Verruca plana treated with individualised homoeopathic medicine – A case report

INTRODUCTION

Warts are benign lesions of the skin and mucosa due to the infection of keratinocytes (the predominant cell type in the epidermis) caused by the human papillomavirus (HPV). The HPV is a deoxyribonucleic acid (DNA) virus that has not been cultured in vitro.^[1] A total of 150 genotypically different types of HPV are known, with classification based on defined variation of the viral DNA. The majority of common warts are caused by HPV types 1, 2, 4, 27, or 57 and plane warts 3 or 10.^[1,2]

Clinically, warts are classified into subtypes including verruca vulgaris, verruca plana, palmoplantar warts, filiform warts, epidermodysplasia verruciformis and anogenital warts.^[2] Verruca plana, or flat warts, are benign epithelial tumours caused by certain HPV strains. These warts are characterised by smooth, flat-topped lesions that typically appear skin-coloured or light brown. Commonly found on the face, neck and backs of hands, they usually measure between 1 and 5 mm in size. Flat warts are more prevalent in children and young adults and often emerge from the following minor skin trauma.^[3,4] These warts tend to cluster together and may be itchy or irritating, although they are generally asymptomatic. HPV strains type 3 and, less often, type 10, 27 and 41 most often cause verruca plana; they can be transmitted through direct contact or through contaminated surfaces such as shared towels.^[2,5] Histopathologically, verruca plana is marked by hyperkeratosis and acanthosis; however, it does not exhibit papillomatosis like verruca vulgaris. Instead, there is only mild elongation of the rete ridges and an absence of parakeratosis. The cells show prominent perinuclear vacuolisation around pyknotic, basophilic nuclei, which are centrally located and can be found in the granular layer. These distinctive cells are known as ‘owl eye’ cells.^[6]

Several methods exist to get rid of warts, including the application of salicylic acid, liquid nitrogen and podophyllin. Other methods include loop electrosurgical excision, CO₂ laser surgery and interferon injections.^[5] However, frequent and over-the-counter use of external applications for months may lead to certain undesirable side effects that, in turn, limit the success rates of these methods.^[7,8] In homoeopathy, warts can be categorised under local maladies, which signify the changes and ailments that appear on the external parts of the body. As mentioned in §189 and §193, local maladies cannot evolve, persist or grow worse without some internal cause. Therefore, to treat these conditions, medicine should be selected based on the totality of symptoms.^[9] Several studies report the efficacy of individualised homoeopathic medicines for treating warts. Various case reports state Thuja, Causticum, Calc phos, Calc carb, Dulcamara, Nat mur and Nitric acid as having been successful in treating warts.^[10-13] We present a case of warts that were treated and have been reported according to the criteria set out in the Hom-CASE (an extension to the CARE guideline for homoeopathic case reports) guideline.

CASE REPORT

Therapeutic intervention

The symptoms of the patient were analysed and evaluated, after which the prominent mental, physical and particular symptoms were used to formulate the totality. The repertorisation was done using RadarOpus software^[14] with different rubrics. On repertorisation of the case, Dulcamara, Calcarea carbonica, Ruta graveolens, Natrum muriaticum and Lycopodium clavatum were the leading [Figure 1]. We then referred to the Materia Medica to differentiate among the remedies. Calcarea carbonica is typically indicated for hot patients with a fair, flabby complexion and excessive sweating, especially on the head. In addition, a strong desire for eggs is a hallmark symptom. However, these drug symptoms do not align with the patient’s symptoms, making this remedy an unsuitable choice. The remedy Lycopodium is hot and intelligent with often male-dominant characteristics; however, Lycopodium does not cover the prominent symptoms observed in this case. The patient’s symptomatology, therefore, does not resonate with the typical profile for Lycopodium. Natrum muriaticum is associated with heat intolerance and a strong desire for salt, along with complaints aggravated by sun exposure; these key features are absent in this patient, due to which Natrum muriaticum is not a suitable remedy for this case. R. graveolens has the modality of aggravation from cold, damp weather, which aligns with the patient’s symptoms. However, R. graveolens primarily acts on the periosteum and cartilage, addressing issues related to strained tendons and presenting with a typical bruise-like soreness. It is better suited for robust, sanguine individuals, with characteristics that do not match this patient’s profile.

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Figure 1:

Repertorisation sheet.

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Like R. graveolens, Dulcamara shows aggravation from cold and damp conditions. However, it primarily addresses skin issues arising from exposure to cold, wet weather. Its indications align more with the patient’s condition compared to the other remedies discussed.

In this case, the mental status of the patient, i.e., anger easily, unable to concentrate properly, along with a tendency to take colds easily, eruptions on the forehead, flat warts, and chilliness, was very prominent in the patient and thus given more weightage while selecting the drug. Dulcamara seemed to be the most suitable remedy in this case; therefore, four doses of Dulcamara 200 were prescribed on 15^th May 2023. Careful analysis of the constitution as well as the mental and physical generals of the patient was performed. We also considered the reportorial results and referred to the Materia Medica^[15,16]. Dulcamara was the right similimum for the case. The medicine was procured from good manufacturing practices-certified SBL Pvt. Ltd. and dispensed from the pharmacy attached to the clinic.

Follow-up

For the first 3 months, the patient followed up every 15 days, during which her condition improved considerably [Table 1]. The patient was followed up for 6 months to observe any recurrence. On her second visit, the wart on her forehead resolved completely [Figures 2 and 3]. On her third visit, she had a mild fever and dry cough; she was treated with Bryonia 30 and improved within a few days. On the subsequent follow-ups, no further complaints occurred and the warts did not recur. She was better both physically and mentally. The curative response to homoeopathic medicine was assessed using the modified Naranjo criteria for homoeopathy inventory. The total score was + 9 (in −6 to + 13 scales), which suggests a ‘definite’ association between homoeopathic medicine and the outcome [Table 2].

Table 1: Follow-up.

Date of visit	Changes of symptomatology	Treatment	Justification
15 May 2023	First prescription	Dulcamara 200/4 doses BD; to be taken early morning empty stomach followed by placebo for 10 days	Based on the symptom and repertorial totality
02 June 2023	No lesion was present on the forehead; however, the skin looks slightly darker than the surrounding area. Irritability and concentration difficulties still present	Placebo	No complaints
16 June 2023	Normal skin colour. Changes in the mental sphere, she looks more obedient than before	Placebo	No complaints
03 July 2023	She developed mild fever and dry cough for 2 days; <night	Bryoniaalba 30/4 doses; BD for 2 days	For acute complaints of cough and fever
28 July 2023	Normal skin. No complaints of fever and runny nose. Her parents said that she now talks politely and concentrates more on her studies	Placebo	No complaints are present
16 August 2023	She was happy because no lesions were present on her forehead. She spoke and replied politely. All the generals were normal	Placebo	No complaints are present
06 September 2023	Normal skin. All the generals were normal	Placebo	No complaints
28 September 2023	No complaints	Nothing prescribed	No complaints
27 October 2023	No complaints	Nothing prescribed	Patient was advised to watch for the recurrence of old or new complaints

BD: Twice daily

Table 2: Assessment using the modified Naranjo criteria score.

Domains	Yes	No	Not sure/N/A
1. Was there an improvement in the main symptom or condition for which the homoeopathic medicine was prescribed?	+2✓	−1	0
2. Did the clinical improvement occur within a plausible time frame relative to the drug intake?	+1✓	−2	0
3. Was there an initial aggravation of symptoms? (need to define in the glossary)	+1	0✓	0
4. Did the effect encompass more than the main symptom or condition, i.e., were other symptoms ultimately improved or changed?	+1✓	0	0
5.Did overall well-being improve? (suggest using a validated scale)	+1✓	0	0
6.(A) Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease?	+1	0	0✓
(B) Direction of cure: did at least two 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	+1	0	0✓
7. Did old symptoms (defined as non-seasonal and non-cyclical that were previously thought to have resolved) reappear temporarily during the course of improvement?	+1	0✓	0
8. Are there alternate causes (other than the medicine) that with a high probability – could have caused the improvement? (consider known course of the disease, other forms of treatment and other clinically relevant interventions)	−3	+1✓	0
9. Was the health improvement confirmed by any objective evidence? (e.g. laboratory test and clinical observation)	+2✓	0	0
10. Did repeat dosing, if conducted, create similar clinical improvement?	+1✓	0	0

N/A: Not applicable, Tick mark means treatment responses to each point (1-10) in respective sections.

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Figure 2:

Before treatment.

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Figure 3:

After treatment.

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DISCUSSION

There has been a considerable upsurge in the demand for homoeopathic treatment. A study shows that 30% of patients attending outpatient departments are seeking help for different dermatological cases; the efficacy of different therapies in treating flat warts is unclear. Cryotherapy and other topical therapies are often expensive and do not prevent recurrence. To reduce the transmission of the virus and keep in mind the cosmetic value, better knowledge and self-management are recommended. Conservative treatments such as salicylic acid, liquid nitrogen, podophyllin, 5% fluorouracil ointment and carbon dioxide cryotherapy, as well as invasive treatments such as interferon injections, cauterisation or surgical removal of warts, are commonly used in modern medicine. However, these invasive methods often merely suppress the disease process, leading to a high chance of recurrence.^[17-19] Dr. Hahnemann noted in the Organon of Medicine, specifically in the footnote of Aphorism 203, that external applications are amongst the most harmful procedures. In contrast, homoeopathy offers a cost-effective, gentle and natural approach to treating diseases, providing relief to patients in a short period.^[20-23] Warts have been extensively discussed by our founder, Dr Hahnemann, in various phases of his life in the Organon of Medicine. For a homoeopath, treating warts can be straightforward if the choice of medicine and potency is precise, accompanied by appropriate repetition, leading to rapid recovery for the patient. This article exemplifies the effectiveness of such an approach.^[10]

In this case report, homoeopathic medicines were chosen based on the totality of symptoms and produced an impressive result in a few days by removing the warts with four doses of Dulcamara 200. Her complaints of the last 2 years were resolved completely within 15 days after medication. A positive outcome was seen in her mental condition as well.

Homoeopathy is a rational system of medicine which promotes the general well-being of the individual. This case report signifies that the greater the similarity between a disease picture and a drug picture, the more likely the results are to be promising. The speedy recovery of this patient not only reduced the duration of her complaints but also produced cost-effectiveness and improved the quality of life within a plausible time frame. This case also signifies the importance of individualisation in homoeopathy. Considering the cost-effectiveness and less side effects of homoeopathic medicines, the use of individualised homoeopathic treatment in warts cases seems to be justifiable.

Considerable literature exists showing the effectiveness of homoeopathy in warts, but scientific evidence is slim.^[20-23] Thus, the scope and effectiveness of homoeopathic remedies in various clinical conditions have to be explored with more well-planned, documented case reports or randomised clinical studies.

CONCLUSION

This case report shows the effectiveness of homoeopathic medicine in viral warts. It reconfirms the importance of individualised homoeopathic treatment based on the principle of homoeopathic medicine, i.e., Similia Similibus Curentur. The outcome also suggests the importance of individualisation in homoeopathy and may be chosen as one of the treatment options for the treatment of flat warts. More case reports, case series and qualitative research trials on this disease condition may strengthen the evidence about the efficacy of homoeopathic treatment in wart cases, especially flat warts.