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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 64-69

A case report of prurigo nodularis responsive to Homoeopathy


1 Central Research Institute of Homoeopathy, Jaipur, Rajasthan, India
2 Department of Forensic Medicine and Toxicology, Bakson Homeopathic Medical College and Hospital, Greater Noida, Uttar Pradesh, India
3 Department of Forensic Medicine and Toxicology, Swasthya Kalyan Homoeopathic Medical College and Research Centre, Jaipur, Rajasthan, India
4 Central Research Institute of Homoeopathy; Homoeopathy University, Jaipur, Rajasthan, India

Date of Submission12-May-2019
Date of Acceptance20-Feb-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Dr. Nidhi Mahajan
Central Research Institute of Homoeopathy, Sector 26, Pratap Nagar, Jaipur - 302 033, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_37_19

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  Abstract 

Introduction: Prurigo nodularis (PN) is a chronic, benign neurodermatitis. The exact cause is unknown. In majority, cases of PN do not have a complete resolution of the nodules even with treatment. Case Summary: Here, a diagnosed case of PN of an 18 year old female with a history of 1 year old eczematous lesion is presented. On the basis of the totality of symptoms, homoeopathic medicine Natrium muriaticum was prescribed and gradually the patient showed stable improvement in the domain of signs and symptoms and reached remission by the end of 4 months. There was no recurrence over the next 1 year. This case report evidently suggests that Homoeopathy can serve as a possible treatment option for the management of PN cases.

Keywords: Case report, Homoeopathy, Natrium muriaticum, Prurigo nodularis


How to cite this article:
Mahajan N, Chaturvedi D, Alaria A, Pal G. A case report of prurigo nodularis responsive to Homoeopathy. Indian J Res Homoeopathy 2020;14:64-9

How to cite this URL:
Mahajan N, Chaturvedi D, Alaria A, Pal G. A case report of prurigo nodularis responsive to Homoeopathy. Indian J Res Homoeopathy [serial online] 2020 [cited 2020 Jun 6];14:64-9. Available from: http://www.ijrh.org/text.asp?2020/14/1/64/282114


  Introduction Top


‘Pruritus’ is originally derived from the Latin word ‘prurire’ -means ‘itch',[1] the medical term for itching. ‘Prurigo’ is a related term that describes the changes appear in the skin after it has itched and been scratched for a long time. In prurigo nodularis (PN), these changes take the form of firm very itchy bumps or nodules on the skin's surface. Lesions can resolve when the person stops scratching the area, although in most of the cases, this can be very difficult without proper treatment.[2]

PN clinically presents with hard, crusty, intensely itchy lumps, in which itching is so intense that people scratch themselves to the point of bleeding. Painful hard lumps range from very small to about a half inch across and have a rough and dry top; there may be a few or hundreds. Common sites of involvement are outer parts of the arms, shoulders and legs. The trunk, face and even palms can also get affected.[3]

The pathophysiology of PN remains to be fully elucidated yet; emerging evidence suggests a principal role of neuroimmune alteration in the pathogenesis of PN.[4] In some cases, it can be seen with other comorbidities such as atopic dermatitis (eczema), lymphoma, chronic autoimmune cholestatic hepatitis, HIV infection, severe anaemia or a chronic kidney disease-related itching known as uremic pruritus.[3]

Differential diagnosis of PN on the basis of clinical presentation and skin biopsy includes dermatitis/eczema, dermatomyositis, pemphigus, hypertrophic lichen planus, nodular scabies, dermatofibromas and keratoacanthomas.[5]

PN is a clinical diagnosis, biopsies are often required to confirm the cases that do not respond to first-line therapies or those with secondary complications such as bleeding or ulceration and other suggested laboratory investigations include a complete blood cell count, complete metabolic panel, thyroid, liver and kidney function tests, hepatitis B and C serologies and HIV serology to exclude association as comorbid condition.[4]

It is an understudied disease compared to other inflammatory skin diseases. There is no standardised diagnostic evaluation criteria or treatment regimen for the disease. The highly pruritic, chronic nature and psychological burden (disease-associated anxiety and depression) of this disease suggests need for greater recognition of PN and an evidence-based workup is necessary for optimal patient management.[4] Conventional treatment includes use of topical or intralesional steroids, severe or recalcitrant cases necessitates use of phototherapy or systemic immunosuppressives. Thalidomide, lenalidomide, opioid receptor antagonists and NK1r antagonists with their toxicity profile makes them less favourable.[6] In majority of cases, PN do not have a complete resolution of the nodules with conventional treatment.[7]

Literature review revealed a case report of 63-year-old male patient treated with Lycopodium Clavatum 200, 1M and 10M with Natrium sulphuricum 6X within 6 months and with added follow-up of 3 months with no relapse.[5] Given the chronic and highly pruritic nature of the disease, there is a very high burden of disease, including high rates of associated psychological effects on the patients as anxiety and depression among the patients of PN.[4] Homoeopathy as a holistic approach in this case report suggests an effective treatment measure for PN.


  Case Report Top


A diagnosed case of PN, of an 18-year-old Hindu female student, visited the OPD (on 01 August, 2017) of CCRH Collaborative OPD at Dr. M. P. K. Homoeopathic Medical College and Hospital, Jaipur, India, with complaints of multiple painful nodular lesions with itching over bilateral legs, forearms and back [Figure 1]a, [Figure 2]a, [Figure 3]a and [Figure 4]a for 1 year. The lesions exuded discharge on scratching, discharge was sticky, watery and bloody on continuous scratching and itching aggravated at night and on scratching. The patient was apparently well 1 year back when gradually she started developing complaint of itching followed by painful nodular lesions. The patient took allopathic medicines for the same with temporary relief for 9 months but lesions relapsed.
Figure 1: (a) Pre-treatment right leg, (b) post-treatment right leg

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Figure 2: (a) Pre-treatment back, (b) post-treatment back

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Figure 3: (a) Pre-treatment b/l leg, (b) post-treatment b/l leg

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Figure 4: (a) Pre-treatment forearms, (b) post-treatment forearms

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There was a history of measles in 2007. She was not on any on-going allopathic medicine or other alternative medicines.

In family history, her mother had hypertension.

She enjoyed dancing (joined dance school for learning) and was passionate for it.

Menstrual cycle was regular (28–30 days), moderate flow and lasting for 3–4 days. There were no associated symptoms. On examination of the skin, there were multiple blackish, blue bumps (nodules) over the forearms, back and legs with firm consistency and sticky, watery, bloody discharge on scratching.

Self-rating, patient global assessment score (PGA, rating was scored on 0–10 scale, ‘considering all the ways in which illness affects the patient', minimum and maximum scores indicates 0-very good and 10-very bad) was 6 on the first visit.

There was no significant finding in general and other systemic examinations.


  Homoeopathic Generals Top


Mental generals

One year back, the patient had issues with her father on her love relationship with a boy. Her father scolded badly and forced her to stay away from the relationship as it was distracting her from studies. The incidence affected the patient badly +++, and she lost her focus on studies and failed in a subject twice leading to further disappointment. The significance of this event as mentioned is that it has been taken as ailment from disappointment as all her complaints had started after that incident. At last, she changed the stream and focused herself on her passion, dancing and decided it as carrier option. She could not bear rude behaviour, which makes her cry ++.

Physical generals

The physical generalities were thirst for small quantities ++ (takes sips) and aversion to sweets ++. She often walks during sleep, she never realises that she walks and since childhood, she is suffering with the complaint (episodic-once or twice in a month) and had taken no treatment for the same.

Analysis of the case

After analysis and evaluation, the characteristic symptoms were considered for framing the totality. Ailments from disappointment, passionate, sensitive to rudeness and somnambulism were important mental symptoms in this case. Thirst for small quantities and aversion to sweets were physical generals. Itching aggravated at night; there were multiple itching, painful, nodular lesions on the forearms, back and legs and discharge was watery, sticky and bloody on scratching lesions. Miasmatic evaluation for the presenting symptom was done with the help of ‘Chronic disease by Dr. Samuel Hahnemann,’ which showed the predominance of psoric miasm.

Selection of remedy was based on repertorisation of the case using Synthesis Repertory, version 9.0 of RADAR software. The repertorisation chart is shown in [Figure 5].
Figure 5: Repetorisation chart

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On the basis of reportorial analysis and after consulting Materia Medica,[8]Natrium muriaticum was selected and 200 potency in single dose was prescribed followed by placebo for 14 days on the first visit (01 August, 2017) [Table 1].
Table 1: Timeline including follow-up

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  Discussion Top


The above case report shows that homoeopathic medicines are helpful in the treatment of PN. In this case, Natrium muriaticum in 200C and 1M potencies was prescribed, which covered the totality of symptoms of the patient and it has shown positive results. Somnambulism was considered as an accessory symptom in the case, gradually the episodes of somnambulism were reduced and presently there is absolute absence of such episodes.

Improvement status of the patient was assessed on the basis of self-rating scale i.e., patient global assessment score with pre-treatment score being 6 which was reduced to 0 post-treatment.

In this case, the total score of outcome as per Modified Naranjo Criteria was 8, which was close to the maximum score of 13. This explicitly shows the causal attribution of the single medicine homoeopathic treatment Natrium muriaticum towards remission of the PN in this case [Table 2].
Table 2: Assessment by Modified Naranjo Criteria score

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The general approach in Homoeopathy towards treatment is ‘The real sick man is prior to the sick body.[9] In this case, important mental generals, physical generals and particulars, i.e., ailments from disappointment, passionate, sensitive to rudeness and somnambulism, were important, thirst for small quantities, aversion to sweets, itching aggravation at night, itching, painful, nodular lesions on forearms, back, and legs, discharges-watery, sticky were included for repertorisation purpose.

There is no specific conventional treatment for PN and available treatment includes oral antihistamines and steroids that may be applied to the skin (topical) or taken internally (systemic). A combination of several treatments may need to be tried but they may not offer complete relief from symptoms for some.[10],[11],[12],[13]

There is no definite diagnostic criteria and treatment regimen for PN so such cases are generally poorly managed. Individualised medicine helps the body to heal itself and hence can serve as a possible treatment option for PN. However, a prospective research study is suggested for scientific validation as this is a single case report.


  Conclusion Top


The present case report shows the role of Homoeopathy in treating the cases of PN where Natrium muriaticum was prescribed as an individualised medicine and showed evident positive results. The outcome of this case report will improve the knowledge of the clinicians in suggesting proper patient management, which will benefit the patients suffering from PN.

Declaration of patient consent

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

Acknowledgement

The authors acknowledge Dr. Chaturbhuja Nayak, President, Homoeopathy University, Jaipur, for his encouragement and guidance regarding case report writing and scientific publication. The authors also acknowledge Dr. Atul Kumar Singh, Principal, Dr. M.P.K., Homoeopathic Medical College, Hospital and Research Centre, for guidance and support.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
Dictionary by Merriam-Webster: America's Most-Trusted Online Dictionary; 2019. Available from: https://www.merriam-webster. com/. [Last accessed on 2018 Jun 27].   Back to cited text no. 1
    
2.
British Association of Dermatologists; 2018. p. 2-3. Available from: http:// www.bad.org.uk/. [Last accessed on 2018 Sep 25].  Back to cited text no. 2
    
3.
Savill T, Warner E. Savill's System of Clinical Medicine. 14th ed. London: Edward Arnold; 2005;951.  Back to cited text no. 3
    
4.
Kwon CD, Khanna R, Williams KA, Kwatra MM, Kwatra SG. Diagnostic Workup and Evaluation of Patients with Prurigo Nodularis. Medicines (Basel) 2019;6.  Back to cited text no. 4
    
5.
Khatri J. Homoeopathy in Prurigo Nodularis; 2018. Available from: https:// hpathy.com/clinical-cases/homoeopathy-in-prurigo-nodularis/. [Last accessed on 2019 Oct 10].  Back to cited text no. 5
    
6.
Kowalski EH, Kneiber D, Valdebran M, Patel U, Amber KT. Treatmentresistant prurigo nodularis: Challenges and solutions. Clin Cosmet Investig Dermatol 2019;12:163-72.  Back to cited text no. 6
    
7.
Prurigo nodularis. Genetic and Rare Diseases Information Center. U.S. Department of Health and Human Services; 2018. Available from: https://rarediseases.info.nih.gov/diseases/7480/prurigonodularis. [Last accessed on 2018 Sep 25].  Back to cited text no. 7
    
8.
Clarke JH. A Dictionary of Practical Materia Medica. New Delhi: B. Jain Publishers; 1999. p. 549-62.  Back to cited text no. 8
    
9.
Kent JT. Lectures on Homoeopathic Philosophy. 5th ed. New Delhi: B Jain Publishers (P) Ltd.; 1989. p. 766-72.  Back to cited text no. 9
    
10.
Oakley A. Nodular Prurigo. Dermnetnz; September, 2014. Available from: https://www.dermnetnz.org/topics/nodularprurigo/. [Last accessed on 2018 Sep 25].  Back to cited text no. 10
    
11.
Prak AH, De la Rosa KM. Prurigo Nodularis. Medscape Reference; 05 June, 2017. Available from: https://emedicine.medscape.com/ article/1088032overview. [Last accessed on 2018 Sep 25].  Back to cited text no. 11
    
12.
Watsky K. Prurigo Nodularis. UpToDate; 8 March, 2018. Available from: https://www.uptodate.com/contents/prurigonodularis. [Last accessed on 2018 Sep 25].  Back to cited text no. 12
    
13.
OssorioGarcía L, JiménezGallo D, RodríguezMateos ME, ArjonaAguilera C, LinaresBarrios M. Treatment of prurigo nodularis with lenalidomide. Dermatol Ther 2017;30. doi: 10.1111/dth.12451.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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