An open clinical trial to analyze Samyak Snigdha Lakshana of Shodhananga Snehapana with Mahatikthakam Ghritam in Psoriasis
Rajkala Ramteke1, G. Vinodkumar2, T. Meharjan3
1Lecturer, PG Department of Panchakarma, KVG Ayurveda College, Sullia, Dakshin Kanada, Karnataka,
2Professor and Head, Department of Panchakarma, Nangeli Ayurveda College, Kuthamangalam, 3Associate
Professor, Department of Kaya Chikitsa, Government of Ayurveda College, Thiruvananthapuram, Kerala, India
An open clinical trial was conducted in Govt. Ayurveda College Hospital, Thiruvananthapuram, Department of Kayachikitsa and Panchakarma. As there is no work done on the Samyak Snigdha Lakshana (SSL), this study was undertaken to work on the different aspects of Samyak Snigdha Lakshana. To minimize variables, subjects suffering with psoriasis and same Ghritam were selected on the basis of strict inclusion and exclusion criteria. Shodhananga Abhyantara Snehapana was advised before Vamana and Virechana. Samyak Snigdha Lakshanas which are described in all texts are different in milieu. Shodhananga Snehapana with Mahatiktakam Ghritam was given according to Koshta and Agni in 30 subjects. Samyak Snigdha Lakshanas were assessed using a special scoring pattern and the biochemical parameters were observed in all subjects. Statistical analysis using paired‘t’ test were done. In all patients Vatanulomana, Diptagni, Snehodvega, Klama and Adhastat Sneha Darshanam were seen; whereas Angalaghava and Twak Snigdhata were noted in less percentage of persons. The onset of various Samyak Snigdha Lakshanas occurs in sequence. There
are changes in some biochemical parameters like serum cholesterol, Serum glutamic‑oxaloacetic transaminase (SGOT) and fat globules in stool after Snehapana. Shodhananga Snehapana with Mahatikthakam Ghritam decrease features of psoriasis up to some extent. More in depth studies are required to evaluate their importance and for their application in modern medical practice.
Key words: Mahatikthakam Ghritam, Psoriasis, Shodhanang Snehapana
Panchakarma is the main treatment modality which is widely used in all the eight branches of Ayurveda. The Shodhana therapy is more admired by virtue of its capability to completely eliminate the Doshas. On the other hand, it has major disadvantages too. If this therapy is not done with proper indication and Purva‑Karma, it may cause hazardous unwanted effects like shock, hemorrhage and death also. To avoid these unwanted effects, Acharyas have instructed to do a proper Purva-Karma. Before adopting Shodhana, it is necessary to do Snehana and Swedanaproperly. Snehapana is a major preparatory procedure because of its multifaceted action. Shodhananga Abhyantara Snehapana is advised before Vamana and Virechana. Samyak Snigdha Lakshanas which are described in all texts are different in milieu. Acharyas have mentioned it in the context of Shodhanartha Snehapana, whereas Acharya like Kashyapa have mentioned it in the context of Shamana Snehapana. So there is no clarification regarding the Samyak Snigdha Lakshana according the type of Snehapana. There are many works available on Snehapana, but there is no work on the Samyak Snigdha Lakshana. Hence this study was planned to work on the different aspects of Samyak Snigdha Lakshana. Psoriasis is a common chronic scaling skin disorder. The latest survey suggests that as many as two in every hundred of the
total population have it at any time in their life. In Ayurvedic classics, Kushtha is the disease where Shodhana is indicated at specific time intervals of which Snehapana is indicated first.
Considering the need of study and availability of the patients, psoriasis patients were selected as the condition usually is not associated with major complications.
Aims and objectives
- To assess the Samyak Snigdha Lakshana subjectively
and objectively with various clinical and biochemical parameters.
- To study the effect of the Snehapana with Mahatikthakam Ghritam in Psoriasis.
Materials and Methods
Source of data
Patients of Psoriasis consulting the OPD of Kayachikitsa
and Panchakarma Department, Govt. Ayurveda College,
Method of collection
30 patients willing to participate in the study were selected
based on the clinical features of Psoriasis, considering the
inclusion and exclusion criteria. Necessary investigations
were carried out and their details were recorded in a special
- Patients with all forms of Psoriasis who are clinically fit to
undergo Shodhananga Shodhana procedure.
- Age ‑.15 to 60 years.
- Sex ‑.Both sexes.
- Clinically unfit for Shodhananga Snehapana.
- Chronic debilitating disease.
- Malignant Hypertension.
- Pregnant ladies.
- Patient not willing for admission.
Blood parameters testing and stool examination were done
before Snehapana, after Snehapana and after Virechana to
assess the changes.
- Haemogram‑ Hb%, TC, DC, ESR.
- Blood chemistry‑ LFT, RFT, BSL, Lipid Profile.
- Urine examination‑ Albumin, Sugar, Deposits.
- Stool examination‑ Fat globules.
Assessment of Agni and Kostha was done in every patient on the
basis of assessment criteria. Deepana and Pachana were done by
administering Panchakolasavam 30 ml twice a day after food
and Vaiswanara Choornam 5 gm twice a day before food with
warm water for 3 to 5 days till the appearance of the Nirama
Lakshanas. In the morning, around 6 a.m. Mahatikthakam
Ghritam was given in Arohana Karma from 30 ml to 300 ml
to the patient when there was Jeerna Ahara Lakshana and
Akshudhita Avastha, with fresh mind, courage and remembering
favorite Devata. Ushna Jala boiled with Sunthi approximately
400‑500 ml was given as Anupana. Snehapana was stopped
after getting Adhastat Sneha Darshanam and Samyak Snigdha
Lakshanas were assessed. An interval of three days was given
between onset of Samyak Snehana and Virechana Karma.
Avipattikar choorna 20‑30 gm according to Koshtha of the
individual was given with honey around 7 a.m. on the day of
Virechana. Samsarjana was advised after Virechana depending
upon the type of Shuddhi.
Criteria of assessment
Detailed history, physical and mental examination was done on
the basis of a specialized proforma designed for this purpose.
Criteria for assessment of Koshtha
Routine Bowel Habit was considered for assessment of Koshtha
as per the following features:
- Frequency per day
- Less than one ‑ 1
- Once/twice ‑ 2
iii. More than two ‑ 3
- Hard Stool ‑ 1
- Soft, well formed ‑ 2
iii. Loose/Watery, not well formed ‑ 3
- No urgency at all, sits long time
with discomfort ‑ 1
- Moderate urgency can be controlled
but no need to sit long ‑ 2
iii. Marked urgency cannot be
controlled ‑ 3
- Your experience regarding intake of 200 ml milk/100 gm
grapes/50 gm Jaggery/200 ml Ikshu Rasa/10 gm Avipathikar
- No change in bowel habit ‑ 1
- Normal well formed stool ‑ 2
iii. Watery stool/not well formed ‑ 3
- Whether changes in food habits will affect the bowel habits
- Frequently hard ‑ 1
- Occasionally ‑ 2
iii. Frequently loose ‑ 3
- 1 to 5 implies ‑ Kroora Koshta
- 6 to10 implies ‑ Madhyama Koshta
- 11 to 15 implies ‑ Mridu Koshta
Assessment of Agni
Effect on hunger, digestion, defecation by occasional, irregular
- No alteration ‑ Tikshn Agni
- Mild/Inequitable alteration ‑ Visham Agni
- Gross alteration ‑ Mand Agni
Criteria to assess Samyak Snigdha Lakshana
The following subjective criteria were considered for assessment
of Samyak Snigdha Lakshana
1 = Urdwavatapravritti, Udgara Bahulya and
0 = Improper evacuation of flatus, faeces, urine and
absence of Udgara Bahulya etc.
2 = Proper evacuation of flatus, faeces and urine.
For easy calculation and understanding of Agnidipti factor,
one standardized formula is accepted based on dose of
Sneha and time taken for digestion.
Test dose×Time taken for digestion
Lesser the Agnibala index (A.B.I.), more will be the
1 = A.B.I.>3
0 = A.B.I.=3
2 = A.B.I.<3
- Twak Snigdhata and Gatra Snigdhata
1 = Dry skin
0 = Softness of skin (Mriduta)
2 = Proper oiliness of skin
- Purisha Snigdhata
1 = Ruksha Purisha
0 = Soft stool
2 = Loose stool with Sneha
1 = No aversion
0 = Minimum aversion without nausea
2 = Nausea, vomiting on thought and sight of
1 = Enthusiastic
0 = Reasonably active as usual
2 = Tiredness without exertion
1 = Heaviness in body
0 = Usual lightness in the body
2 = Feeling of lightness in the body
7‑8 = Avara Samyak Snigdha Lakshana
9‑11 = Madhyama Samyak Snigdha Lakshana
12‑14 = Pravara Samyak Snigdha Lakshana
<7 = Asnigdha Lakshana
Observation and Results
Maximum patients were from 45 to 60 years age group. Among
total patients, 67% of subjects were male and 33% were female.
Religion wise distribution showed that maximum number
of patients (74%) were from Hindu community. Most of the
patients (40%) were having occupations which led to mental
stress. Economic status wise distribution of patient shows that
37% patients were belonging to middle class. 53% patients were
of Vatakapha Prakriti and 66.6% patients were of Madhyama
Sara and 56.6% of Madhyama Samhana. Also, maximum
number of patients’ (53.3%), were of Avara Satva category,
which may be due to Manasika involvement in Kushta or due
to social stigma of skin diseases.
Among all subjects, 49.9% were having Avara Satmya where
as 39.9% patients were having Madhyama Satmya. Maximum
patients 46.6% were having Madhyama Abhyavaharana
Shakti followed by 33.3% and 19.9% of Avara and Pravara
Abhyavaharana Shakti respectively. The Jarana Shakti wise
distribution shows maximum patients were having Madhyama
Jarana Shakti, i.e. 56.7%. In the study, 53.2% patients were
having Vishama Agni and 59.9% of patients were having
Kroora Koshtha. Among psoriasis features, 100% subjects
were having scaling over skin whereas only 26.6% subjects
were having itching over skin lesion. 66.6% subjects reported
pain as a symptom and 73.2% subjects had erythematic on
the lesions. Maximum of 39.9% subjects were administered
Ghrita in the dose of 800‑1000 ml. Maximum of 49.9%
subjects were given 250‑300 ml dose on last day. Maximum
of 56.6% subjects took 6‑7 days for Samyaka Snehana. 36.6%
subjects required 4‑5 days for getting Samyak Snigdha Lakshana.
Observations on Samyak Snigdha Lakshana
In the Arohana Snehapana group, after administration of Sneha,
the symptoms of Sneha Jiryamana were observed. The mean
onset time and duration of those symptoms were noted in
minute [Table 1].
All the Sneha Jiryamana Lakshana reported by the subjects
automatically subsided on Sneha Jeerna.
Observation related with mean score of Samyak Snigdha Lakshana
with S.D. and percentage was on last day of Snehapana all
subjects showed Vatanulomana, Diptagni, Purisha Snigdhata and
Snehodvega with mean score of 1.9, 1.9, 2.0 and 1.8 respectively.
Whereas 93.3% subjects showed Klama Lakshana with S.D. 0.4,
86.5% subjects noticed Twak Snigdhata with mean score of 1.4
(S.D.±0.8) and only 13.3% subjects perceived Angalaghavata
with mean score of 0.6 (S.D.±0.2) [Table 2].
The pattern of Samyak Snigdha Lakshana found in 30 subjects
with respect to Snehapana days. Vatanulomana was seen in 80%
of subjects on 1st day, 87.7, 96.4, 97.6, 98.5, 89.6 and 100% of
subjects showed on subsequent days. Diptagni was seen in 100%
subjects on 1st day followed by 97.5% of subjects on 2nd day,
93.4% on 3rd day, 96.5% on 4th day, 95.9% on 5th day, 98.3% on
6th day and 100% subjects on 7th day [Table 3].
Maximum number subjects (60%) noted Pravara Snigdhata
grade while 30% subjects reported Madhyama Snehana grade
and only 10% subjects put in the picture were of Avara Snehana
grade [Table 4].
The details of Samyak Snigdha Lakshana during the gap
days shows - on the 1st and 2nd gap day, Vatanulomana was
experienced by all subjects while on 3rd day only 96.5% of
subjects recounted it. Diptagni was described by all subjects on
1st Vishrama Dina whereas 93.2% subjects reported it on 2nd day
and 83.5% stated it on 3rd gap day [Table 5].
The role of Snehana according to Prakriti reveals that maximum
subjects, i.e. 11, who took 6‑7 days to get Samyak Snehana were of
Vata-Kaphaja Prakriti and the same no. of subjects attained Pravara
Snigdhata grade. Among Pitta-Kaphaja Prakriti subjects, five subjects
necessitated 4‑5 days for Snehana therapy and two subjects required
6‑7 days and only one patient required 1‑3 days for Snehana therapy.
Among them, five subjects got Pravara Snigdhata grade and two
subjects reported Madhyama Snigdhata grade.
In case of Vata-Pittaja Prakriti, maximum four subjects required
6‑7 days for Samyak Snehana therapy, 1 patient got Samyak
Snehana in 1‑3 days and the same no. in 4‑5 days. Among
them four subjects attained Madhyama Snehana grade and two
subjects reported Pravara Snigdhata grade [Table 6].
In this study, seven subjects of Vishamagni amongst sixteen
took 4-5 days for Samyak Snehana and nine subjects required
6‑7 days for getting Samyak Snigdha Lakshana. Out of them,
eight subjects got Pravara Snigdhata grade, six subjects got
Madhyama Snigdhata grade and only two subjects got Avara
Snigdhata grade. Among Mandagni subjects, six subjects
attained Samyak Snehana in 6‑7 days and three subjects took
4‑5 days. Amongst them, six subjects attained Pravara Samyak
Snehana grade, two subjects reported Madhyama Snigdhata
grade and only one patient showed Avara Snigdhata grade.
Among five subjects having Tikshnagni, two subjects achieved
Samyak Snehana in 6‑7 days and one subject took 4‑5 days.
Amongst them four subjects attained Pravara Samyak Snehana
grade, one subject reported Madhyama Snigdhata grade [Table 7].
In this study sixteen subjects having Kroora Koshta among
eighteen, took 6‑7 days for Samyak Snehana and two subjects
required 4‑5 days for getting Samyak Snigdha Lakshana. Out of
whom eight subjects got Pravara Snigdhata grade, eight subjects
got Madhyama Snigdhata grade and only two subjects got Avara
Among Madhyama Koshta subjects, only one subject attained
Samyak Snehana in 6‑7 days and the rest seven subjects took
4‑5 days. Amongst them seven subjects achieved Pravara Samyak
Snehana grade and only one patient showed Avara Snigdhata
grade. Among Mridu Koshta subjects, two subjects attained
Samyak Snehana in 1‑3 days and two subjects took 4‑5 days. Out
of them three subjects attained Pravara Samyak Snehana grade,
one subject reported Avara Snigdhata grade [Table 8].
Effect of therapy
Effect of Snehapana on blood parameters
Effect of Snehapana on erythrocyte sedimentation rate was found
decreased with statistically insignificant results [Table 9]. Serum
cholesterol level was decreased significantly (P<0.01) in SSL
and AS in comparison to BS [Table 10]. SGOT and SGPT levels
were decreased in SSL and AS in comparison to BS which was
statistically significant (P<0.01) [Tables 11, 12]. But the changes
found in all the blood parameters were within physiological limits.
Effect of Snehapana on stool parameter
The result of Snepana was assessed on stool fat globules which
was found statistically highly significant (P<0.01) in BS, SSL
and AS as compared to each other [Table 13].
Effect of Snehapana on psoriasis features
Effect of Snepana was assessed on cardinal features of Psoriasis
i.e. on Scaling shows statistically highly significant results
(P<0.01) [Table 14]. Maximum number of subjects who showed
Pravara grade of Snehana, also reported Pravara Shodhana and
vice versa [Table 15]. No significant increase or decrease in vital
data like pulse, respiratory rate and blood pressure were found
before and after Snehapana
Shodhanartha Abhyantara Snehapana is the foundation for
purification procedures. There are mainly two effects of the
which may be because of Snigdha Guna of Sneha. Due to intake
of Sneha Anulomana of Apana Vayu occurred, which resulted
in the good functioning of Apana Vayu and Pachaka Pitta and
in turn Agnidipti was observed. Purisha Snigdhata was started
to be observed from 3rd day onwards. It suggests the gradual
Snigdhata of Purishavaha Srotas, which will reach maximum
by 7th day. Twak Snigdhata suggests that Sneha has reached up
to Rasa, Rakta, Mamsa and also Majja Dhatu as explained by
Vagbhata, “Sneho Akshi Twagvisham…”
Caraka explains this with illustration that just as water saturates the
cloth to its capacity then drains off, similarly the unctuous dose gets
digested according to the strength of Agni and drains off when it
exceeds the limit of Agni. Cakrapani comments that it is direction
to find when to stop Snehapana. The data suggest that all the
symptoms of Samyak Snehana do not appear on the same day but
as Snehana process goes on, the Lakshana appear one by one. At
first Mahastrotas becomes Snigdha. So, Agnidipti and Vatanulomana
are observed in initial days. Further when Asamhata Varchas appears
the complete Snehana of Annavaha and Purishavaha Srotas can
be understood. Afterwards Twak Snigdhata appears. This reveals
that Snigdhata has reached up to Dhatu level. At last Snehodvega
and Adhastat Sneha Darshanam were noted suggesting that there
is no need of further Snehana. So from the above data it can be
understood that the onset of Snehana Lakshana described by Caraka
and other Acharyas are in the sequence of appearance. However the
symptom like Twak Snigdhata is little difficult to achieve or may not
appear in all the patients.
Probable mode of action of Snehana
- Shodhananga Abhyantara Snehapana is the basis to
make a smooth platform for Shodhana, i.e. to attain the
Utkleshavastha of Dosha.
- The importance of Snehana as Purva Karma for Shodhana
is well known.
iii. The features produced after Snehana suggest that there
is loosening of morbid Doshas which were adherent to the
walls of transforming channels and which in turn will help in
the Shodhana Karma, performed afterwards. When Snehana
was done by increasing dose schedule where increase of dose
per day was decided according to Agni, Koshta, Bala Avastha,
etc. the Snehana occured in its full fledged form.
- Snehodvega suggests the Sanchayavastha by “Chayakarane
Vidvesha” as per Sushruta. The symptoms of Rasa Vridhi like
Hrillasa, Praseka signifies the increase of Apyamsha in the
body which is the action of Snehana i.e., Vriddhi for bringing
the Doshas from Sakha into the Koshtha from where they
can be easily expelled out. Adhastat Sneha Darshanam
suggests that there is no need for further Snehana.
- After proper Snehapana three days gap has been given
before Virechana to get Agni in its normal form so that it
can digest Virechana medicine as ‘Pachyamane Virechanam’
is told by Acharya.
- Effect of Virechana Karma was also dependent upon
vii. Mahatikthakam Ghritam was used for Snehana and so it
has provided Shamana effect on Psoriasis features.
Snehapana should be done with well planned method.
Consideration of Agni and Koshtha must be done for deciding
the dose and duration of Snehapana. Onset of various SSL
occurs in sequence which may be helpful in predicting the
duration of Snehapana. There are no significant changes
in the blood parameters due to Snehapana. The significant
changes in stool with respect to presence of fat globules were
seen. Shodhananga Snehapana with Mahatikthakam Ghritam
in Psoriasis decreases the clinical features to some extent. If
Virechana is performed after proper Snehana, better and safer
Suddhi can be achieved.
For this study I am very thankful to all my seniors, juniors, classmates
and my patients who tried to understand while I communicated in
Malayalam and taught me a better language for communication.
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Address for correspondence: Dr. Rajkala Ramteke,
Lecturer, PG Department of Panchakarma, KVG Ayurveda
College, Sullia, Dakshin Kanada, Karnataka, India.