Department of Agada Tantra, Sri Dharmasthala Manjunatheswara College of Ayurveda and Hospital, Hassan
Pama Kustha is one among the eleven varieties of Kshudra Ku??ha (skin disease) described in Ayurveda, is characterized by kandu (itching), pidaka (papules)and srava (discharge). It is the most common contagious disease. These clinical features show close resemblance to Scabies, a contagious ectoparasitic infestation caused by Sarcoptes scabiei. Approximately 300 million cases of scabies are reported world-wide each year and may cause large nosocomial outbreaks. It is especially widespread in tropical regions and in crowded living conditions, where children and vulnerable groups are more commonly affected. This case study presents a patient diagnosed as Pama Ku??ha with clinical presentation of whitish and blackish papules with itching, nocturnal aggravation, and burrow-like lesions predominantly on interdigital spaces, wrists, and external genatalia. Ayurveda treatment protocol- kostha shodhana (purification therapy) and shamana (palliative) therapies were done targeting krimi (parasitic infestation) and Kapha-Pitta dosha vitiation.Assessment was done before and after 7 days of treatment. Significant relief in itching, reduction of lesions, and overall improvement in quality of life were observed. The given Ayurvedic treatment protocol was found to be effective in the management of Pama which shows the true potential and efficacy of our science.
Human Scabies is a highly contagious parasitic skin infestation caused by Sarcoptes scabiei var. hominis. Globally, it affects over 200 million people at any given time, with cumulative annual cases exceeding 400 million. The condition is particularly prevalent in hot, tropical regions and densely populated resource-poor areas, where prevalence in children may range from 5% to 50%. Although sporadic in high-income countries, outbreaks in healthcare facilities and vulnerable communities impose a significant economic burden. Scabies mites burrow into the skin to lay eggs, leading to intense itching often worsens at night along with characteristic linear burrows and papules. In adults, lesions typically occur on the finger webs, wrists, limbs, and belt area, with inflamed bumps occasionally seen on the male genitalia and female breasts. Infants and young children may present with a more widespread rash involving the palms, soles, ankles, and scalp. Symptoms usually appear 4–6 weeks after infestation, and recurrent infections are common. Diagnosis is primarily clinical, based on recognition of itching, burrows, and papular eruptions. Treatment generally involves topical scabicides, with oral agents.1 Resistance has increasingly been reported against frontline agents such as permethrin and ivermectin, while concerns regarding neurotoxicity with lindane and the potential adverse effects of repeated ivermectin use further restrict their safety profile.2 Moreover, recurrence is frequently observed when close contacts and contaminated fomites, such as clothing and bedding, are not treated concurrently, thereby compromising long-term disease control.3 The clinical conditions can be correlated to Pama as described in Ayurveda Classics. Pama is one of the eleven types of Kshudra Kushta, which is caused by Kapha pitta dosha pathogenesis4. It is characterized by extreme itchy eruptions of white, reddish or black color seen over buttocks, hands and elbow joint. The main aim of treatment is to address the Kapha Pitta Dushti with sukshma Krimi. Personal hygiene and dietary regimen are a very necessary part of the treatment.
Case Description
Presenting complaints:
A 17 years old male patient reported to visha chikitsa Out-Patient Department (OPD) of Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan with complains of whitish papules over interdigital spaces of bilateral hands, fingers, wrist and scrotum. He also complains of blackish lesions over dorsal aspect of bilateral hands associated with severe itching all over the body in the past 3 months.
History of present illness:
Patient was apparently normal 3 months back. He initially noticed whitish papular eruptions over the fingers of left hand associated with itching. Subsequently, he mentioned similar complaints in his hostel mates with whom he had close contact. After about one week, the lesions gradually spread to the bilateral interdigital spaces, fingers, and wrists, later extending to the scrotal region. Initially, the lesions were associated with pus discharge secondary to scratching, which later turned blackish in colour. The itching was persistent, with marked aggravation during the night, disturbing sleep, and was partially relieved on washing the affected parts with warm water. He had taken allopathic medication for a month but did not find relief from the complains. So, he approached SDMCAHH for further management.
History of past illness:
Nothing significant
Family history:
Patients younger brother has itchy blackish lesions over body.
Personal History: -
Diet – Mixed (intake of curd, chicken, junk food frequently)
Appetite – Good
Bowel – Regular
Micturation – Regular
Sleep – sound
General Examination: -
There was no evidence of pallor, edema, icterus, cyanosis, clubbing or lymphadenopathy on observation.
Asta-Vidha Pareeksha:
Nadi: 74 bpm
Mala: Prakruta
Mutra: Prakruta
Jihwa: Lipta
Shabda: Spashta
Sparsha: Anushna-Sheeta
Drik: Prakruta
Akriti: Madhyama
Dashavidha pareeksha
Prakruti: Kapha vata
Vikruti: Pitta Kapha
Saara: Asthi
Samhanana: Madhyama
Pramana- Madyama
Satva: Madhyama
Satmya: Madhura Katu rasa pradhana
Aharashakti: Madhyama
Vyayama shakti: Madhyama
Vaya: Youvana
Vital Signs
Temperature: - Afebrile
Heart Rate – 74 bpm
Respiratory Rate – 18 cpm
BP- 120/80mmhg
Anthropometry
Weight– 59kg
Height- 180cm
Systemic Examination:
The patient was fully conscious and well oriented. The heart sounds were normal, with S1 and S2 heard clearly and no extra sounds or murmurs. The lungs were clear on both sides with normal breath sounds. The abdomen was soft, without pain or swelling of any organs.
Local Examination:
Integumentary System
On Inspection:
Distribution- Localized and symmetrical
Site- B/L Interdigital spaces, B/L fingers, B/L wrist, B/L thigh region, scrotum
Number of lesions- Multiple
Type of lesions- Papule
Size of lesion- <1CM
Texture- dry
Colour- Whitish in interdigital spaces and scrotum, blackish over fingers
Discharge- present initially on excessive itching
Diagnostic Criteria5
Swetha aruna shyava pidaka (whitish/red/blackish popular eruptions)
Kandu(itching)
Srava (discharge)
TREATMENT PLAN
Initially amapachana and rookshana was done by giving bilwadi gulika and amahara kashaya twice a day. After proper amapachana and rookshana, snehapana (internal oleation) was administered with panchatiktaka guggulu ghrita (30ml, 60ml and 90ml) for 3 days respectively. Samyaksnigda lakshana (signs of adequate oleation) was attained with 90ml.Further patient was subjected to sarvanga abyanga (oil massage) with marichadi taila and followed by bashpa sweda(sudation) for 2 days. Last day virechana (purgation therapy) was done with avipathikara choorna 40gms with 100ml triphala kashaya. Total number of vegas (purgavtive bouts) observed were 7, hence avara shudhi (mild purification) was attained. Light diet (thin gruel and kichhdi) was given throughout the course of treatment and samsarjana karma (gradual dietary regimen) was adviced for 3 days.
Assessment criteria: Grading criteria
|
Clinical features |
Grade 0 |
Grade1 |
Grade2 |
Grade3 |
|
Swetha aruna shyava pidaka (papules) |
Absent |
1-3 papules |
4-7 papules |
More than 7 papules |
|
Kandu (itching) |
Absent |
Mild itching |
Moderate itching |
Severe itching |
|
Srava (discharge) |
Absent |
Mild discharge |
Moderate discharge |
Severe discharge |
OBSERVATION
Assessment of patient was done by the grading criteria
|
Clinical features |
Before treatment (0th day) |
After treatment (9th day) |
|
Swetha aruna shyava pidaka (papules) |
Grade 3 |
Grade 1 |
|
Kandu (itching) |
Grade 3 |
Grade 1 |
|
Srava (discharge) |
Grade 1 |
Grade 0 |
Before Treatment
After Treatment
RESULT
Prior to treatment, the patient presented with multiple whitish papules over fingers, wrists, and scrotum, in addition to burrow-like lesions in the interdigital spaces. Blackish lesions were evident on the dorsal aspect of both hands, along with mild fluid discharge and generalized pruritus. Following the course of treatment, a significant reduction in the number of papules was observed, the burrow-like lesions had reduced, the dorsal hand lesions had dried, fluid discharge was no longer present, and the intensity of pruritus was markedly diminished. Overall, the clinical findings indicated substantial improvement in the patient’s condition.
Dietary Regimen And Lifestyle Adviced:
The patient was advised to follow a light and wholesome diet including greengram, moong dal wheat,finger millets and buttermilk. In terms of lifestyle, daily bath was recommended to maintain cleanliness. The patient was also instructed to avoid dairy products, non-veg and junk food as well as irregular habits such as day sleep and late nights which could aggravate the condition.
|
Medicines given on Discharge: |
||
|
Sl no |
Medicines |
Dose |
|
1 |
Aragwadadhi Kashaya |
15ml-0-15ml (B/F) |
|
2 |
Khadirarista |
15ml-0-15ml (A/F) |
|
3 |
Krumikutara rasa |
2-0-2 A/F |
|
3 |
Bilwadi Gulika |
1-0-1 A/F |
|
4 |
Gandhaka rasayana |
1-0-1 B/F |
|
5 |
Haridra khanda |
5gms-0-5gms A/F |
|
6 |
Gandha karpura |
External application |
DISCUSSION
In this present case, depending on causative factor (contagious) and symptoms (papules, itching and discharge) this case was diagnosed as Pama kushta. The clinical features of Pama bear close resemblance to scabies. In Ayurveda, Pama is characterized by shwetha–aruna–shyava pidaka (white/red/black papules), kandu(itching) and srava (discharge)6. Similarly, scabies in modern medicine presents with whitish or blackish papules, burrow-like lesions, pustules, and marked nocturnal itching causing high Morbidity in health care workers and in low Socio-economic sectors of the society. Poor personal hygiene, poor eating habits and living standards, unawareness about health with contact history are the important etiological factors for infestation of the disease.7 The parallel symptomatology suggests that Pama described in classical Ayurvedic texts can be correlated with scabies, thereby supporting its clinical relevance in contemporary practice. Pama is Kapha Pitta dominant disease. Acharya Sushruta has given that in the pathogenesis of any Kushtha, dosha and krumi plays a major role.8There are many Sukshma Krumi present in Abhyantara and Bahya pradesha of Shareera which are unable to see by naked eyes. Hence by considering this, the study was aimed at finding the effect of Krumihara chikitsa, that includes Apakarshana of krimi (evacuation), Prakruthi Vighata (destruction of the favourable environment of krimi) and Nidana Parivarjana (avoidance of etiological factors)9 So, first bheshaja apakarshana was done through Virechana. Further shamana aushadis were given for the purpose of Prakrutivighatka of krimi and avoidance of the causative factors are adviced to be followed by the patient.
Rationale of intervention
For Deepana and pachana
Bilwadi gulika being kaphavatagna possesses Deepana, pachana and krimighna properties which helps in amapachana and correction of impaired agni which is important before administering snehapana.10 Amahara Kashaya is a freshly prepared herbal decoction. It includes ardraka and purana guda which again is agnideepaka, amashayashodhaka and raktha prasadaka.11
Mode of action of Panchatiktaka Guggulu Ghrita in snehapana
Considering the potent action of Pancha tiktha guggulu gritha for its pittahara, kustaghna, kandugna and raktaprasadaka action, it had been opted for snehapana.Tikta rasa aids in kleda shoshana(removal of excess moisture) and balances kapha and pitta thereby alleviating symptoms like kandu and srava.12
Sarvanga Abyanga and Swedana
Snehana and Swedana helps to bring the doshas from shakha to koshta before Shodhana. Sarvanga Abhyanga was done with marichadi taila which is indicated in Pama Kushta. Based on the properties of the ingredients, marichadi taila acts as kapha shamaka, kandughna and Kushtaghna.13
Mode of action of Virechana aushadi
Avipattikara churna a rational composition of herbs formulated to strengthen digestive fire with subsidiary effect on pitta and also expels excessive pitta by its mild laxative action.One of the main ingredients is trivrut. It has bhedana, rechana and shothahara properties leading to pitta virechana. This action of trivrut is also contributed by mridu rechaka or anulomana action of triphala. Both trivrut and triphala helps in mridu virechana.14
Mode of action of Shamana aushadi
Aragwadadhi Kashaya
It is indicated in kusta. The ingredients in Aragwadhadi Kashaya reduces kapha dosha.It has antibacterial, antimicrobial, antiparasitic, and anti-inflammatory properties. It has mild laxative effects and it aids to eliminate accumulated toxins through stools.15
Khadirarista
Khadira is kapha pitta shamaka and mainly has Kushtaghna and krumighna properties. Its antibacterial and antihelminthic properties helps in all types of kusta and krimi.16
Krumikuthara rasa
Ingredients include Parada (purified mercury), Gandhaka (purified sulphur), and Kutaja (Holarrhena antidysenterica) which have antibacterial, antifungal, and antihelminthic properties and are mainly indicated in intestinal or other parasitic worm infestations.17
Gandhaka rasayana
Gandhaka Rasayana is a polyherbal Ayurvedic medicine with Rakta Shodhaka, Kushthaghna, and Kandughna properties. Its ushna veerya and katu kashaya rasa helps in deepana, pachana, and reducing kapha and kleda. With its antibacterial and antifungal actions, it effectively reduces kandu and pidika.18
Haridra Khanda
Haridra (Curcuma longa L.) and other ingredients in this formulation works efficiently for skin disorders as they are pitta-kaphahara in nature. The presence of cow’s ghee and milk acts towards balancing of pitta while loha bhasma plays role for improvement of immunity. Its anti-inflammatory, anti-allergic, tridoshaghna, kandughna, kushthghna properties, will help pacify the pathogenesis occurring in pama kusta.19
Gandha karpoora
SDM Pharmacy’s Gandha Karpoora is classical combination of shudha gandhaka, karpoora and tankana bhasma for external application. Gandhaka acts as best kaphaghna and kledaghna. Karpoora is sheethala, kapha pittagna and gives cooling effect and reduces itching and irritation. Tankana Bhasma is having ruksha guna and is kaphagna, hence helps in pacifying srava and kandu.20
CONCLUSION
Pama is explained in the context of kshudra kushta which is having a close resemblance with scabies. Such a disease can be effectively managed through shodhana. The present case was successfully treated and managed through virechana karma. After the treatment there was much reduction in number of papules and itching. From the current casestudy we can draw a conclusion that pama kustha can be successfully treated and managed through Ayurvedic line of treatment. No adverse reactions were observed during the course of treatment and later patient was advised to follow proper dietary regimen and lifestyle to avoid the recurrences of the disease.
REFERENCE
Ananya Latha Bhat*, Chaitra H., Neethu M., Madhusudhana V., Therapeutic Approach of Ayurveda in Pama Kusta: A Case Study 164-170. https://doi.org/10.5281/zenodo.17323495
10.5281/zenodo.17323495
