EFFICACY OF LEECH THERAPY IN THE MANAGEMENT OF PSORIASIS

Dr. Siddhartha Thakur MD. (Kayachikitsa) IMS, BHU Consultant Ayurveda Physician

Introduction
Psoriasis is a papulosquamous dermatosis of unknown etiology with spontaneous remission, relapse and seasonal variation. It clinically presets with lesions of varying size and configuration. Distributed all over the body with silverly scales, covering loops of dilated superficial capillaries underneath which are presented as tiny bleeding point on removal of scale (Auspitzs sign). It affects about 2% of the world population. Various races and communities differ in the susceptibility to this disease. In India it affects about 1.5% of the population including both male and female. It appears to be common in Europeans than in Orientals. Like other skin disorders psoriasis is challenge to the medical science. In modern medicine there is no definite treatment for this disease. The medicines, which are available to treat the disease, are not very effective and cannot be used for long term management because of their local and systematic side effect as well toxicity. Raktamokshana is one of the procedures described in Ayurveda, for the treatment of different diseases. Leeches are one of the tools for Raktamokshana. The saliva of leech contains many active substances like Hirudin, Calin, Destabilase, Eglins, Hyaluronidase etc. which are responsible for the cure of disease. The saliva of leech has antiinflammatory, anti-coagulant, anesthetic, vasodilator action.

Material and method Selection of patients

A series of 32 cases of uncomplicated psoriasis patients visiting O.P.D and I.P.D. of Kayachikitsa were selected for the present clinical study from the S.S. hospitals, Banaras Hindu University, Varanasi during the period of August 2005 to march 2008.

Inclusion criteria
1. Patients of twelve years to seventy ears aged 2. Clinical signs, symptoms, and history of present illness suggestive of psoriasis (kitibh)

Exclusion criteria
1. 2. 3. 4. Patients having age less than twelve years and more than seventy years. Patients having inconclusive diagnosis. Patients of psoriatic arthropathy and psoriatic erythroderma. Patients having cardiac disease, renal disease and endocrine disorders were excluded in the study to avoid overlapping of symptomatology.

Criteria for diagnosis of Psoriasis

1. Sharply defined erythemo-squamous lesions varying in size from pinpoint to large plaques. 2. Presence of erythema, scaling and indurations in the lesions. 3. Surface consists of non-coherent scales. 4. Positive Auspitzs sign-(bleeding occurs after scratching of scales) 5. Positive onion peeling sign/candle grease sign(after scratching the scales fall like peels of onion). After making proper diagnosis of psoriasis patients were selected for leech therapy.

Scoring (PASI score)

The four main anatomical sites are assessed. The head (h), upper extremities (u), trunk (t) and lower extremities (I) roughly corresponding to 10,20,30 and 40 % of the body surface area (BSA), respectively. The PASI score is calculated as followsPASI= 0.1(Eh + Sh + Ih) Ah + 0.2(Eu + Su + Iu) Au + 0.3(Et + St + It) At + 0.4(EL + SL + IL) AL

Where E= Erythema, S= Scaling, I=Indurations and A= Area

E,S and I are assessed according to a 4 point scale where 0 1 2 3 4 = = = = = No symptoms Slight Moderate Marked Very marked

A is assigned a numerical value based on the extent of lesion in a given anatomic site: 1 2 3 4 5 6 (<10%) (10-29%) (30-49%) (50-69%) (70-89%) (90-100)

Scoring criteria for other symptoms

Score 0Score 1Score 2Score 3No symptoms Mild Moderate Severe

LEECH THERAPY

Selection of leech ( Hirudo medicinalis):

Out of twelve, only six varieties of nonpoisonous leeches are used for medicinal purpose. Sankumukhi type of leech is preferably used for medicinal purposes due to its rapid blood sucking capacity. As per classical description of Ayurveda, the leech neither too long, nor too small should be preferred for therapeutic purposes. Storage and maintenance of leechLeech should be stored in well labeled container having multiple pores on the top for proper aeration. Temperature should be maintained around 5-27o C. The water of container should be de-chlorinated and should be replaced after 5 to 6 day. About 59 leeches can be kept the container of chlorinated water. If it is not possible to get the dechlorinated water than keep the container of chlorinated water open in the air for a period of time and then use it for storage of leech. It is better to avoid direct exposure of sunlight to the leeches.

Method of application Purva karma: Proper Snehana (Oleation) and Swedana (Sudation) of the patient. Purification of leech by pouring the leech in water mixed with turmeric powder. Part preparation- cleaning of part of the body to which leech is going to be applied.

Pradhana karma: Before application prick the skin with sharp and sterile needle so that drop of blood comes out then applied the leech through its front end and covers the leech by wet cotton. If the leech is not ready to suck the blood from the body part then application of madhu, ghrita, or butter should be done. Observation of leech 1. Gradual distention in the central portion of the body. 2. Itching and burning sensation at the site of bite. 3. Pulsations on the body of leech may be visible. Removal of leech: After 30-70 minutes the leech is removed by itself, or by application of turmeric powder on the mouth of leech.

Paschata karma:

Care of wound: After detachment of leech there is triangular wound created by mouth of leech. The blood comes out from the wound. The bleeding from wound is checked by application of Yastimadhu or turmeric powder. Induction of emesis: The leech that applied to the lesion under goes process of vaman so that the same leech can be applied next time to the same patient. For the vaman of leech turmeric powder is applied over mouth of leech. The leech vomits out all the blood sucked by it to get purified. Sometimes pressing of leech from caudal to front end is required for proper emirs. After proper vaman, leech should be put in fresh water, where it swims swiftly and than settles down. Replace the leech in a clean jar or aquarium

Contra indication of leech therapy 1. Blood clotting disorder 2. Severe anemia 3. Allergic reaction to active substances of the leech like Hirudin, Calin, hyaluronidase, Eglin, kollagenage, apyrase, destabilase, piyavit etc. 4. Human with weak constitution. 5. Pregnancy

Precaution during leech application 1. Bleeding and clotting time of the patient should be normal. 2. Gentle handling of teeth. 3. Cover the leech with wet cotton.

Frequency of leech application: The frequency of leech application will vary according to disease and severity. Generally leech should be applied once in a week up to six sittings. One leech should be reserved for a particular patient to avoid cross infection. Parameters of assessment 1. 2. 3. 4. Estimation of psoriasis area severity index(PASI Score) Patients report as his observations. General assessment of the doctors (researcher). Photographer taken at regular intervals.

5. Side/ toxic effects of the drug, if any.

Observation and result All statistical analysis is done where unpaired t-test p value <0.001 were considered to be statistically highly significant. The p value>0.05 were considered to be non-significant.

TABLE: Showing effect of leech therapy in patients of psoriasis (n=32) Means SD Symptoms Before treatment 3.19 0.78 3.19 0.78 2.75 0.44 1.67 1.30 0.94 1.27 After treatment 1.44 0.56 1.31 0.59 1.19 0.47 0.53 0.72 0.13 0.34 19.95 7.33 Paired BT-AT 1.750.76 T=12.99 P<0.001 1.880.70 T=15.00 P<0.001 1.560.70 T=13.21 P<0.001 1.161.11 T=5.89 P<0.001 0.811.12 T=4.10 P<0.001 6.254.23 T=8.36 P<0.001 t-test

Erythema

Scaling Induration

Itching

Burning sensation

PASI Score

26.20 9.08

From demographic observations significant higher incidence has been observed in Hindu, married, male of 21-30 years age group having mixed dietary habit and rural habitat. The

disease was more common in farmer of lower socioeconomic status. The disease is more prevalent in vita- kappa predominant people and blood group B+ve. The onset was observed to be insidious and duration of disease was more than three years. The majority of patients had irregular bowel habit and addiction. The winter season, physical trauma and stress was observed as aggravating factor.

Discussion Ayurveda describes many paramedical procedures including Jalaukavcharana for the treatment of various diseases. Jalaukavcharana (leech therapy) is one of the important and much emphasized procedures carried as a last resort to treat various disease of rakta pradoshaj origin. The ancient authors Charaka and Sushruta treated successfully many incurable wounds, and other medical disease like Hirudin, Calin, destabilase etc. which are responsible for the therapeutic effect. The saliva of leech has got bioactive substances having anti-inflammatory, anti-coagulant, anesthetic, vasodilator etc. action. Though the mechanism of action still not yet clear, but the clinical trials in various settings showed encouraging results. The possible mechanism of action of leech therapy in psoriasis is seems to be due to its anti-inflammatory substance of saliva.

Some words:
This study was done with Dr. PK Rai, under supervision of Dr. OP Singh, Prof. Dr. NP. Rai (dept.of kaya IMS, BHU). After encouraging previous result, fifteen diagnosed psoriasis case were selected from OPD OF Ojus Ayurveda Hospital & Research Centre, Samakhusi & Central Ayurveda Hospital, for clinical study on Efficiency of Panchkarma (Sodhana) & compound Ayurvedic drugs on treatment of psoriasis. Study was done from June 15, 2010 to June 14, 2012. Out of 15 cases, 9 cases gave optimum recovery result (80 to 95%), 3 case on (50-69%) recovery and 3 cases have discontinued medication. The detail will be published on any next research papers. This study encourage to further study. In near future, leech therapy ( with adopting update scientific measures) will be established in Ojus Ayurveda Hospital & Research Centre and rearrange to further & clinical study on psoriasis with compound treatment (leech therapy+ Panchkarma +Ayurvedic drugs).