Individualised Homoeopathic Management of SAPHO Syndrome: A Case Report

Dr M. S. Pratheeba Rani
Dr S. Jaimithra, MD

Abstract
SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis) is a rare chronic autoinflammatory disorder characterised by inflammatory osteoarticular lesions associated with dermatological manifestations. Owing to its variable clinical presentation and lack of a specific diagnostic test, the condition is frequently misdiagnosed, resulting in delayed treatment. Conventional management is mainly symptomatic, and long-term disease control remains challenging in many patients.

This case report describes the clinical course of a 34-year-old woman with recurrent palmoplantar pustulosis and sterile osteitis involving the right sternoclavicular joint. The diagnosis was established using the modified Kahn diagnostic criteria after exclusion of infective, autoimmune and malignant conditions. Individualised homoeopathic treatment was prescribed following detailed case-taking, evaluation of characteristic symptoms, repertorisation and Materia Medica consultation. Rhus toxicodendron was selected as the constitutional remedy based on the patient’s characteristic modalities and was later supported by an intercurrent prescription of Sulphur.

During twelve months of follow-up, the patient demonstrated progressive reduction in skin lesions, improvement in joint pain and morning stiffness, normalisation of inflammatory markers, and radiological improvement on magnetic resonance imaging. No major relapse occurred during the final three months of observation.

Although a single case cannot establish therapeutic efficacy, this report demonstrates the systematic application of individualised homoeopathic principles in the management of SAPHO syndrome and highlights the need for further well-designed clinical studies in this uncommon disorder.

Keywords : SAPHO syndrome; Palmoplantar pustulosis; Osteitis; Hyperostosis; Individualised homoeopathy; Case report

Abbreviations

• SAPHO – Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis
• ESR – Erythrocyte Sedimentation Rate
• CRP – C-Reactive Protein
• MRI – Magnetic Resonance Imaging
• HLA-B27 – Human Leukocyte Antigen B27
• ICD – International Classification of Diseases

Introduction
SAPHO syndrome is an uncommon chronic autoinflammatory disorder characterised by a combination of osteoarticular inflammation and dermatological manifestations, including palmoplantar pustulosis, severe acne and psoriasis. The syndrome encompasses a spectrum of sterile inflammatory bone lesions, hyperostosis and synovitis that most commonly involve the anterior chest wall, clavicle, sternoclavicular joints and spine. Because the cutaneous and skeletal manifestations may occur years apart, diagnosis is often delayed or mistaken for chronic osteomyelitis, septic arthritis, spondyloarthropathy or bone malignancy.

The diagnosis of SAPHO syndrome is primarily clinical and is based on recognised diagnostic criteria after careful exclusion of infectious and neoplastic conditions. Laboratory investigations are generally non-specific, while imaging studies such as magnetic resonance imaging and bone scintigraphy provide important supportive evidence. Conventional treatment includes non-steroidal anti-inflammatory drugs, corticosteroids, disease-modifying antirheumatic drugs, bisphosphonates and biological agents; however, responses are variable and complete remission is uncommon.

Reports describing the homoeopathic management of SAPHO syndrome remain extremely limited in the published literature. This case was selected because it demonstrates the application of classical homoeopathic principles in a rare chronic inflammatory disorder with combined dermatological and musculoskeletal manifestations. The report also illustrates the process of individualisation, repertorial analysis and remedy selection based on characteristic symptoms rather than diagnosis alone.

Objectives of the Study

1. To document the clinical presentation, diagnostic evaluation and management of a patient with SAPHO syndrome treated with individualised homoeopathy.
2. To demonstrate the process of homoeopathic case analysis, repertorisation and constitutional remedy selection in a rare chronic inflammatory disorder.
3. To evaluate the clinical outcome through serial follow-up, laboratory investigations and radiological assessment.

Case History
A 34-year-old woman presented to the outpatient department with recurrent painful pustular eruptions over both palms and soles for two years, associated with progressive pain and swelling over the right sternoclavicular joint for the preceding eight months. The skin lesions initially appeared as small sterile pustules that gradually enlarged, ruptured and healed with scaling, recurring every few weeks. The eruptions were associated with itching and occasional burning, causing difficulty in performing routine household activities.

The joint pain was dull, deep-seated and aching in nature, localised to the right sternoclavicular region with visible swelling. The pain was most severe on initiating movement after rest, particularly in the morning, and gradually improved with continued gentle movement. Cold and damp weather aggravated the symptoms, while warmth afforded relief. Mild morning stiffness of both wrists lasting approximately 20 minutes was also reported.

The patient had previously consulted several physicians and had received repeated courses of antibiotics and non-steroidal anti-inflammatory drugs on the suspicion of septic arthritis. Although temporary symptomatic relief was obtained, the symptoms recurred repeatedly, and no sustained improvement was achieved.

She associated exacerbations of both skin and joint complaints with periods of emotional stress at work.

Past Medical History
There was no history of tuberculosis, diabetes mellitus, psoriasis, inflammatory bowel disease, autoimmune disorders or previous major surgery. No history of trauma to the affected region was elicited.

Family History
The patient’s mother had a history of psoriasis. There was no family history of inflammatory arthritis, malignancy or autoimmune disease.

Personal History

• Appetite: Normal.
• Thirst: Increased; preferred large quantities of cold water at long intervals.
• Bowel habits: Regular.
• Bladder habits: Normal.
• Sleep: Refreshing, though disturbed during painful exacerbations.
• Perspiration: Profuse perspiration over the scalp during sleep.
• Thermal reaction: Chilly patient; preferred warmth.
• Addictions: None.

Mental Generals
The patient was anxious regarding the progressive nature of her illness and feared permanent damage to her bones. She was emotionally sensitive but tended to suppress her worries rather than express them openly. During painful episodes she became irritable when disturbed and preferred to remain quiet. She repeatedly examined the affected area during consultation and expressed concern that “the disease is slowly destroying my bone.”

Physical Examination

• The patient appeared moderately built and nourished. General examination was unremarkable.
• Local examination revealed diffuse swelling and tenderness over the right sternoclavicular joint without erythema or local warmth. Pain increased on initial shoulder movement but improved after repeated movement.
• Dermatological examination demonstrated multiple sterile pustules with surrounding erythema and scaling over both palms and soles. No active acne lesions were present.
• Systemic examination of the cardiovascular, respiratory, abdominal and neurological systems revealed no abnormality.

Diagnosis
The diagnosis of SAPHO syndrome was established on the basis of the characteristic clinical presentation, imaging findings and exclusion of infective and malignant conditions.

The coexistence of sterile palmoplantar pustulosis with inflammatory osteitis involving the sternoclavicular joint fulfilled the modified Kahn diagnostic criteria (2003) for SAPHO syndrome.

Differential diagnoses considered included:

• Septic arthritis
• Chronic recurrent multifocal osteomyelitis
• Seronegative spondyloarthritis
• Rheumatoid arthritis
• Primary bone tumour and metastatic disease
• These conditions were excluded by microbiological investigations, serological testing and radiological evaluation.

Although SAPHO syndrome has no dedicated ICD-10 code, the diagnosis was documented using M86.30 (Chronic multifocal osteomyelitis, unspecified) with L40.3 (Palmoplantar pustulosis). The corresponding ICD-11 classification recognises SAPHO syndrome as a distinct clinical entity.

The prognosis was explained to the patient as generally favourable regarding survival but characterised by a chronic relapsing course requiring long-term follow-up.

Investigations

• Routine laboratory investigations demonstrated mild systemic inflammation.
• Baseline investigations were as follows:
• Haemoglobin: Within normal limits
• Total leucocyte count: Normal
• Platelet count: Normal
• ESR: 42 mm/hour
• CRP: Mildly elevated
• Rheumatoid factor: Negative
• Anti-CCP antibody: Negative
• HLA-B27: Negative
• Liver and renal function tests: Within normal limits

Microbiological Examination
Culture of material obtained from a pustular lesion showed no bacterial growth, confirming the sterile nature of the lesions.

Radiological Findings
Magnetic Resonance Imaging (MRI) of the sternoclavicular region demonstrated bone marrow oedema with periosteal reaction involving the medial end of the clavicle and adjacent sternum, consistent with inflammatory osteitis.

Bone scintigraphy revealed increased radionuclide uptake involving the sternoclavicular region, producing the characteristic “bull’s head sign”, a recognised imaging feature supportive of SAPHO syndrome.

The clinical presentation, laboratory findings and imaging studies collectively supported the diagnosis after exclusion of infective and malignant pathology.

Case Analysis
Following detailed case-taking, the symptoms were evaluated according to classical homoeopathic principles, giving priority to characteristic, peculiar and individualising features rather than the pathological diagnosis alone.

Characteristic Symptoms

Mental Generals

• Anxiety regarding the future course of the illness.
• Suppression of emotions.
• Irrability when interrupted during pain.

Physical Generals

• Chilly patient.
• Desire for warmth.
• Profuse perspiration of the scalp during sleep.
• Thirst for large quantities of cold water at long intervals.

Particular Symptoms

• Pain in the sternoclavicular joint worse on beginning to move.
• Marked relief from continued gentle motion.
• Aggravation in cold, damp weather.
• Relief from warmth.
• Recurrent sterile pustules over palms and soles with itching and burning.

The chronic relapsing course of the disease, together with the family history of psoriasis, suggested a predominantly psoric miasm with sycotic predominance.

Repertorisation

Repertorisation was carried out using Kent’s Repertory of the Homoeopathic Materia Medica.

The principal rubrics selected were:

• Extremities – Pain – joints – amelioration from continued motion
• Generalities – Cold, damp weather – aggravation
• Generalities – Warmth – ameliorates
• Head – Perspiration during sleep
• Generalities – Thirst – large quantities at long intervals
• Skin – Eruptions – pustules – palms
• Skin – Eruptions – pustules – soles

Analysis of these rubrics indicated Rhus toxicodendron as the leading remedy.

Differential comparison was undertaken with Bryonia alba, Calcarea carbonica and Sulphur.

Bryonia alba was excluded because the patient’s pain improved with movement rather than worsened by motion.

Calcarea carbonica was considered because of perspiration of the head; however, the patient’s marked thirst and characteristic relief from continued motion did not correspond to its symptom picture.

Sulphur covered several dermatological features but did not correspond to the prominent musculoskeletal modalities observed during the initial consultation.

The totality of symptoms most closely corresponded with Rhus toxicodendron.

Remedy Selection and Prescription
Based on the repertorial result and confirmation from Boericke’s Materia Medica, Rhus toxicodendron 200C was prescribed as the constitutional remedy.

A single dose was administered, followed by placebo (Saccharum lactis).

The patient was advised to avoid unnecessary repetition of the medicine and to report any significant changes. Repetition of the remedy was based on clinical response rather than fixed intervals.

At six months, after substantial improvement in the acute musculoskeletal symptoms but persistence of mild cutaneous susceptibility, Sulphur 200C was prescribed as an intercurrent constitutional remedy in view of the underlying constitutional picture and residual psoric manifestations.

At twelve months, owing to sustained improvement with occasional residual tenderness, a single dose of Rhus toxicodendron 1M was administered.

Supportive physiotherapy for shoulder mobility was continued throughout the treatment period. No additional conventional medication was required after commencement of homoeopathic treatment.

Follow-up : The patient was reviewed regularly over a period of twelve months.

Initial Visit
Prescription: Rhus toxicodendron 200C, single dose.

Assessment: Active palmoplantar pustulosis with sternoclavicular pain (VAS 7/10) and morning stiffness lasting approximately 20 minutes.

4 Weeks

Prescription: Placebo; remedy withheld.

Assessment: Mild aggravation of skin lesions for three days, followed by noticeable improvement. Sternoclavicular pain reduced to VAS 4/10, and morning stiffness decreased to approximately 10 minutes.

8 Weeks

Prescription: Rhus toxicodendron 200C repeated.

Assessment: Significant reduction in the frequency of pustular eruptions. Pain further reduced to VAS 3/10, with improvement in sleep quality and ability to perform daily activities.

6 Months

Prescription: Sulphur 200C, single dose (intercurrent remedy).

Assessment: Skin lesions were largely quiescent, with only occasional mild stress-related flare-ups. Sternoclavicular pain reduced to VAS 1–2/10, and ESR showed a downward trend.

12 Months

Prescription: Rhus toxicodendron 1M, single dose.

Assessment: No new pustular eruptions during the preceding three months. Only minimal tenderness remained over the sternoclavicular joint. ESR and CRP returned to normal limits, and follow-up MRI demonstrated a marked reduction in bone marrow oedema.

The patient was advised to continue annual follow-up because SAPHO syndrome has a chronic relapsing course. Future prescriptions would be based on any changes in the totality of symptoms following individualised homoeopathic principles.

Discussion
SAPHO syndrome is an uncommon chronic autoinflammatory disorder characterised by sterile osteitis, hyperostosis, synovitis and inflammatory skin manifestations. Owing to its rarity and heterogeneous clinical presentation, diagnosis is frequently delayed, particularly when osteoarticular and cutaneous manifestations do not appear simultaneously. In the present case, the patient had initially received repeated courses of antibiotics because infective arthritis was suspected. The diagnosis became evident only after correlating the characteristic palmoplantar pustulosis with imaging findings of sterile sternoclavicular osteitis and excluding infective, autoimmune and malignant causes.

The management of SAPHO syndrome remains challenging. Conventional treatment aims primarily at controlling symptoms using non-steroidal anti-inflammatory drugs, corticosteroids, disease-modifying antirheumatic drugs, bisphosphonates or biological agents. However, therapeutic responses are variable, and recurrence is common. Consequently, many patients require prolonged follow-up and repeated treatment.

Homoeopathic management in the present case was based on the principle of individualisation rather than the disease diagnosis. The prescription was guided by the patient’s characteristic modalities, physical generals, mental symptoms and overall constitutional picture. The prominent modalities—pain aggravated on beginning to move and relieved by continued movement, aggravation from cold damp weather, amelioration from warmth, profuse perspiration of the scalp during sleep and thirst for large quantities of cold water—formed the basis of repertorial analysis and Materia Medica differentiation.

Rhus toxicodendron corresponded closely to the totality of symptoms and was selected as the constitutional remedy. During follow-up, a brief initial aggravation was observed, followed by progressive improvement in both musculoskeletal and cutaneous symptoms. An intercurrent prescription of Sulphur was later administered after improvement had stabilised, with the intention of addressing the underlying constitutional susceptibility. Subsequent follow-up demonstrated continued clinical improvement without significant relapse.

The improvement observed was reflected not only in subjective symptoms but also by reduction in inflammatory markers and radiological improvement on MRI. Nevertheless, the chronic relapsing nature of SAPHO syndrome should be recognised, and a favourable outcome in a single patient cannot establish therapeutic efficacy or prove causality. Spontaneous fluctuations in disease activity and the supportive role of physiotherapy may also have contributed to the overall clinical course.

Despite these limitations, the present report contributes to the limited published literature describing the application of individualised homoeopathy in SAPHO syndrome. Carefully documented case reports may provide valuable clinical observations and generate hypotheses for future prospective studies employing validated outcome measures and longer follow-up.

Conclusion
This case demonstrates the systematic application of classical individualised homoeopathy in the management of a patient with SAPHO syndrome. Prescription was based on characteristic symptoms obtained through detailed case-taking and repertorial analysis rather than on the pathological diagnosis alone.

During twelve months of observation, the patient experienced progressive reduction in palmoplantar pustulosis, marked improvement in sternoclavicular pain and morning stiffness, normalisation of inflammatory markers and favourable radiological changes. Although these findings suggest a positive clinical association with the prescribed treatment, they should be interpreted cautiously because conclusions cannot be drawn from a single case report.

Further well-designed observational studies and controlled clinical research are required to evaluate the potential role of individualised homoeopathy in patients with SAPHO syndrome.

Patient Consent
Written informed consent was obtained from the patient for publication of this case report and the accompanying clinical information. Every effort has been made to preserve patient anonymity.

Ethical Considerations
Institutional Ethics Committee approval was not required for this anonymised single-patient case report. The report was prepared in accordance with the ethical principles of the Declaration of Helsinki.

Conflict of Interest
The authors declare that they have no conflict of interest.

Funding
No financial support or external funding was received for this work.

Author Contributions
Dr M. S. Pratheeba Rani: Case management, case documentation, case analysis, manuscript preparation and final approval.
Dr S. Jaimithra: Literature review, manuscript revision, critical intellectual input and final approval.

Acknowledgements
The authors sincerely thank the patient for providing consent to publish this case and for her cooperation throughout the treatment and follow-up period.

References

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Dr M. S. Pratheeba Rani, MD (Hom)
Gold Medalist & Senior Homeopathic Consultant
204-B, Santhapet, Gudiyattam – 632602, Tamil Nadu, India
Contact: +91 9842089006 / +91 9514335168
Email: skhcgudiyattam@gmail.com

Dr S. Jaimithra, MD
Senior Homeopathic Consultant
Nadupet, Gudiyattam, Tamil Nadu, India
Contact: +91 91501 03765