Clinical Cases

A Case of Venous Ulcers – Lipodermatosis Scleroderma

Dr. Saritha Agarwal shares a case of lipodermatosis scleroderma in a man of 76. Hot patient, suspicious, dictatorial and burning ulcers were among the symptoms leading to the simillimum.

A 76 year-old man presented on 27/11/2018 with chronic non-healing ulcers in both legs since 5 yrs. The ulcers had burning pain with discharge of water and blood, non-offensive. There is redness around the ulcer with swelling of both the lower limbs. Burning pain < night/ prolonged sitting> open air. He had been on regular allopathic medication and ointment with temporary improvement and then recurrence of symptoms within a week. He was diagnosed with Lipodermatosclerosis.

Past History – Hypertension since 15 years.  He is on a Meta xl 50/OD.

Knee replacement surgery in 2010 of the left knee, which was not successful and now the patient walks with a stick.

Family History – No significant family history

Personal History

Appetite – Good

Thirst – Normal, 3 lit/day

Bowe l- Very hard stool, passes once in 2-3 days.

Urine – Benign Prostatic Hypertrophy since 4 years; urine flow is increased at night with urgency and residual urine.

Sleep-disturbed due to frequent urination.

Dreams- of dead people

Perspiration- Normal

Thermals – likes cold weather, cannot stand heat and wants fanning in all seasons.

Mentals – Retired after 16 years from a government job. He had been very active in his work. He was always smiling and very friendly with people around. Loves talking to people. Very dictatorial as a person. He says that he loves himself the most. No fears and phobias, he is very courageous.

As stated by his daughters, he is very suspicious about his wife. He keeps tormenting her that she is having an affair with the young tenant boys in their house. He is always watchful and is very abusive towards her.

Analysis of the Case

Mentals

Suspicious

Dictatorial

Dreams of the dead

Loquacity

Abusive

Active

Physical Generals

Hot patient

Desires chicken

Particulars

Venous ulcers

Discharge blood

Discharge water

Repertorisation Chart

Remedy NameLachPhosLycCaustArsNux-vSulphRhus-tBellMercBryDulc
Totality191919171616161615151414
Symptoms Covered665655545544
Kingdom
[Complete ] [Skin]Ulcers:Burning:33444344242
[Complete ] [Mind]Loquacity:433233344144
[Complete ] [Mind]Suspiciousness, mistrustfulness:434443444343
[Complete ] [Mind]Dictatorial:3343131133
[Complete ] [Generalities]Food and drinks:Chicken:Desires:131
[Complete ] [Generalities]Discharges, secretions:Bloody:444344444444

 

As per the Organon of Medicine- 6th Aphorism

  • 6 Sixth Edition

The unprejudiced observer – well aware of the futility of transcendental speculations which can receive no confirmation from experience – be his powers of penetration ever so great, takes note of nothing in every individual disease, except the changes in the health of the body and of the mind (morbid phenomena, accidents, symptoms) which can be perceived externally by means of the senses; that is to say, he notices only the deviations from the former healthy state of the now diseased individual, which are felt by the patient himself, remarked by those around him and observed by the physician. All these perceptible signs represent the disease in its whole extent, that is, together they form the true and only conceivable portrait of the disease.

In this case apart from the totality of symptoms, information given by the daughter (which was never shared by the patient himself)  helped to select the simillimum and get good results within a short time.

First prescription

Lachesis 200/ 3 doses

Sac lac daily 2 doses for 15 days

Follow up:

12/12/2018 Ulcers have healed up. But he has developed 2 small ones over the left big toe. Sac lac for 15 days

25/12/2018 Ulcers have healed up. No blood or watery discharge. Redness in the lower leg++          Sac Lac for 15 days

09/01/2019 ulcers have healed+

severe pain in the knees < rising from sleep

gas formation, distension of abdomen since 2 days

hard stool

appetite good

appetite – eating very little quantity

has lost his son in law, feeling sad about it

28/01/2019 mild redness and swelling of legs

no pain or burning

pain in knees is slightly better

gas formation is better

Lachesis 200/ 3 doses

Sac Lac for 15 days

11/02/2019 not much change in pain in knees

sob < walking

no cough or cold

no palpitation+

lots of flatus+

occ burning in stomach+

constipation+,

sleeps good

Appetite good

o/e redness of the rt leg+         Sac Lac for 15 days

28/02/2019 redness of the leg is better

now he has constipation and gas formation

pain in knees slightly better

he is able to walk at home       Sac Lac for 15 days

15/03/2019 reddish discolouration around the ankle region.

No much pain.

pain in knees slightly better

constipated+        Sac Lac for 30 days

16/04/2019 mild redness of rt lower limb

pain in the knees is slightly better

no change in constipation

bowels –  once in 2 days , has to be mechanically removed. associated with bloating of abdomen and tenderness.

urine output is good

urgency+

Rx:  Lycopodium 200/3doses

Sac Lac for 30 days

22/05/2019 constipated, has to be mechanically removed

urine output is good

he has residual urine++

urine frequent – 4 times

no urgency at night

pain in knee no much change  Sac Lac for 15  days

08/06/2019 Bowel is better now.

pain in knees < walking ,but is able to walk at home

no problem with skin now      Sac Lac for 15 days

Before Treatment                            

Before Treatment

After Treatment

About the disease:

Lipodermatosclerosis is a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs. Lipodermatosclerosis is also known as sclerosing panniculitis and hypodermitis sclerodermaformis. Lipodermatosclerosis is common, affecting middle-aged or older people. It is more common in women and is associated with immobility and a high body mass index (obesity).

This is caused by:

  • Incompetent venous valves
  • Venous outflow obstruction
  • Dysfunction of the calf muscle pump [2].

The resulting venous hypertension causes an increase of leukocytes within the veins, which then migrate into surrounding tissue. The leukocytes become activated, attracting and releasing proinflammatory cells and cytokines, inducing a chronic inflammatory state. Increased collagen production leads to the fibrosis of subcutaneous fat.

Clinical features of lipodermatosclerosis:

Acute phase

Acute lipodermatosclerosis may mimic cellulitis, with induration, erythema, pain, itch, aching, and a feeling of swelling or heaviness in one or, more often, both lower limbs [2]. In the acute phase, signs may be localised to a single plaque but are usually more widespread. The most commonly affected areas are the pretibial or medial aspect of the leg.

Acute lipodermatosclerosis

Chronic phase

Induration, erythema, and pain continue in the chronic phase of lipodermatosclerosis. Subcutaneous fibrosis may result in significant narrowing of the distal lower limb, causing the leg to have an ‘upside-down champagne bottle’ appearance. Other clinical features of chronic venous insufficiency may be present, including hyperpigmentation of the skin from haemosiderin deposition, atrophie blanche, varicose veins, venous eczema, and venous ulcers.

Chronic lipodermatosclerosis

What are the complications of lipodermatosclerosis?

Lipodermatosclerosis is associated with poor wound healing because of the chronic inflammatory state and fibrosis. Venous ulcers commonly co-exist and may be difficult to treat.

How is lipodermatosclerosis diagnosed?

Lipodermatosclerosis is usually diagnosed clinically. Underlying venous insufficiency may be confirmed using Doppler studies.

A biopsy is helpful but should be performed with caution because of the likelihood of poor wound healing [3]. Any biopsy also needs to include the panniculus. The characteristic features seen upon biopsy are dependent on the stage of disease but include subcutaneous lobular and septal changes including:

  • Adipocyte necrosis
  • Pseudocyst formation
  • Lipomembranous (fatty tissue) change
  • Macrophage collections forming lipogranulomas (a nodule of inflamed fat cells around a foreign body)
  • Iron deposition [4,5].

What is the differential diagnosis for lipodermatosclerosis?

Differential diagnoses for lipodermatosclerosis can include:

  • Cellulitis
  • Erythema nodosum
  • Other causes of panniculitis
  • Morphoea (localised scleroderma)
  • Cutaneous vasculitis
  • Necrobiosis lipoidica.

What is the treatment for lipodermatosclerosis?

General measures

Physical activity (walking) should be encouraged to increase the functionality of the calf muscle pump. Weight reduction is effective if obesity is a factor.

Compression therapy and elevation

Mechanical compression therapy using compression stockings or socks is the mainstay of treatment, encouraging venous return and assisting with symptom control, but may be poorly tolerated in some individuals.

Elevation of the legs can help reduce oedema and pain.

Allopathic Medical treatment

  • Stanozolol can be effective for pain relief and has also shown to reduce dermal thickness [6].
  • Pentoxifylline has been shown to be useful in venous ulcers in conjunction with compression or in patients who cannot tolerate compression.
  • Combination therapy with hydroxychloroquine may reduce symptoms that are refractory to other treatments [7,8].
  • Intralesional steroid injection of triamcinolone has proven to be effective at alleviating symptoms [9].
  • Tetracyclines, such as doxycycline or minocycline, have anti-inflammatory and anti-angiogenic properties that may provide benefit [10–12].
  • Phlebotonic drugs that modify the tone of the vein wall, including diosmin, hydroxyethylrutoside, or horse chestnut seed extract (escin), may reduce oedema and other symptoms [13].
  • Ultrasound therapy may offer symptomatic benefit, relief of erythema, hardness and pain [14, 15].
  • Ultraviolet radiation (UVA1) has been reported to be effective [16].
  • Emollients and topical steroids are useful in the management of associated venous eczema.

Surgical treatment

Treatment of underlying venous insufficiency can improve symptoms and may reduce the risk of ulcer recurrence. Referral to a vascular surgeon should be considered. Leg vein therapies include:

  • Endovenous ablation by laser, radiofrequency (RF) catheter, steam, cyanoacrylate and mechanical occlusion with chemical assistance (MOCA)
  • Sclerotherapy
  • Vein surgery [17].

What is the outcome for lipodermatosclerosis?

Venous insufficiency is a progressive disease. Although treatment can improve symptoms or slow progression, its associated conditions such as lipodermatosclerosis are usually chronic and recurring.

 

About the author

Dr Saritha Agarwal

Dr Saritha Agarwal

Dr. Saritha Agarwal completed M.D in Materia Medica and Fellowship Course in Advanced Homeopathy (F.C.A.H) from MUHS. Currently she is pursuing an e-Learning course Diploma from the International Academy of Classical Homeopathy (Greece). She has been practicing classical Homeopathy since 2000. Dr. Agarwal worked as a Senior Homeopathic Consultant for three years at Dr Batras’ Homeopathy Clinic and now practices in her own clinic.

1 Comment

  • A very nice illustration of the complementary relation between Lachesis and Lycopodium and a demonstration that Lachesis is not always a remedy for women.

    Do you know if the behavior of the patient with his wife is better now ?

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