Psoriasis and Homoeopathic Management

Dr Rubina Mansoori  

Psoriasis is a chronic, autoimmune genetic disease manifesting as skin lesions and affecting approximately 2% of the global population.

Key words: Psoriasis, Immune-mediated Disease, Homoeopathy, PASI score, DQLI score

DEFINITION OF PSORIASIS:
Psoriasis is a complex, chronic, multifactorial, inflammatory disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate.

According to the International Classification of Diseases, Tenth Revision, psoriasis falls under the ICD-10 code range L40-L45.

EPIDEMIOLOGY AND GENETICS:

• The prevalence of psoriasis is said to be 2% of the world’s population.
• The prevalence of psoriasis in India is estimated to be between 0.44% and 2.8% of the adult population.
• A positive family history has been reported by 35% to 90% of patients with psoriasis.
• If both parents had psoriasis, the risk of their child developing psoriasis was 41%, whereas if only one parent were affected, the risk was 14%; the risk was 6% if just one sibling had psoriasis.
• First peak reported to occur at 15–20 years of age and a second one at 55–60 years.
• Psoriasis is associated with HLA-Cw6, with the presence of HLA-Cw6 conferring a relative risk for developing psoriasis.

MODYFYING AND TRIGERRGING FACTORS:

1. Koebner phenomenon : It refers to the induction of lesions by cutaneous trauma of any kind—be it physical, chemical, mechanical, allergic, or of any other nature. Psoriatic lesions tend to develop at sites of skin injury. Induction has been reported at sites of sunburn, operation wounds, vaccination, site of bites (insects, animals),burns, drug reactions, dermatitis, lichen planus, miliaria, pressure, skin tests, vitiligo, and herpes zoster.
2. Infections: Beta-hemolytic streptococcal throat infection often precede guttate psoriasis. Severe psoriasis may be the initial presentation of HIV infection.
3. Sunlight: Psoriasis may occur or worsen after sun exposure, mainly due to Kobnerisation at sights of sunburn or polymorphic light eruption.
4. Endocrine factors: Hypocalcemia has been reported to be a triggering factor for generalized pustular psoriasis.
5. Pregnancy: Pregnancy may alter disease activity, e.g. 50% of the patients in one series reported improvement. However, postpartum period, more often than not, sees an exacerbation.
6. Seasonal Variations: Most patients experience worsening of psoriasis during winters. High humidity is usually considered beneficial.
7. Alcohol consumption, smoking and obesity: Obesity, increased alcohol consumption, and smoking have all been associated with psoriasis. Weight gain often precedes the development of psoriasis.
8. Drugs: There are many drugs that have been implicated in precipitating or exacerbating psoriasis. These include beta-blockers, lithium, antimalarials, imiquimod, NSAIDs, IFNs, and ACE inhibitors. Too rapid withdrawal of corticosteroid therapy in patients with psoriasis may result in precipitation of pustular psoriasis as well as flares of plaque psoriasis or may cause erythroderma as a rebound phenomenon.
9. Psychogenic stress: Psychogenic stress is a triggering factor in psoriasis, with a heightened cortisol response to stress.² It have an abnormal hypothalamic–adrenal axis response to acute stress. Stress might induce alterations in the psoriatic lesion by increasing the neuropeptide content with a concomitant decrease in the activity of neuropeptide-degrading enzymes, especially mast cell chymase. An increased beta endorphin levels, normally observed in psoriatic skin, might affect both substance P (SP)-mediated neurogenic inflammation and transmission of sensory stimuli by its local antinociceptive effects. A marked proliferation of cutaneous nerves and elevated levels of SP, vasoactive intestinal peptide (VIP), protein gene product (PGP 9.5), calcitonin gene-related peptide (CGRP), and nerve growth factor (NGF) have been documented in plaques of psoriasis. These neuropeptides can initiate cutaneous inflammation. interactional networks between cutaneous nerves, keratinocytes, melanocytes, dermal mast cells, Langerhans cells, and microvascular endothelial cells. These networks suggest the possibility of neurogenic inflammation,referring to the release of neuropeptides from peripheral nerve endings of non-myelinated C and thinly myelinated Ad fibers. These can induce a cascade of pro-inflammatory events when they are stimulated antidromically.

ETIOPATHOGENESIS:

Epidermal hyperproliferation with loss of differentiation:

The transit time for keratinocyte migration from basal layer to shedding from stratum corneum, is shortened from approximately 28 to 5 days so that immature cells reach the stratum corneum prematurely.⁵ The cell cycle time of hyperproliferating psoriatic keratinocytes is short. While maturation and shedding of keratinocytes takes 28 days in normal epidermis ,it occurs in 5 days in psoriatic epidermis. Growth factors released by various cell types stimulate the increased cell proliferation of keratinocytes.

Dilatation and proliferation of dermal blood vessels (angiogenesis):

It involves vascular changes with tortuosity of dermal capillary loop vessels and release of mediators such as vascular endothelial growth factor (VEGF), IL-8 secreted  by keratinocytes.⁵

The endothelial cells swell and become activated. The activated endothelial cells gets activated and lay down the basement membrane for structural support to form novel vessel network. Activation and swelling of endothelial cells results in widening of intracellular spaces and dermal blood vessels dilate.

Antigen driven activation of autoreactive T- cells and accumulation of inflammatory cells:

The occurrence of triggering environmental factors in genetically predisposed individuals causes stressed keratinocytes which induce interferon-α (IFN-α) production by plasmacytoid dendritic cells ,thereby activating dermal DCs (dDCs). Keratinocyte-derived interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) also contribute to the activation of dDCs. Activated dDCs then migrate to the skin-draining lymph nodes to present an as-yet-unknown antigen to T cells and (via secretion of different types of cytokines such as IL-12 and IL-23 by DCs) which promote their differentiation into T helper 1 (Th1), Th17, and Th22 cells. Th1 cells, Th17 cells and Th22 cells  migrate via lymphatic and blood vessels into psoriatic dermis, attracted by the keratinocyte-derived chemokines ,this ultimately leads to the formation of a psoriatic plaque. Th1 cells release IFN-γ and TNF-α, which amplify the inflammatory cascade, acting on keratinocytes and dDCs. Th17 cells secrete IL-17A and IL-17F (and also IFN-γ and IL-22), which stimulate keratinocyte proliferation and the release of β-defensin 1/2, S100A7/8/9 and the neutrophil-recruiting chemokines CXCL1, CXCL3, CXCL5 and CXCL8. Neutrophils (N) infiltrate the stratum corneum and produce reactive oxygen species (ROS) and α-defensin with antimicrobial activity, as well as CXCL8, IL-6 and CCL20. Th22 cells secrete IL-22, which induces further release of keratinocyte-derived T-cell-recruiting chemokines. Moreover, inflammatory DCs (iDCs) produce IL-23, nitric oxide (NO) radicals and TNF-α, while natural killer T (NKT) cells release TNF-α and IFN-γ. Keratinocytes also release vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiopoietin (Ang), thereby promoting neoangiogenesis. Macrophage (M)-derived chemokine CCL19 promotes clustering of Th cells expressing chemokine receptor CCR7 with DCs in the proximity of blood vessels, with further T-cell activation. At the dermal–epidermal junction, memory CD8+ cytotoxic T cells (Tc1) expressing very-late antigen-1 (VLA-1) bind to collagen IV, allowing entry into the epidermis and contributing to disease pathogenesis by releasing both Th1 and Th17 cytokines. Cross-talk between keratinocytes, producing TNF-α, IL-1β and transforming growth factor-β (TGF-β), and fibroblasts, which in turn release keratinocyte growth factor (KGF), epidermal growth factor (EGF) and TGF-β, and possibly Th22 cells releasing FGFs, contribute to tissue reorganization and deposition of extracellular matrix (e.g. collagen, proteoglycans). LC, Langerhans  cell.

HISTOLOGIC FEATURES:

• In the papillary dermis, the capillaries are increased in number and length and they have a tortuous appearance.
• The epidermis is acanthotic (thickening) with focal accumulations of neutrophils and lymphocytes.
• The granular layer is absent and the stratum corneum still contains flattened nuclei (parakeratosis). In the stratum corneum, large accumulationsof neutrophils are observed, surrounded by parakeratosis (retention of nuclei in stratum corneum).
• The accumulation of neutrophils within a spongiotic pustule is referred to as a “spongiform
• pustule of Kogoj and the accumulation of neutrophil remnants in the stratum corneum, surrounded by parakeratosis, as a “microabscess of Munro”.
• In the papillary dermis, the capillaries are elongated and tortuous, extending upward into elongated club-shaped dermal papillae; only a small suprapapillary plate of epidermal cells covers the tip of these dermal papillae. (“Auspitz” phenomenon)
• The rete ridges are elongated and have a squared-off appearance. The bases of some of the rete ridges also coalesce. The horny layer has parakeratotic foci with an absence of the stratum granulosum.

CLINICAL FEATURES OF PSORIASIS:

SYMPTOMS:

Most commonly, psoriasis presents as chronic, bilaterally symmetrical, well-defined, erythematous, dry, red, scaly papules, and plaques.

The skin lesions share the same important hallmarks: erythema, thickening, and scale. ²

SIGNS:

Auspitz sign:

Grattage Test: Scales in a psoriatic plaque can be accentuated by grating with a glass slide.

Gently scrape lesion with a glass slide. This accentuates the silvery scales (Grattage test positive). Scrape off all the scales.

When the scales are completely scraped off, the stratum mucosum (basement membrane) is exposed and is seen as a moist red surface (membrane of Bulkeley) through which dilated capillaries can be seen as red spots.

On further scraping, these capillaries at the tips of elongated papillae are torn leading to multiple bleeding points. This is a characteristic feature of psoriasis and is known as “Auspitz sign”.

Woronoff’s ring: Psoriatic lesions are sometimes surrounded by a pale blanching ring, or hypopigmented halo which is referred to as Woronoff’s ring.

Koebner’s phenomenon: There is development of isomorphic lesions at the sites of local trauma in an uninvolved area of the skin of a psoriatic patient.

TYPES OF PSORIASIS:

Chronic Plaque Psoriasis (Psoriasis Vulgaris):

This is the commonest type of psoriasis, seen in 90% of patients.

Site of lesion: Often symmetrical lesions on the elbows and knees; additional sites include the scalp, presacrum, hands, feet, intergluteal fold, and umbilicus.

The scalp, elbows, knees and lumbosacral area are sites of predilection, as are the hands and feet. The genitalia are involved in up to 45% of patients.

Present more commonly on the extensor surfaces of the body (particularly the

elbows and knees), lumbosacral area and back

Characteristics of lesion: Well-demarcated, erythem­atous plaque with silvery scale.

Lesions may be surrounded by a peripheral, blanching ring (Woronoff ’s ring), especially when patient is receiving phototherapy.

Variations in distribution
	Site of lesion	Characteristics of lesion
Scalp Psoriasis	Scalp and Scalp margins The lesions of psoriasis often advance onto the periphery of the face, the retroauricular areas and the posterior upper neck.	Well-demarcated, erythematous plaques with silvery scale. Scale may be attached for some distance onto scalp hairs, giving an asbestos-like appearance (pityriasis amiantacea). Occasionally alopecia may be seen within lesions
Palmoplantar Psoriasis	Palmar and plantar surfaces	Erythematous scaling plaques of the palmar and plantar surfaces . Occasionally, there is well-demarcated hyperkeratosis with minimal erythema
Nail Psoriasis	Nail matrix ,nail bed, and hyponychium.	Fingernails > toenails Associated with psoriatic arthritis. Findings include nail pitting, oil spots (salmon patch), onycholysis with proximal red rim, splinter hemorrhages, subungual debris. Nail matrix psoriasis: which manifests as: Pitting: deep, irregular pits. Nail bed psoriasis: which manifests as: Nail plate thickening: which is not friable. Subumgual hyperkeratosis: accumulation of solid keratinous material under nail plate. Discoloration and dystrophy of nail plate: nail plate becomes yellow or brown and dystrophic. Onycholysis: separation of distal nail plate from the nail bed. Oil spots: yellow red discoloration in centre of nail.
Variations In Morphology And Distribution
	Site of lesion	Characteristics of lesion
Guttate Psoriasis	More common on trunk, it can also involve head and limbs. The palms and soles are usually spared.	Small papule or plaque (3 mm to 1.5 cm) with adherent scale. Affects children > adults. Often preceded by an upper respiratory tract infection.
Erythrodermic Psoriasis	Affection of most or all of the body seen as widespread	Generalized erythema of the skin, with areas of scaling. Gradual or acute onset. Nail changes, facial sparing, and a history of typical plaque-type psoriasis may be helpful clues.
Inverse Psoriasis	Axilla and groins Axilla, inguinal crease, intergluteal cleft, inframammary area, and retroauricular fold.	Shiny, pink, well-demarcated thin plaques with minimal scale.
Pustular Psoriasis	All over body	Generalized pustular psoriasis (von Zum­busch pattern). Erythema and sterile pustules arising within erythematous, painful skin; lakes of pus characteristic. Often associated with fever. Triggering factors – pregnancy (termed impetigo herpetiformis),  rapid tapering of CS, hypocalcemia, infections.
	Palm and Sole	Localised Palmoplantar pustular psoriasis  (pustulosis) Sterile pustules on palms/soles. May have no evidence of psoriasis elsewhere. Triggering factors – infections, stress. May be aggravated by smoking. Associated with inflammatory bone lesions
Sebopsoriasis	Lesion occur in the distribution pattern of seborrhoeic dermatitis.	Lesions tend to have yellowish rather than silvery scale.

PSORIATIC ARTHRITIS:

• Seen in 5–30% of patients with cutaneous psoriasis.
• Most commonly is an asymmetric oligoarthritis affecting the distal interphalangeal joints.
• More rarely, but classically, is arthritis of all the interphalangeal joints.
• Occasionally, presentation is rheumatoid arthritis-like, affecting small- and medium-sized joints symmetrically.
• Arthritis mutilans – rare form with acute, rapidly progressive joint inflammation and destruction; softening and telescoping of the digits.
• Spondylitis and sacroiliitis – axial arthritis as well as arthritis of the knees and sacroiliac joints; may be HLA-B27-positive and may have associated inflammatory bowel disease or uveitis.

COMORBIDITIES ASSOCIATED WITH PSORIASIS:

Fig. 2- Comorbidities Associated With Psoriasis

• The association of psoriasis with diabetes has been known for more than a century and with cardiovascular disease.
• The studies indicate that general medical issues comprising the “metabolic syndrome” (i.e., diabetes, dyslipidemia, hypertension, and obesity) should be taken care of when treating patients with moderate to severe psoriasis.
• Both adults and children with psoriasis have found that metabolic syndrome and its individual constituents are more prevalent in patients with psoriasis.
• As body weight is concerned, there is a direct relationship between increasing body mass index (BMI) and incident psoriasis.
• Psoriasis also confers an increased risk of diabetes mellitus. Increasing severity of psoriasis increases the risk of acquiring diabetes and also its microvascular complications.
• Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis have also been associated with psoriasis. A few recent studies have shown an association with crohn’s disease, but not with ulcerative colitis.

• There is possibly an association with gout as well, although it may be more related to the treatment received.
• Hypocalcemia has been associated with severe and pustular forms of the disease.
• Associations with systemic disease include lymphoma and cancer.
• Psoriasis is known to have a significant negative impact on the patient’s QoL. Profound psychological morbidity, in particular with depression, is often associated. At least one-third of patients suffer from pathological worry and anxiety. Concerns about appearance can result in reduced self-esteem, embarrassment, guilt, suicidal ideation, sexual problems, and employment problems. Feeling of stigmatization can lead to non-compliance with treatment and worsening of the disease. Stress in the form of pathological worry has a deleterious effect on response to therapy.
• Psoriatic arthritis, a seronegative arthropathy, is a frequent and classical association with psoriasis.
• Some of the skin diseases associated with psoriasis include acquired bullous disorders, especially bullous pemphigoid and vitiligo.

INVESTIGATIONS:

The diagnosis of psoriasis can usually be made on clinical grounds alone and a biopsy is rarely, if ever, required.

Biopsy:

Skin biopsy shows the following :

Epidermal changes:

• Loss of granular layer and regular acanthosis.
• Suprapapillary thinning.
• Collection of polymorphs in the epidermis to form spongiform pustule of Kogoj and Munro’s micro abscesses.

Dermal changes:

• Dilatation and tortuosity of capillary loops in the dermal papillae.
• Lymphocytic infiltrate in the upper dermis.

Biochemical or serological:

The biochemical or serological changes are inconsistently observed in patients with psoriasis. These include an elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP),

serum uric acid levels, a decreased serum folate.

Serum immunological markers:

There are many serum immunological markers reported to be elevated in psoriasis including

soluble IL-2 receptor, soluble ICAM-1, IL-6, and TNF-α. However, the clinical significance or use of these markers as diagnostic or prognostic indicators has not been proven.

Other Tests:

Rule out:

• Metabolic syndrome, diabetes, insulin resistance, hypertension and dyslipidemia.
• Hypocalcemia, especially in pustular psoriasis.
• Anaemia and hypoproteinemia, in erythrodermic psoriasis.

Radiological Changes:

In Psoriatic Arthritis simultaneous presence of ankylosis, periosteal new bone formation, erosions and osteolysis strongly suggestive of psoriatic arthritis.

SCALE FOR CALCULATING PSORIASIS:

The Psoriasis Area and Severity Index (PASI):

The Psoriasis Area and Severity Index (PASI) is a quantitative rating score for measuring the severity of psoriatic lesions based on area coverage and plaque appearance.

Intensity/Severity of psoriatic lesions: A representative area of psoriasis is selected for each body region.

In this area, the intensity of each of the following signs is assessed as none (0), mild (1), moderate (2), severe (3) or very severe (4).

• Redness,
• Thickness
• Scaling

The three intensity scores are added up for each of the four body regions to give subtotals A1, A2, A3, A4.

Each subtotal is multiplied by the body surface area (BSA) represented by that region.

• A1 x 1 gives B1
• A2 x 2 gives B2
• A3 x 3 gives B3
• A4 x 4 gives B4

Area Spread/Area of psoriatic involvement: The percentage area affected by psoriasis is evaluated in the four regions of the body. In each region, the area is expressed as nil (0), 1-9%  (1), 10-29%  (2), 30-49%  (3), 50-69%  (4), 70-89%  (5),  90-100%  (6).

• Head and neck

• Upper limbs
• Trunk

• Lower limbs

Each of the body area scores is multiplied by the area affected.

• B1 x (0 to 6)= C1
• B2 x (0 to 6)= C2
• B3 x (0 to 6)= C3

B4 x (0 to 6) = C4                                   

Total score: The PASI score is C1 + C2 + C3 + C4.

PASI scoring table:

	Before treatment		Total	After treatment		Total
Severity of psoriatic lesion	Head	Erythema- Induration- Scaling-	A1=	Head	Erythema- Induration- Scaling-	A1=
	Upper limb	Erythema Induration Scaling	A2=	Upper limb	Erythema Induration Scaling	A2=
	Trunk	Erythema Induration Scaling	A3=	Trunk	Erythema Induration Scaling	A3=
	Lower limb	Erythema Induration Scaling	A4=	Lower limb	Erythema Induration Scaling	A4=
Correction factor for area of involvement	Head	A1 × 0.1	B1=	Head	A1 × 0.1	B1=
	Upper limb	A2 × 0.2	B2=	Upper limb	A2 × 0.2	B2=
	Trunk	A3 × 0.3	B3=	Trunk	A3 × 0.3	B3=
	Lower limb	A4 × 0.4	B4=	Lower limb	A4 × 0.4	B4=
Area of psoriatic involvement (degree of involvement)	Head	B1 × BSA score	C1=	Head	B1 × BSA score	C1=
	Trunk	B2 × BSA score	C2=	Trunk	B2 × BSA score	C2=
	Upper limb	B3 × BSA score	C3=	Trunk	B3 × BSA score	C3=
	Lower limb	B4 × BSA score	C4=	Lower limb	B4 × BSA score	C4=
Total Score C1 + C2 + C3 + C4

Dermatology Life Quality Index (DLQI):

The Dermatology Life Quality Index questionnaire is designed for use in adults, i.e. patients over the age of 16.

Scoring:

The scoring of each question is as follows:

Very much         scored 3

A lot                   scored 2

A little                 scored 1

Not at all             scored 0

Not relevant        scored 0

Question 7, ‘prevented work or studying’   scored 3

How To Interpret Meaning Of DLQI Scores:

0 – 1 no effect at all on patient’s life

2 – 5 no effect at all on patient’s life

6 – 10 moderate effect on patient’s life

11 – 20 very large effect on patient’s life

21 – 30 extremely large effect on patient’s life

DLQI scoring table:

Quality Of Life	Before treatment Score	After treatment Score
Over the last week, how itchy, sore, painful or stinging has your skin been?
Over the last week, how embarrassed or self conscious have you been because of your skin?
Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?
Over the last week, how much has your skin influenced the clothes you wear?
Over the last week, how much has your skin affected any social or leisure activities?
Over the last week, how much has your skin made it difficult for you to do any sport?
Over the last week,has your skin prevented you from working or studying?
Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?
Over the last week, how much has your skin caused any sexual difficulties?
Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?
Total Score

 MIASMATIC EVALUATION OF PSORIASIS:

Psora	Sycosis	Syphilis	Tubercular
Eruption are papular and associated with itching. Scales and crust ,thin and light, fine and small and usually quite general over affected part Psoriasis have syco- psoric base.     Psoric nails have dry, harsh appearance	Fish scale eruption can be psyco –psoric or tri miasmatic combining the dryness of psora, thickened skin of sycotic and squamous character of syphilis. Psoriasis has gouty element.     Sycotic nails are thick Ridges which can be longitudinal or horizontal on the nails.	Ulcerated skin with pus and blood represent syphilis. Scale and crust thick and heavy patchy. Eruption   found                about joint, flexures of body. Deep cracks and fissures in the skin (mainly palms and soles)   Syphilitic nails are thin. Pitted nails	Eruption pustular. 11 Skin eruption with glandular involvement.                     Recurrent brittle nails which drop off and then grow again
Carbonitrogenoid constitution	Hydorgenoid costitution	Oxygenoid costitution	Changeable constitution                        with alternation                        and periodicity
Eruptive diathesis	Rheumatic        and gouty diathesis. Lithic and uric acid Proliferative diathesis.	Suppurative      or ulcerative diathesis	Scrofulous diathesis
Psoric skin complaints are aggravated by cold,in winter and from undressing.     Amelioration from natural discharges such as   sweat,   from reappearance                               of suppressed      skin eruptions.	Sycotic skin eruptions are aggravated by consumption of meat, humid, rainy weather and from changes in weather.         Amelioration in dry weather.	Syphilis skin complaints are aggravated in night, in summer, from warmth of bed and from warmth in general.             Amelioration    from abnormal discharge.	Tubercular                          skin complaints           are aggravated at night, by touch and pressure, thinking of complaints, warmth of bed.       Amelioration from open air, dry weather

HOMEOPATHIC MANAGEMENT:

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

Arsenic Album: Skin dry, scaly, bran like, with itching and burning; eruption like fish scales; wax like, dirty, white skin. Desquamation of the skin of the body. The skin of the whole body peels off in large scales. The thickened epidermis comes off. The skin of the whole body, except the head, came off. Desquamation of a large part of the body. Worse: midnight; after midnight; after ,sea shore ,Quinine Better: hot applications (Dry).

Calcarea Carb: Skin eruptions covered with bran – like scales, eruptions with thick scales and yellow pus under them; Itching, agg. towards evening and in bed; eruptions, burn and itch; burning itch with heat, pricking, smarting, itching, agg. by cold, yet not amel. by heat, sweaty palms.

Lycopodium: Psoriasis of the hands and fingers has the same furfuraceous look, occasionally fissured and bleeding. Eruptions about the knees, genitals, ears, face; glandular swellings, fissures on the heels with watery oozing. Pustules exuding bloody, corrosive, putrid pus, sometimes milky or curdled. Burning, or burning itching. Skin becomes thick and indurated. Dry, shrunken, especially palms, Violent itching; fissured eruptions. Worse warm applications. Better: Cold applications.

Phosphorus: Psoriasis on the knees, elbows legs and eyebrows. Red points, with corrosive itching, in a spot as large as the hand, in the bend of the right elbow. Desquamation of the epidermis. The skin of the hands is very rough and dry. The skin cracked over the finger-joints, as from great cold. Indurations in the skin. Itching, scabby, cracked, and scaly eruption on different parts of the body; the arms and hands most affected. Itching eruption upon the anterior surface of the arms, from the bends of the elbow down nearly to the wrist. Eruption on the right hands, extends along and anterior surface of the ulnar side of the hand; on the left, it extended over the metacarpal bone of the thumb. Burning in the skin of both upper arms Burning sensation in the palms of the hands. Irresistible desire to scratch, which temporarily relieved; continued scratching caused a raw, smarting, burning, rarely relieved; continued scratching caused a raw, smarting, burning, sore feeling. Aggravation: change of weather, putting hands in cold water. Ameoliration-washing with cold water

Sulphur: Desquamation of the fingers (the epidermis scales off in round spots). Eruption with burning itching. Ill effects of alcohol. Red burning spots in the upper and forearms (after washing with soap and water). The scales on the head in great numbers, the patches of eruption appeared less red after the bath. Formation of an erythematous patch, the size of the palm, on the outside of the leg, which, especially at night in bed, itches constantly, compelling him to scratch. A scaly eruption, which had been driven away by external applications, reappeared, with violent burning, itching, after scratching. Scaly, rough, dry, harsh, agg. after bathing or after washing in water. Itching all over body, painful after scratching; itching, amel. after scratching but followed by smarting and burning. Itching, agg. at night, in bed, covering up warm; obliged to scratch until it bleeds.

Nux Vomica: Ill effects of alcohol, drugs. Eruptions with burning, pricking, itching. Aggravation – Evening. Mental worry. Amelioration – Warmth

Pulsatilla: Psoriasis with a burning itching on becoming warm in bed, before midnight, aggravated by scratching; is unable to sleep on account of it. Intolerable itching in the evening in bed.

Natrum Mur: Skin dry, rough; itching, amel. by scratching. Itching agg. behind ears, bends of knees, elbows, border of hair and scalp.

Psorinum: Psoriasis, dark red or brownish color, scales thick, grayish white; patient dreads the cold, yet itching is agg. in warm room or in bed. Thick, dirty looking mass, composed of scales and pus, itching intensely. Burning stinging itching, sleepless from intolerable itching, stings when body becomes warm, agg. night when in bed. Scratches until it bleeds, itching with burning or with a biting sensation, agg. in cool air, night, in bed.

Arsenicum Iodatum: Dry, scaly, itching. Psoriasis. Marked exfoliation of skin in large scales, leaving a raw exuding surface beneath. Worse from dry, cold weather.

Kali Arsenicum: Psoriasis in numerous patches, with great itching. Discoloration of skin after psoriasis. Dry, scaly, wilted skin. Better on rainy days. Aversion to open air.

REFERENCES:

1. IADVL Textbook of Dermatology, S. Sacchidanand Bhalani Publisher, 5th Edition, 2022
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14. https://emedicine.medscape.com/article/1943419-overview?form=fpf
15. https://pmc.ncbi.nlm.nih.gov/articles/PMC4928455/
16. https://pmc.ncbi.nlm.nih.gov/articles/PMC5134161/
17. https://dermnetnz.org/topics/pasi-score
18. https://www.imperial.nhs.uk/-/media/website/services/dermatology/patient-forms/dermatology-life-quality-iindex-dlqi.pdf

Dr. Rubina Mansoori MD (Hom)
Homoeopathic Materia Medica, Navi Mumbai
Email : rubin3040@gmail.com