Unani and modern aspects of psoriasis (Da’u-us-Sadaf) treatment: a review

INTRODUCTION

The prevalence of psoriasis estimated to be approximately worldwide is 2-3% and in adults varies from 0.44 to 2.8%, in India on the basis of hospital-based studies with a much lower prevalence in children.^1,2 Both sexes equally affected ³ but in some studies it is twice more common in males compared to females and most of the patients are in their third or fourth decade of life.⁴ Psoriasis may start at any age but is unusual before the age of 5 years.⁵ The oldest record onset was in a patient aged 107. In 1841 AD Ferdinand Von Hebra was the first who worked on Willan’s notes and given the name psoriasis to this skin disorder and described its clinical picture that is being used today.⁶ hence it is termed as Willan’slepra.⁷

The word psoriasis is derived from Greek word ‘psora’ meaning ‘itch’ ‘iasis’ meaning “action, condition”. Psoriasis is a chronic inflammatory skin disorder clinically characterized by well defined, erythematous sharply demarcated papules and rounded plaques, covered by silvery micaceous scale. The skin lesions are variably pruritic.^8-12 It can affect any part of the body with varying intensity, mainly skin and joints, sometimes it appears as a single spot, while on the other time it involves whole skin of body. Skin rapidly accumulates at the sites and shows like white silvery appearance. Plaques ma appear on any site of the skin including scalp and genitals, but commonly on the skin of the elbows and knees.^5,8 Pathophysiology behind the development of psoriasis is T-cell activation, which migrated from lymph nodes and systemic circulation to skin and causes release of cytokines, that trigger on cutaneous inflammation and hyperproliferation of the epidermis results in erythematous, raised plaques with overlying scale.^13,14

Da’u-us-Sadaf is derived from Arabic words “daun” means ‘disease’ and “Sadaf” means ‘oyster shell’. Psoriasis or Da’u-us-Sadaf are not mentioned in any classic literature since ancient times. It was considered in the context of Taqashur-e-Jild and Qashaf-e-Jild by Unani physicians; Razi (841-926 AD), Majoosi (930-994 AD), Ahmad Bin Mohd Tabari (985 AD), Ibn-e-Zohr (1091-1162 AD), Akbar Arzani (death 1722 AD) Azam Khan (1813-1902) because of dryness of the skin and scale formation, which clinically resembles very much with psoriasis (Da’u-us-Sadaf).^15-20 It is also described under the various heading in Unani system of medicine, such as Taqashshur-e-Jild, Qooba-e-Mutaqashsherah, Chambal, Apras, Talaq, Sa’af-e-Qishri and Al-Sadfiah besides Da’u-us- Sadaf.^{15,17-19,21-27}

PATHOGENESIS

There are two key pathophysiological aspects.^5,11 First is hyperproliferation of keratinocytes with grossly increased mitotic index and an abnormal pattern of differentiation involving the retention of nuclei in the stratum corneum. The turnover of keratinocytes alters keratinization, resulting in thickened epidermis (seen as papules and plaques) and para-keratotic stratum corneum (silvery scales). Secondly, there is a large inflammatory cell infiltrate comprising polymorphs, T-cells and inflammatory cells. T-lymphocytes for epidermal proliferation play an important role, but the exact mechanism is not clear. In unani medicine, pathogenesis of the disease mentioned by unani scholars.

According to Ali Ibn-e-Abbas Al-Majoosi has described that Tabiyat expels the khilt-e-Ghaleez from internal organs towards skin resulting in the dryness and itching of the skin, but in this condition skin is unable to remove Khilt-e-Ghaleez leading to accumulation of sauda in skin and produce Taqashur-e-Jild.¹⁶ Ibn-e-Zohar excessive amount of morbid melancholic humour (Khilt-e-Sauda) is accumulated in the skin, which leads to malfunctioning of skin and it becomes unable to take proper nutrition and to remove morbid melancholic humour (Khilt-e-Sauda). As a result of that, skin tissues become dead and fall out in the form of scales.¹⁸ When excessive amount of morbid melancholic humour (Ghair Tabyee Sauda) accumulates in the body, then spleen could not absorb it completely because it is imbalanced either in quantity or quality or both. Being unable to absorb by spleen, it spreads in the blood, from which the organs take their nutrition. This leads to occurrence of dangerous diseases whose recovery into the healthy state is not very easy as this khilth (humor) is not suitable for the Tabiat of the body.²¹ Peeling like scales of the fish after roughness of the skin can be seen in condition of Qashaf and Taqashur-e-Jild by Hakim Akbar Arzani in Tibb-e-Akbar.¹⁹ Similar condition like roughness and scaling of the skin is called Qashf wa Taqashur-e-Jild in which itching and burning occurs has also described by Hakim Mohammad Azam Khan in his book Aksee-r-Azam.²⁰ In brief we can describe the pathogenesis of psoriasis in unani literature in the name of both Taqashur-e-Jild (scaling of the skin) and Qashaf-ul-Jild (dirtiness of the skin). Khilt is Hirreef and Lazza’a (irritant) responsible for Qashaf-e-Jild resulting itching and burning along with dryness.

ETIOLOGY

In Unani system of medicine, abnormal humors (Sauda-e-Mohtaraq, Merah-e-Safra/ Balgham-e-Merari), indigest-ion, uncleanness; diet (cold, dry and salty diets) are the factors responsible for the cause of this disease.^16,17,19-21 In modern medicine, the exact cause of psoriasis is still unknown but it is considered to be an autoimmune disease and several factors.^2,5,11 Genetic factors e.g. autosomal dominant inheritance or polygenic, monozygotic twins etc., triggers, trauma e.g. scrathes, injuries and surgical incisions, infections e.g. β hemolytic streptococcal throat infections often precede guttate psoriasis and HIV infection precipitate explosive psoriasis, drugs e.g. anti-malarial, β–Blockers, anti-malignant, immunosuppressive, NSAID, lithium etc. are known to cause psoriasis from drug reactions, immunological factors e.g. helper T-cells play a key role, biochemical changes: e.g. increased level of cyclic nucleotides, arachidonic acid, polyamines, calmodulin etc., endocrinal factors, and others; smoking, low humidity, emotional stress, obesity and alcoholism can exacerbate.

TYPES OF PSORIASIS

Psoriasis is divided into two major groups epidemiologically.²⁸ Type-1 psoriasis (early onset psoriasis); it occurs at early age of life or before the age of 40 years and associated with the HLA-CW6 antigen and family history.^5,29 Type-2 psoriasis (late onset psoriasis); it occurs in an individual’s fifties or sixties, a family history is less common and the HLA CW6 is not so prominent in this disease. Psoriasis further can be classified clinically as below.^8,28-33

Stable plaque psoriasis (nummular psoriasis/psoriasis vulgaris)

This is the most common type of psoriasis in which individual lesions are well demarcated erythemato-squamous plaque and range from a few millimeters to several centimeters in diameter. Mainly it affects elbows, knees, scalp, lumbo-sacral area, retro auricular, intergluteal cleft and umbilical area. If the palm-sized lesions predominate called psoriasis geographical, coin-sized lesions nummular psoriasis and involving whole of the body, known as generalized or universal psoriasis.^8,28,30

Guttate psoriasis (eruptive psoriasis)

It is most frequent form in children and young adults, the lesion is pinhead to pea sized rain drops like erythematous papules erupt abruptly and distributed bilaterally symmetrically all over the body, especially on the trunk and upper extremities, sparing the soles and palms. Streptococcal throat infection may also frequently precede the onset or flare up of the disease by 1-2 weeks.^28,31,32

Erythrodermic psoriasis (exfoliative psoriasis)

Skin becomes universally red and scaly, or more rarely just red with very little scale present due to mainly sunburn and steroidal anti-inflammatory.^5,8,11

Pustular psoriasis

It is a severe form of lesion consists of tiny superficial sterile pustules which may appear on psoriatic plaque or occur independently. This may be of two types.

Generalized pustular psoriasis (Von Zumbush psoriasis)

It is rare but very serious, onset is usually sudden with large number of small sterile pustules erupting on red base. It is usually associated with pyrexia.^5,8,11

Localized pustular psoriasis (Barber’s psoriasis)

It affects the palms and soles, eruption is chronic and comprises small sterile pustules which lie on a red base.^5,8,11

Psoriasis inversus (flexural psoriasis)

Major skin folds such as axillae, groins, sub mammary folds, vulva, gluteal cleft, periumbilical region, retro-auricular area, glans of uncircumcised penis are involved in this type of psoriasis.^29-33

Arthropathic psoriasis (psoriasis arthropathica)

It is an autoimmune inflammatory disorder, associated with psoriasis with a negative test for rheumatoid factor, occurs in 5-10% of psoriasis patient and its peak occurrence is between 20-40 years of age and in both sexes.^29-33

CLINICAL FEATURES

It should be carefully examined, because of psoriatic lesion is characterized by its particular morphology and the site of predilection.

Morphology

Primary lesion in psoriasis is a mild itchy papule or plaque, which is well demarcated, indurated, erythematous, scaly or plaque.^2,34,35

Site of predilection

According to Koebner or Isomorphic phenomenon, it affects the pressure points e.g. elbows, knees, scalp (from where it may spill on to the forehead and nape of neck), extensor surface, lumbosacral area and back.^2,35,36

Signs

Grattage test

It is positive when gentle scraping the lesion with a glass slide produces the silvery scales.^2,37

Auspitz sign

It is the characteristic of psoriasis if become positive on deep scraping, the capillaries at the tip of elongated papillae are torn leading to multiple bleeding points.^2,8,28,29

Candle grease sign

When a psoriatic lesion is scratched with the help of glass slide, candle grease like scales are produced.^2,35

Membrane of bulkeley

When the scales are completely scraped off, the stratum mucosum (basement membrane) is exposed and a moist red surface is seen.^2,35

Koebner’s or Isomorphic phenomenon

If there is development of isomorphic lesion at the site of local trauma of uninvolved skin, the lesion develops 7 to 14 days after the injury.²

Holo or Woronoff sign

After treatment with ultra violet radiation or topical steroid due to deficiency of prostaglandin E, if a zone of hypopigmentation seen around the plaque.^2,11,35

DIAGNOSIS

Diagnosis of the psoriasis may be on the basis of family history of psoriasis, previous attacks, presence of itchy lesions (at particular sites e.g. elbow, knee, scalp, back and nails), lesions covered with silvery scales, candle grease sign, Auspitz sign and Koebner phenomenon. Seasonal variations also may be responsible for psoriasis. Sometime skin biopsy for typical histopathology and skin scrapping (KOH smear) may be needed to confirm the disease and to distinguish from other skin disorders. Following investigations may also be helpful for the diagnosis of psoriasis.^2,8,31,34,38

TLC

Its value may be raised in psoriasis.

ESR

Normal in psoriasis but in generalized pustular psoriasis it may be elevated.

Serum calcium

In pustular and erythrodermic psoriasis the calcium is decreased in serum.

Serum uric acid

May be elevated in up to 89% patients.

Immunoglobulin

It is generally normal but IgA deficiency and monoclonal gammopathy are documented in association with psoriasis.

Anti-nuclear antibody

It is found in rheumatic arthritis but negative in psoriatic arthritis.

Nail dipping and skin scraping

It is carried out to exclude the fungal infection because it is negative in psoriasis.

Skin biopsy

It is performed to confirm the diagnosis by histopathological examination of psoriasis.

Throat swab

It is useful in guttate psoriasis.

DIFFERENTIAL DIAGNOSIS

It can be differentiated from lichen planus, pityriasis rosea, tinea corporis, secondary syphilis, lichen simplex, Reiter’s syndrome, Atopic dermatitis, Candidiasis, Seborrheic dermatitis.^{2,5,8,28,29,31}

COMPLICATIONS

Following complications may be found in the result of psoriasis; infection, itching, arthritis, hepatic failure, nephritis and renal failure, amyloidosis.^29-31,38

MANAGEMENT OF PSORIASIS

There is no curative agent for psoriasis and the treatment suppresses the condition only as long as it is administered. The main aim of the treatment in this disease is to decrease epidermal proliferation and underlying inflammation. For this purpose, systemic agents (Table 1) as well as topical agents (Table 2) may be given in case of psoriasis.

USOOL-E-ILAJ (PRINCIPLE OF TREATMENT)

Unani scholars has emphasized the Usool-e-Ilaj (principle of treatment) in the following; evacuations of black bile (Istifragh or Tanqiyahe Sauda), use of blood purifier (Tasfeeh-e-Dam), use of Munzijate Sauda (Melancholic concoctives), use of Mushilate Sauda (Melancholic purgatives), Tabreed Badan (genesis of ratoobat or fluids in the body), try to restore normal temperament (Tadeele Mizaj), correct the digestion (Islahe Hazm), and topical application of jali (detergent), murakhi (emollient), murattib and mohallil (anti-inflammatory) advia in the form of tila, zimad and roghan (jelly, ointment, or oil).

ILAJ (TREATMENT)

In the Unani system of medicine, the principle of treatment is based on the following treatment methods or modalities: Ilaj Bil Dawa (pharmacotherapy) Ilaj Bil Ghiza (diet therapy), Ilaj Bil Tadabeer (regimental therapy).

Ilaj Bil Dawa (pharmacotherapy)

I is recommended for psoriasis in unani medicine are Nuzuj Wa Tanqiyah-e-Ghair Tabayiah Akhlat-e-Saudavia (concoction and expulsion of abnormal humors) along with Tahleel-e-Auram (resolution), Tasfeeh-e-Dam (blood purification), Taskeen-e-Jild (demulcefication), Indimal-e-Zakhm (cicatrization), Tarteeb-e-Umoomi Wa Muqami (general and local moisturization) and use of Jali (detergent) drugs. Keeping in view of these above pharmacological properties, the Unani drugs to be prescribed in psoriasis (Da’u-us-Sadaf), are as follows; Nuskha Matbookh (Table 3) for evacuation of abnormal Melancholic humor in the treatment of Taqasshur-e-Jild suggested by Mohammad Tabri.¹⁷

Method of preparation

All the above single drugs to be boiled in 1700ml of water. After evaporation of 2/3 of water, it to be filtered and preserved, given to the patient orally (with mixing of sugar 17gm if not diabetic) in two to three divided doses on empty stomach and Nuskha Tabeekh-e-Afteemoon (Table 4) for sterilization of the body from waste matter suggested by Hkm Akbar Arzani.¹⁹

Method of preparation

All the above single drugs to be boiled in 2070ml of water until ¾ part of water evaporated. Remaining ¼ part of water preserved after filtering and then it to be given to the patient orally in two to three divided doses with mixing to be boiled in 2070 ml of water until ¾ part of water evaporated. Remaining ¼ part of water preserved after filtering and then it to be given to the patient orally in two to three divided doses (with mixing of 24g of sugar if not diabetic).

There are several single drugs as well as compound drugs are being used in the treatment of psoriasis (Da’u-us-Sadaf). But as per need, all following medicines as single or multiple in the form of Joshanda (decoction), Khesanda/Zulal (infusion), Safoof (powder) orally can be given. But there are a lot of medicine in unani literature which may be used are listed in (Table 5).

Compound drugs (Advia-e-Murakkabah) used in psoriasis

The formulated drugs for the treatment of psoriasis (Da’u-us-Sadaf) are administered by oral as well as topical are below in (Table 6).

Ilaj Bil Ghiza (dieto-therapy)

In psoriasis, patients are advised.^{8,16,19,40,49} Avoid the intake of such food items that lead to the increased production of Ghair Tabai Saudavi Mada (morbid black bile) that are the actual culprits for the commencement of this disease, avoid meat and sweet items, avoid sour and salt diets that produce balgham (phlegm) and sauda (black bile), avoid alcohol consumption, and use cold and moist diet for tarteeb mizaj (change temperament) like fresh milk, lamb meat and bottle gourd. Take soft and easily digestible food like mash (black gram), kaddu (pumpkin), asfanakh (spinach), fresh milk and Ma-ul-Jubn (whey) should be used. Soup of mash (black gram) and kaddu (pumpkin), fresh milk with mash (black gram) and kaddu (pumpkin), himsiya (gram) and Maghz-e-Badam (almond).

Ilaj Bil Tadabeer (regimental therapy)

This type of therapy facilitates the waste material from the body to expel out by the following modes.

Taleeque (leeching)

It is performed on site of lesion because it is very effective and beneficial in chronic inflammatory skin diseases and unhealed ulcer.⁵¹

FASD (venesection)

In this case open the Rag-e-Basaleeque (baselic vein) of both hand with intervening period of 7 days.^15,17,19,49

Hijama (cupping)

It evacuates the humours to allow tissues to release toxins and remove toxins through surface of the skin, suggested by Zakariyya-al-Razi, Azam Khan, Ghulam Jeelani and Qarshi in Taqashur-e-Jild.^15,23,51

Hammam (bathing)

Daily bath or twice in a weak is more effective for this inflammatory.⁵²

Inkebab (vapour bath)

For this purpose, decoction of Baboona (Matricaria chamomilla) 30gm, Akleel-ul-Mulk (Astragalus hamosus) 30gm, Qaisoom (Artimisia abrotanum) 30 gm, Marzanjosh (Origanum majorana) 15 gm, Izkhar (Andropogon jwarancusa) 15 gm, Gul-e-Surkh (Rosa damascena) 15 gm, Badyan (Foeniculum vulgare) 15gm can be used.⁵³

Abzan (sits bath)

By decoction of Tukhm-e-Kataan (Linum usitatissimum) 15 gm, Tukhm-e-Teerah Tezak (Eruca sativa) 15gm, Tukhm-e-Gazar (Daucus carota) 15 gm, Tukhm-e-Shaljam (Brassica rapa) 15 gm, Suddab (Ruta graveolens) 15 gm.⁵³

CONCLUSION

Keeping the review in mind it can be concluded that Unani system of medicine is a deep rooted system of medicine in India that deals with treatment of psoriasis since ancient times by adopting various modes of treatment; Ilaj Bid-Dawa (pharmacotherapy), Ilaj Bil-Ghiza (dietotherapy), Ilaj Bit-Tadbeer (regimenal therapy). A number of studies carried out on different unani drugs like Dar Hald (Berberis Aristata), Aak (Calotrpis procera), Babchi (psoralea corylifolia), Gheekwar (aloe vera), Karanj (pongania pinnata), Berg-e-Inderjau Shirin (Wrightia tinctoria), Kutaja (holarrhena pubescens), Majeth (Rubia cordifolia) and effective in treatment of psoriasis. However further research in this area is required to explore the more secret behind these drugs in the treatment of psoriasis.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the all staff of school who involved in this work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Pariser DM, Bagel J, Gelfand JM, Korman NJ, Ritchlin CT, Strober BE, et al. National Psoriasis Foundation Clinical Consensus on Disease Severity. Arch Dermatol. 2007;143:239-24.
2. 2. Khanna N. Illustrated Synopsis of Dematology, Sexually Transmitted Disease, Published by Elsevier, 2nd Edition; 2008:37-48.
3. 3. Dogra S, Mahajan R. Psoriasis: Epidemiology, clinical features, co-morbidities, and clinical scoring. Indian Dermatol Online J. 2016;7:471-80.
4. 4. Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Ind J Der Ven Lep. 2010;76(6):595-601.
5. 5. Boon A. Nicholas et al. Davidson’s Principles and Practice of Medicine. 20th ed; Churchill, Livingstone; 2006:1287-1292.
6. 6. The History of Psoriasis. Available at http://www.healthspas.co.za/spa/articles/Psoriasis.php.
7. 7. Glickman FS. Lepra, psora, psoriasis. J Am Acad Dermatol.1986;14:863-6.
8. 8. Braunwald. Harrison’s Principles of Internal Medicine. 17th McGraw Hill Medical Publishing Division, New York, London, New Delhi. 2008;1:315-16.
9. 9. Thomas L, Venes R. Taber’s Cyclopedic Medical Dictionary. 9th ed. Delhi: Jaypee Brothers; 2002:1782.
10. 10. Smoller BR. Horn Dermatiology in Systemic Disease. New York: Oxford University Press; 2001:25-28.
11. 11. Goldman L, Ausiello D. Cecil Textbook of Medicine. 22nd ed. Delhi: Saunders Imprint of Elsevier; 2004:2461-2462.
12. 12. Virendra NS. Text Book of Clinical Dermatology. 4^th ed. Delhi: Jaypee Brothers Medical Publishers; 2006:126-135.
13. 13. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med. 2009;361(5):496-509.
14. 14. Nickoloff BJ, Smith WT, Bonish B, Porcelli SA. Response of murine and normal human skin to injection of allogeneic blood derived psoriatic immunocytes: detection of T-cells expressing receptors typically present on natural killer cells, including CD 94, CD 158 and CD 161. Arch Dermatol. 1999;135(5):546-52.
15. 15. Razi ABMBZ. Kitab-AL-Hawi Fil-Tibb. 1st ed., Hyderabad; Dairatul Moarif; 1970.
16. 16. Majoosi ABA. Kamil-us-Sanaah. Urdu Translation by Kantoori HG. Lucknow; Matba Munshi Naval Kishor: Year Not Mentioned.
17. 17. Tabari, Ahmad Bin Mohammad: Al-Moalejat-ul-Buqratiya, Urdu translation, Vol. 1st part I-5, 183-85. 2, Part 6-8, CCRUM, New Delhi. 1997;151-185.
18. 18. Ibne Zohr AMAM. Kitab-ut-Taiseer Fil Madavat-e-Wa-al-Tadbeer. 1st ed, New Delhi; Urdu Translation by CCRUM; 1986.
19. 19. Arzani HA. Tibb-e-Akbar Urdu. Lucknow; Munshi Naval Kishor; 1883.
20. 20. Khan MA. Akseer-e-Azam. Kanpur; Matba Nizami: 1289 Hijri.
21. 21. Ibn-e-Rushd, Abul Walid Mohammad: “Kitab-ul-Kulliyat”, Urdu Tarjamah CCRUM New Delhi; 1980:89-90.
22. 22. Sharah Asbab. Cancer - from the horizons of Unani medicine. Current Drug Therapy. 2019;14(2).
23. 23. Jeelani, Hakim Ghulam: “Makhzan-e-Hikmat”, Matba SH of set Press, New Delhi; 1996;2:698.
24. 24. Kabeeruddin, Hakim Mohammad: “Tashreeh-e-Kabeer”, Qarol Bagh, Delhi; 1924;2:563-70.
25. 25. Toor SH. Kamil-ut-Tashkhees Pub. Bu Idarah Tarjuman-Al-tib Lahore. Year not mentioned; 94-95.
26. 26. Israili, Mohammad Ayyub: “Tarjamh Urdu Shareh-e-Asbab”, Munshi Naval Kishore, Lucknow. 2018;2:414-15.
27. 27. Ghaznivi, Khalid: “Amraz-E-Jild Wa Ilaj-e-Nabvi”, Azeem Publisher, New Delhi; 1993:257-260.
28. 28. Behl PN. Practice of Dermatology. New Delhi; CBS Publishers and Distributors; 2000.
29. 29. Falco BO. “Dermatology” Springer - Verlag Berlin Heidelberg New York; 1991:417-434.
30. 30. Arnold, Harry L. “Andrew’s Disease of the Skin Clinical Dermatology”, 8th Ed; WB Saunders Company. 1990;1(13):198-204.
31. 31. Champion RH. “Text Book of Dermatology”, 6th ed; Black well science Ltd. etc. 1998;2:1598-643.
32. 32. Fitzpatrick, Freedberg, Irwin M. “Dermatology in general Medicine” 6th Ed. Medical publishing division McGraw Hill. 2003;1:407-20.
33. 33. Lal S. Clinical pattern of psoriasis in Punjab. India J Dermatol Venereol. 1966;35:5-12.
34. 34. Fitzpatrick, James E. “Dermatology Secrets” Hanley and Belfus, INC Medical Publisher, Philadelphia. 1996;1(5):39-42.
35. 35. Valia RG. “Text Book and Atlas of Dermatology”, 2nd Ed; Bhalani Publishing House Mumbai, India. 2001;2:812-34.
36. 36. McKee HP. “Essential skin pathology”. London: Mosby international Ltd.; 1999:71-72.
37. 37. Rocha PP. “The inflammatory Response in mild and in Severe Psoriasis”. British J Dermatology. 2004; 150:927.
38. 38. Sainani, Gurumukh S. “API Text Book Of Medicine”, 6th Ed; Association of Physicians of India, Mumbai; 1999:1198-1199.
39. 39. Khan MS. Da-us-Sadaf (Psoriasis), 1st ed., New Delhi; Idara Kitab-us-Shifa; 2011.
40. 40. Anonymous. Unani Treatment for Some Common Skin Disorders. New Delhi; CCRUM. Department of AYUSH; 2007.
41. 41. Alam M, Joy S, Kalaimani S, Veluchamy G. Contribution to the process and product standardization of 777 oil used in psoriasis. J Research in Ayurveda and Sidha. 1994;15(1-2):75-9.
42. 42. Sharma S, Rai NP. The clinical profile of hepatoprotective drug in the management of Kitibh (Psoriasis vulgaris), Proceeding of International Congress on Ayurveda, Chennai; 2000:13.
43. 43. Upadhayay R. Calotropis procera (Ait) R.br. an important ethnomedicinal plant, National Symposium on Emerging trends in Indian Medicinal Plants. Lucknow; 2003:7.
44. 44. Volger BK, Ernst E. Aloe vera:a systemic review of its clinical effectiveness. Br J Gen Pract. 1999;49(447):823-8.
45. 45. Atique A, Iqbal M. Traditional single drug administration for the psychosomatic dermal disease. Hamdard Medicus. 1992;35(2):76-81.
46. 46. Tse WP, Cheng CH, Che CT, Zhao M, Lin ZX. Induction of apoptosis underlies the Radix Rubiae mediated anti proliferative action on human epidermal keratinocytes: Implications for psoriasis treatment. Int J Mol Med. 2007;20(5):663-72.
47. 47. Kabiruddin HM. Bayaz-e-Kabeer. Vol. 2, Haiderabad Deccan; Hikmat Book Depo: YNM.
48. 48. Khan MS, Lari QH, Khan MA. (Physico-chemical and Pharmacological Prospective of Roghan-e-Narjeel (Coconut Oil). Int J Phar Sci Res. 2016;7(3): 1286-91.
49. 49. Sina I. Al Qanoon fit Tib Vol-2, 4 (Arabic). New Delhi: Institute of History of Medicine and Medical Research; 1408 Hijri. p. 409-10,405-416.
50. 50. Alam MT, Hasan I, Parvenu A, Nazamuddin M, Parveen S. Leach therapy (Taleeq): indication, contraindications and standard operative procedures (sop). J Biological Scientific Opinion. 2013;1(4):358-61.
51. 51. Qarshi HM, Hasan, Jamiul Hikmat. Vol-2. New Delhi: Idara Kitabushshifa; 2011:1005.
52. 52. Sultana A, Ahmad A, Begum M. Ilaj bil-Tadbeer, A Non-Medical Therapy in Unani System of Medicine, A Review. J Complementary Alternative Med. 2015;1(1):1-6.
53. 53. Hamdani SKDH. Usool-e-Tib. Aligarh; Litho Color Printer; 1980.