Dr Margret Redson S R
ABSTRACT:
Skin being the most exterior part of the body, is one of the important sense organ and come with it a great deal of aesthetic /cosmetic problems. Asian type of skin is more prone to present with post-inflammatory hyperpigmentation, melasma, lentigines and freckles. The main skin diseases reported are acne, atopic dermatitis and viral infections.
Among the hypersensitivity diseases, dermatitis as a subgroup stands first with a rate of 24.50% of the total. Among the dermatitis group, contact dermatitis (17.54% of the total) is the most commonly reported skin disease.
INTRODUCTION:
Contact dermatitis is an inflammatory eczematous skin disease. It is caused by chemicals or metal ions that exert toxic effects without inducing a T-cell response (contact irritants) or by small reactive chemicals that modify proteins and induce innate and adaptive immune responses (contact allergens).
Contact dermatitis is divided into irritant contact dermatitis and allergic contact dermatitis. Irritant contact dermatitis is a nonspecific response of the skin to direct chemical damage that releases mediators of inflammation predominantly from epidermal cells while allergic contact dermatitis is a delayed (type 4) hypersensitivity reaction to exogenous contact antigens.
ETIOLOGY:
Irritant contact dermatitis:
Chemical or physical agents and microtrauma may produce skin irritation thus causing Irritant contact dermatitis. Physical irritants like friction, abrasions, occlusion, and detergents like sodium lauryl sulfate produce more irritant contact dermatitis in combination than alone.
Contact dermatitis Allergic:
Common etiological allergens for allergic contact dermatitis are nickel, balsam of Peru, chromium, neomycin, formaldehyde, thiomersal, fragrance mix, cobalt, and parthenium. Poison Ivy (Toxicodendron, formerly known as Rhus).
EPIDEMIOLOGY:
Females, infants, elderly, and individuals with atopic tendencies are more susceptible to irritant contact dermatitis. Risk factors for allergic contact dermatitis include age, occupation, and history of atopic dermatitis. Overall contact dermatitis is most common in people with red hair and fair skin. Women are more likely to develop contact dermatitis because of the use of jewelry and fragrances.
PATHOPHYSIOLOGY:
Irritant contact dermatitis:
It is due to inflammation from the release of proinflammatory cytokines from keratinocytes, usually in response to chemical stimuli which leads to skin barrier disruption, epidermal cellular changes, and cytokine release.
Irritants can be classified as:
-cumulatively toxic (e.g., hand soap causing irritant dermatitis in a hospital employee).
-subtoxic
-degenerative
-toxic (e.g., hydrofluoric acid exposure at a chemical plant).
Allergic contact dermatitis:
Repeated skin exposure to allergens in a sensitized individual causes T cell mediated inflammatory changes.
Allergic contact dermatitis has two phases:
-The sensitization phase in which antigen-specific effector T cells are induced in the draining lymph nodes by antigen captured cutaneous dendritic cells that migrate from the skin.
-The elicitation phase includes effector T cells that are activated in the skin by antigen captured cutaneous dendritic cells and produce various chemical mediators, which create antigen-specific inflammation.
Both irritant contact dermatitis and allergic contact dermatitis can present with three morphological patterns.
- Acute phase: erythema, oedema, oozing, crusting, tenderness, vesicles or pustules
- Subacute phase: crusts, scales, and hyperpigmentation
- Chronic phase: Lichenification
CASE REPORT:
PRELIMINARY DATA:
- Patient name: Mrs. A
- Age: 38y
- Sex: Female
- Religion: Hindu
- Occupation: Teacher
- Marital status: married
- Residence: Vijayanagar
- Date of case taking: 23/11/2022
PRESENTING COMPLAINTS:
Presented with the complaints of itching, burning sensation and blackish discoloration on dorsum of feet bilaterally since 3 months.
| LOCATION | SENSATION | MODALITY | CONCOMITANT |
| Integumentary system
Skin B/l dorsum of feet since 3 months Gradual onset and gradual progression |
Itching
Burning sensation Blackish discoloration |
A/F leather contact (chappal)
< night >hot application |
HISTORY OF PRESENTING COMPLAINTS:
Patient was apparently well 3 months ago, gradually developed itching on the dorsum of feet bilaterally which was after contact with leather (chappal), developed redness and rashes on the area in contact with skin surface and also had itching and burning sensation for which patient consulted dermatologist and was prescribed external application (steroid) following which redness and rashes was better but the discoloration remained thereafter along with itching and burning sensation. Itching worse at night and better by hot water application.
PAST-HISTORY:
Medical history – Allopathic medication for the presenting complaint.
Allergic history – Not allergic to drug, dust and diet.
FAMILY HISTORY:
Father – diabetic and hypertensive
Mother – bronchial asthma
Elder sister – urticaria
PERSONAL HISTORY:
- Diet: veg/non-veg
- Appetite: Increased
- Hunger: Tolerable
- Thirst: Thirsty, 3l/day
- Desires: sweets
- Aversion: nil
- Bowel habit: Regular, 1t/day, no difficulty. Diarrhoea when anxious
- Urine: 4-5t/day, no difficulty.
- Perspiration: Generalised
- Sleep: Good. Refreshing
- Dreams: Un remembered
- Thermals: Ambithermal
MENSTRUAL HISTORY:
LMP-19/10/2023
Cycles-Regular
Duration – 5 days
Associated complaints – Nil
OBSTRETICAL HISTORY:
G2P2A0L2D0
G1P1-FTNHD
G2P2-FTNHD
LIFE SPACE INVESTIGATION:
Patient hails from lower middle socio economic status. Father’s occupation is carpenter, mother worked as a house maid. Has 3 siblings, 1 elder sister and 2 younger brothers. Completed her degree and now working as a teacher. At academics she was an average student. Is extroverted. Had many friends. Childhood was uneventful. Got married at the age of 23, no strained relationships. Like things to be tidy, in place. Adulthood also uneventful.
As a person, she is
- Anxious about health (enquired many questions related to the condition)
- Fastidious
- Fear of being alone, of darkness.
GENERAL PHYSICAL EXAMINATION:
- Well oriented with time, place and person.
- Moderately built and nourished.
- No pallor, cyanosis, icterus, oedema and lymphadenopathy.
- Vitals:
- Temperature: afebrile at the time of examination
- BP: 110/70 mm hg
- PR: 72 beats/min
SYSTEMIC EXAMINATION:
- Respiratory system:
- Normal vesicular breath sounds heard
- No added sounds
- Cardiovascular system:
- S1 S2 heard, No murmur
Skin:
Blackish discoloration present on the dorsum of feet bilaterally.
No redness, no bleeding, no discharge.
Blood investigation done as on 23/11/2022
- CBC- normal study
- FBS-98mg/dl
- PPBS-109mg/dl
CLINICAL DIAGNOSIS:
Irritant contact dermatitis
ANALYSIS OF CASE:
| Common symptoms | Uncommon symptoms |
| · Itching
· Burning · Blackish discoloration of skin |
· Itching <night
· Itching >hot application · Appetite increased · Thirst increased · Diarrhoea on becoming anxious · Fastidious · Anxious about health · Fear of being alone |
EVALUATION OF SYMPTOMS:
| Mental generals | Physical generals
|
Characteristic particulars |
| · Fastidious
· Fastidious · Anxious about health · Fear of being alone |
· Appetite diminished
· Thirst increased · Thermal-chilly pt
|
· Itching of skin <night
· >hot application |
TOTALITY OF SYMPTOMS:
- Anxious about health
- Fastidious
- Fear to be alone
- Appetite increased
- Thirst increased
- Thermal-chilly
- Itching <night
- >hot application
- Burning sensation
- Blackish discoloration of skin
REPERTORIAL APPROACH:
Kent’s repertory
REPERTORIAL TOTALITY:
- Mind, anxious health about
- Mind, fastidious
- Mind, fear (apprehension, dread), alone of being
- Stomach, Thirst
- Stomach, Appetite, increased
- Skin, burning
- Skin, discoloration, blackish
- Skin, itching, night
REPERTORIAL PROPER:
- Arsenicum album 19/7
- Phosphorus 15/6
- Pulsatilla 13/7
- Sulphur 14/6
- Nux vomica 12/7
- Lachesis 12/6
- Lycopodium 13/5
PRESCRIPTION:
Ars alb 200 / OD × 3 days
No 2 pills / TID × 2 weeks
FOLLOW UP:
| DATE | SYMPTOMS | PRESCRIPTION |
| 8/12/2022
|
Complaints of itching and burning of skin persists
Blackish discoloration present |
Ars alb plain /TID×2 weeks |
| 27/12/2022
|
C/o of itching and burning increased
Blackish discoloration persists |
Ars alb 200 / 0D×3 days
KS 6X 2-2-2 / 2 weeks |
| 22/01/2023 | C/o itching and burning of skin better by 40%
Blackish discoloration better |
SL BD × 3 days
KS 6X 2-2-2 / 2 weeks |
| 18/02/2023 | C/o itching and burning of skin better by 90%
Blackish discoloration better by 80% |
SL OD×3 days
KS 6X 2-2-2 /2 weeks |
CONCLUSION:
External application is the most abused method of treatment in skin diseases. Application of steroidal ointment has many side effects (local and systemic effects). Homoeopathy treats a person holistically wherein we take into account mind of a person from where most of the disease prop up or keep up the disease. In the above mentioned case, patient used steroidal ointment which did no good to the patient and resulted in blackish discoloration. Taking into account mental picture of the patient, Arsenicum album was prescribed. Patient was completely better of the complaints
CONSENT FOR PUBLICATION: written informed consent obtained from the patient for publication.
BIBLIOGRAPHY:
1) https://www.ncbi.nlm.nih.gov/books/NBK459230/
2) Organon of medicine, 6th edition.
3) Repertory of homeopathic materia medica by Dr. J T Kent
Dr.Margret Redson S R
PG scholar, Department of Practice of Medicine
Government homoeopathic college and hospital Bengaluru-560079
margretredson@gmail.com
Under the guidance of
Dr Veerabhadrappa C
Professor, Department of Practice of Medicine
Government homoeopathic college and hospital, Bengaluru-560079
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