An insight into pityriasis and its homoeopathic management

Dr. Nanritam Chopra¹ and Dr. Shruti Vashisht²

1. MD (PGR), Dept. of Materia Medica, Dr.M.P.K.Homoeopathic Medical College, Hospital & Research Centre, Jaipur (A constituent unit of Homoeopathy University, Jaipur, Raj. 302029) India.
2. MD (PGR), Dept. of Materia Medica, Dr.M.P.K.Homoeopathic Medical College, Hospital & Research Centre, Jaipur (A constituent unit of Homoeopathy University, Jaipur, Raj. 302029) India.

ABSTRACT
Pityriasis is a common skin condition we come across in daily clinical practice. This ususally occurs in Children and Adolescent age or middle adult age group. Different types of pityriasis have different causes, it maybe fungal, viral or associated with some other skin disease or deficiencies or due to environmental factors also. Therefore, its treatment is decided by looking into the overall condition and history of the patient. It can also be confused with different other skin conditions like vitiligo, psoriasis or leprosy. However , we can treat this successfully with the help of our prestigious Materia Medica books and different Repertories.

KEYWORDS :  Pityriasis, types of pityriasis, differential diagnosis, management, Rubrics from repertories, Homoeopathic management.

INTRODUCTION
Pityriasis is a skin disease characterized by the shedding of the fine flaky scales from the surface. This condition can occur due to various causes as discussed later but it holds a cosmetic seriousness when it comes to its ability to affect an individual’s life. Most commonly affected is the children and young age adults and thus require appropriate and careful inquiry of the patient. 

This skin condition can be classified into the following types depending on the causes, predisposing factors, associated factors or many different reasons which are further explained in detail for proper differentiation [1]:

• Pityriasis versicolor 
• Pityriasis alba 
• Pityriasis rosea 

• Pityriasis rubra pilaria
• Pityriasis lichenoids chronica
• Pityriasis lichenoids et varioliformis acuta
• Pityriasis rubra pilaria[1]

1. PITYRIASIS VERSICOLOR:  Pityriasis Versicolor is also known as tinea versicolor is a frequent benign superficial fungal infection caused by a commensal yeast, Malassezia furfur. Clinically it is identified by hypopigmented finely scaled macules. The most frequently affected site is upper trunk which later spread to neck and upper arms.[1],[2] 

Epidemiology: Pityriasis versicolor is most common in warm and humid climates. Prevalence rate in  India is 12%. Frequently affected age group is 20-40 years of age and males are predominantly affected.

Risk factors[2]: Factors that favours the pathogenic conversion in this type include :

• Genetic predisposition 
• Environmental conditions such as heat and humidity 
• Malnutrition
• Pregnancy
• Use of oral contraceptive pills
• Diabetes

Signs and symptoms include discolored patches of skin are most noticeable symptom and they may be  lighter or darker then surrounding skin, dry, itchy. Patches are however prominent with tanning and disappear in cold climates.[1],[2],[3]

Diagnosis of pityriasis versicolor is usually made from clinical presentation of lesions (Hypopigmented perifollicular macules that become confluent) and is confirmed by Wood lamp examination: the scaly lesion may show pale yellow, golden yellow or coppery orange fluorescence & by  KOH mount: Scraping the lesion and mounting them with 10% KOH solution confirms diagnosis by showing clusters of spherical, thick walled yeasts with short broad hyphae resembling ‘sphagetti and meat balls. [1][2]                                                                                                  

2. PITYRIASIS ALBA 

It is a common, benign skin disorder occurring predominantly in children and adolescents. The name refers to its appearance: pityriasis refers to its fine scale and alba to its pale color (hypopigmentation). It is characterized by ill-defined macules and patches (or thin plaques), round or oval in shape, often with mild scaling and sometimes with mild pruritus. The lesions initially may be mildly erythematous, and over time they become hypopigmented. They are most commonly located on the face (the cheeks especially), arms, and upper trunk; and they are more noticeable in people with darker skin types. [11]

Epidemiology -This  is most common in children aged 11 to 16 years, with 90% of cases occurring in children younger than 12 years. More commonly found in patients with a history of atopy , and a slight male predominance has been noted in some studies.There is no clear racial predominance, although the lesions may be more noticeable in those with darker skin types.[11]

Pityriasis alba is not seasonal, although scaling may be worse in the winter (as a result of dry air in homes) and lesions may be more obvious in the spring and summer (as a result of sun exposure and darkening of the surrounding skin).Normal skin pigmentation returns spontaneously, usually within one year.[11]

Etiology [11] – No specific cause of pityriasis alba has been identified in the researches done till now. It is not contagious and no infectious etiology has been reported to have caused such hypopigmented lesions.

Predisposing factors for Pityriasis Alba  [13] :  Xerosis also appears to be a risk factor. Frequent bathing and hot water temperatures may exacerbate this.  There is also a higher incidence in children with poorer socioeconomic backgrounds

Signs and Symptoms [13] – This condition is most of the time asymptomatic. It mostly present as multiple round or oval shaped whitish scaly patches with ill-defined border.

• At times with mild itching. The family history of the patient might include atopic dermatitis.
• The hypopigmentation becomes more apparent with sun exposure, during summer and spring.
• Found  predominantly on face. Also can be seen on neck, upper arms and upper trunk 

3. PITYRIASIS ROSEA (PR) : Pityriasis rosea is also known as pityriasis circinata. Pityriasis rosea means pink coloured scales. It is papulosquamous disorder characterised by large erythematous  scaly plaque called as herald patch followed by secondary lesions. The site of lesions are trunk and proximal extremities with Christmas tree appearance.[1],[2],[4]    

Etiology: The eitiology of pityriasis rosea is unknown . Factors like seasonal variations suggest that it is an infectious disease  caused by virus(HHV-7⁵² more frequently ) has often been implicated, but PR is not contagious. It is more common in winter season.

Epidemiology :- The approximate incidence of rosea is 2%. It affects usually 10-35 years of age. It affcets both genders and incidence is lowest in summer season.[1]

Signs and Symptoms:-The eruptions are usually seen by prodrome of sore throat, gastric disturbance, fever and arthralgia. The main symptom is appearance of herald patch which  is located on neck or proximal extremities is seen in 90% of cases. Usually, people complain of mild pruritis.[1][2]

Diagnosis: Serological testing to rule out syphilis is advisable in patients diagnosed with PR, as secondary syphillis can closely mimic PR.[1]

4. PITYRIASIS RUBRA PILARIS : Pityriasis rubra pilaris is a rare inflammatory papulosquamous disorder. As the name suggests, characterstic lesions are scaly(pityriasis),pink to orange(rubra)follicular (pilaris)papules. The etiology is unknown in most though it is familial in few patients, probably autosomal dominant inheritance.[1],[5]

Epidemiology: PRP occurs in both gender and prevalence rate is rare. Mostly seen in two age variants- Juvenile variant :from 5-10 years & Adult  variant : from 40-60 years. The affected areas are trunk, dorsal aspects of digits, yellow-orange thickening is seen on palms and soles and nail plates. [5],[6],[7]  

Signs & Symptom : The widely accepted classification of PRP was proposed by Griffiths. Griffith established five types of PRP based on clinical features, age of onset and prognosis, subsequently a sixth subtype is added due to recent association with HIV.

Type I: classical adult onset

Type II: atypical adult onset

Type III: classical juvenile onset 

Type IV: circumscribed juvenile onset

Type V: atypical juvenile onset

Type VI: HIV associated

Systemic symptoms such as malaise, fatigue, fever and chills accompany PRP. ⁵

Diagnosis: PRP is diagnosed based on classical clinical and histopathological features.⁵

5. PITYRIASIS LICHENOIDS CHRONICA  : Pityriasis lichenoids chronica is relatively mild form of pityriasis lichenoids. It causes development of small scaling papules on skin. Onset of papules is gradual. Initially, they appear pink and scaly, gradually flatten and become brown in colour over period of weeks. Etiology of PLC is unknown. In some cases people with PLC have had infections including EBV, toxoplasmosis and HIV.  Diagnosis of PLC is based on clinical presentation of eruption on skin. A skin biopsy confirms the diagnosis.[6][7][8] 

6. PLEVA ( Pityriasis lichenoids et varioliformis acuta) is uncommon skin disease that presents as skin eruption of multiple, small, red papules that develop into polymorphic lesions with periods of varying remissions, as well as sequel of hypopigmentation and hyperpigmentation. Symptoms include burning and pruritis. Most commonly occurs on trunk, extremities, flexural areas but diffuse and genearlised patterns may also occurs. Histological examination of skin biopsy specimen is standard for identification of PLEVA. [8],[9]

Prevalence of pityriasis in India [12] – A study on Epidemiology and clinical characteristics of Hypopigmented and Depigmented Lesion in patients; of Children and Adolescent age group ; in Hadoti region in Rajasthan from April 2015 to March 2016, the age group 0-19 yr with hypopigmented and depigmented lesions irrespective of sex reported that the most common disorder was Pityriasis alba, seen in 27.1111%, followed by Pityriasis versicolor in 21%, Vitiligo 19.1111%, Post inflammatory hypopigmentation in 14%.

Differential diagnosis : Most of us get confused in diagnosing pityriasis in our intial years of practice and thus we need to know the differentiating characteristics of the conditions most likely to get confused with, which are as follows:

1.Vitiligo: In this we find well defined depigmented macules whereas in pityriasis versicolor hypopigmented perfollicular lesions are seen. Scaling is present in PV whereas absent in vitiligo. Leucotrichia(whitening of hair) is only present in vitiligo.[1],[3],[4]

2. Leprosy: PV lesions are always macular whereas in leprosy lesions are hypopigmented and atrophic. Sensations are present in PV whereas in leprosy hypoanaesthesia is seen and the hair may be lost in leprosy and preserved in PV.[1],[5]

2. Psoriasis : In older children and adults, the early erythematous lesions of pityriasis alba may be mistaken for psoriasis. However, the distribution, lack of psoriatic scales, and sparing of scalp, elbows, and knees exclude this diagnosis.[1],[3]

MANAGEMENT  OF  PITYRIASIS : [1][9]

• The key is to educate the patient on the benign nature of the disorder. 
• No treatment is required and the condition spontaneously regresses in 12-24 months.
• Treatment consists primarily of good general skin care. 
• The affected areas should be protected from sun exposure, as darkening of the surrounding skin may worsen the cosmetic appearance. Sunscreen may help prevent the lesions from sunburning and decrease the darkening of the surrounding skin.
• Mild emollients, such as petroleum jelly , may reduce scaling. 
• Patients  should be informed that causative agent of PV is a commensal fungal agent of normal skin flora and therefore is not contagious .
• Recurrence rate is common and prophylactic therapy may help in reducing higher rate of recurrence.
• Good personal hygiene may be helpful in limiting recurrences. Specifically, patients should take shower as soon as possible after participating in exercises or activities that produce perspiration. 

HOMOEOPATHIC MANAGEMENT

Going through different materia medica books and consulting different repertories this condition can be treated with proper individualisation. Following are some rubrics which one can find for the type of eruptions or lesions found in Pityriasis. 

Rubrics in Synthesis Repertory [17]

• SKIN- Eruptions- Pityriasis Versicolor
• SKIN- Eruptions- Pityriasis ( see scaly)
• SKIN- Eruptions- Scaly-Spots
• SKIN- Eruptions- Scaly- bran like
• SKIN- Discoloration -White-Spots
• Skin – eruptions- scaly- white

In different regional chapters

• Face- discoloration- pale- spots in        
• Face- discolration- white spots ( pale)
• Face- eruptions- scurfy- white
• Chest –Eruptions-Scaly
• Back-Eruptions-Cervical region-scales
• Extremities-Eruptions-Upper limbs-upper arm-scaly white
• Extremities-Eruptions-Upper limbs

 Rubrics in Kent’s repertory [18]

• Skin – Eruptions – Scaly- Spots
• Skin – Eruptions –Scaly – Bran like
• Skin- Eruptions – Scaly- White
• Skin – Discoloration-Pale, spots
• Skin – discoloration -white spots
• In different regional chapters
• Face – discoloration –pale- spots, in  
• Face – discoloration -white spots       
• Back-Eruptions-Scales-Cervical region, white
• Chest-Eruptions-yellow, scaly, itching spots
• Extremities –Eruptions upper limbs-scales

Rubrics in Boericke repertory

• Skin-Pityriasis (dermatitis exfoliativa)
• Skin- Spots, white
• Skin –eruptions- dry, scaly
• Face- Eruptions – scales

Also in clinical repertories like :

Rubrics in Clarke repertory

• Pityriasis
• Pityriasis versicolor.
• Tinea versicolor

Rubrics in Murphy repertory

• Skin: Pityriasis, skin, (see Eruption, scaly ): Versicolor 
• Skin: Eruption: Scaly- Bran like
• Skin: Eruption-spots 

HOMOEOPATHIC MEDICINES FOR  PITYRIASIS  [14],[15],[16] :

ARSENIC  ALBUM
Clinically  indicated in skin conditions as Acne rosacea, Pityriasis , Psoriasis, Purpura, Ringworm. Skin will appear dry as parchment, cold and bluish sometimes yellowish tinge of the skin. Symptoms like shootings, hot itching and violent burning in the skin. Reddish or bluish or tettery spots, covered with furfur, with burning nocturnal pains. Miliary eruptions, red and white, chiefly in the head, face, and neck. Causation can be poor diet,  fruits or the ailments resulting from Sea-bathing and sea-travelling. The skin symptoms, esp. at night or with coverings, like fish-scales worse from cold and scratching and better from heat.

BACILLINUM
Dr. Burnett has shown that ringworm of the scalp and pityriasis versicolor on the body respond very well to this remedy. An inter-current course of Bacillinum is often beneficial in patients who have a personal or family history of chest affections. An eczematous condition of the margins of the eyelids a strong indication for it with aggravation at night and early morning, in cold air. May be accompanied by enlargement of the glands of neck. 

CARBOLIC ACID
Carbolic acid, like the Carbons, is a powerful antiseptic. Clinically indicated for Acne , Burns, Carbuncle, Erysipelas, Gangrene ,Psoriasis ,Pityriasis versicolor , Scarlatina. Offensive odour from skin with roughness is charachteristic. The skin is inflamed, and other symptoms appear, with burning pain, tingling, itching, and numbness. Putrid discharges are a marked indication for this remedy. 

MANGANUM ACETICUM
This remedy has its clinical indication in Pityriasis, Psoriasis, anaemia, climacteric flushings, dysmenorrhoea, and Rhagades. Symptoms include burning all over skin, in evening, and when rising from bed. Itching tetters. The skin does not heal easily; Skin complaints in bend of the joints with voluptuous itching; ameliorated by scratching. Acts beautifully in chronic skin complaints associated with amenorrhoea, worse at menstrual period or menopause. 

MEZEREUM
Wonderful remedy for Pityriasis capitis and Pityriasis versicolor. Large, irregular, sometimes confluent, distinctly defined copper colored spots on the skin with distressing burning and itching, aggravated at menstrual period, at which time spots assume a darker color, especially at edges, and also worse in bed. Itching of scalp; aggravated at night, by rubbing;  Slightly better in open air. Also there is strong tendency to ulceration. 

PHYTOLACCA  DECANDRA
Skin indications with symptoms like Rash or scarlet eruption all over the body. Skin being cool, shrivelled, dry, lead-coloured. Causation can be Exposure to cold and damp. The itching aggravate by scratching ; from heat of bed. Itching begin on hands and feet and spread over whole body; rash followed four hours later. Itching aggravate forepart of night, preventing sleep till midnight. Phytolacca mother tincture can be used as a preventive of pityriasis versicolor.

BERBERIS AQUIFOLIUM
It is known as Oregon Grape and Commonly indicated in the skin diseases like eczema, roughness of the Face, Herpes, Pityriasis, Psoriasis. It has been used by the physicians in chronic skin diseases and for removing pimples from the faces of girls. Indications include pimply, dry, rough, scaly skin along with pruritus. Eruptions on scalp extending to face and neck. Its tincture can be used as a local application. 

CANTHARIS
This remedy is beneficial in Pityriasis, especially in children. There is erythema, from exposure to rays of sun. Clinically in eczema solaris. Eruptions with mealy scales (bran-like scales). Burning and prickling sensation is marked relieved by cold applications. Erysipelatous inflammation of skin, followed by prickling.   

COLCHICUM AUTUMNALE
Generally indicated in sequele of eruptive diseases, scarlet fever, typhoid fever, etc., suppression of urine.  Specifically in pityriasis on inner surface of left thigh and on corresponding part of scrotum. Eruption with redness; on ulnar side of forearm; over whole body, as from nettles along with sticking and burning here and there, after scratching redness and the itching changes to another place. Pink spots on the back ,chest and abdomen. Worse from sunrise to sunset, scratching, evening.

GRAPHITES
Clinical indication of this medicine include Pityriasis capitis, dryness of the skin, with cracking; localization of the eruption; abundant desquamation from the hairy scalp. The skin is rough and hard, obstinate dryness of the skin, and absence of perspiration. Tetters or scabby eruptions, sometimes with secretion of corrosive serum or with itching in the evening, and at night. The typical Graphites patient being “fat, chilly, and costive.”  

NATRIUM  ARSENICOSUM
Clinically indicated in Pityriasis rubra and Pityriasis alba.The principal clinical use of Nat. ars. has been in diphtheria (dark purple throat, great swelling, much prostration, but not much pain) and in affections of the eyes and nose, the root of nose.  Skin indications include squamous eruption, scales thin, white and when removed leave skin slightly reddened; if scales remain they cause itching. Aggravation when warmth from exercise. Sepia and Natr. ars. are the principal internal remedies for pityriasis pilaris. 

SEPIA OFFICINALIS
Skin is yellow, like jaundice. Excessive sensibility of the skin. Soreness of skin and humid places in bends of joints.  Dry itch; bad effects where itch has been suppressed by Mercurius or Sulphur. Tetters in general.  Also indicated in herpetic spots (brown or reddish ) on skin with itching and burning sensation. 

SULPHUR
Indicated for Pityriasis of head and chest. Skin is dry, scaly, unhealthy; every little injury suppurates.  Skin affections after local medication.  Desquamation and excoriation of skin in several places. Pruritus, especially from warmth, in evening, often recurs in spring-time, in damp weather. Itching, burning; worse scratching and washing. 

THUJA  OCCIDENTALIS
Indicated in Pityriasis affecting forehead, face, ears and neck, aggravation after washing in warm water. White, scaly, peeling-off eruption over the scalp, extending over the forehead, temples, ears, and neck. Tingling-biting, stinging-itching on the scalp, >> by scratching. Perspiration, smelling of honey (sweetish), on uncovered parts of head (face and hands), with dryness of the covered parts. Light-brown blotches (freckles) on face.

LESS COMMONLY USED HOMOEOPATHIC MEDICINES FOR  PITYRIASIS  [14][15]:

• ERYTHRINUS –  It is  a kind of Red Mullet (South America). Tincture of the fish. It has clinical indication of Pityriasis rubra (Syphilis). Dr. Burnett is the authority for this medicine. He bases his use of it on an account of its effects on some sailors who ate the fish. They came out with a peculiar red rash which became chronic, and which the doctors took for a form of syphilis. Dr. Burnett cured with it a case of pityriasis rubra appearing in a large patch on the chest and benefited other cases too. He believes this form of skin affection to be a manifestation of syphilis in the second generation, the father of the patient he cured having had syphilis. 
• NUPHAR  LUTEUM – Also known as Small Yellow Pond Lily. Clinical indication of Pityriasis capitis, with intense itching and falling out of the hair. On different parts of body there are red blotches, regular in outline, ovoid or circular and covered with little silvery white scales. With evening aggravation. As eruption disappears, scales ceases to reproduce and skin at place of each blotch became pale red or yellowish.
• THYREOIDINUM – Indicated in Pityriasis rubra of intense redness and scaliness and also with intense itching. Excessive flushing of skin and symmetrical eruptions; edges raised and thickened. Peeling of skin beginning on legs and extending over whole surface. There is desquamation of skin of hands and feet.

CONCLUSION
Hence, Pityriasis which is most commonly encountered in the young and middle adult age groups, a skin condition having different subtypes due to different causative and environmental factors need to be dealt with carefully and the treatment of which can only be possible by proper individualisation through the help of different repertories and material medica books. However, in order to avoid confusion of diagnosis with other diseases one should have a proper knowledge about the distinguishing features of all.  At the same time,  it’s essential for the suffering individual to be provided with knowledge of the disease so that the further management can be done appropriately. 

REFERENCES:

1. Khanna N. Illustrated synopsis of Dermatalogy and sexually transmitted diseases. 5th ed. Elsevier; 2017, pg117-129.
2. Gupta AK, Foley KA. Antifungal Treatment for Pityriasis Versicolor. J Fungi (Basel). 2015;1(1):13-29. Published 2015 Mar 12. doi:10.3390/jof1010013
3. https://www.ncbi.nlm.nih.gov/books/NBK482500/
4. https://www.ncbi.nlm.nih.gov/books/NBK482436/
5. Ankad BS, Beergouder SL. Pityriasis lichenoides et varioliformis acuta in skin of color: new observations by dermoscopy. Dermatol Pract Concept. 2017;7(1):27-34. Published 2017 Jan 31. doi:10.5826/dpc.0701a05
6.  https://www.ncbi.nlm.nih.gov/pubmed/17298
7. Kambil S. A clinical and epidemiological study of pityriasis versicolor. International Journal of Scientific Study. 2017;5(9).
8. Gupta AK, Foley KA. Antifungal Treatment for Pityriasis Versicolor. J Fungi (Basel). 2015   Mar 12;1(1):13-15.
9. Alvarado Z, Pereira C. Fungal diseases in children and adolescents in a referral centre in Bogota, Colombia. Mycoses. 2018 Aug;61(8):543-548. 9.
10. Drago F, Ciccarese G, Rebora A, Broccolo F, Parodi A. Pityriasis Rosea: A Comprehensive Classification. Dermatology. 2016;232(4):431-437. doi:10.1159/000445375
11. Givler D, Basit H, Givler A. Pityriasis Alba [Internet]. Ncbi.nlm.nih.gov. 2019 [cited 114 September 2019]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK121110141/ 
12. Soni B, Raghavendra K R, Yadav DK, Kumawat P, Singhal A. A clinico-epidemiological study of hypopigmented and depigmented lesions in children and adolescent age group in Hadoti region (South East Rajasthan). Indian J Paediatr Dermatol [serial online] 20115 [cited 2019 Sep 22];116:9-111. Available from: http://www.ijpd.in/text.asp?20115/116/1/9/11616121411 
13. Heymann W, Millett C. Pityriasis Alba – Dermatology Advisor [Internet]. Dermatology Advisor. 2019 [cited 20 September 2019]. Available from: https://www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/pityriasis-alba
14. Clarke J. A dictionary of practical materia medica. Noida, U.P.: B.Jain Publishers(P) LTD.; 2017
15. Phatak S. Materia medica of homoeopathic medicines. New Delhi: B. Jain publishers (P.); 2008.
16. Boericke W. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory. Third revised and augmented edition based on 9 th edition. Noida, India: B. Jain Publishers (P) Ltd; 2016. 
17. Schroyens F. Synthesis (Repertorium Homoeopathicum Syntheticum). Version 8.1. Published in India by arrangement with Homoeopathic Book Publishers, UK by B. Jain Publishers (P) Ltd. New Delhi; 2001.
18. Kent.J.T : Repertory of Homoeopathic Materia medica