Cumulative irritant contact dermatitis treated with individualised homoeopathic medicine – An evidence-based case report

Chief complaints

A 47-year-old married woman from the Punjabi community, working as a school teacher, presented with the following complaints:

• Multiple eruptions on both hands with tremendous itching (since 6 months) [Figure 1]

  

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  Figure 1:

  Pretreatment status of hand affected with contact dermatitis (a) denotes dorsal aspect of hand, (b) denotes palmar aspect of hand.

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• Heaviness in the abdomen after eating with loud eructations that persist the entire day (since 6–7 months).

She complains of uncontrollable itching while using water despite changing soaps and detergents many times in the past 6 months. She has also tried avoiding using them (as advised) but even without soap, the slightest contact with water brings back all the complaints.

As exhibited in Table 1 are the presenting complaints of the patient in Location, Sensation, Modalities and Concomitant form as given by Dr Boenninghausen’s.

Associated complaints

As exhibited in Table 2, are the associated complaints of the patient.

Drug history

She had used some topical applications on and off for 6 months; they only temporarily relieved the itching. For the past few days, she has only been applying coconut oil, which alleviates the itching.

Family history

• Mother: Deceased (natural death), no history of autoimmune diseases

• Father: Deceased (natural death), no history of autoimmune diseases

• Brother: Hypertensive (8–9 years)

• Daughter: Polycystic ovarian syndrome (since 2 months).

Medical history

No major illnesses such as diabetes, hypertension and thyroid problems.

Physical generals

As shown in Table 3, the physical generals exhibit few characteristic features which help to individualise the patient.

Life space

She emphasised the importance of her husband’s support as she confided in him about trivial concerns; minor arguments with people disturb her mentally and she feels best in his calming presence. Despite lacking practical evidence, she also harbours fears of her husband being romantically involved elsewhere, which she believes could devastate her life. She expressed anxiety about the possibility of the disease spreading to other parts of her body, which could potentially hinder her ability to perform daily tasks in the future and this is the thought which brought her to the physician. In addition, she mentioned engaging in regular walks and other activities to maintain her health.

Physical examination

• Height: 5’4’

• Weight: 80 kg

• Gait: Steady

• Pallor: Not detected

• Icterus: Absent

• Cyanosis: Absent

• Clubbing: Absent

• Lymphadenopathy: Not present

• Temperature: Afebrile

• Systemic Examination

• CNS: Conscious, well oriented

• CVS: S1 S2 heard

• Respiratory: Air entry bilaterally equal

• Abdomen: Soft, non-tender.

Local examination

Differential diagnosis

• Atopic d-ermatitis

• Cumulative irritant contact dermatitis

• Psoriasis.

Diagnostic and clinical assessment

The diagnosis was established from the history of exposure to irritants, while the intensity and duration of the symptoms in the affected area were assessed through clinical examination. Pattern and distribution also played a key role in differentiating this case from other varieties of dermatitis. The Visual Analogue Scale (VAS) was used for assessment. Further, the Modified Naranjo Criteria for Homoeopathy (MONARCH) causal attribution inventory was used to assess the relation of individualised homoeopathic medicine with the outcome.

Diagnostic reasoning

Atopic dermatitis appears early in childhood, occurs mainly on flexor surfaces and is symmetrical in distribution.^[7] Moreover, it is characterised by periods of remission and exacerbations; this case history does not depict any childhood presentation and both flexor and extensor surfaces are involved.

Psoriasis is a papulosquamous, immune-mediated disorder of the skin usually associated with systemic involvement.^[8] Well-demarcated plaques characterise it with overlying silvery scales.^[9]

ICD is the most common type of contact dermatitis. It is the skin’s reaction to the harmful or physical impacts of various environmental substances.^[10] History of contact with soaps and detergents indicating repeated exposure for months with bilateral involvement of affected body parts and no history of autoimmune diseases in the family indicates a case of ICD. The final diagnosis was, therefore, cumulative ICD.

Case processing

To compile the comprehensive array of symptoms, an extensive case-taking process was conducted for analysis and evaluation. Mental general, physical general and specific characteristic symptoms were taken into account utilizing Dr Kent’s method of gradation [Table 4].^[11] As exhibited in Table 4, is the analysis of the case.

Totality Repertorial Syndrome (RS)

As exhibited in Figure 2 is the repertorisation sheet of the case analysed using Zomeo Software.

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Figure 2:

Repertorisation using Zomeo Software. Significance of color-each color denoted a specific gradation like pink denotes grade 4 symptoms covered by a remedy. Red denotes grade 3, orange denotes 2^nd grade and green denotes 1^st grade . The color provides the reader a better easy understanding of which remedy covers which symptom in higher grades.

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• Anxiety about future

• Arguments disturb her

• Fear something bad will happen

• Itching > scratching; Itching < water

• Itching is so violent that it causes bleeding

• Whitish sticky discharge, non-offensive.

Potential differential field (PDF) for the case

Desire – Chicken++

Thermal- Chilly

These were the two symptoms included in the potential differential field which when added with repertorial totality, should match the conceptual image of the case. Graphites, Calcarea carbonica and Arsenic albums are thermally chilly, whereas Sulphur and Pulsatilla are hot. A desire for chicken is only covered by Graphites among the closely indicated remedies for this case. In referring to Materia Medica, two other remedies cover the desire for chicken (Ferrum iodatum and Phosphorus), but they do not cover the totality of the case.

Remedy differentiation

The remedy was selected using Zomeo Homeopathic Software by Mind Technologies Pvt. Ltd. As the case presented with characteristic mentals and prominent generals, Kent’s approach was used. The repertorisation chart [Figure 2] presents the five closest remedies: Sulphur, Arsenic album, Graphites, Pulsatilla and Calcarea carbonica. Sulphur has the most points (22/7), followed by Pulsatilla (19/5); however, both remedies are thermally hot, which becomes the potential differential field in this case. Arsenic album is characterised by anxiety, restlessness, aggravation by cold, worse 1–2 am, thirst for sips with marked periodicity and deep-seated insecurity, which are absent in this case.^[12] Graphites and Calcarea carb are close; Calcarea is chilly, obese and easily exhausted by mental work but has the perseverance to complete the task, whereas Graphites are physically more robust and have an aversion to mental work. Graphites act best in constitutions with a tendency to obesity, which is not of a healthy kind as we find Calcarea showing improper nutrition.^[13] However, sweat of the head and cold, damp feet, which are the features of Calcarea are not much prominent under Graphites.^[14] Further, Calcarea does not cover a very marked mental general that binds the case of ‘Discords agg, ailments from.’ Desire for chicken is marked in Graphites which is also included in the potential differential field for this case. After final consultation of the repertorisation chart and Materia Medica, Graphites were selected as the final prescription.

Prescription: Graphites 200C single dose.

Materia Medica Differentiation

Graphites have the carbon element which belongs to the second series of the periodic table, whose theme is of events after conception causing separation from the mother. In this series, Boron is confused about whether he is connected to the mother; carbon fears not being able to survive on his own.^[15] In this case, this is reflected in the patient’s thought process, as she feels she cannot survive without her husband’s support. Furthermore, the themes of columns thirteen and fourteen reflect their structure to be under attack and loss is unavoidable.^[15] They need to make a superhuman effort to maintain it; if it progresses, they understand they have failed and nothing can be done. These shades reflected by the patients fall in these themes and thus, Graphites were selected amongst all the remedies.

The individual requiring Graphites is often affected by grief, especially if it is a woman. She experiences heightened anxiety and apprehension, often fearing imaginary accidents looming on the horizon.^[16] This constant state of unease leads to restlessness and an inability to stay in one place. She cannot find solace and is compelled to move about constantly. This anxious disposition, coupled with low spirits, is a hallmark symptom of Graphites.^[16]

The Graphites patient struggles with indecision, feeling apprehensive and despondent. This remedy addresses constipation, particularly when accompanied by large, knotty stools coated in mucus threads. In addition, Graphites relieve discomfort in the anus, characterised by smarting, soreness and itching.^[17] Skin issues such as oozing, sticky exudation and rough, hard and persistently dry patches unaffected by eczema also respond well to Graphites.

Justification of the selected potency

The potency was moderate to high; this was determined based on the relatively young age of the patient, with the availability of characteristic generals (mental and physical) and particulars. The pathology of the presented case is structurally reversible and the disease progress was insidious. Thus, Graphites were administered in the 200C potency.

Assessment according to MONARCH inventory [Table 5]. As exhibited in Table 5 is the MONARCH causal attribution inventory.