Psoriasis is common, visible and lifelong. Estimates of its prevalence differ considerably between countries and populations (Parisi et al., 2013), and the World Health Organization has recognised it as a serious noncommunicable disease with a heavy burden of stigma and impaired quality of life (World Health Organization, 2016). Chronic plaque psoriasis, the usual form, follows a course of exacerbation and partial remission over decades. Conventional treatment can control it and, with modern biologic agents, often clear it, but treatment is continuous, costly, and not without risk (Armstrong and Read, 2020).

It is unsurprising that many people with psoriasis turn to other systems of medicine. In India, Ayurveda is a recognised part of the health system, and its physicians treat skin disease routinely (Sharma et al., 2007). The distinctive Ayurvedic offering for a chronic condition of this kind is Panchakarma, a programme of bodily purification followed by palliative medicines and a prescribed regimen. Accounts of psoriasis clearing after Panchakarma circulate widely in clinics, in journals of Ayurveda and among patients.

This article reviews what is known. It was prompted by a simple observation about the form in which such accounts usually appear: a description of one treated person, with photographs before and after a course of therapy. The review asks what evidence of that kind can show, how it relates to the other evidence available, and why the duration of follow-up, taken here as at least twelve months, is central to interpreting any claim of benefit in a disease that waxes and wanes without intervention.

The review is narrative. It draws on standard dermatological sources for the nature and measurement of psoriasis, on the classical Ayurvedic account of skin disease, on published reviews of complementary medicine in psoriasis, and on methodological guidance for case reports and for trials of traditional medicine. It does not present a systematic search, and it does not pool results. The Ayurvedic clinical literature on psoriasis is scattered across journals of uneven indexing, so the characterisation of it given here is general and should be read as such. No new clinical observations are reported.

Any assessment of Ayurvedic treatment for a biomedically defined disease has to begin by noting that the two systems describe the condition differently. The accounts are summarised briefly here.

Panchakarma means five procedures, though in practice it denotes a structured sequence in three phases, shown in Figure 1. The preparatory phase aims to mobilise the morbid dosha. It begins with medicines to improve digestion, followed by internal oleation, in which medicated ghee is drunk in increasing amounts over several days, and then by external oil massage and sudation. Bitter medicated ghees are the customary choice in skin disease.

The principal phase is eliminative. Therapeutic emesis (vamana) and purgation (virechana) are the procedures most often used in psoriasis, chosen according to the predominant dosha and the strength of the patient, and bloodletting (raktamokshana) has classical sanction in kushtha. In Kerala practice, pouring of medicated buttermilk over the head or body (takradhara) is widely employed. The after-care phase restores the diet in graded steps. Palliative treatment then continues with oral compound medicines and external oils, together with advice on diet and conduct (Conboy et al., 2009). A course is thus a package of many components delivered over weeks, individualised to the patient, and followed by months of medication. Any claim about "Panchakarma" is a claim about this whole package.

The evidence bearing on Panchakarma in psoriasis is of several kinds, and they differ sharply in what they can support. Table 1 sets them side by side.

Whether a report can be compared with others depends on what was measured and for how long. Dermatology has standard instruments. The Psoriasis Area and Severity Index combines the extent of involvement with the redness, thickness and scaling of plaques in four body regions into a single score (Fredriksson and Pettersson, 1978), and the proportion of patients reaching a seventy-five per cent reduction is the conventional benchmark of response. The Dermatology Life Quality Index records the effect of skin disease on daily life from the patient's side (Finlay and Khan, 1994). A European consensus has defined treatment goals in terms of both (Mrowietz et al., 2011). Ayurvedic reports that use these instruments, scored by an assessor who did not deliver the treatment and supported by standardised photographs, can be read alongside the dermatological literature. Reports that rely on symptom grades devised for the occasion cannot.

Duration is the more neglected issue. An assessment at the end of a four- or six-week course captures the point at which emollient, rest and expectation effects are at their height. Psoriasis is defined by relapse, so the informative questions are how long improvement lasts, how severe the recurrence is, and what maintenance was needed. Twelve months is a reasonable minimum horizon for three reasons. It spans a full cycle of seasons, which removes the confounding effect of summer improvement. It is long enough for a relapse to declare itself after any plausible carry-over of treatment. And it matches the classical instruction that purification be repeated periodically, so that the regimen is observed as the texts intend it to be used.

Follow-up of that length raises its own reporting demands. The account should state every intervention received during the year, including conventional topical or systemic drugs, phototherapy and further Ayurvedic courses, with dates. Severity and quality-of-life scores should be recorded at fixed intervals and not only when the skin looks well. A relapse criterion should be defined in advance. The CARE guidelines for case reports provide a suitable structure, including a timeline and the patient's own perspective (Gagnier et al., 2014).

Panchakarma is an intervention with physiological cost. Induced vomiting and purgation can cause dehydration and electrolyte disturbance, and the classical texts themselves list the persons in whom they are contraindicated and the complications of faulty administration. Large oral doses of ghee are a consideration in a population already prone to cardiometabolic disease. Psoriasis can also be worsened by skin injury, which is relevant to bloodletting and to vigorous massage. Published accounts seldom report adverse events systematically, and absence of mention is not evidence of absence.

The medicines given after purification raise a separate issue. Surveys of Ayurvedic products sold in the United States and over the Internet found that a substantial minority contained detectable lead, mercury or arsenic (Saper et al., 2004; Saper et al., 2008). Some classical formulations used in skin disease include processed metals and minerals by design. Reports should therefore identify each product, its manufacturer and batch, in the manner recommended for trials of herbal interventions (Gagnier et al., 2006). A further hazard is indirect: abrupt withdrawal of systemic conventional therapy in order to begin Ayurvedic treatment can precipitate a severe flare.

Three steps would move the field forward. The first is better case reporting: CARE-compliant accounts with validated scores, independent assessment, complete disclosure of concurrent treatment and follow-up to twelve months or beyond, including cases that relapsed. The second is prospective registries in Ayurvedic hospitals that enrol consecutive patients with plaque psoriasis, so that the denominator is known and favourable cases are not selected. The third is a pragmatic randomised comparison of an individualised Panchakarma-based programme with guideline-based dermatological care, using shared outcome measures and blinded assessment, on the model already applied in joint disease. Product quality testing should accompany all three.

The belief that Panchakarma benefits chronic plaque psoriasis rests on classical authority, clinical experience and a body of case reports and uncontrolled studies. That body of work shows that the treatment is practised, is acceptable to patients, and is often followed by improvement. It does not yet show that the improvement is caused by the treatment or that it lasts. Because the disease remits and relapses of its own accord, observation over at least twelve months, with standard measures and full disclosure of other treatment, is the least that a credible report requires. Patients considering this route are best served by physicians of both systems who share information and keep conventional options open.

To be declared by the author(s) before publication.

To be declared by the author(s) before publication.