibit immunomodulator activity¹⁵. The presented cases were chosen to evaluate efficacy of CUD in the cases of Psoriasis due to their immunomodulator effect. One case was treated only with CUD and other was given CUD after therapeutic purgation. Both the cases showed significant changes in clinical features within 2 months of medication. Therapeutic purgation is commonly practiced by Ayurveda practitioners for the management of psoriasis which is indicated for the various skin disorders in Ayurvedic classics¹⁶. Thus, therapeutic purgation was expected to show the clinical efficacy in clinical features of psoriasis. But it is difficult to differentiate efficacy of CUD and therapeutic purgation separately. Besides this, first case showed its uniqueness due to its response with the use of CUD separately along with little dietary regulation.

Though both the cases showed improvement, they were observed for very short period of 3 months which is not enough to strengthen the hypothesis of anti-psoriatic property of CUD. Psoriasis is a disease of relapse and remission pattern and thus requires long term follow up for minimum 2 to 3 years. Moreover, the randomized clinical controlled trials are requisite for CUD and therapeutic purgation for long duration to evaluate the clinical efficacy and drawbacks of the therapeutic aspects if any.

Cow urine is the non-toxic waste material which contains 95% water, 2.5% urea and remaining 2.5% a mixture of minerals, salts, hormones and enzymes¹⁷. It exhibits the properties as pungent (katu rasa), easily digestible (laghu), penetrating easily through body channels (tikshna), improves intellect (medhya)¹⁸. It contains aurum hydroxide (swarna kshar) which mainly shows immunomodulator effect and allantoin that exhibits keratolytic activity⁹. Other compositions like urea, carbolic acid, phenol, etc show antimicrobial property and prevent psoriatic lesions from superadded infections. A vasodilator kallikrein and fibrinolytic enzyme urokinase improves circulation to affected part and help in maintaining vascular integrity along with the nitrogen, sulfur, sodium and calcium components which act as blood purifiers¹⁹. Thus, it possibly helps for immunomodulator effect of cow urine by enhancing purified blood which may alter the hyperkeratosis of the psoriatic lesion.

Here in the presented case reports, the intervention of CUD showed positive clinical efficacy (Fig 2). CUD is more effective than cow urine of which antimicrobial, antifungal and anticancer properties have been examined^20,21. On the other hand, in Ayurveda, therapeutic purgation has been advocated for balancing and eliminating vitiated doshas prior starting of medication in skin disorders for better clinical results²². It mainly removes deeply accumulated vitiated doshas (especially pitta) and toxins from body through anal region. In Ayurveda, vitiated blood is also major contributing factor for skin disorders and hence it requires blood cleansing therapies during the management. Therapeutic purgation indirectly brings this blood cleansing effect by eliminating vitiated pitta dosha²³. Skin disorders have been observed to aggravate due to dairy products and Ayurveda claims to restrict them during medication^24,25. Excessive use of salt, meat, contradictory diet is some provoking factors for skin disorders and thus should be avoided. Scientific validation over dietary focus in the management of psoriasis is separately another matter of research and need further evaluation.

CONCLUSION:

The use of CUD along with dietary restrictions of contradictory diet may exhibit good clinical results in the cases of psoriasis. The further clinical, exploratory and experimental studies are needed to unveil hidden facts of CUD.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

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Received on 27.06.2021 Modified on 24.09.2021

Research J. Pharm.and Tech 2022; 15(9):4182-4186.

DOI: 10.52711/0974-360X.2022.00701