Atopic dermatitis and homeopathic Management

Dr Nishtha Bhatt
MD (Hom, Organon of Medicine), Mumbai

Key words: Atopic Eczema, Inflammation, Pruritis, Homoeopathy, SCORAD score

Introduction: Atopic Eczema (also called atopic dermatitis (AD)) is an inflammatory, chronically relapsing, non-contagious and extremely pruritic skin disease.

Problem statement: In this modern world Eczematous diseases are very common with an estimated prevalence of more than 10% in the general population. According to statistics 15-25% of all dermatological patients suffer from eczema. Surveys have shown that Eczema prevalence is increasing.

A gradual increase in the prevalence of Atopic Eczema has been observed recently and it can be ascribed to environmental changes consequent to rapid development all over the world. The upward trend is also true in Indian context. Since the beginning of the twentieth century, many mucosal inflammatory disorders have become more common; Atopic Eczema (AE) is a classic example of such a disease.

World Allergy Organization states with a prevalence of 2-5% (in children and young adults approximately 10%), atopic eczema is one of the most commonly seen dermatitis. Homoeopathic management is one of the best way to deal with the cases of Atopic Eczema Treatment is based on the holistic approach and principles of Homoeopathy.

DEFINITION OF ATOPIC ECZEMA

Atopic Eczema is a cutaneous expression of the Atopic state, characterized by family history of asthma, allergic rhinitis, or eczema. According to International classification of Disease Atopic Eczema comes under ICD-10, L20.0

CAUSES AND PATHOLOGY 

1. Hereditary factors

• A family history of Atopy can be obtained in approximately 43-73% of the cases with AE. Patients without a family history of atopy present clinically in a same way as those with one. However, they usually have a less severe form of atopic eczema (AE) and a better spontaneous remission. The control of IgE production lies on chromosome 11q13 marker D11S97.

2. Environmental factors

• AE is more common in urban than rural areas. This is probably because of industrialization and a changed lifestyle. AE is known to aggravate during winter. 
• The role of food allergens in pathogenesis of AE is debated. Food does not play a role in all patients with AE; a subset of patients may have food induced aggravation. The commonest manifestation of food hypersensitivity in patients with AE is gastrointestinal symptoms, respiratory symptoms, and Skin symptoms.

3. Immune dysregulation

• Raised IgE levels and increased number of eosinophil are found in blood of AE patients; in addition, the blood is rich in allergen specific T cells, which produces IL-4, IL-5 and IL-13. 

4. Infective factors

• Pityrosporumovale, lipophilic yeast, is a natural colonizer of human skin, usually at puberty, IgE antibodies against P. ovale have been found in 49% cases of AE. 

5. Psychological factors

• Atopic eczema has tremendous psychological effects on an individual. It can interfere with the mental stability, social and emotional adjustment, working capabilities, sexual behavior, and quality of life. Stress is an important factor in the precipitation of flares in patients with AE.

SIGNS AND SYMPTOMS

The evolution of AE has been divided into three arbitrary phases.

	Infantile phase (birth to two years of age)	Childhood phase (two years to puberty)	Adult phase (starts from puberty)
Areas of involvement	-Forehead, and scalp that are intensely pruritic beginning on the cheeks,. -Lesions might remain localized to the face or might extend to the trunk or particularly the extensor aspect of the extremities in scattered, ill-defined, often symmetric patches.  -By 8-10 months, the extensor surface of the arms and legs often show dermatitis, perhaps because of the role of friction associated with crawling and the exposure of these sites to irritants and allergic triggers	-The hands, feet, wrists, ankles, and popliteal and antecubital regions.  -Although flexural localizations more common, some children show and inverse pattern and primary involvement of the extensor areas. -Facial involvement, when present tend to localize  to the perioral and peri-orbital regions	-The flexures face and neck, the upper arms and back, and the dorsal aspect of hands, feet, fingers, and toes.
Characteristic of lesion	erythematous and vesicles  In children aged one year or older, nummular patches may accompany the more typical dry, erythematous scaling patches of atopic eczema.	It may be a continuation of infantile phase.  More lichenified papules and plaques, representing more chronic disease.	Dry, scaling, erythematous papules and plaques and the formation of lichenified plaques.

As there are no laboratory marker specific for the disease, “stigmata” and minimal manifestations of E have been found to have diagnostic significance.

CLINICAL FEATURES OF ATOPIC ECZEMA

1. Pruritis and scratching
2. Courses marked by exacerbation and remissions
3. Lesions typical of eczematous dermatitis
4. Personal or family history of Atopy (asthma, allergic rhinitis, food allergies, or    eczema)
5. Clinical course lasting longer than 6 weeks
6. Lichenification of skin

STIGMATA OF ATOPY

• Dry skin
• Hyperlinearity of palms and sole
• Linear grooves of fingertips
• Dennie-Morgan fold (Atopy fold, doubled intraorbicular fold)
• Hertoghe’s sign (hypodense lateral eyebrows)
• Short distance between scalp hair growth in the temporal hairline and eyebrows
• Periorbital shadow (halo)
• Delayed blanching after intracutaneous injection of acetylcholine
• White dermatographism

DIAGNOSTIC CRITERIA

The diagnosis of AE is based on signs and symptoms; there are no laboratory standards for the diagnosis. 

Hafkin and Rajka first proposed a systematic approach towards the standardization of the diagnosis of AE by incorporating three major or basic feature and 23 minor features. They suggested that diagnosis of AD could be established if three of the major and three of the minor criteria are present:

1. Major or basic criteria

1. Pruritus
2. Typical morphology and distribution (flexural Lichenification or linearity in adults and facial and extensor involvement in infants and children).
3. Chronic or chronically relapsing dermatitis.
4. Personal or family history of atopy (asthma, allergic rhinitis, or atopic dermatitis).

2. Minor or less characteristic features:

1. Xerosis.
2. Icthyosis, palmar hyperlinearity or keratosis pilaris.
3. Immediate (type I) skin test reactivity.
4. Elevated serum IgE.
5. Early age onset.
6. Tendency towards cutaneous infections (esp. Staph. aureus and HSV infection)/ impaired cell mediated immunity.
7. Tendency towards nonspecific hand or foot dermatitis.
8. Nipple eczema.
9. Cheilitis.
10. Recurrent conjunctivitis.
11. Dennie-Morgan infraorbital folds (bilateral symmetrical folds formed by two additional creases beneath the eyelids).
12. Keratoconus (conical cornea resulting from degenerative changes, leading to thr cornea being pushed outwards due to intraocular pressure).
13. Posterior or anterior subscapular cataracts (small opacities and translucent globules seen in the lens at the pole in front of the posterior or anterior capsules).
14. Orbital darkening (bluish to grayish periorbita pigmentation, possibly following chronic rubbing).
15. White dermatographism/ delayed blanch (development of a delayed white line on firm stroking of the skin, instead of the usual red line seen normally).
16. Facial pallor/ facial erythema.
17. Pitryiasis Alba.
18. Anterior neck folds.
19. Itch when sweating.
20. Intolerance to wool or lipid solvents.
21. Perifolicular accentuation.
22. Food intolerance.
23. Course influenced by environmental/ emotional factors.

SCALE for calculating Atopic Eczema

SCORAD scoring table 

	Before treatment	Total	After treatment	Total
Spread	Head and neck 9% Upper limbs 9% each Lower limbs 18% each Anterior trunk 18% Back 18% 1% for genitals.	A	Head and neck 9% Upper limbs 9% each Lower limbs 18% each Anterior trunk 18% Back 18% 1% for genitals.	A
Intensity	Redness-  Swelling-  Oozing / crusting-  Scratch marks-  Skin thickening (Lichenification)-  Dryness (this is assessed in an area where there is no inflammation)-	B	Redness-  Swelling-  Oozing / crusting-  Scratch marks-  Skin thickening (Lichenification)-  Dryness (this is assessed in an area where there is no inflammation)-	B
Subjective signs	Pruritus-  Sleeplessness-	C	Pruritus- Sleeplessness-	C
Total score A/5+7B/2+C=

Spread: To determine extent, the sites affected by eczema are shaded on a drawing of a body. The rule of 9 is used to calculate the affected area (A) as a percentage of the whole body.

• Head and neck 9%
• Upper limbs 9% each
• Lower limbs 18% each
• Anterior trunk 18%
• Back 18%
• 1% for genitals.

The score for each area is added up. The total area is ‘A’, which has a possible maximum of 100%.

Intensity: A representative area of eczema is selected. In this area, the intensity of each of the following signs is assessed as none (0), mild (1), moderate (2) or severe (3).

• Redness
• Swelling
• Oozing / crusting
• Scratch marks
• Skin thickening (Lichenification)
• Dryness (this is assessed in an area where there is no inflammation)

The intensity scores are added together to give ‘B’ (maximum 18).

Subjective signs: Subjective symptoms i.e., itch and sleeplessness, are each scored by the patient or relative using a visual analogue scale where 0 is no itch (or no sleeplessness) and 10 is the worst imaginable itch (or sleeplessness). These scores are added to give ‘C’ (maximum 20).

-Pruritis

-Sleeplessness

Total score:  The SCORAD for that individual is A/5 + 7B/2 + C

HOMEOPATHIC MANAGEMENT

Homoeopathy at the other hand is found out to be very effective in treatment of Atopic Eczema if managed with correct similimum and correct Posology.

Some of the homeopathic remedies useful in cases of atopic eczema are as follows:

• Sulphur: Atopic Dermatitis with dry scaly skin and itching
• Graphites: Atopic Dermatitis that appears in folds of skin
• RhusTox: Atopic Dermatitis with asthmatic troubles. Reddened skin with excessive itching, or fluid-filled vesicular eruptions on skin.
• Mezereum: Atopic Dermatitis with weeping eruptions on the scalp. Thick scab formation on scalp with discharge of thick pus.
• Natrum Mur: Atopic Dermatitis cases where the eruptions appear on the margin of scalp or along hairline
• Arsenicum Album: It is a valuable remedy in Eczema, when vesicles appear, which turn into pustules and for scabs, with copious scaling and much burning.
• Calcarea Carb: Eczema of the children, when it appears on the scalp, with a tendency to spread downwards and over the face. Frequently it appears in patches on the face or scalp, forming thick crusts, which are often white, like chalk deposits.
• Petroleum: Eczema, wherever it may appear, forming thick scabs and oozing pus. The skin soon grows more harsh and dry and there form deep cracks and fissures which bleed and suppurate.
• Staphysagria: eruption is usually dry and formed of very thick scabs and itches violently; when scratching stops the itching in one place, it goes to another. At other times, these scabs are moist and yellowish in color and very offensive.

References:

1. Harrison’s Principles of Internal Medicine, 18^TH international edition, McGraw-Hill, Anthony S. Fauci, 2011
2. IADVL Textbook of dermatology Volume 1, 3^rd edition, R.G. Valia Ameet R. Valia, 2008
3. Davidson’s Principles and Practice of Medicine, 20^th Edition, Nicholas A. Boon Nicki R.Colledge, 2006
4. An Illustrated Handbook of  Skin and Sexually Transmitted Infections, 6^th Edition, Dr. Uday Khopkar, Bhalani Publisher, 2009
5. Boericke’s New Manual of Homeopathic  Materia Medica with Repertory, B. Jain publisher, 9^th edition, 2012
6. http://www.worldallergy.org/public/allergic_diseases_center/atopiceczema/
7. https://www.dermnetnz.org/topics/scorad