There are certain skin ailments like Psoriasis, Eczema and Urticaria which are commonly known to everyone, and most skin ailments are commonly understood as some kind of allergy by laymen. Even when prescribing a homoeopathic remedy, (especially for skin complaints), diagnosis is considered least important as ‘Totality of Symptoms’ is the basis of selecting the simillimum.
Today I would like to talk about a lesser known skin ailment named Prurigo Nodularis and present a case discussion.
Looking much similar to Eczema/Dermatitis, this skin ailment, as the name suggests (‘Prurigo’ meaning Pruritis or Itching) is characterized by the common symptom ‘Severe Itching’. We find nodule formation, especially around hair follicles, followed by itching and redness of skin. The lesions look much similar than urticarial/nettle rash in the beginning, which gradually shape up into the characteristic inflamed nodular patches more than 0.5 cm in size, and get further excoriated after scratching.
Causes of Prurigo Nodularis:
Prurigo is classified under auto-immune skin disorders, where in most cases the cause of occurrence is not clear, though research and studies show that there is some past or family history of atopic dermatitis, hay fever, asthma or eosinophilia related in more than 80% of cases.
Rarely, it is seen associated with internal conditions like HIV infection, chronic liver diseases, chronic renal failure, gluten intolerance, depression and other psychiatric disorders, or in patients under long standing allopathic medications in chronic or so called incurable diseases.
The lesions are of varying sizes from 0.5 to 5 cms in diameter, characterized by inflamed nodules, which cause scratching. Lesions can occur anywhere, but mainly on extensor surfaces of the body, i.e. limbs and trunk. Scratching may sometimes lead to to mucus discharge or bleeding from lesions. In severe pruritic cases there can be gradual hyper pigmentation. Continuous itch causes anxiety and irritability.
Prurigo Nodularis can be differentiated from the following conditions on the basis of clinical presentation and skin biopsy.
- Hypertrophic Lichen Planus
- Nodular Scabies
- Repeated scratching can cause xerosis, hence topical emollients are a must in this case, irrespective of the line of treatment.
- Simultaneous treatment of associated diseases also helps in alleviating the symptoms.
- Topical steroids are the most common local applications advised in these cases.
- In severe conditions oral corticosteroids are also prescribed.
- Coal Tar applications have been used in those who have side effects from topical steroids.
- Calcipotriol along with topical steroids are also used.
- Thalidomide oral therapy is also chosen sometimes as a 3rd line of treatment in obstinate cases.
- UVB light and Cryosurgeries are also preferred in extreme cases.
In spite of so many options available in allopathy, side effects of the treatments result in doubtful outcome. Also, recurrent steroids suppress liver and kidney function, which may be contra-indicated for the patients suffering from associated renal and liver diseases.
Being an autoimmune disease, it can be completely cured only with a constitutional prescription, though following specifics can help in symptomatic relief in acute exacerbations:
Often indicated remedies include: Chelidonium, Mezereum , Ars Iod, Clematis Erecta, Ranunculus Bulbosus, Rhus Tox, Staphysagria, Sulphur, Urtica Urens, Fagopyrum, Rhus Venenata, Graphites.
Biochemic remedies like Calc sulph, Silicea , Nat sulph, Kali sulph and Kali phos also help in alleviating itching.
A Case of Prurigo Nodularis
Name of Patient: Mr. S.K.
Age: 63 years
Occupation: Retired Bank Manager.
Case History: Patient came with severe itching on various parts of his body presenting inflamed nodular eruptions. In the beginning, eruptions suddenly started on fingers. Considering this an allergic eruption he avoided everything but emollients, as they used to alleviate his itch.
But as the eruptions started getting extensive, he visited a dermatologist, who diagnosed it as a Prurigo Nodularis and prescribed an oral steroid, topical steroid and an emollient. Being a believer in Homeopathy and knowing the side effects of steroids he did not continue with those medications and came for consultation.
Patient: “Doctor I am suffering from these tacky patches since last one month and the itch is extremely bad. I don’t know how it developed but it’s getting worse day by day. Sometimes when I scratch some kind of watery discharge oozes but that happens rarely when the itch is worse. Itching is severe in morning on waking up and after sometime after taking bath. Scratching relieves itching but only for a while. Yes moisturizers do help me and that too petroleum jelly, the usual emollients don’t last for even an hour and the itch relapses.”
Constitution: Short to medium statured fair skin man with thin legs and trunk and comparatively large belly, lax fibres, bald, with a few lentigines on cheek bones. Skin tags and warts all over his neck and few on ears also.
Onset and Life space: All his problems started after he was retired. He was a bank manager and was always in the good graces of all his customers, but not all colleagues, and he was diplomatic. Good with seniors and strict with juniors. He used to be rebellious at times even with seniors. Duty bound in work, he would complete his work always before time and was even proactive. Financial struggle was the main thing on which his life was based. He was doing business also along with the job but was deceived by his partner, after which his life took a big turn financially and he has struggled all through his life to come out of that financial turmoil. Things are settling down now, as family life is settled and kids are settled in their life. Sometimes he gets extremely emotional and sometimes indifferent to happenings around him. He arried at an older age since never thought about settling down. His family pushed him to get into family life. High responsibility alternates with lethargy and lack of responsibility. He loves a luxurious life and wants the same for his family. Love for luxury with financial insecurities. Benevolent. Short tempered at times.
- USG Abdomen shows: Mild fatty liver
- Patient his associated Rt. sided inguinal hernia which is asymptomatic
- Borderline hypertension and high cholesterol
- Pain in small joints started from right side
- Flatulent at times
- Craving for spicy, fried and fatty food
- Hot patient, perspiration always profuse on head
- Patient got premature graying of hair and baldness
The remedy was prescribed on mental and physical generals:
Lycopodium 200 single dose followed by Sac lac for 1 month.
1st follow up: Itching reduced considerably. Patches reduced to 30%. First 15 days showed considerable improvement, but since last 15 days the itching is slightly more compared to first half.
Lycopodium 200, single dose with Nat sulph 6x bd for 1 month.
2nd follow up: Much better, itching was much reduced. Patches reduced by more than 50%
Nat sulph 6x and Sac lac bd for 1 month.
3rd follow up: Since last week itching has increased. Emotional turmoil was there so slightly disturbed.
Lycopodium 1m single dose, Single dose and Nat sulph 6x+Sac lac bd for 1 month.
4th and 5th follow ups showed progressive improvement hence Sac lac was prescribed .
6th follow up: After 80% improvement there were 2-3 new patches.
Lycopodium 10M single dose, Nat sulph 6x and sac lac for 1 month.
All patches went away within 2 months, after which patient was on sac lac for 3 more months.