Plantar psoriasis treated with homoeopathic medicine: An evidence-based case report

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease that affects 2–5% of the general population; it is characterised by keratinised plaques with white scales. Palmoplantar psoriasis (PP) is a variant of psoriasis that specifically affects the skin of the palms and soles of individuals of all ages.^[1] PP patients present with burning or pain and worse health-related quality of life than patients with other forms of psoriasis.^[2] The morphology of PP can range from thick, hyperkeratotic plaques with fissuring to pustular lesions of the palms and/or soles.^[3] The former refers to sharply outlined, erythematous, scaly plaques with hyperkeratosis without the presence of pustular lesions. The pustular variety includes macroscopic, sterile pustules and erythema with yellow-brown spots.^[2]

Despite the relatively small body surface area affected, patients with psoriasis of the hands and feet can experience poor quality of life due to pain and its visible impact.^[2] Unfortunately, PP is also frequently resistant to treatment, making it quite a therapeutic challenge.^[4] PP is generally resistant to topical therapy and hence a decreased efficacy and a need for systemic therapy. Topical medications for psoriasis include corticosteroids, Vitamin D analogues, keratolytics, anthralin, coal tar and tazarotene. They may be used individually or in various combinations.^[5]

In this report, we present a case of PP that showed marked improvement within a plausible time frame with individualised homoeopathic intervention. The psoriasis area and severity index (PASI) score was used for changes in psoriasis lesions, the dermatology life quality index (DLQI) was used to assess the quality of life and the modified Naranjo criteria for homeopathy (MONARCH) inventory was used to assess the causal relationship between homeopathic intervention and clinical outcome.^[6-8]

CASE REPORT

Patient information

A 38-year-old woman (homemaker) presented in the outpatient department of Homoeopathic Drug Research Institute, Lucknow on 5 May 2022, with complaints of plantar psoriasis on both feet for 25 years.

The chief complaints were cracked soles with pain, itching and burning, along with scaly plaque over the bilateral soles for 25 years. The complaint originated after she bathed in a lake (location unspecified). The lesions initially appeared on the left foot and subsequently spread to the right foot, affecting some areas of the soles and dorsum of both feet over a 3-year period [Figure 1]. If the cracks deepened, they would bleed. The complaints were worse in rainy weather.

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Figure 1:

(a-d) Plantar psoriasis before homoeopathic treatment (Day 0).

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Analysis of the case and repertorisation

Cracked soles, scaly plaques, abruptness in behaviour, despair of recovery, rainy weather aggravation and a desire for chalk were the symptoms considered for totality and repertorisation. Considering the symptomatology, the synthesis repertory was preferred using Radar Opus software (version 2.2.16) of Zeus Soft, Belgium, Europe. The repertorisation chart is presented in Figure 2. According to repertorial analysis, Sepia (10/5), Sulphur (7/5), and Arsenicum album (7/4) had the highest gradation.

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Figure 2:

Repertorial chart.

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Sulphur was ruled out as the patient’s thermal sensitivity was chilly. Arsenicum album was ruled out as it did not meet the rubric for a desire for indigestible things, which was noted in the patient; the patient lacked the fastidiousness characteristic of Arsenicum album. Abruptness was marked in the patient’s behaviour, which was lacking in Alumina. A strong modality for the main complaint was aggravation in rainy weather; this is lacking in Acid Nitricum.

Follow-up and outcomes

Each follow-up was at 1-month to 2-month intervals. A detailed account of the follow-ups regarding the respective prescriptions and changes in potency is shown in Table 1. W ithin three months of homeopathic treatment, the psoriasis lesions had completely healed. The outcome and possible causal attribution of the changes in this case were ascertained using the MONARCH inventory [Table 2].

Table 1: Follow-up chart.

Follow-up	Symptoms	Medicine	PASI score
Baseline 05 May 2022	Crack and cuts on bilateral soles with pain, itching and burning along with scaly plaque over bilateral soles. Bleeding from the cracks	Sepia 30/OD/7 days Placebo/BD/15 days	8.4
23 May 2022	Cracks and cuts on bilateral soles were better; pain, itching and burning were reduced; scaly plaque over bilateral soles was reduced; there was no bleeding from the cracks	Sepia 200/OD/1 dose Placebo/BD/15 days	-
07 June 2022	Crack and cuts on bilateral soles were markedly reduced; there was no pain, itching, or burning in soles; scaly plaque over bilateral soles was markedly reduced; there was no bleeding from the cracks [Refer Figure 3]	Placebo/BD/30 days	-
05 July 2022	Cracks and cuts on bilateral soles were markedly reduced; there was no pain, itching, or burning in soles; scaly plaque over bilateral soles was markedly reduced; there was no bleeding from the cracks	Placebo/BD/30 days	-
09 August 2022	Cracks and cuts on bilateral soles were markedly reduced; there was no pain, itching, or burning in soles; scaly plaque over bilateral soles was relieved; there was no bleeding from the cracks [Refer Figure 4]	Placebo/BD/30 days	0

PASI: Psoriasis area and severity index, OD: Once daily, BD: Twice daily

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Figure 3:

(a-c) Plantar psoriasis during homoeopathic treatment.

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Figure 4:

(a-d) Plantar psoriasis after homoeopathic treatment (3 months from baseline).

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Table 2: Dermatology life quality index.

S. No.	Items	Score at the beginning	Score at the end
1.	Over the last week, how itchy, sore, painful, or stinging has your skin been? • Very much • A lot • A little • Not at all	3	0
2.	Over the last week, how embarrassed or self have you been because of your skin? • Very much • A lot -conscious • A little • Not at all	3	0
3.	Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? • Very much • A lot • A little • Not at all	2	0
4.	Over the last week, how much has your skin influenced the clothes/shoes you wear? • Very much • A lot • A little • Not at all	3	0
5.	Over the last week, how much has your skin affected any social or leisure activities? • Very much • A lot • A little • Not at all	3	0
6.	Over the last week, how much has your skin made it difficult for you to do any sport? • Very much • A lot • A little • Not at all	1	0
7.	Over the last week, has your skin prevented you from working or studying? • Yes • No	No	No
	If ‘No’, over the last week how much has your skin been a problem at work or studying? • A lot • A little • Not at all	1	0
8.	Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? • Very much • A lot • A little • Not at all	1	0
9.	Over the last week, how much has your skin caused any sexual difficulties • Very much • A lot • A little • Not at all	0	0
10.	Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy or by taking up time? • Very much • A lot • A little • Not at all	1	0
	Total score	18/30	00/30

DISCUSSION

Homoeopathy treats the patient, not the disease; it takes into account the totality of symptoms, which include all the uncommon general and particular symptoms of the individual.^[11] The objective of publishing this case report is to provide evidence of the individualised homoeopathic approach considering both physical and mental generals in the case. Sepia was prescribed considering the totality of symptoms based on uncommon generals and particulars mentioned, which resulted in marked improvement in PP.

In a previous case report, Syphilinum reduced PP lesions considerably within 10 days, and it disappeared completely in 2 months and 20 days. No recurrence of PP was observed for another 5 years as well.^[12] In another case report, the patient displayed significant improvement with sulphur, achieving full recovery within 6 months. Notably, there was no relapse for over 2 years, indicating that the benefits of the therapy persisted long after the treatment concluded.^[13]

In the present case, the DLQI was used to assess the patient’s quality of life, which showed significant improvement from pre-treatment (18/30) to post-treatment (0/30) [Table 2]. The PASI score reduced significantly from 8.4 to 0 [Table 1]. The MONARCH [Table 3] criteria were applied to assess the causal attribution of the clinical outcome in the case to the prescribed homeopathic medicine, which shows a definite causal attribution to the homeopathic medicine prescribed.

The strength of the present case lies in the outcome of the case, indicating that individualised homoeopathic treatment markedly improved the PP lesion without any relapse. The holistic approach used in the present case may be a useful strategy in treating chronic conditions. The limitation of the case report lies in the fact that a generalising statement on the efficacy of a particular therapy or a remedy cannot be made. This case report supports the hypothesis that such disease conditions require research using larger patient samples for evidence-based studies.

CONCLUSION

This case report suggests a marked effect of individualised homoeopathic medicine in PP without any relapse. To establish the effectiveness of homoeopathy in treating PP skin lesions, randomised controlled trials with an adequate sample size can be implemented which may further validate the role of homoeopathic medicines in the management of PP lesions.