Lichen planus an autoimmune disease treated using Homoeopathic medicine – An evidence-based case report

INTRODUCTION

Lichen planus (LP) is a non-inheritable reaction pattern precipitated by unknown factors.^[1] Clinically, the term lichenoid is used to describe flat-topped, shiny papular eruptions that resemble LP. It presents as severely itchy violaceous flat-topped papules 3–5 mm wide, occurring on several body parts. The clinical presentation of LP varies according to its variant. The skin lesion is usually characterised by the six Ps - planar, purple, polygonal, pruritic, papules, and plaques.^[1] Various LP subtypes are more prevalent amongst certain communities and subgroups. Of note, LP is more common in male children which is unusual for an autoimmune disease.^[2] Depending on where they appear on the body, the signs and symptoms of LP include shiny, hard, and reddish-purple papular lesions, with occasional Wickham’s striae. The lesion may occur as a linear configuration that follows trauma lines (Koebner phenomenon). Signs occur in the nails (edges or grooves on the nails, splitting, thinning, and loss of nails) and in the mouth (spots with minute white dots and lines which look like lace, redness and swelling, peeling of the gums and painful sores). Signs also appear on the scalp in the form of lichen planopilaris.^[3] Histology reveals a distinctive ‘sawtooth’ pattern of epidermal hyperplasia, hyperparakeratosis with thickening of the granular layer and vacuolar alteration in the epidermis’ basal layer, along with significant infiltration (mostly T lymphocytes) at the dermalepidermal junction.^[4] In association with mucosal lesions, there is a possibility of malignancy developing. Common treatments include topical steroids, topical calcineurin inhibitors, psoralen with ultraviolet A (PUVA), narrowband ultraviolet B (UVB), oral corticosteroids, and acitretin.^[5]

However, modern medicine has a suppressive approach to treatment along with several adverse effects, which is why patients often seek other options. Homoeopathy is an alternative therapy that was developed by the German physician Dr. Samuel Hahnemann. Several studies have demonstrated the efficacy of individualised Homoeopathic medicines in the successful treatment of LP with or without mucosal involvement.^[6-8] We present a case wherein Homoeopathic treatment helped successfully manage a case of LP.

CASE REPORT

Intervention

For the repertorisation [Figure 1], the totality was restlessness of mind, anxious, complaints aggravated by thinking of them, fear of death when she stays alone, fastidious, desire for sweets, thirst profuse and burning sensation of skin that aggravates at night.

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Figure 1:

Repertorial sheet (Repertorisation chart). Each column acronym denotes short form of Homoeopathic medicine like-Ars: Arsenicum Album, Nux - v: Nux Vomica, Arg-n: Argentum Nitricum, Bry: Bryonia Alba, Calc: Calcarea Carbonicum, Carb-v: Carbo Vegetatabilis, Kali-c: Kali Carbonicum, Merc: Mercurus solubilis, Phos: Phosphorus, Sulph: Sulphur, Nat-m: Natrum Muriaticum, Rhus-t: Rhus Toxicodendron, Sabad: Sabadilla, Caust: Causticum, Chin: Cinchona Officinalis, numbers are defined as value of symptoms which denotes priority of medicine for totality of symptom covering.

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The three main remedies yielded by repertorisation were Nux v, Arg n, and Ars alb. While all of them covered the characteristic symptoms such as anxiety, mental restlessness, and increased thirst, the fastidious nature and burning sensation of skin at night indicated Ars alb. The remedy was prescribed in a single dose of 30C.

Follow-up and outcome

The follow-up course and the changes in the patient’s symptoms are outlined in Table 1.

Table 1: Follow-ups and outcomes.

Date	Symptoms	Prescription
December 11, 2019	Papular skin eruptions on both legs (anterior tibial side) and on both palms for 3 months [Figures 2a and 2b]	Arsenicum album30 Single dose.
January 09, 2020	Improvement started. Redness of skin lesion ameliorated.	Placebo for the next month.
February 11, 2020	Redness and multiple spots of skin lesion reduced.	Placebo for the next 1 month
March 10, 2020	Further improvement seen.	Placebo for the next 1 month
April 11, 2020	Minimal lesions remained.	Placebo for the next 1 month
	The redness over the skin lesion started decreasing. Only a few dark spots remained in some areas as healing signs [Figure 3a and b].	Placebo for the next 6 months. The patient was advised to report and visit the physician if complaints returned.
December 30, 2020	1) No return of the complaints; the patient’s condition is improving. 2) Sleeps well now. 3) Passing regular stools. 4) All generalities, including hunger, thirst, and sleep, improved. 5) Skin looks normal [Figures 4a and b] 6) The patient’s restlessness and anxiety had reduced, according to her daughter.	No medicine; if the complaint returned, the patient was advised to report immediately. She was also advised to visit the physician at 3-month intervals so that any reappearance of the complaints can be noted.
March 28, 2021	No return of the problems; patient’s condition keeps improving.	No medication
June 30, 2021	No return of the problems; patient continues to recover.	No medication
September 27, 2021	No repetition of the complaints; patient’s condition continues to improve.	No medication
December 31, 2021	No return of the complaints; the patient’s condition continues to improve.	No medication
June 15, 2022	No recurrence of the complaints after 2.5 years of treatment.	Patient was considered cured but was advised to contact the physician in case of recurrence.

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Figure 2:

Before treatment picture. (a) Right leg multiple red lesion. (b) Left leg multiple red lesion.

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Figure 3:

Mid treatment picture. (a) Right leg multiple red lesions reduced. (b) Left leg multiple red lesions reduced.

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Figure 4:

After treatment picture. (a) Right leg red lesions disappeared. (b) Left leg multiple red lesions disappeared.

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The modified Naranjo criteria are applied to this case to establish the causal relationship between the Homoeopathic remedy administered and the changes in the patient’s symptoms/signs [Table 2].^[10] The total score of the outcome was 8.

Table 2: Follow-up assessment using MONARCH inventory guidelines.

Domain	Question	Answer	Score
1.	Was there an improvement in the main symptom or condition for which homoeopathic medicine was prescribed?	Yes	+2
2.	Did the clinical improvement occur within a plausible timeframe relative to the medicine intake?	Yes	+1
3.	Was there a homoeopathic aggravation of symptoms?	Yes	+1
4.	Did the effect encompass more than the main symptom or condition (i.e., were other symptoms not related to the main presenting complaint improved or changed)?	Yes	+1
5.	Did overall well-being improve? (Suggest using a validated scale or mention about changes in physical, emotional, and behavioural elements)	Yes (patient’s laziness and dullness improved remarkably; his fear got reduced; he can get along with his friends easily after treatment)	+1
6A.	Direction of cure: Did some symptoms improve in the opposite order of the development of symptoms of the disease?	No	0
6B.	Direction of cure: Did at least one of the following aspects apply to the order of improvement of symptoms: – From organs of more importance to those of less importance? – From deeper to more superficial aspects of the individual? – From the top downwards?	Yes	+1
7.	Did ‘old symptoms’ (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement?	No	0
8.	Are there alternative causes (i.e. other than the medicine) that – with a high probability – could have produced the improvement? (consider the known course of disease, other forms of treatment, and other clinically relevant interventions)	No	+1
9.	Was the health improvement confirmed by any objective evidence? (e.g., investigations, clinical examination, etc.)	Yes	+2
10.	Did repeat dosing, if conducted, create similar clinical improvement?	Yes	+1
	Total score obtained		11

DISCUSSION

LP is an idiopathic autoimmune disease mostly affecting the cell-mediated immune system. Based on data, cutaneous LP is approximated to occur in <1% of the population.^[11] Cutaneous LP develops mostly between the ages of 30 and 60 years.^[11-14]

Since there is no established curative therapy for LP, therapy focuses on managing and suppressing the illness. Topical and oral calcineurin inhibitors, topical and oral steroids, PUVA, metronidazole, itraconazole, griseofulvin, hydroxychloroquine, dapsone, and thalidomide are some of these.^[5,15] These treatments come with potential adverse effects, some of which could be quite serious.^[15]

Some studies have explored complementary therapies such as aloe vera and conventional Chinese medicine. Aloe vera was found to be more effective in treating oral LP than triamcinolone.^[16]

In the literature, Homoeopathic remedies have been discussed as a potential substitute for corticosteroids in treating LP. Medicines such as Antim crud, Ars alb, Ars iod, Jugl c, Kali bi, Sul iod, Ign, Sepia, Sulphur, and Thuja have been found to be effective for treating LP.^[17,18] In one study, Lycopodium, Ignatia, Aurum metallicum, and Carcinosinum were successfully used to treat LP.^[6] Ignatia was found to be very effective in reducing lesion size and pain scores in a randomized controlled trial with a sample size of 30 patients and a 4-month follow-up period.^[19]

Homoeopathic medications are posited to function by encouraging the formation of nanomolecules, which then affect physical and pathological processes in the human body.^[20-22]

The case report describes the usefulness of Homoeopathic medicines in the treatment of LP. This case report of LP with severe symptoms improved with individual Homoeopathic treatment.

In this case, some of the patient’s distinctive symptoms that matched those of Arsenicum album were fastidiousness, restlessness, impatience, anxious, chilly patient, and profuse thirst.^[23]

For optimal efficacy of treatment and minimising the possibility of symptom aggravation, the right potency needs to be selected; it should be determined by the patient’s susceptibility.^[24-26] Arsenicum album 30 was the most similar drug in this case. It was chosen after properly evaluating and analysing the full spectrum of symptoms and individualising the case. After considering the Law of similarity and the Law of minimum, just one dose was administered.

With individualised Homoeopathic treatment, the patient’s local symptoms were reduced, and the general condition improved. According to the Modified Naranjo criteria, there was improvement in the primary symptom (+2) within a plausible time frame after taking the remedy (+1), with improvement in other symptoms (+1) and general well-being (+1) and with no other alternative causes that could have caused the improvement (+1). There was also an objective improvement in skin lesions after taking the remedy, as evidenced by photographs (+2). Thus, in this case, the total score of 8 indicates a causal attribution of the Homoeopathic treatment to the result.

The specified aetiology of LP is unknown. However, certain factors may be responsible for the development of autoimmune diseases.^[4] In this respect, homoeopathy has a promising role in the treatment of autoimmune diseases, since Homoeopathic treatment is not based on the symptoms of the disease alone but also considers the patient’s psychological and emotional symptoms.^[24] Each person has their own triggers, whether psychological, emotional, physical, or genetic. Homoeopathic treatment determines the cause of the triggering factors and treats them accordingly. This naturally restores the balance of the body’s immune system.^[25] In addition, it is a relatively affordable form of therapy that is well tolerated by all types of patients and can be administered during pregnancy, with a wide range of potential benefits.^[27,28] Our case report shows a positive effect of individualised Homoeopathic medicine in managing the case of LP. Randomised controlled trials also support this conclusion.^[8] The limitation of this study is that it is a single case report. In the future, case series need to be recorded and published to establish the effectiveness of individualised Homoeopathic treatment in LP. These assertions need to be supported by larger investigations, which may also help to confirm the role of homoeopathy in LP.

CONCLUSION

In this case, individualised Homoeopathic treatment helped in curing LP along with gradual improvement in overall well-being. Thus, this case demonstrates the role of Homoeopathic medicine in the successful treatment of LP.