RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
ANNEXURE – II
APPLICATION FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS(IN BLOCK LETTERS) / Dr LIZA MICHAEL
DEPARTMENT OF MATERIA MEDICA,
FATHER MULLER HOMOEOPATHIC
MEDICAL COLLEGE AND HOSPITAL,
UNIVERSITY ROAD, DERALAKATTE,
MANGALORE – 574105, (KARNATAKA).
PERMANENT ADDRESS / LISIEUX BHAWAN
GUDUMBA P.O.
GAURABAGH, KURSI ROAD,
LUCKNOW – 226026, (UTTAR PRADESH)
2. / NAME OF THE INSTITUTION / FATHER MULLER HOMOEOPATHIC
MEDICAL COLLEGE AND HOSPITAL,
DERALAKATTE, MANGALORE -574105
3. / COURSE OF THE STUDY AND SUBJECT / MD (HOM)
MATERIA MEDICA
4. / DATE OF ADMISSION TO THE COURSE / 26-05-2010.
5. / TITLE OF THE TOPIC
“A STUDY TO EVOLVE A SUITABLE HOMOEOPATHIC APPROACH IN THE EFFECTIVE MANAGEMENT OF ATOPIC DERMATITIS”
6. / BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Skin diseases represent one of the most frequent causes of morbidity in developing countries. Atopic dermatitis is a very common often chronic skin disease that affects a large percentage of the world’s population. Despite the frequency of atopic dermatitis; it is often viewed by the society and the medical community as a minor dermatologic condition. However atopic dermatitis is a chronic skin disease that causes a lot of psychosocial stress. Psychic stress, primarily as “daily hassles” and feelings of stigmatization can be severe strain factors and have an adverse effect on life quality.
Atopic dermatitis in children can have a major effect on their quality of life, disrupting family and social relationships as well as interfering with recreational and school activities. In adults it may interfere with employment opportunities or disrupt spousal relationships. Dermatitic eruptions represent a major portion of the skin diseases seen in infancy and childhood. Annual costs of atopic dermatitis are similar to those of other chronic diseases such as emphysema, psoriasis & epilepsy.
All the different modes of treatment have only helped in palliating the disease. Homoeopathic treatment is superior to other modes of treatment since it treats the cause and not the effects. It is the man who is sick and not his body and as a matter of fact he needs to be treated1. It is here the concept of individualization comes into practice, where the physical as well as mental characteristic of individual is taken.
Considering the endogenous factors in atopic dermatitis, a detailed case taking is necessary in person diagnosis, disease diagnosis and management of case, both specific as well as general. Therefore this study has been taken to evolve a suitable homoeopathic approach in the effective management in atopic dermatitis.
6.2 REVIEW OF LITERATURE
SYNONYMS
Neurodermatitis, endogenous eczema, dermatitis atopica, flexural eczema, infantile eczema, neurodermatis, Besnier’s prurigo, prurigo diathsique2.
HISTORICAL ASPECTS
Atopic dermatitis is a genetically determined disorder, which was described by Besnier as ‘prurigo diathetique’ in 1892 and was known in Europe as Besnier’s prurigo. In 1923, Coca and Cooke used the term ‘atopy’ and the original description included asthma and hay fever. Later it was realized that Besnier’s prurigo also fell within this category. In 1933, Wise and Sulberger used the term ‘Atopic Dermatitis’ and in 1935 Hill and Sulberger characterized the clinical entity. Atopic dermatitis is the designation that is now used universally15.
DEFINITION
The term Atopic dermatitis describes a chronic, inherited, relapsing, pruritic skin condition with clinical features of xerosis, inflammation and lichenification9.
EPIDEMIOLOGY
Atopic dermatitis is a major cause of morbidity in children in the world. The incidence of atopic dermatitis is unknown, but the prevalence has been reported to be as low as 2% and as high as 20%, a likely range is 5 to 10%. In older children and adults, the disease affects females in greater numbers than males with an incidence ratio of 2:1. Atopic dermatitis appears to be particularly common in Caucasians and Chinese and is more common in highly industrialized countries and in higher social classes.
GENETIC PREDISPOSITION
There is a strong family history of associated atopic diseases in families of patients with atopic dermatitis. The mode of inheritance is not entirely clear but appears to be polygenic.
Monozygotic twins are often concordant for the disease with an incidence of 86% if one twin has the disease, whereas the incidence is dizygotic twins is 21%, similar to that occurring in siblings.
AETIO-PATHOGENESIS
Although the aetiopathogenesis of atopic dermatitis are still unclear, evidence suggests that IgE- mediated late phase responses, as well as cytokine imbalances and cell mediated reactions (T- lymphocyte activation), contribute in some way. Expressed more specifically, there is an expansion of the skin-homing type -2 cytokine secreting T-cells, leading to increased levels of interleukin-4, 10 and 13 and of IgE. The IgE mediated reactions may be to ingested food or to inhaled or contactant aeroallergens, such as human dander, grass pollens and house dust mites. Recently, antigens of staphylococcus aureus and other bacteria have been considered as possible stimulants of the IgE response. The acute inflammation seen is atopic dermatitis may be due to histamine and mast cell mediators.
Vascular changes, white dermographism and delayed blanching of skin are seen in atopic dermatitis. Skin temperature and blood flow are decreased in the fingers but not other parts of these patients.
Essential fatty acids are vital to the integrity, maturation and function of the skin. They are the lipids that maintain the epidermal barrier function and cellular immunoregulation. Essential fatty acids are stored in the phospholipids in the cell membranes. They are the precursors of eicosanoids a collective name for prostaglandins, leucotriens and thromboxanes, which are important in the production of inflammation and the regulation of cell division. The exact role of eicosanoids in atopic dermatitis is uncertain but prostaglandins enhance the itching produced by histamine.
Genetic factors also appear to be involved in the pathogenesis of atopic dermatitis in some way. This is confirmed by the frequent presence of a family history of atopy and the high concordance in twins.
Psychological factors play a significant role in Atopic dermatitis. It is well known that atopics, when under stress tend to scratch. Life stress situations play an important role in triggering the disease and may be responsible for persistence, exacerbation or relapse. An atopic personality is described as outwardly calm, but seething with suppressed anxieties, frustration, insecurity and aggression, egoistic and possessing above average intelligence.
CLINICAL FEATURES
Atopic dermatitis comes under the classification of the endogenous or constitutional type of eczema in which the cause of the problem stems from the patient’s inherent rather than the environment.
· Persistent pruritus with secondary effects from scratching is characteristic of atopic dermatitis. The itchiness is made worse by changes in temperature, by rough clothing and other minor environmental alterations.
· Excoriation and chronic thickening of the skin with accentuated skin markings (lichenification) result from the perpetual scratching.
· Generalized xerosis or dry skin is a major feature of atopic dermatitis.
Hill and Sulzberger characterized 3 distinct clinical phases of atopic dermatitis, in which both the site and the morphology of the lesions change with age.
§ Infantile phase-(2 months to 2 years)
Ø In this phase, atopic dermatitis appears on the cheeks, perioral area, scalp, around the ears and on the body sparing the diaper area.
Ø The extensor tops of the feet and the elbows are often involved.
Ø The lesions are often exudative.
§ Childhood phase-(2 to 12 years)
Ø There is flexural involvement ( anticubital & poplitial fossae, neck, wrists & ankles)
Ø Scratching and chronicity lead to lichenification.
§ Adult phase-( from 12 years onwards)
Ø Flexural involvement is common
Ø Hand dermatitis may be the only manifestation.
Ø Upper eyelid dermatitis is another frequent finding.
Ø The dermatitis can be diffuse and patchy on the body.
Ø Associated findings are dry skin, icthyosis vulgaris & keratosis pilaris.
HISTOPATHOLOGY
The histology varies from an acute dermatitis with spongiosis and a lymphocytic infiltrate to a chronic dermatitis with acanthosis, hyperkeratosis, parakeratosis and a perivascular lymphocytic infiltrate around blood vessels. Demyelination and fibrosis of cutaneous nerves are seen at all levels of the dermis.
COMPLICATIONS
· Lesions are frequently colonized with staphylococcus aureus, secondary infection resulting in another flare of dermatitis or persistence is common.
· Increased susceptibility to viral infections like herpes simplex, mollusca contagiosa, cellulitis, viral warts and cutaneous fungal infections.
· Cataracts
· Hypo pigmentation and hyper pigmentation may result from previous inflammation.
· Emotional and behavioral problems may be frequent in children affected by moderate to severe disease.
DIFFERENTIAL DIAGNOSIS
§ Contact dermatitis
§ Nummular eczema and seborrheic dermatitis.
§ Scabies
§ Cutaneous T-cell lymphoma.
§ Tinea infections
§ Uncommon:-Congenital disorders, metabolic disorders (Zinc deficiency) & immune deficiency disorders.
GENERAL MANAGEMENT
1. Avoid frequent use of harsh soaps and detergents on the affected skin.
2. The frequency of bathing in minimized to as much as is reasonable.
3. The regular use of bland, greasy emollients improves disease severity.
4. Aggravating factors must be eliminated or controlled.
· If specific foods flare the disease, then they should be avoided.
· The environment should be cool and well ventilated.
· Soft, light, cotton clothing is best. Wool or other coarse fibers are to be avoided.
· Stress reduction techniques may be helpful.
· Patients with severe atopic dermatitis may need treatment with UV light therapy.
HOMOEOPATHIC APPROACH
Diseases represent to us the reaction of the patient to the unfavorable environmental factors and that this reaction manifests as signs and symptoms. The pattern of reaction is determined not only by factors that caused that illness, but also by the constitution of the affected person.11
For the effective management of a case, a homoeopathic physician will have to be well conversed with the diagnosis of disease, the patient as a person and the remedy selected and administered on the law of similia. 12
Disease diagnosis aids the prescription by giving information about the location (tissues and organs) and the pathological changes (type, degree, extent) 12. This helps the physician to
1.Determine the dominant miasm
2. To select cases those come within homoeopathic scope.
The data for this comes from chief complaint as well as other complaints. The symptom must be complete regarding location, sensation modalities and concomitants. Of this modalities are most important which includes circumstances of occurrences, aggravating and ameliorating factors12. In foot note of aphorism ‘7’, Hahnemann explains about the circumstances of occurrences , that is exciting and maintaining causes; removal of which will help in cure13.
PERSON DIAGNOSIS:
This is the main aspect of the homoeopathic approach where individualization is done.
The study of the patient as such is done under 2 headings:-
a. Cross section study of the patient: This gives the physician a good idea of the present illness the type of disturbance in 3 planes – physical, emotional and intellectual.
1. Symptoms of emotion include anxiety, anger, irritability, jealousy, love, hate, fear etc. it is not the mere presence of an emotional but its expression in an intense manner or any peculiarities associated with its expression, enhances its value in remedy selection.
2. Symptoms of intellect determine the capacities of the individual. It is considered under the categories as
a. Disturbances in perception and formulation: like hallucinations, illusions, delusions, ideas and confusions.
b. Disturbances of memory12.
3. Symptoms of body. These include those symptoms that are predicated of the patient as a whole, which include his reaction to meteorological conditions, time bodily functions, food etc 14.
b. Longitudinal sectional study of the patient :
A study of the personal history right though the early formative years along with the family background and social and cultural afflictions enable to understand fully the development of the personality. The study of the past also, enables the physician to determine the constitutional and familial tendencies and miasmatic influences that operate in the patient. This helps in the selection of a constitutional remedy or an antimiasmatic remedy as the case demands, there by effecting a permanent cure12.
REMEDY SELECTION
The remedy is selected on the basis of totality of symptoms – simillimum. Selection of a remedy is best explained by susceptibility. Susceptibility is an expression of vacuum in an individual. Homoeopathic administration of a remedy is filling up the vacuum and meeting the susceptibility. A patient may be susceptible to a number of remedies but the greatest susceptibility is manifest to the simillimum15.
THE IMPORTANT REMEDIES FOR ATOPIC DERMATITIS ARE AS FOLLOWS:
Arsenicum album:
Itching, burning and offensive discharge. Eruptions, papular, dry, rough, scaly, worse cold scratching and at night18.Burns like fire as if a hot iron was thrust into the ulcer. Great restlessness, anxiety, anguish and fear of death19.Changes place continually. Thinks it useless to take medicine18.
Graphites:
Stout, of fair complexion, with tendency to skin affections and constipation, music makes her weep. Apprehensive, despondency, indecision. Very dry skin, never perspires, humid, spreading and scurfy eczema16. Eruptions, oozing out a thin, sticky exudation, worse at night18. Digestive system alternate with skin trouble. Internal burning, emaciation with skin disturbances20.
Mezerium:
Eczema intolerable itching worse in bed. Eruptions ulcerate and form thick scabs under which purulent matter exudes18.Affected part is cold and symptoms are of one side. External chilliness with internal burning. Itching aggravation warm bath20.
Rhus tox:
Extreme restlessness, with continued change of position. Burning eczema with scale
formation. The fresh cold air is not tolerated, it makes the skin painful. Eruptions
alternate with dysentery. Itching better by hot water and tendency to invade large
surfaces, rather than to penetrate deeply into tissues19.
Sulphur:
Dirty filthy people full of ulcers; standing is the worse position, walks stooping, and most symptoms on left side19.Very forgetful. Very selfish, no regard for others. Dry, scaly, unhealthy; every little injury suppurates. Itching, burning worse at night, warmth of bed, scratching and washing20.Excoriations especially in folds18.
Vinca minor:
Great sensitiveness of the skin, with redness and soreness from slight rubbing. Eczema of head and face; pustules, itching, burning and offensive odour worse at night18.Hair matted together. Weeping eczema intermingled with foul thick crust20.