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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 226-236

Homoeopathic research in vitiligo: Current scenario


Central Council for Research in Homoeopathy, Ministry of AYUSH, Government of India, New Delhi, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Deepti Dewan
Consultant (Extra-Mural Research), Central Council for Research in Homoeopathy, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_33_17

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  Abstract 


Objective: The objective of the study was to conduct a review of the existing literature on homoeopathic research conducted on Vitiligo. Materials and Methods: A comprehensive online and manual search of research studies on vitiligo through Homoeopathy was conducted to identify publications in international search databases and library of Central Council for Research in Homoeopathy published during the period from 2006 to 2016. Relevant research was categorised by study type and appraised according to study design with their clinical outcomes. Results: In this review, 11 articles related to Homoeopathy on vitiligo were identified, of which four clinical observational studies and three case reports were assessed. Conclusion: Studies identify a positive role of Homoeopathy in vitiligo were repigmentation has been reported. The treatment, however, is prolonged and needs to be based on homoeopathic principles of totality and individualized treatment. Further, a larger number of studies on convincing evidence-based parameters including validated scales are essential requirements to document the usefulness of Homoeopathy in vitiligo.

Keywords: Central Council for Research in Homoeopathy, Homoeopathy, Observational studies, Randomised controlled trials, Vitiligo


How to cite this article:
Dewan D, Taneja D, Singh U, Mittal R, Khurana A. Homoeopathic research in vitiligo: Current scenario. Indian J Res Homoeopathy 2017;11:226-36

How to cite this URL:
Dewan D, Taneja D, Singh U, Mittal R, Khurana A. Homoeopathic research in vitiligo: Current scenario. Indian J Res Homoeopathy [serial online] 2017 [cited 2018 Jun 18];11:226-36. Available from: http://www.ijrh.org/text.asp?2017/11/4/226/221958




  Introduction Top


Vitiligo is a common chronic skin depigmentation disorder. It is due to stoppage of melanin formation by the melanocytes and presents as asymptomatic depigmented macules anywhere on the body including mucous membranes of lips and genitalia.[1] In vitiligo, there is a marked reduction or even absence of melanocytes and melanin in the epidermis. Histochemically, there is a lack of DOPA-positive melanocytes in the basal layer of epidermis. The macules vary in size and shape as well as in colour. Some of the lesions or some parts of the lesions may be hypopigmented rather than depigmented. The course of the disease is very variable. The lesions in some patients may remain static or progress very slowly, whereas, in others, the disease progresses very fast and cover the whole body in few months. In few cases, spontaneous repigmentation has been noticed. It is usually perifollicular.[1]

It affects around 0.5%–1% of the world population.[2],[3] As high as 8.8% prevalence have been reported in India, where considerable stigma is attached to the disease.[4] Vitiligo patches can appear anywhere on the skin, but commonly affected sites include the area around the orifices, the genitals or any sun-exposed areas such as the face and hands. The hair and rarely, the eyes may also be affected.[4],[5]

Fifty percent of cases appear before the age of 20, with the disfigurement resulting in psychiatric morbidity in 16%–35% of those affected. Depression, sleep disturbances, suicidal thoughts, suicidal attempts, difficulties in relationships, and avoidance of social situations have been reported in individuals afflicted by vitiligo before adulthood [6]

The proportion of patients with positive family history varies from one part of the world to another. In India, in particular, it ranges from 6.25% to 18%. Some studies reveal it as high as 40%.[7]

The disease pathogenesis of vitiligo has not been fully elucidated. Autoimmune, biochemical and oxidative stress, genetic, neuronal and environmental factors are thought to interact and contribute to the development of vitiligo.[6] Diagnosis of vitiligo is straightforward and can be made in primary care but atypical presentations may require expert assessment by a dermatologist. Patients with vitiligo often develop autoimmune thyroid disease or other autoimmune diseases. A blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in patients with vitiligo. Wood's lamp may be of use in determining extent and activity of vitiligo, as well as monitoring response to therapy and the progress of lesions over time.[8]

However, several diseases that are frequently misdiagnosed as vitiligo.[8] These are Halo naevus, Hypopigmented naevus, Idiopathic guttate hypomelanosis, Leprosy, Lichen sclerosus (for genital vitiligo), Melanoma-associated leucoderma, Melasma, Mycosis fungoides-associated depigmentation, Naevus anaemicus, Naevus of ito, Piebaldism, Pityriasis alba, Pityriasis versicolor, Post-inflammatory depigmentation, for example, Scleroderma, Psoriasis, Atopic eczema, Post-traumatic depigmentation, Topical or drug-induced Depigmentation and Tuberous sclerosis.

Vitiligo and homoeopathy

In 19th century, practitioners acknowledged limitations for treatment of this condition and suggested Sulphide of Arsenicum to lessen the patch.[9] Various stains were also advocated to temporary conceal the existing condition.[10]

The homoeopathic literature [1],[9],[10],[11],[12],[13] subsequently suggested a number of medicines for the conditions mentioned as 'vitiligo,' 'leucoderma,' 'hypopigmented spots' such as: Alumina, Ammonium carbonicum, Antimonium crudum, Arsenicum album, Arsenicum sulphuratum flavum, Aurum metallicum, Berberis vulgaris, Bryonia alba, Calcarea carbonica, Carbo animalis, Coca, Dulcamara, Graphites, Kalium muriaticum, Lycopodium clavatum, Mercurius solubilis, Natrum muriaticum, Natrum carbonicum, Nitricum acidum, Phosphoricum acidum, Pulsatilla, Sambucus nigra, Sepia officinalis, Silicea terra, Sumbulus moschatus, Sulphur, Tarentula hispanica, Veratrum album and Zincum phosphoricum.

Further, patients frequently seek treatment of vitiligo from homoeopathic practitioners. There is, however, no comprehensive review to identify evidence base in Homoeopathy for treatment of vitiligo. This study was undertaken to identify the research conducted in Homoeopathy for treatment of vitiligo.


  Materials and Methods Top


The following criteria were adopted for undertaking this review:

Types of studies

This review included studies where the intervention was aimed at treating symptoms related to vitiligo through Homoeopathy. Any study where symptoms could at least be partially attributed to vitiligo treatments was included in this review.

All types of Randomised Controlled Trials (RCTs) and observational studies undertaken in any setting were included in the review. Well-documented and peer-reviewed case reports were also included.

Studies related to exclusively allopathic and complementary mode of therapeutics (Ayurveda, Unani, Siddha, Yoga and Naturopathy) along with expert opinions on the vitiligo were excluded from this review.

Homoeopathy was defined, for the purpose of this review, as the use of homoeopathic medicines prepared in accordance with officially recognised homoeopathic pharmacopoeias. Any homoeopathic prescribing strategy was included.

Search methods for identification of studies

Electronic searches

A systematic literature search was conducted in the main international search databases (PubMed, Medscape and Science direct) for all clinical studies (both concluded clinical trials and reviews articles) published in the period from 2006 to August 2016. Online IJRH (Official publication of Central Council for Research in Homoeopathy [CCRH] [www.ijrh.org]) and clinical series published by council were also searched for articles on vitiligo and its scope of treatment in Homoeopathy.

Handsearching

Manual search was taken up at CCRH, an apex body which undertakes homoeopathic research in India. The CCRH library publishes Current Health literature Awareness Services (CHLAS), indexing the Journals/titles available in the library on quarterly basis. Furthermore, bulletin of National Institute of Homoeopathy was also manually searched on clinical studies related to vitiligo and its homoeopathic treatment.

For this search, all keywords related to Vitiligo i.e., hypopigmentation, depigmentation, leucoderma, pigmentation disorders, white patches, clinical studies, skin diseases and Homoeopathy were used. A total of 11 articles [14],[15],[16],[17],[18],[19],[20],[21],[22],[23] were identified [Figure 1].
Figure 1: Flow diagram

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Data analysis

The studies were assessed manually by two authors [DD, US], and details of the study of the identified fields were added manually. Third author [DT] re-examined the studies and cross-checked the entries made. The details of included studies as tabulated are given in [Table 1].
Table 1: Studies included in the review

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  Results Top


Number of articles

In this review, 11 articles related to Homoeopathy on vitiligo were identified, in which five are clinical observational studies,[14],[15],[16],[17] three are case records,[18],[19],[20] one is a double-blind, randomised, placebo-controlled homoeopathic pathogenetic trial,[23] one is a pilot data collection study within a programme of quality assurance, improvement and development across all five homoeopathic hospitals in the UK National Health Service [21] and one is a telephonic survey done at Homoeopathic Clinic, Lucca, Homoeopathic Reference Centre Region of Tuscany, Italy.[22]

Out of these 11 studies, seven studies (four clinical observational studies and three case records) were included in this review. Human pathogenetic trial, data collection study, news paper report and telephonic survey were excluded from this review.

Number of participants

In two observational studies, the number of participants are less than 50,[15],[16] whereas two studies have participants more than 200.[14],[17] Three are single-patient case reports.[18],[19],[20]

Duration of treatment

One study has duration of treatment between 6 months to 1 year.[15],[17] In the remaining five studies, the duration of treatment is more than 1 year.[14],[16],[18],[19],[20]

Homoeopathic treatment approach

A constitutional mode of homoeopathic approach is followed exclusively in seven studies.[14],[15],[16],[17],[18],[19],[20] This approach has been detailed as determining totality of symptoms followed by case analysis and Miasmatic diagnosis.[14] In one of the observational study, Arsenicum sulphuratum flavum was the experimental drug, but in few cases, other homoeopathic medicines were also prescribed after detailed case taking as per homoeopathic principles.[17] In all three case records, prescription was done on the basis of case analysis and totality of symptom but no valid scales were used for assessments.[18],[19],[20]

Medicines prescribed frequently

Medicines that are frequently prescribed in the clinical cases for vitiligo were identified in review as: Sulphur, Arsenicum album, Arsenicum sulphuratum flavum, Calcarea carbonica, Causticum, Hydroquinone, Phosphorus, Lycopodium clavatum, Natrum muriaticum, Natrum sulphuricum, Nitricum acidum, Sepia officinalis, Silicea terra, Thuja occidentalis, Tuberculinum and Mercurius solubilis. The potency used has shown no common pattern varying from 6 to 10 M in centesimal scale. 50 millesimal potency was reported to be used in one study.[20]

Assessment/outcome parameters

In one study, standardised validated scales were used in the assessment of vitiligo such as Vitiligo Area Severity Index score, Vitiligo European Task Force score and Dermatological Life Quality Index,[15] while remaining five studies used totality of symptoms along with photographs of the patients at entry, during and after treatment as the outcome assessment measures. No standardised validated outcome scales were used in these five studies.[16],[17],[18],[19],[20] In the study conducted by Central Council for Research in Homoeopathy, assessment was done on the basis of Vitiligo Symptom Score developed internally and photographs of the patients.[14],[19] The primary outcome measure was to identify the usefulness of individualised homoeopathic medicine in the repigmentation of the patches and the secondary outcome measure was to identify a group of homoeopathic medicines in the management of the vitiligo.

Treatment outcomes

All the studies reported positive outcomes, reflecting a rationale to use homoeopathy in the treatment of vitiligo.

Type of publication

Four studies are published in peer-reviewed journals,[14],[15],[18],[19] whereas three studies are non-peer-reviewed articles,[16],[17],[20]

Level of evidences for clinical research

For three studies, the level of evidence for clinical research [24] in the reviewed articles is 'B' which includes the controlled and uncontrolled observational studies,[14],[15],[17] whereas for five studies, level of evidences is 'C' including the case reports.[16],[18],[19],[20]


  Discussion Top


This is only a literature review, attempting to collate the existing studies to identify their strong and weak aspects and to develop suggestions for future studies. A meta-analysis of the studies was not attempted considering the variations in patients' inclusion/exclusion and assessment parameters. No fixed criteria for study inclusion/exclusion were developed to do a systemic review. It was seen that in homoeopathic system very less number of studies have been conducted on vitiligo. Most are observational studies or isolated reporting of cases. There are no RCTs for treatment efficacy in vitiligo.

In these studies reviewed the treatment strategies followed were mainly constitutional with added in inclusion of mental & physical generals to develop patients's picture. Vitiligo being a chronic relapsing condition, so a constitutional and a holistic approach is favoured. It is recommended that a vitiligo symptom totality or symptom syndrome adhering to the homoeopathic individualistic approach may be formed to acquire a most common set of homoeopathic remedies effective in the disease and obtain better results.

Drugs such as Calcarea carbonica, Arsenicum album, Sulphur, Phosphorus, Natrum muriaticum, Thuja, Lycopodium, Mercurius solubilis and Arsenicum sulphuratum flavum were most frequently prescribed which are identified as constitutional medicine with the exception of Ars. Sulph flavum. Nosodes are also reported to be prescribed in static cases as an intercurrent remedy and keeping in view the frequent remissions and relapses which can pose as an obstacle to cure of patients as advocated by Dr Hahnemann (Aphorism 3 and 252 in Organon of Medicine). In this review, Tuberculinum and Syphilinum were found useful. Studies with specific medicines or constitutional medicines further validating their symptoms syndrome can be conducted in future to identify definite treatment strategy for vitiligo patients.

The investigators had not used or applied any validated scales for the assessment of the disease. It is recommended to develop study protocols for vitiligo incorporating the usage of validated scales. Vitiligo itself is a big social stigma for the patient, so assessment of quality of life must be an important part of the treatment including psychological support. The studies reported in the review used photographs of the patients for assessment which alone limits the possibility to draw firm conclusions on the effectiveness of Homeopathy in vitiligo.

Only observational studies were carried out reporting positive extrapolations of homoeopathic treatment, but due to lack of a control group, it is difficult to assess the extent of response to Homoeopathy. Keeping this in view, future studies may be designed to investigate the true extent of placebo or context effects in homoeopathic treatment. Further, more vigorous research designs including pragmatic methodology and RCTs are required for scientific validation of results.

In most of the studies, reviewed patients were followed up for 2–3 years or less which is a small period for the assessment of treatment outcomes as vitiligo is a chronic slow-progressing disease, and rate of its progression varies over the years. However, it has been identified that the patients usually tend to drop out after a period of 1 year. The treatment strategy may be focussed on retaining the patient for a longer follow-up period for a reduction in the relapse rate of disease. Studies identifying treatment approaches and use of the future studies on vitiligo can be designed by overcoming these flaws.

In study by CCRH,[14] it was seen that a considerable number of patients dropped out after some months of continuing treatment. This could be due to the fact that it was proposed to give treatment for 2 years and the disease has an unpredictable course. In the majority of patients, even though no complete repigmentation was seen, the progression was checked, which could have given better results after a longer follow-up.

The sample size or the number of patients participating in the studies reviewed is highly varied for getting a desired statistical outcome. Further research having optimal sample size identified on the basis of already existing studies can be designed to assess the efficacy of homoeopathic medicines in vitiligo. Effect sizes can be used to determine the sample size for follow-up studies or examining effects across studies, which again depends on the research question and the experimental design.[25]

The review illustrates the usefulness of Homoeopathy in treatment of vitiligo, but the role of homoeopathic treatment must be explored further on studies focussing on the efficacy of treatment based on specific outcome parameters.


  Conclusion Top


Although not associated with any physical discomfort vitiligo causes considerable psychological morbidity. Studies identify a positive role of Homoeopathy in vitiligo where varying degrees of repigmentation is reported.

The treatment, however, is prolonged and needs to be based on homoeopathic principles of totality and constitutional treatment. A larger number of studies on strong evidence-based parameters, with rigorous study designs including RCTs with validated scales, are essentially required to be conducted to develop evidence base of Homoeopathy for vitiligo treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

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Prasad RV, Raveender CH, Lakhsmi B, Singh K, Vichitra AK, Oberai P, et al. Clinical Evaluation of Predefined Homoeopathic Medicine in Vitiligo Clinical Research Studies Series – II, Central Council for Research in Homoeopathy, New Delhi (India); 2009. p. 85-92.  Back to cited text no. 17
    
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  [Full text]  


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