Individualised homoeopathic medicine in the treatment of psoriasis: An evidence-based case report

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease characterised by well-defined, erythematous scaly plaques that primarily affect the extensor surfaces and the scalp. It typically follows a relapsing and remitting course.^[1] Its prevalence ranges from 0.09% to 11.43% worldwide.^[2] Psoriasis commonly begins in the second to fourth decades of life, but can also manifest in infancy or old age. The familial occurrence of psoriasis (7–36%) indicates a genetic component. Both genetic and environmental factors contribute to the disease, with similar onset and severity observed in familial cases.^[1] Psoriasis prevalence in the general population is approximately 2% and increases to 10% in individuals with Crohn’s disease and 5.7% in those with ulcerative colitis.^[3] Psoriasis manifests in several ways: Plaque, flexural, guttate, pustular or erythrodermic psoriasis. The most common form is plaque psoriasis, which presents as well-demarcated salmon pink plaques with silvery-white scale, typically in a symmetrical distribution and affecting the extensor surfaces (especially elbows and knees), trunk, and scalp.^[4] Differential diagnosis includes tinea infections, pityriasis rosea, and lichen planus. Psoriasis lesions are distinct, presenting as well-circumscribed, circular, red papules or plaques covered by grey or silvery-white, dry scales. These lesions typically appear symmetrically on the scalp, elbows, knees, lumbosacral area and body folds. Lesions can also develop at the site of injury or trauma, known as Koebner’s phenomenon. Uncontrolled or progressive psoriasis may lead to generalised exfoliative erythroderma. Nail involvement is common, especially in the presence of psoriatic arthritis. When the tongue is affected, sharply circumscribed gyrate red patches with a white-yellow border may be present, resembling a map referred to as geographic tongue. Psoriasis has a variable course, presenting as chronic, stable plaques or with acute onset, rapid progression, and widespread involvement. Clinical variants of psoriasis include flexural, guttate, erythrodermic and pustular psoriasis.^[5] Unless the diagnosis based on appearance is uncertain, a skin biopsy is usually unnecessary. Assessing the impact on the patient’s life is crucial, and it is measured using the Dermatology life quality index. Disease extent is evaluated using the psoriasis area and severity index (PASI).^[6] As there is an association between psoriasis and metabolic syndrome, assessing and managing the comorbidities and cardiovascular risk factors is essential. HIV testing should be considered in severe or treatment-resistant cases. In modern medicine, three treatment options are available based on the type of psoriasis: topical, systemic and phototherapy.^[7] Topical treatments are suitable for mild to moderate psoriasis, including medications such as dithranol, calcineurin inhibitors, coal tars, retinoids, salicylic acid, vitamin D analogues and corticosteroids.^[7] Among the systemic drugs used for psoriasis, methotrexate and cyclosporine are commonly prescribed.^[7] In addition, biologic drugs have shown effectiveness in treatment.^[7]

Numerous case reports have provided evidence supporting the efficacy of homoeopathic treatment in psoriasis.^[8-12] In a multicentric study conducted using a pragmatic model, the objective was to evaluate the response to individualised homoeopathic treatment in psoriasis patients, focusing on changes in disease severity and quality of life (QoL) measured using the Psoriasis area severity index (PASI) and Psoriasis Disability index (PDI) scales, respectively.^[13] The study followed up those participants regularly for 1 year, and those who completed the 1-year follow-up were included in a long-term assessment for an additional 2 years. Significant reductions were observed in PASI scores and patient and physician global assessment scales. Another prospective multicentre observational study evaluated patients over a 2-year period using standardised questionnaires to assess complaint severity and health-related QoL, amongst other factors.^[14] The results showed a marked improvement in complaint severity, with large effect sizes, and an improvement in QoL based on the SF-36 questionnaire. A double-blind, randomised, placebo-controlled trial involving 51 patients with psoriasisconducted at the National Institute of Homoeopathy in India revealed the efficacy of homoeopathy.^[15]

CASE REPORT

A 42-year-old man visited our clinic on 15 February 2021, presenting with crusty, scaly, silvery and pinkish eruption observed over his forearms, abdominal region and back. These eruptions caused itching and marked exfoliation of the scales. The itching was aggravated by warmth and at night.

The patient has had psoriasis for the past 15 years. Initially, the eruption manifested on the forearms, subsequently spreading to the abdomen and eventually affecting the chest. The patient reported a dry cough aggravated at night and on lying down. He had headache after anxiety or anger, specifically after interactions with his family members or students. He was a teacher by profession, belonging to an upper socio-economic class. His dietary habits were irregular. For this present complaint, he sought consultations with both allopathic and ayurvedic treatments, yet experienced no satisfactory results. Finally, he opted to visit our clinic. The patient had a history of hypertension, type 2 diabetes mellitus and hypercholesterolemia for the last 2, 4 and 1 year, respectively. The patient’s father had a history of cerebrovascular accident almost 15 years ago, whereas the mother was diagnosed with type 2 diabetes mellitus. Father died 8 years back, and mother is alive and currently on allopathic medicine for that.

Diagnostic assessment

The diagnosis was made based on the history and clinical findings. Examination of the affected areas revealed shiny, scaly, silvery and pinkish patches with raised lesions showing well-defined margins, particularly prominent on the extensor surfaces [Figure 1]. Auspitz’s sign, characterised by the presence of punctate haemorrhagic spots upon scale removal, was positive, which is a hallmark of psoriasis vulgaris.

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Figure 1: (a-c) Photographic images of the case before treatment.

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Therapeutic intervention

On repertorisation considering the characteristic symptoms mentioned earlier, following Kent’s repertory and conducted using HOMPATH zomeo software manufactured by Mind Technologies based in Mumbai, Maharashtra, India [Figure 2]. It was seen that Arsenic alb covered the highest number of rubrics (15) and scored the highest (34), followed by Mezereum (32/15), Phosphorus (32/14) and Sulphur (32/13).

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Figure 2: Repertorisation chart.

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Referring to the authentic Materia Medica and considering the patient’s comprehensive totality of symptoms, medical history, family background and the active miasmatic state, Mezereum was chosen as the most suitable remedy for this case.^[17]

Follow-up assessments

The patient was consistently followed up at approximately monthly intervals for nearly 2 years. Details regarding alterations in signs and symptoms, along with the prescribed medications during each follow-up, are documented in Table 1.

Table 1: Follow-up.

Date	Symptoms	Prescription
15 February 2021	Chief complaints along with general symptoms.	Mezereum 30C, single dose.
14 March 2021	Patient is better. Itching reduced. All the other complaints are the same.	Placebo
16 April 2021	Patient is better. Itching and scaling reduced. All the other complaints are the same.	Placebo
17 May 2021	Complaints recurred. Scaling, along with itching increased.	Mezereum 30C, one single dose.
13 June 2021	Mild improvement in the patient’s skin complaints.	Placebo
12 July 2021	Skin complaints ameliorated. The itching and intensity of the scaly eruptions reduced. Tendency to headache reduced. Anxiety was the same.	Placebo
11 August 2021	Skin eruption recurred.	Mezereum 30C/1 dose
17 September 2021	No improvement	Sulphur 30C/1 dose.
18 October 2021	Skin complaints reduced; headache is the same. All the other complaints same.	Placebo
12 November 2021	Complaints same.	Mezereum 200C, one single dose.
17 December 2021	Patient reported amelioration in anxiety, irritability, headache, itching, scaling and cough.	Placebo
15 January 2022	The patient was better.	Placebo
13 February 2022	Improvement ceased.	Sulphur 30C, one single dose. As an intercurrent medicine.
14 March 2022	Crustiness, scaliness and itching of the eruption ameliorated considerably. All other complaints better as well.	Placebo
12 April 2022	Skin complaints and headache recurred.	Mezereum 200C, one single dose.
17 May 2022	Skin complaints considerably reduced. All other complaints, including headache, relieved as well.	Placebo
11 June 2022	Skin complaints ameliorated further. Significant disappearance of the skin complaint noticed.	Placebo
18 July 2022	Itching recurred	Mezereum 200C, one single dose.
13 August 2022	Marked disappearance of the skin complaints.	Placebo
15 September 2022	No complaints	Placebo
17 October 2022	No complaints	Placebo
16 November 2022	No complaints	Placebo
14 December 2022	No complaints	Placebo
13 January 2023	No complaints	Placebo
17 February 2023	No complaints	Placebo
12 March 2022	No complaints	Placebo

Response to the course of treatment

The patient responded well with immediately with the initial application of our individualised homoeopathic drug Mezereum, and this improvement continued thereafter throughout the whole course of follow-up period.

Objective evidence

The patient exhibited gradual improvement following the administration of Mezereum 30C. There was a notable reduction in the patient’s complaints, and these issues resolved completely within the span of almost 2 years [Figure 3].

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Figure 3: (a and b) Photographic images of the case after treatment.

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Intervention adherence and tolerability

The patient strictly followed the prescribed dosage and timing instructions and completely refrained from using other medications from any other systems of medicine and external applications.

Adverse or unanticipated events

During the course of treatment, no untoward events categorised as adverse drug reactions were reported by either patient according to established standard criteria.

DISCUSSION

Homoeopathy is a safe and alternative option for patients with psoriasis, offering both palliative relief and potential curative treatment.^[19] As modern medicine plays a limited role in addressing this condition, homoeopathy stands out. In this particular case report, we prescribed Mezereum as a constitutional remedy to address a chronic miasmatic disease such as psoriasis. This choice was based on highly significant characteristic symptoms exhibited by the patient, such as headache after any annoyance and worsening of the itching due to warmth in bed. Dr. Tyler highlights in her work ‘Homoeopathic Drug Pictures’ that Mezereum tends to worsen at night, from warmth, particularly from the heat of the bed.^[20] It is the singular drug listed in the repertory for ‘eruption itching, worse from warmth of fire’. Regarding the anxiousness and annoyance, Dr. Tyler mentions ‘Everything vexes him, he wants to say all kinds of annoying and vexatious things’.^[20] Dr. Clarke mentions that Mezereum has ‘Anguish and in quietude, esp. in solitude, with wish for society’, which was prominent in this case.^[21] The patient specifically mentioned that spending time without any students or family members caused him anxiety; he felt something very bad was going to happen. Moreover, the patient did not exhibit typical characteristics matching other remedies such as Arsenicum album, Phosphorus, Sulphur or Lycopodium clavatum, all of which ranked around Mezereum in the repertorial analysis. As the treatment progressed, Mezereum was prescribed in gradually increasing doses, in conjunction with Sulphur as an intercurrent remedy, as indicated in the follow-up details provided in Table 1. A case report by Rahman and Dey similarly illustrates an approach in which Syphilinum was eventually selected as the remedy, despite its 23^rd rank in the repertorial analysis.^[22] This case reaffirms that in homoeopathy, the ultimate decision in selecting the similimum often emerges from the comprehensive Materia Medica evaluation. Dr. Dunham’s case study mentioned in Clarke’s Materia Medica highlights the successful cure of a skin condition in a young patient presenting with a thick, whitish, scabby and itching eruption over the scalp that worsened at night, through the use of homoeopathic medicine Mezereum.^[23] Dr. Gibson’s study on Mezereum suggests its therapeutic effectiveness, particularly in cases of psoriasis affecting the palmar region.^[24] In a case report by Rompicherla and Ponnam plantar psoriasis was managed using individualised homoeopathic remedies Pulsatilla nigricans and Mercurius solubilis, based on the acute totality, which provided relief during the acute exacerbation.^[8] Another case of psoriasis was reported by Pawar et al.,^[25] utilising Staphysagria as a constitutional remedy alongside Psorinum as an intercurrent remedy.In a double-blind, randomised, placebo-controlled trial conducted by Balamurugan et al.^[15] for psoriasis vulgaris, Calcarea carbonica, Mercurius solubilis, Arsenicum album and Petroleum were the most frequently prescribed medicines, showcasing their relevance in such cases. In a case series conducted by Mohan involving 25 patients, the following medicines were found beneficial: Calcarea carbonica, Graphites, Natrum muriaticum, Pulsatilla, Arsenicum album, Thuja occidentalis, Sepia, Nitricum acidum, Sulphur and Thyroidinum.^[9] Intercurrent remedies such as Tuberculinum, Syphilinum and Carcinosin were utilised based on specific history and indications.

Homoeopathy, as a holistic treatment method, should be advocated for addressing this longstanding autoimmune and multifactorial disease, which results from the intricate interplay between the body’s genetics, immune system, psychology and environment. According to the Hahnemannian classification of disease, psoriasis falls under the category of true natural chronic disease.^[16] As homoeopaths, conducting a thorough constitutional analysis that integrates both mental and physical symptoms is crucial to identify an anti-miasmatic constitutional homoeopathic remedy to cure the case. Considering the fundamental pathology of psoriasis, it is regarded as an amalgamation of all three miasms, often termed as the ‘marriage’ of all the miasms or stigmata, although its characteristics predominantly exhibit psoric and sycotic tendencies.^[26] Allopathy, while offering partial relief, primarily treats the effects rather than addressing the root cause.^[16] Moreover, drugs commonly used in modern medicine, such as topical steroids and methotrexate, cause significant adverse effects.^[27,28] Indeed, the application of homoeopathy in psoriasis cases can encounter limitations, especially in instances involving addictions such as smoking and alcohol consumption. Smoking and alcohol use have been closely linked to psoriasis. In addition, in cases of ‘erythrodermic’ psoriasis, which is deemed a medical emergency, applying homoeopathy can be challenging. However, despite these challenges, the presented case was effectively managed, as evidenced by post-treatment images of the affected areas [Figure 3]. Moreover, subjective assessments indicated notable improvements in both general and specific symptoms. The Modified Naranjo Criteria were applied to ascertain the causal attribution between the homoeopathic medicine and the changes in the patient’s symptoms and signs [Table 2].^[28] The total score based on the outcome was 9. This case study underscores the potential of the homoeopathic approach, showcasing promising results through meticulous selection of medicine, potency and repetition. It suggests that homoeopathy could serve as an alternative to conventional medicine. It also encourages aspiring homoeopaths to conduct clinical trials to explore new dimensions in this field. However, it is important to note that this study is purely observational in nature and being and lacks the capability to draw definitive conclusions regarding the efficacy of homoeopathic medicines in treating psoriasis. Further research involving rigorous and blinded randomised clinical trials is essential to establish a conclusive inference regarding the effectiveness of homoeopathic remedies in managing psoriasis.

CONCLUSION

This case report highlights the usefulness of homeopathy in the management of diseases like psoriasis. The positive outcomes observed in this case suggest that homeopathy can be a valuable therapeutic option. However, further studies and clinical interventions with homeopathic medicines are necessary to establish their efficacy in similar conditions. Overall, this case report supports the use of individualised homeopathic treatment and emphasizes the need for more research to explore the potential benefits of homeopathic medicines in the treatment of psoriasis and other similar diseases.