Homoeopathic Management Of Nummular Eczema: A Case Report

-by Dr Deeksha ¹, Dr Anita Alaria^1
1PG Scholar, M.D.(Hom.)PART-II, Department of Homoeopathic Philosophy & Organon of Medicine, Dr.M.P.K.Homoeopathic Medical College, Constituent College of Homoeopathy University,  Saipura, Jaipur, Rajasthan, Jaipur, Rajasthan.

ABSTRACT

Nummular eczema also is known as discoid eczema, is an uncommon eczematous disorder. It clinically presents with extremely itchy, sharply demarcated coin-shaped vesicular or crusted plaques, worse in the winters. Here, a 52 years old male presented with 10 years history of eczematous skin lesion. A diagnosis of nummular eczema was made. On the basis of the totality of symptoms, Arsenicum album was prescribed and the patient gradually showed stable improvement assessed using Visual Analogue Scale (VAS) score and reached remission by the end of four months, without any relapse over the next one year. This case report demonstrates the role of Arsenic album in cases of eczema.

Keywords- Nummular eczema, eczema, Arsenicum album, Homoeopathy.

Abbreviations – VAS-Visual Analogue Scale OPD – Outdoor Patient Department; K/C/O-Known Case Of; tds-ter die sumendum (Three times a day);<- Aggravation;>- Amelioration.

INTRODUCTION

Nummular eczema (also known as discoid eczema and nummular dermatitis) is an uncommon   idiopathic inflammatory eczematous disorder with a chronic relapsing course.¹

The word “nummular” is derived from the Latin word “coin,” as the spots can look coin-shaped on the skin. Nummular eczema appears more frequently in men, usually between the ages of 55-65. Women usually get their first flare of nummular eczema between the ages of 13-25. It can also affect children.^2,3

The exact cause of nummular eczema (nummular dermatitis) is unknown. Known triggers for nummular eczema includes, damage to the skin such as through an insect bite, scrapes and scratches, chemical burns, reaction to inflammation (as with atopic dermatitis and/or stasis dermatitis) elsewhere on the body, dry skin especially in the winter, metals like nickel, poor blood flow or swelling in the lower legs, medications like topical antibiotic creams, isotretinoin and interferon.²

It clinically presents as slightly raised, pink-red, scaly discs, varying in diameter from 1cm to 4cm, on the arms and legs and, less frequently, on the trunk. The disorder is usually quite itchy and the skin on the arms and legs is often dry as well.^2,3

It can be difficult to treat because it seems to affect people differently. Modern medicine is aimed towards making the patient healthy symptomatically, by pharmaceutical drugs and symptom-based approach. The modern medical treatments are based on medicines like Hydrocortisone, Corticosteroids and other immunosuppressive drugs and anti-inflammatory drugs. Ultraviolet light therapy is also used in some severe cases.^2,4

The holistic approach of Homoeopathy treats the person as a whole, recognizing that every person is unique and works towards eliminating the basic sensitivity to develop eczema or such a lesion using internal medicine.

Visual Analogue Scale (VAS) – Visual analogue scale is psychometric measuring instrument designed to document the characteristics of disease-related symptom severity in individual patients and use this to achieve a rapid (statistically measurable and reproducible) classification of symptom severity and disease control. VAS can also be used in routine patient history taking and to monitor the course of a chronic disease Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being un dimensional, for example only measuring scratching activity. Currently, only a few resources are available to measure pruritus. A visual analogue scale has been used most often to quantify pruritus.⁵

No case report or study was found on the Homoeopathic treatment of nummular eczema.
The aim of this article is to report the evident role of Homoeopathy in the management of nummular eczema.

Case profile

A 52 years old male patient programme officer at Akashwani by profession, came to our OPD (OPD reg. no. 7300/16; dated – 28/12/16 ) with complaints of itching papular vesicular lesions with watery, serous, sticky discharge scratching after and plaques over hands and legs bilaterally during winters^{+ +}; itching and burning in lesions, aggravation at night⁺⁺, from 10 years. The patient was apparently well 10 years back then gradually he started developing complaint of papular, vesicular and plaque lesions. The patient had already taken Allopathic medicines for the same with temporary relief for10 years. The patient was taking no other medicine for any type of illnesses. These lesions disappear during summers (seasonal variation).

Family History: Father- died (K/C/O of hypertension died due to Myocardial Infarction).

Physical Generals: Thirst- frequent but little at a time. Sleep was disturbed due to itching in lesions. Thermal reaction of the patient was chilly.

Mentals

The patient seems to be always in a state of anxiety about health with restlessness⁺⁺⁺ (patient asked whether it is curable or not and wanted to be reassured and frequently change physician if he was not relieved within few months, easily become restless). He was very particular about his work⁺⁺⁺ and doesn’t like to bear any compromise about it from himself and his co-workers; Suspicious⁺⁺⁺ (talking to the point with suspicious looks while case taking, having no close friend keeps thing to himself and doesn’t trust others).

General and systemic examination: Nothing abnormal detected.

Local Examination (skin lesions)

• Site-B/L legs and hands (dorsum)
• Type of lesion –plaques with blackish discolouration
• Colour of lesion –blackish-red
• Margin- ill-defined
• Shape –polygonal
• Discharge-present(serous, sticky, watery, occasionally bloody)
• Consistency-firm
• Number-multiple

Visual Analogue Scale⁵ Score- 8

Analysis of the case

After analyzing the symptoms by Kent’s method, the characteristic mentals and physical generals and particular symptoms were considered for framing the totality. Anxiety with restlessness due to his disease condition, very particular for his duties and suspicious. Thirst-frequent for small quantity, thermally chilly patient were physical generals. Plaque lesions with blackish discolouration over hands aggravation in winters, Itching and burning in eruptions aggravation night, Sticky, watery, serous discharges from eruptions after scratching were important particulars included in totality. Miasmatic evaluation for presenting symptom was done with the help of “The Chronic disease by Dr Samuel Hahnemann” showed the predominance of psoric miasm.^6,7

Selection of remedy by Repertorial method using Synthesis repertory, version 9.0 of RADAR software systemic repertorization was done. The repertorization chart given in Figure 1.

On the basis of reportorial totality and consulting materia medica^8,9 Arsenicum album [Patients are anxious, restlessness; intolerable burning in the skin; vesicular eruptions; return of sufferings periodically(every year)]  was selected and Arsenicum album 200/single dose followed by Phytum 30/tds/14 days was prescribed on the first visit (28/12/2016).

Repertorial totality( Synthesis 9.0 )

MIND-RESTLESSNESS-anxious; MIND-DUTY-too much sense of duty; MIND-SUSPICIOUS; STOMACH-THIRST-small quantities, for-often; SKIN-ERUPTIONS-crusty; SKIN-ERUPTIONS-winter; SKIN-ERUPTIONS-itching-night; SKIN-ERUPTIONS-burning-night; SKIN-ERUPTIONS-discharging-scratching, after.

Repertorization

Figure 1: Image showing the repertorization sheet. Repertorization was done from Synthesis repertory using RADAR software.

Discussion

In this case, Arsenicum album was primarily selected as the first prescription on the basis of the totality of symptom in 200 potencies on 28/12/2016. Arsenicum album with increasing potencies (up to 1M,) was prescribed following Homoeopathic philosophy for four months and progressive improvement was observed, evidently reported on Visual Analogue scale (VAS) scale for itching. Itching, burning and discharges of eczema were gradually relieved and by the end of 3 months and follow-up was maintained for 1 year and 4 months (28/12/2016-18/4/2018), which is given in detail in (table 1). It supports directions for the second prescription by Dr J.T. Kent “if a remedy has benefitted the patient, never leave it until one or more doses of higher potency has been given.” ⁷

Table 1: Changes in symptomatology and Follow-up

DATE	CHANGE IN SYMPTOM	PRESCRIPTION
11/01/2017	Itching and burning in lesions over b / l hands and legs <night-reduced. Discharge –serous , sticky, watery from lesions of b/l hands and legs < after scratching –reduced. VAS Score- 6 No new lesions appeared.	Phytum 30/tds/14 days
25/01/2017	Itching and burning in lesions over b/l hands and legs <night- present same as before. Discharge –serous, sticky, watery from lesions of b/l hand and legs < after scratching – same as before. VAS Score- 7 No new lesions appeared.	Arsenic album 200/1 dose Phytum 30/ tds /14 days
8/02/2017	Itching , burning in lesions over b/l hands and legs <night-better. Discharge –serous, sticky, watery from lesions of  b/l hand and legs < after scratching -reduced. VAS Score- 5	Phytum 30/tds/14 days
22/02/2017	Itching, burning in lesions over b/l hands and legs <night-better. Discharge – serous , sticky, watery from  lesions of  b/l hands and legs < after scratching -reduced. VAS Score- 3	Phytum 30/tds/14 days
8/03/2017	Itching and burning in lesions over b/l hands and legs <night-present  as previous. Discharge –serous, sticky, watery from lesions of b/l hand and legs < after scratching –present as previous. VAS Score- 6	Arsenic album 1m/1 dose Phytum 30/tds/14 days
22/03/2017	Itching, burning in lesions over b/l hands and legs<night-better. Discharge –serous, sticky, watery from lesions of b/l hands and legs < after scratching -reduced. VAS Score- 4	Phytum 30/tds/14 days
5/04/2017	Itching ,burning in lesions over b/l hands and legs<night-better. Discharge –serous, sticky, watery from lesions of b/l hands and legs < after scratching -reduced. VAS Score- 2	Phytum 30/tds/14 days
19/4, 3/5 ,17/5, 31/5,14/6, 28/6,28/7,30/8, 27/9,25/10,29/11, 13/12,4/1/2018, 18/1, 1/2, 15/2, 1/3, 15/3,29/3, 12/4,18/4/2018	General condition -better. No new lesion appeared and old symptoms not relapsed. On and off VAS (itching) score remained between 0 to 2.	Phytum 30/tds

Conclusion

Aim of Homeopathy is to cure the underlying cause of the disease rather than merely treating symptom superficially. Homoeopathy treats skin affections with individualized internal medicines as these are not local maladies but internal affections and need to be treated internally. It treats the disturbances of the immune system and treats the roots of this disease. Non-recurrence of complaints for a year with no relapse during the winter season (seasonal relapse) and remission by the end of four months reported evidently with Visual Analogue Scale (VAS) score for itching and photographic evidence. Evidence suggest that Homoeopathy has a remarkable role in the treatment of patients suffering from the eczematous lesion (nummular eczema) without any relapse and with complete resolution.

Patient consent

The authors certify that they have obtained patient consent via E-mail and the patient has given his consent for his photographs and other clinical information to be reported in the journal. The patient was made to understand that his name and initials will not be published and due efforts will be made to conceal his identity.

References:

1. Jiamton S, Tangjaturonrusamee C, Kulthanan K. Clinical features and aggravating factors in nummular eczema in Thais. Asian Pac J Allergy Immunol [Internet]. 2013 [cited 9 June 2019]; 31(1):36-42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23517392
2. Nummular Eczema | National Eczema Association [Internet]. National Eczema Association. 2019 [cited 9 June 2019]. Available from: https://nationaleczema.org/eczema/types-of-eczema/nummular-eczema/
3. Miller, J.Nummular Dermatitis: Background, Pathophysiology, Etiology. [Internet]. 2018 [cited 9 June 2019] Emedicine.medscape.com. Available at: https://emedicine.medscape.com/article/1123605-overview [Accessed 9 Jun. 2019].
4. Poudel, R., Belbase, B. and Kafle, N. (2015). Nummular eczema. Journal of Community Hospital Internal Medicine Perspectives, [Internet].2015[cited 9 June.2019] ;5(3), p.27909. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475258/
5. Elman S, Hynan L, Gabriel V, Mayo M. The 5-D itch scale: a new measure of pruritus. British Journal of Dermatology. 2010[cited 9 June.2019]; 162(3):587-593. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875190/
6. Hahnemann S. The chronic diseases, their peculiar nature and their homoeopathic cure. NewDelhi: Publishers (P) Ltd.; 1991.
7. Kent JT. Lectures on Homoeopathic Philosophy. 5^th ed.New Delhi: B Jain Publishers (P) Ltd;1989.
8. Clarke, J.H. A Dictionary of Practical Materia Medica. New Delhi: B. Jain Publishers; 1999.
9. Boericke W. New Manual of Homoeopathic Materia Medica and Repertory (With Relationship of Remedies).Augmented Edition based on 9th ed.New Delhi.B.Jain Publishers(P)Ltd.;2000.Hahnemann S. The chronic diseases, their peculiar nature and their homoeopathic cure. New Delhi: Publishers (P) Ltd.; 1991.

PHOTOGRAPHS OF PATIENT
Before Treatment (28/12/2016)	During Treatment (22/03/2017)

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