Dr Sulochana K
ABSTRACT
Vitiligo, a common depigmenting skin disorder it is characterized by the selective loss of melanocytes which results in typical non scaly, chalky-white macules, its prevalence in worldwide has been estimated to be 0.5–2%. In recent years by considerable progress in understanding the pathogenesis of vitiligo, they concluded it to be an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although it affects psychologically and cause considerable burden on daily life1.Vitiligo can be triggered by stress to the melanin pigment-producing cells of the skin, the melanocytes. Vitiligo is caused by a dynamic interplay between genetic and environmental risks that initiates an autoimmune attack on melanocytes in the skin2.
A case report of a 12yr old girl diagnosed with vitiligo, was given Natrium muriaticum as a constitutional remedy.
KEYWORDS: Vitiligo, Homoeopathy, melanin, Natrium muriaticum
Definition
Vitiligo, a depigmenting skin disorder, characterized by the selective loss of melanocytes, which in turn leads to pigment dilution in the affected areas of the skin1.
Epidemiology
Its prevalence is estimated to be 0.5–2% of the population, in both adults and children worldwide. Vitiligo affects ethnic groups and all skin type people1. Incidence rate is between 0.1-2% showing multifactorial etiology and polygenic inheritance3.
Adults and children of both sexes are equally affected, although the greater number of reports among females is probably due to the greater social consequences to women and girls affected by this condition. However, majority of the vitiligo cases reported begin during the period of active growth. Almost half the patients present before the age of 20 years and nearly 70-80% before the age of 30 years4.
TRIGGERING / PRECIPITATING FACTORS
It is difficult to precisely define the triggering factors for vitiligo. Nevertheless, it is essential to elicit the details of history of emotional stress, drug intake, infections, trauma, injury existed prior to the development of vitiligo lesions. It is believed that major oxidative stress occurs in vitiligo skin, which is evidenced by low catalase levels and cellular vacuolization in the epidermis, thus leading to the accumulation of epidermal hydrogen peroxide4.
CLASSIFICATION
Classified as – Segmental vitiligo (SV) and non-segmental vitiligo (NSV)
In 2011, an international consensus classified SV separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of NSV. “Mixed vitiligo” in which SV and NSV coexist in one patient, is classified as a subgroup of NSV 1.
CLINICAL FEATURES
Vitiligo is characterized by the appearance of patchy discoloration evident in the form of typical chalky-white or milky macule(s). The macules are round and / or oval in shape, often with scalloped margins.
The size of the macules may vary from a few millimeters to several centimeter.
The lesions are asymptomatic although itching / burning may precede or accompany the onset of the lesions in a few patients. Vitiligo is a slow and progressive disease and may have remissions and exacerbations correlating with triggering events.
Although any part of the skin and / or mucous membranes is amenable to develop vitiligo, the disease has a predilection for normal hyperpigmented regions such as the face, groin, axillae, areolae and genitalia.4
PATHOGENESIS
Multiple mechanisms have been proposed for melanocyte destruction in vitiligo such as genetic, autoimmune responses, oxidative stress, generation of inflammatory mediators and melanocyte detachment mechanisms.
None of these proposed theories are sufficient to explain the different vitiligo phenotypes, and it is still under debate.
Genetics of Vitiligo
Genetic factor influences are complex. Epidemiological studies have shown that vitiligo tends to aggregate in families.
Tyrosinase, which is encoded by the TYRgene, is an enzyme that catalyzes the rate-limiting steps of melanin biosynthesis, it is major autoantigen in generalized vitiligo. The NALP1 gene on chromosome 17p13, encoding the NACHT leucine-rich repeat protein 1, is a regulator of the innate immune system. It has been linked to vitiligo-associated multiple autoimmune disease.
Although many of the specific mechanisms arising from these genetic factors are still being explored, it is now evident that vitiligo is an autoimmune disease.
Oxidative Stress
Research into the pathogenesis of vitiligo suggests that oxidative stress may be the initial event in the destruction of melanocytes.
Reactive oxygen species (ROS) are released from melanocytes in response to stress. In turn, this causes widespread alteration of the antioxidant system: An imbalance of elevated oxidative stress markers and a significant depletion of antioxidative mechanisms in the skin and in the blood.
Both endogenous and exogenous stimuli can potentially generate ROS in vitiligo.
Innate Immunity
Innate immunity in vitiligo bridges the gap between oxidative stress and adaptive immunity in vitiligo. It is likely that the activation of innate immune cells occurs early in vitiligo, by sensing stress signals released from melanocytes and possibly keratinocyte. As mentioned above, there is an association between vitiligo susceptibility and genetic changes in NALP1, a regulator of the innate immune system.
Adaptive Immunity
Both humoral and cell-mediated immune abnormalities are implicated in the pathogenesis of vitiligo1.
DIAGNOSIS
Clinically vitiligo can be diagnosed based upon the finding of acquired, amelanotic, non-scaly, chalky-white macules with distinct margins in a typical distribution: periorificial, lips and tips of distal extremities, penis, segmental and areas of friction.
It does not usually require confirmatory laboratory tests. A skin biopsy or other tests are not necessary except to exclude other disorders.
The absence of melanocytes in a lesion can be assessed noninvasively by in vivo confocal microscopy or by a skin biopsy. The histology of the centre of a vitiligo lesion reveals complete loss of melanin pigment in the epidermis and absence of melanocytes.
The diagnosis of vitiligo may be facilitated by the use of a Wood’s lamp, a hand-held ultraviolet (UV) irradiation device that emits1.
CONVENTIONAL MANAGEMENT
Topical and systemic immunomodulatory agents (corticosteroids and calcineurin inhibitors) for regulating autoimmune response, decrease in oxidative stress in melanocytes by means of topical and systemic antioxidants, activation of melanocyte regeneration using phototherapy (UVB in particular) and transplantation of pigment cells. Following successful repigmentation, application of calcineurin inhibitors is recommended to prevent recurrences. Combination therapies of are generally considered to be more successful than monotherapies5.
HOMOEOPATHIC MANAGEMENT
Homeopathic medicine includes a holistic approach to the understanding of the patient and integrates this approach to provide individualized patient treatment. Certain diseases may manifest when genetic predisposition combines with stress, and homeopathy recognizes these factors6.
CASE
Presenting complaint
A case of 12 year old girl, came to the OPD of Govt. Homoeopathic medical college and hospital, with the complaints hypo-pigmented patches over both sides of inguinal region since one and half years.
History of presenting complaints
Patient was apparently healthy before the complaints started, since 1 and half year she started getting hypo-pigmented patches over inguinal region, first it appeared over right side later after 6 months even it started on left side, first appeared as small hypo-pigmented patch, irregular in shape gradually increasing in its size. Right side measures 9*3cm, left side measures 3*2 cm. No any burning, itching or peeling of skin present.
Past history – Took allopathic treatment, didn’t felt better.
Family history – History of HTN.
Physical generals
Patient feels thirsty, she has desire for spicy, fried items and aversion to milk, perspiration increased over nose+ and palms especially when writing, thermally she is a hot patient.
Mentals
Patient was cooperative, first little shyness she showed later started telling her complaints freely, when asked about her school, told that she is not liking new school, as they shifted their home 2 yrs back, she has to shift to a new school, patient started weeping telling that no one talks to me, no one is making friend with me , if i give anything to them they won’t take it, average in studies, her father says previously she used get good marks now she is showing no interest in studies and stubborn at things, she doesn’t listen to her mother sometimes, her father also tells she weeps sometimes thinking about her old friends and old school.
Analysis and evaluation of symptom
| Mental general | Physical general | Characteristic particular |
| Weeping 2+ | Thirsty | Hypopigmentation over bilateral inguinal region |
| Want of affection2+ | Desires spicy2+, fried items | |
| Obstinate | Aversion milk | |
| Perspiration on nose | ||
| Perspiration increased on palms < writing | ||
| Hot patient |
Repertorial totality
Repertory selected – Synthesis repertory7
- Mind, obstinate
- Mind, loves affection – sympathy from others desire for
- Mind, weeping
- Stomach, thirst
- Generals, food and drinks, desire spicy
- Generals, food and drinks, aversion milk
- Nose, perspiration, on
- Extremities, perspiration, hand, palms, exertion on
- Skin, vitiligo
Repertorial result
- Natrum mur – 15/8
- Phosphorous – 16/7
- Calcarea – 15/7
- Sepia – 10/7
- Ars alb – 11/6
Prescription – 23/7/2019
Natrium muriaticum 200, 1 dose (EMES)
DISCUSSION AND CONCLUSION
Homoeopathic medicine includes a holistic approach to the understanding of the patient as a whole, considers the patient’s susceptibility to certain kind of stress6.
Dr Samuel Hahnemann in the Organon of medicine has told regarding the disadvantages of local application for the local maladies. Here, the case showed good improvement from Constitutional Homoeopathic approach, where we can see decrease in the size of the patch. This case shows the scope of Homoeopathy in autoimmune conditions.
PATIENT CONSENT
Patient’s consent was obtained. All the details were informed to her in her own vernacular language
CONFLICT OF INTEREST
None declared
REFERENCES
- Bergqvist C, Ezzedine K. Vitiligo: a review. Dermatology. 2020;236(6):571-92. https://www.karger.com/Article/Abstract/506103
- Rashighi M, Harris JE. Vitiligo pathogenesis and emerging treatments. Dermatologic clinics. 2017 Apr 1;35(2):257-65. https://www.derm.theclinics.com/article/S0733-8635(16)30141-3/abstract
- Bagherani N, Yaghoobi R, Omidian M. Hypothesis: zinc can be effective in treatment of vitiligo. Indian Journal of Dermatology. 2011 Sep;56(5):480. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221203/
- Sehgal VN, Srivastava G. Vitiligo: compendium of clinico-epidemiological features. Indian Journal of Dermatology Venereology and Leprology. 2007 May 1;73(3):149.https://ijdvl.com/?viewpdf=1&embedded=true&article=8d9d630053b86dc008ef109af47f0f54rNWNU20%3D
- Bleuel R. Therapeutisches Management bei Vitiligo Therapeutic management of vitiligo. https://www.researchgate.net/profile/Rachela-Bleuel 2/publication/328752446_Therapeutisches_Management_bei_Vitiligo/links/5e1a3aa1a6fdcc28376ba243/Therapeutisches-Management-bei-Vitiligo.pdf
- Mahesh S, Mallappa M, Tsintzas D, Vithoulkas G. Homeopathic treatment of vitiligo: a report of fourteen cases. The American journal of case reports. 2017;18:1276.https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5723025/
- Schroyens F, Synthesis. Version 9.1. New Delhi: B Jain Publishers.2004
Dr Sulochana K
PG scholar (MD – PART II)
Dept of Organon of Medicine with Homoeopathic Philosophy
GHMC&H, Bengaluru – 560079
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