A Comparative Clinical Analysis of two different Courses of Navana Nasya with Shiro Abhyanga in Darunaka with Special Reference to Scalp Psoriasis

Introduction

Panchakarma is an integral part of Ayurvedic treatment, designed to eliminate the vitiated doshas through the route nearest to the affected area and maintain a state of equilibrium (Doshasamyata). Nasya karma is an important therapeutic module in the Panchakarma and the most important treatment for the diseases of Urdhwa Jatru.¹ It can be categorized into five main types,² out of which Navana Nasya is one of the treatments for Darunaka according to Acharya Vagbhata.

Shirovirechana (a type of Navana Nasya) is indicated in Kapha Pradhana, Kaphajanya, and Kaphanubandha disease conditions located in jatrurdhva pradesha, ie, above the clavicle region. Shiro abhyanga with moordhni taila is indicated in shirorogas with roukshya and kandwadi Lakshanas.³

Psoriasis is a chronic inflammatory skin disorder clinically characterized by erythematous, sharply demarcated papules and rounded plaques, covered by silvery micaceous scales.⁴ It is one of the most common dermatologic diseases, affecting up to 1% of the world’s population. The most common form of psoriasis is plaque psoriasis which predominantly occurs on the elbows, knees, and scalp. Researchers estimate that at least half (50%) of the people who have plaque psoriasis have at least one flare-up on the scalp.⁵ Scalp psoriasis relates to a condition called Darunaka in Ayurveda, having pradhanata of kapha and vata dosha characterized by itching, hair fall, numbness, and dryness and scaling of the skin over the scalp region. Nasya karma is the choice of treatment for scalp psoriasis as the sthana of the disease is urdhwa jatru. Shiro abhyanga is also performed to treat the dryness and itching.

Generally, Nasya karma is done for seven consecutive days which is the duration mentioned by Acharya Vagbhata. Also, while explaining about Kushta Chikitsa, he has suggested Shirovirechana with a gap of two days. Therefore, the present study was conducted to compare the effects of Navana Nasya and shiro abhyanga, performed with Bhringarajadi taila,⁶ on Darunaka, especially scalp psoriasis.⁷ Bhringarajadi taila was chosen by virtue of its kaphavatanut, keshya, twachya, rasayana, krimi, and kushtanut properties.8

As scalp psoriasis is aggravated by dandruff, many people mistake it as just dandruff and there are chances of neglecting it. Hence, this study was an attempt to differentiate between these two and find an effective and safe remedy for scalp psoriasis.

Objectives: To evaluate the effect of:

1. Navana Nasya for seven consecutive days along with shiro abhyanga for 21 days on scalp psoriasis.

2. Navana Nasya in seven sittings with a gap of 2 days along with shiro abhyanga for 21 days on scalp psoriasis.

3. To compare the effect of the two different courses of Navana Nasya along with shiro abhyanga.

Materials And Methods

The study included 40 patients who fulfilled the inclusion criteria and were randomly selected from the outpatient and inpatient departments (OPD and IPD) of Shri Jayachamarajendra Institute of Indian Medicine, Bengaluru.

Diagnostic criteria: The diagnosis of the disease was mainly based on the signs and symptoms mentioned in the modern9 and classical texts, which are as follows:

• Itching
• Hair fall/temporary hair loss
• Dryness and scaling of scalp
• Reddish plaques on the scalp
• Dandruff-like flaking and silvery-white scales
• Scalp bleed
• Burning sensation or soreness of scalp

Inclusion criteria: Male and female patients in the age group of 16-70 years, who had been diagnosed with scalp psoriasis and were suitable for Navana Nasya karma.

Exclusion criteria: Patients who had cardiac disease and were on antihypertensive drugs and also those who had any other systemic disorders.

Study design: A randomized comparative clinical study.

The patient was advised not to get exposed to cold wind, dust, smoke, and sunshine, and avoid head bath, excessive talking, anger, sneezing, laughing, and shaking their head during the course of treatment. A light meal and lukewarm water were recommended.

Assessment criteria: The parameters were graded as shown in Table 2. The Psoriasis Area and Severity Index (PASI) scores were analyzed before and after the treatment.

Results

Most of the patients were in the age group of 16-30 years (37.5%) and 41-50 years (25%) in both the groups. Males and females constituted 65% and 35%, respectively. Majority (82.5%) of them were belonged to the middle class. Family history of the disease was absent in 85% of the cases. Maximum number of patients (20) had alpa nidra pravrutti, 18 patients had vishamagni, and 9 patients had mandagni. Also, 18 (45%) and 15 (37.5%) patients were found to have Vata-Pitta prakruthi and Kapha-Vata prakruthi, respectively.

Data related to the disease: Out of 40 patients (20 each in group A and group B), 24 (60%) patients had chronicity in the range of 1-10 years; 60% presented with mental stress as a predisposing factor; 57.5% of the patients had a flare-up during the winter season. Majority of the patients indulged in Vata-Kapha prakopaka nidanas like Nidra vaipareetya (50%), Rookshahara (42.5%), Vishamashana (40%), and Ati prayoga of kaphakara ahara (40%).

Analysis of the effects on group A showed statistically highly significant (P<0.001) results with: 43.33% difference in area; 65.116% difference in itching, 44.83% difference in erythema, 43.56% difference in scaling, and 51.35% difference in thickness; and 63.98% difference in the PASI score (of each scalp section), 63.97% difference in the total PASI score,

Analysis of the effects on group B showed statistically highly significant (P<0.001) results with: 49.85% difference in area; 66.67% difference in itching, 40% difference in erythema, 63.06% difference in scaling; 69.32% difference in thickness; and 76.210% difference in the PASI score (of each scalp section), 76.209% difference in the total PASI score. Overall, the effect of therapy after 21 days of treatment showed 71.18% relief in group A and 75.65% relief in group B.

Discussion

As Nasya karma is the treatment of choice for the diseases of head and neck, it was selected for the present study on scalp psoriasis. Massaging and fomentation of Urdhwa Jatru seemed to have an impact on the blood circulation to the head and face. The efferent vasodilator nerves, which are spread out on the superficial surface of the face, receive stimulation due to fomentation and might increase the blood flow to the brain, ie, create momentary hyperemia. Shiro abhyanga with moordhni taila is indicated in shirorogas with roukshya and kandwadi lakshanas which are present in the form of scaling and itching in scalp psoriasis. Hence, to reduce the scaling and itching, ²¹ days of shiro abhyanga was performed. Different methods of stroking adopted during shiro abhyanga helped to detach the firmly adherent scales from the scalp. In males, hair trimming was done before the treatment, which aided in the quick reduction of scaling and thickness.

This treatment was repeated thrice in 3 patients due to recurrence of symptoms. It was observed that the recurrence period was extended during the 2nd and 3rd repeat treatment, indicating that repeated Nasya extended the duration of recurrence. This observation proved the importance of Stoka dosha nirharana concept of Kushta and its interpretation in Darunaka Chikitsa.

Darunaka is characterized by Kandu, Rukshata, Twaksphutana, and Keshachyuti. It can be correlated with scalp psoriasis in contemporary science as it includes majority of the signs and symptoms associated with it. All the drugs in trikatu choorna have kaphavatahara, kushtahara, krimighna, and srotoshodhaka properties and hence, are useful in skin disorders. Pippali, an ingredient, acts as Rasayana by rejuvenating rasa and rakta dhatu. Bhringarajadi taila is a kalpa explained in Sharngadhara Samhita as darunanashaka, which is used for shiro abhyanga as well as Nasya karma. It has Bhringaraja swarasa as the main ingredient which has diaphoretic action on the skin due to rasa, rakta, and mamsa dhatu properties. It also promotes immunity. The snigdha guna present in the taila reduces the dryness, thereby preventing the shedding of scales and hair fall. Itching, being a lakshana of kapha, is also pacified by its ushna guna.

Modern science says that any lipid-soluble substance has a greater chance of passive absorption directly through the olfactory cells of the lining membrane. Later, the drug may traverse through capillaries and veins. As Nasya consists of taila dravya action, it may be fastacting and beneficial. This concept was well understood by our ancient scholars. Hence, they processed the drug in lipid media. Shringataka Marma includes srotas where ghrana, shrotra, and akshitarpanasiras are united. This is the area where the medicine gets absorbed. The taila is made lukewarm and instilled, which brings about vasodilation. It facilitates the drug absorption. The posture advised in Nasya is also significant as it allows the taila to reach the olfactory area in the upper part of the nasal cavity, and the olfactory neurons are stimulated. It has been found that the cilia of the olfactory cells contain relatively large quantities of lipoid materials and lipid-soluble substances that cause marked stimulation of an olfactory cell. The drug might be absorbed initially by a passive process across the cell wall.

After the completion of treatment, 10 patients (50%) in group A and 13 patients (65%) in group B showed marked improvement. This indicates that Nasya (7 sittings) administered once in three days along with Bhringarajadi taila in the shiro abhyanga group had better relief than the Nasya performed for 7 consecutive days.

Conclusion

Based on the conceptual analysis and observations made in the clinical study, the following conclusions can be drawn. The signs and symptoms seen in Darunaka correlate well with scalp psoriasis. Hetu vyadhi pratyaneeka Chikitsa-Navana Nasya adopted in the study helped in the elimination of vitiated kapha dosha and vatashamana through srotoshodhana in kapala and Shiro abhyanga, leading to Vyadhi shamana. The present study demonstrated that both courses of treatment – seven continuous days and seven sittings of Navana Nasya along with Shiro Abhyanga, showed highly significant changes in the scalp psoriasis. However, the seven sittings method (Nasya once in 3 days) was reported to be more convenient and effective by the patient. Statistically too, group B showed significant improvement with regard to the scaling and thickness when compared to group A. Overall, group B showed better results (75.65%) than group A (71.18 %) for scalp psoriasis treatment.

Conflicts of Interest

Declared.