GOUT

Gout is metabolically mediated type of arthritis strongly associated with genetics as a major cause, to which diet and lifestyle plays a contributory factor in its pathogenesis.It is primarily caused due to disorder of purine metabolism (purine is one of the major component of our gene it forms base pairs / nucleotides with pyrimidine to give structure to our gene; also purine is present in many food that we eat esp. certain sea food and many pulses).

Its when the final product of purine metabolism i.e uric acid, starts crystallizing and forming Monosodium Urate Monohydrate then it starts depositing in joint and tissues around joint its called gout and not mere hyperuricemia can be termed as gout.

PATHOGENESIS OF GOUT

GOUT PATHOGENESIS FLOW CHART
Purine De Novo Synthesis with Salvage Pathway and GOUT
Purine De Novo Synthesis with Salvage Pathway and GOUT

Overproduction of uric acid may be due to one or more of following factors:-

  • Catabolism,
  • Loss of purine salvage mechanism,
  • Defective or sluggish transportation,
  • Under excretion of uric acid,
  •  Reduced elimination of uric acid due competition of metabolites for elimination,

which results into  hyperuricemia triggering Gout.

Although hyperuricemia has been found to trigger gout but many having maintaining uric acid within normal limits still develop gout and many having uric acid on higher side are still not developing gout. So genetics has major role in determining at what level of serum uric acid the patient may develop Gout.

When Uric acid crystalises into monosodium urate, it then starts precipitating in joints, tendons and surrounding tissues,in small clusters of deposits called tophi. Each tophus is collection of monosodium urate crystals surrounded by a protein wall. This protein wall prevents its interaction with surrounding cells and thus prevents inflamatory response. Occasionally this walled-off tophi breaks open the protein wall and so the urate crystals comes out naked in contact with surrounding cells, which may be due to medical, surgical metabolic, physical stress or sometimes even rise in serum uric acid levels may lead to breaking of this wall, which causes acute inflamation and sets in acute arthritis within few hours.

SYMPTOMS OF GOUT

Its usually observed that small joints of extremities which are not sufficiently insulated to tolerate cold and shocks and those that are in region where circulation is affected due to gravity dependence, like great toe and ankle , small joints of feet, hands and wrist are more prone compared to other joints. Although it can affect all the joints and can present itself with different signs and symptoms but it is classically known as Podagra for the one characteristic symptom it frequently presents in most of the patients, its the intense burning and sharp excruciating pain with mild redness and swelling especially on base of great toe (at first metatarso-phalangeal joint) starting suddenly and frequently at night waking patient up from sleep.

 

 GENES ASSOCIATED WITH HYPERURICEAMIA AND GOUT

1) Absence of gene associated with breakdown of Uric Acid.

In humans unlike other carnivorous primates(meat eater in particular) the Uricase /urate oxidase, an enzyme which breaks down uric acid to 5hydroxyisourate then to allantoin,  has became non functional during evolution phase and is present only as psuedogene/junk gene so, the humans have tendency towards probability of elevated levels of uric acid due to lack of breakdown and accumulation which may trigger gout.

Uric Acid though may have beneficial effect as its a very powerful antioxidant and scavenger, helping body to protect itself from oxidative damage and thus prolonging life and reducing age-specific cancers, so hominids may have opted out the Uricase gene in selective evolution.

After we identified urate oxidase and its activity, we have artificially prepared protien Rasburicase. Rasburicase is now used to treat patient developing acute hyperuriceamia during chemotherapy. Also a PEGylated form of urate oxidase is in clinical development for treatment of chronic hyperuriceamia having “treatment failure gout”.

2) Defect in genes associated transportation and transfer of uric acid for elimination.
  • SLC2A9 The encoded protein by this gene plays a role in transportation of uric acid and also in development and survival of chondrocytes in the cartilage matrix. Any SNP (single neucleotide polymorphism) in this gene causes transcript variants encoding different isoforms, which increases the risk of development of Hyperuriceamia and also it may alter joint cartilage matrix both of these anomaly plays a major role in formation of gout.
  • SLC22A12 has 2 transcript variants encoding different isoforms; basically it encodes urate transporter and urate anion exchanger protein which regulates the level of urate in the blood; its an integral membrane protien primarily found in kidney; SNP of this gene causes altered reabsorption of Uric Acid by the kidney.
3) Genes associated with purine salvage mechanism.
  • PRPSAP1 and HPRT1 are gene related to Purine salvage mechanism.
  • Phosphoribosyl Pyrophosphate Synthatase associated Protein 1(PRPSAP1).
  • PRPP (5-phosphoribosyl 1- pyrophosphate) is a substrate used by HGPRT during purine salvage pathway.
  • Hypoxanthine Phosphoribosyl Transferase 1 (produce hypoxanthine-guanine phosphoribosyl transferase (HGRPT)which plays main role in generation of purine nucleotide through purine salvage pathway).

SNP or deletion of any of the above mentioned gene causes hyperuriceamia and also other severe conditions.

4)Certain Genetic Disease And Syndromes Presents Hyperuricemia And Gout As One Of The Symptom Like In  :-

  1. Familial Juvenile Hypouricemic Nephropathy (FJHN) associated with UMOD gene. UMOD gene produces Tamm horsfall protien, whose function is still not well understood but defect in this gene produce many autosomal renal disorders characterised by juvenile onset of hyperuricemia, gout and progressive renal failure.
  2. Medullary Cystic Kidney disease (type I and II).
  3. Lesch Nyham Syndrome is an X-linked Syndrome caused due to HPRT1 Gene deletion (details of HPRT1 have been mentioned elsewhere above in this page).

Physical trauma, Wasting Diseases ,Surgery are associated with increased uric acid levels.

MEDICINES ASSOCIATED WITH HYPERURICEMIA

Diuretics in higher doses, niacin, aspirin ACE inihibitors angiotensin receptor blockers  beta Blockers ritonavir pyrazineamide ciclosporin tacrolimus.

DIAGNOSIS OF GOUT

In patients with recurrent acute episodes of arthritis especially of great toe accompanying hyperuricemia is sufficient to establish the diagnosis. However an episode of acute arthritis in many instances may not accompany hyperuricemia, so arthroscentesis should be done for synovial fluid analysis for visualising monosodium urate crystals or tophus is the only confirmatory test whether patient is hyperuricemic or not.

DIET AND LIFESTYLE ASSOCIATED TO GOUT AND HYPERURICEMIA

Food rich in purine especially red meat and sea food is considered to be associated with hyperuricemia. Its found that moderate consumption of purine rich vegetarian diet is not associated with the condition. Also total protien  has no impact untill not much of it is in form of purine.

Alcohol consumption and Fructose sweetened food and drinks are strongly associated with it.

Metabolic syndrome, diabetes, cardiovascular disease, and aging process are also associated with this condition and they tend to worsen each other.

Vitamin C, Coffee and switching to Dairy Products for protein requirement will also help.

Weight reduction and regular exercise helps reduce Uric acid.

Raised uric acid level is also associated with renal stones and urate nephropathy.

HOMOEOPATHIC REMEDIES FOR GOUT and HYPERURICEMIA(raised serum uric acid)

ARNICA MONTANA

Arnica is a traumatic remedy par excellence. Arnica is an useful remedy in chronic cases of gout. Old cases of gout rouse into a new soreness of joints with great sensitiveness. Arnica is an important remedy in injuries, bruises, shocks etc. Trauma in all its varieties mental or physical and their effects recent or remote are met with this remedy. If we observe a arnica patient in order to get the external manifestations of his state, he is constantly moving,turning and highly restless. The patient has sore lame bruised feeling, so sore that he can lie on one part only for a while and must keep changing position as the bed he lies on feels hard. Limbs ache as if beaten. Inflamation of joints.

ACTEA RACEMOSA

Actea racemosa is a very well indicated remedy in gouty and rheumatic diathesis. Swelling of joints with raised uric acid levels. Its muscular and crampy pains are primarily neurotic origin, occuring in nearly every part of the body. Pains of actea racemosa are like that of electric shock, comes suddenly and also its relieved suddenly. There is stiffness and pain in the tendo achillies. It has wide action on muscles nerves joints. Rheumatic aching pains in joints and muscles with stifness of joints. Causes depression of mind with low spirits and exhaustion along with oversensitiveness especially during pain.

ABROTANUM

Abrotanum is a very valuable remedy which is used more frequently. Indicated in gout and increased uric acid levels. Rheumatism and gout alternate with haemorrhoids. Abrotanum increases circulation and opens small arteries as a result the blood flow and local defense of joints and muscles is stimulated. Abrotanum relives gout pain.

ACONITE NAPELLUS

Aconite napellus is very well indicated in rheumatic and gouty conditions of joints. Those that come on as first attack. Not old rheumatic and gouty attacks but those that come on from exposure to cold. Rapidity of action of aconite determines its symptomatology. Presents with Symptoms are acute painful and violent pain in the joints. Aconite is indicated in acute onset of pain and swelling. Used in 1st stage of inflammatory condition with severe mental restlessness. Fear. Fright and anxiety.

BELLADONNA

Belladona is useful in inflamtory rheumatism and gout.Symptoms that suggest this remedy are sudden onset, swollen joints, red hot, throbbing pain with extreme sensitiveness. Complaints of belladona that is the pains and suffering come on suddenly run a regular course and subside suddenly. Sudden attack of cold worsens the complaints.

COLCHICUM AUTUMNALE

Colchicum is a primary remedy used for treatment of gout because of its effectiveness.most useful in chronic gout.
Colchicum has marked action of the joints, indicated in case of gouty arthritis and increased uric acid levels. Helps in relieving the gouty paroxysms. Inflammation of great toe, gout in heel, cannot bear to be touched. Oedematous swelling and coldness of feet. Joints are red hot swollen. Pains are usually worse in evening and night.

LEDUM PALUSTURE

Ledum pal is mostly used in rheumatic and gouty diathesis. Remedy affects the fibrous tissues of joints especially small joints, ankles,heels.Used in cases where the gouty pains shoot through the foot, limbs and smaller joints. There is great swelling in the foot and ankle. Joints hot and swollen with with cracking in joints. Gouty nodosities. Ball of great toe is swollen. Soles are very painful can hardly step on them. Aggravation from warmth is so vreat that the patient can only get relief to his rheumatism by sitting with his feet in icy cold water.

NATRUM SULPHURICUM

Natrum sulph is used for symptoms associated with gout it may be acute or chronic. Swelling and burning of joints. Pain compels frequent change in position with stiffness of joints. Burning in sole with oedema of feet.

RHUS TOXICODENDRON

Rhus tox is one of the most frequently indicated remedy for rheumatic and gouty complaints. Rhus tox usually affects the fibrous tissue markedly joints, tendons, producing pain and stiffness. Rhus plays a good role in gouty complaints. Hot painful swelling of joints. Tearning pains in tendons, ligaments and fasciae. Affects the smaller joints, parts feel sore and bruised with stiffmess. All complaints worse from cold damp weather and motion in any ailment and relieved from warmth.

URTICA URENS

Urtica is useful in rheumatic and gouty diathesis. This remedy helps in elimination of uric acid from the body. The patient has tendency to uric acid and gout formation. The joint complaints are usually associated with hive like erruptions. Presents with pain in small joints. Worse from exposure to cold moist air, wet weather.

BENZOICUM ACIDUM

Benzoicum Acidim is a very Specific and Infallible remedy in cases of chronic and acute gout, usually given in lower potencies in frequent repetitions.

Tophus of Gout
LARGE TOPHUS OF GOUT AT Dr SHAH’s Homoeopathy

 

Large Tophus Of Gout at Dr Shah's Homoeopathy
LARGE TOPHUS OF GOUT 2 IMAGE CLICKED AT Dr SHAH’s HOMOEOPATHY by Dr DEEPAN P SHAH
Podagra Gout Hyperuricemia
PODAGRA GOUT HYPERURICEMIA
Podagra – Inflamation of 1st Metatarsophalangeal Joint (Joint of great toe to feet) in patient with Hyperuricemiam or elevated Uric Acid. Its a classical presentation of Gout.
PODAGRA GOUT HYPERURICEMIA
PODAGRA GOUT HYPERURICEMIA
Podagra – Inflamation of 1st Metatarsophalangeal Joint (Joint of great toe to feet) in patient with Hyperuricemiam or elevated Uric Acid. Its a classical presentation of Gout.

RHEUMATOID ARTHRITIS

RHEUMATOID ARTHRITIS HINDI EXPLANATORY VIDEO

Rheumatoid arthritis is a chronic systemic auto-immune disorder predominantly affecting synovial joints.

Rheumatoid Athritis may also affect tissues other than those in joint; like blood, skin, pleura, lungs, kidney, nerves, heart, pericardium, blood vessels, eyes, liver etc.

CAUSES OF RHEUMATOID ARTHRITIS (RA)

It is still unclear how it is caused but it is believed to be combination of

1) Genetic Factors

HLA-DR4 – HLADRB1 is storngly associated with Rheumatoid Arthritis but not in all ethnicity it shows the same significance.

MHC class II related allotypes and T-cell Associated Protein PTPN22 are also found to be associated with RA.

2) Environmental and Lifestyle Factors

Environmental factors like radiations, pollution etc. Exposure to fine crystalline form of pure silica i.e. Silicon Dioxide can cause Rheumatoid Arthritis, is an established fact.

Lifestyle factors like addiction to cigarette smoking, mental stress, physical stress and digestive disturbances are also doubted (though unconfirmed).

Hormonal fluctuations during pregnancy, menopause, hormonal medications etc. are also believed to be strong contributing factors.

Still we are not able to link any infectious agent or vector associated to RA.

PATHOGENESIS AND PATHOPHYSIOLOGY OF RHEUMATOID ARTHRITIS (RA)

It has been observed that there is an abnormal immune response, where in, there is a state of persistent cellular activation, due to constant positive feedback (probably due to inhibition of negative feedback pathway or exaggerated positive feedback due to certain factors) causing formation of immune complexes and autoimmunity. This initially shows up in synovial joint and less frequently or later in other organs and tissues as well.

Rheumatoid Arthritis manifests in following phases :-

  • Initial phase – shows non-specific inflamation
  • Amplification phase – caused by T-cell activation
  • Chronic inflamatory Phase – where Cytokines like Interlukine-1 Interlukine-6 Tumour Necrosis Factor-alpha comes in picture causing chronic inflamation and tissue injury

Antibodies to IgGFc are called Rheumatoid Factor (RF/ RA factor) and Antibodies to Citrulinated Peptides (ACPA) are major factors specific in pathology of Rheumatoid Arthritis.

Other nonspecific factors are abnormally Glycosylated Antibodies. These are believed to be the contributing factors in arthritis. Though they are not specific to Rheumatoid Arthritis and are also present in many other Autoimmune conditions.

B lymphocytes    Plasma cells    RA factor and ACPA(of IGg And Igm Classes) + Fc receptors & compliment (binding due to antibody’s altered N glycans) (simultaneously; doubted TNF activation at this Stage)  Macrophage activation    Synovial macrophage & dendritic cells further expresses MHC class II molecules    →  Synovial oedmatous inflamation with T cell activation(also doubted TNF activation through T cell product IL17) and infiltration(mainly CD4 and CD8)    Intense inflamation – Granulation tissue formation -Angiogenesis – Inflamatory products damaging tissues – Thickening of synovium- Cartilage disintegration -Bone disintegration-Joint degeneration.

It is observed that presence of B-cell and T-cell at site is not necessary for the pathogenesis. So the exact role of B-cell and T-cell is doubted. Also TNF a major foctor responsible for progress of Rheumatoid Arthritis is doubted that wether its predominantly derived through B-cell or T-cell channel or through both as presented in above flow chart.

Other factors like IL1, IL6, IL15, IL17 are also believed to be important in pathogenesis of Rheumatoid Arthritis.

Signs and Symptoms of Rheumatoid Arthritis

General Symptoms

  • Fatigue
  • Low Grade Fever not necessarily in all cases.
  • Malaise
  • Morning Stiffness
  • Loss of appetite
  • Weight Loss

Arthritis

Polyarthritis i.e. multiple joint involvement -small joints of hands, feet and spine are affected more than compared to larger joints like – knee, shoulder, hip joints but not always, in many patients, initially it may present as Monoarthritis ie single joint involvement.

Synovitis and erosion of joint tissue, tendinitis,  with surrounding tissue swelling. It presents as swollen, tender,  warm joints, causing stiffness and resulting into loss of range of motion of joint.

Morning stiffness difficultly in motion of affected joint with sensation of stiffness and pain. Morning stiffness lasts for more than an hour. Aggravation of pain and stiffness of joints  on prolonged rest and ammelioration on motion is a distinguishing character of inflamatory arthritis like Rhuematoid Arthritis in its early stages, compared to non inflamatory conditions like osteoarthritis, where the causes are mechanical so it has motion aggravation and rest ammelioration and morning stiffness is not prolonged for more than an hour, pain is nociceptive and not neuropathic.

Various Deformities

  • Necrotising Granuloma or Rheumatoid Nodule typically appears over areas where there is excessive mechanical stress, like bony processes or prominencies eg knuckles, wrist, elbow, heel etc, they are few milimeters to centimeter in diameter.
  • Ulnar deviation of fingers.
  • Button Hole Deformity or Boutonniere Deformity –  proximal interphalangeal joints flexed and distal interphalangeal joints extended.
  • Swan Neck Deformity flexed distal interphalengeal joint and proximal interphalengeal joint hyperextended
  • Hammer Toe Deformity
  • Z-thumb deformity or Z deformity the interphalengeal joint gets hyperextended and there is subluxation of metacarpo-phalengeal joint with fixed flexion.
  • Arthritis Mutilans
  • Atlanto axial subluxation due to erosion of odontoid process and transverse process which initially presents as clumsiness and may progress into quadripelgai and eventually death.
with Ulnar Deviation of fingers in Rheumatoid Arthritis
Swan Neck Deformity with Ulnar Deviation of fingers and Rheumatoid Nodules

 

Multiple Necrotising Granomatous Nodules of Rheumatoid Arthritis
Multiple Rheumatoid nodules seen on knuckles and wrist

 

Disfigurement in rheumatoid arthritis
Disfigurement of hand in rheumatoid arthritis

 

Disfigurement of Toes in Rheumatoid Arthritis
Disfigurement of Toes and feet in Rheumatoid Arthritis

 

Disfigurement of Rheumatoid Arthritis
Disfigurement of toes in Rheumatoid Arthritis

Skin Symptoms of Rheumatoid Arthritis

Necrotising Granuloma or rheumatic nodule many a times appears in the skin.

Rheumatic Nodule of Skin in patient with Rheumatoid Arthritis
Rheumatic Nodule of Skin in patient with Rheumatoid Arthritis

Mononeuritis Multiplex caused due to severe Rhematic vasculitis and vasculitic nerve infarction of small and medium sized blood vessels also giving rise to skin ulcers

Occasionally the skin may also present with

  • Pyoderma Gangrenosum
  • Sweet’s Syndrome
  • Erythema Nodosum
  • Lobe Paniculitis
  • Atrophy of finger skin
  • Palmar Erythema
  • Fragile Skin

Few of above complications are due to prolonged allopathic medication.

Lungs involvement

Fibrosis of lungs is well recognised consequence of allopathic treatment for Rheumatoid Arthritis.

Caplans syndrome, when RA pt gets exposed to coal dust it gives rise to rheumatoid lung nodules.

Pleural effusion is associated with Rheumatoid Arthritis.

Cardiac involvement in Rheumatoid Arthritis

Rheumatiod Arthritis  may affect heart and cause pericarditis, endocarditis, valvulitis, Left Ventricular Failure, Fibrosis.

Rheumatiod Arthritis significantly increases risk of artherosclerosis, myocardial infarction, stroke.

Most of the RA patients do not develop pain of angina or myocardial infarction so are at high risk to be left undiagnosed.

Rheumatoid Arthritis Affects major components of blood

In blood, Rheumatoid Arthritis causes Hepcidin levels to increase leading to Anaemia of Chronic Disease.

Leucocytopenia in patients with felty’s syndrome.

Neutropenia and Thrombocytosis if inflamation persists.

Rheumatoid Arthritis Affects Kidneys

Renal Amyloidisis is consequence of chronic inflamation of RA.

Allopathic treatment of RA may cause membranous nephropathy.

Eye Manifestation of Rheumatoid Arthritis

Episcleritis, Scleritis, Keratitis Keratoconjunctivitis, Scleromalacia, Keratomalacia, Xeropthalmia are occular complications of Rheumatoid Arthritis.

Liver Complications in Rheumatoid Arthritis

Liver may be affected due to prolonged allopathic treatment of Rhuematoid Arthritis and if there are any other inflamatory Liver complaints or autoimmune conditions affecting liver, coexisting with RA, it can create complications in liver.

Neuronal Complications Due To Rheumatoid Arthritis

RA affects neurons to cause Peripheral neuropathy, Mononeuritis Multiplex, Carpel Tunnel Syndrome, Myelopathy due to Rheumatoid disease of spine. Atlanto-Axial subluxation due to erosion of odontoid process and transverse process which initially presents as clumsiness and may progress into quadripelgai and eventually death.

DIAGNOSIS OF RHEUMATOID ARTHRITIS (RA)

X-rays 

X-rays may not show any changes in early stages though sometimes mild soft tissue swelling might be visible in later stages along with soft tissue swelling it may show juxta-articular osteopenia and loss off joint space in advanced stage it may also show nodes  bony erosion subluxation of affected joints.

Blood Tests

Test for RA factor

Negative serological tests doesnt exclude the probablity of Rheumatoid Arthritis. As 20-25% of RA patients are negative for RA factor test which is considerably large number. Also during first year of development of rheumatoid factor majority of the patients are usually negative. 10% of healthy person may show positive for RA Factor. Even persons with Hepatitis C and persons with chronic autoimmune diseases like Systemic Lupus erythematosus or  Sjogren’s syndrome may show positive RA factor test. So the test is not specific and also not much sensitive.

Test for ACPA (measured as Anti-CCP antibodies)

ACPA with 95% specificity is much more specific compared to RA factor test but has lower sensitivity only 60-70% compared to 80-85% of RA Factor test.

Patients with clinical features and all other investigations pointing towards Rheumatoid Arthritis except their RA Factor and Anti-CCP tests are negative sich patients are called seronegative Rheumatoid Arthritis cases almost 25% cases falls in this category.

New point of care test is introduced where in; RF and anti-MCV are detected which has sensitivity of 72% and specificity of 99.7%

Other non-specific, indirect, additional supportive tests to RA factor and ANTI-CCP tests are :-

ESR; CRP; CBC; RFT; LFT; ANA; Ferritin levels.

DIAGNOSIS AND CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS 

This diagnosis and classification criterion is jointly developed  by American College of Rheumatology and European League Against Rheumatism has become widely accepted globally is as follows:

A Score of 1-10 is established by adding scores of following 4 different criteria

  1. Number and type of joints involved
  2. RA factor and ACPA tests
  3. Acute Phase Reactants CRP and ESR
  4. Duration of Disease

1) Score Rating of NUMBER and TYPE of JOINTS involved

  • 1 Large joint = 0 points
  • 2-10 Large Joints =1 point
  • 1-3 small joints(with/ without Large Joint involvement) = 2 points
  • 4-10 small joints(with/without Large joint involvement) = 3 points
  • Involvement of more than 10 joints including atleast 1 small joint =5 points

2) Score Rating of Specific Serological Tests (RA factor and ACPA)

  • Negative RA factor and ACPA = 0 points
  • Low positive RA factor or Low Positive ACPA = 2 points
  • High Positive RA factor or High positive ACPA = 3 points

3) Score Rating of Acute Phase Reactants

  • Elevated ESR and CRP = 1 point

4) Score Rating of Duration of disease

  • Duration of Arthritis if more than 6 months =1 point

A score of 6 or above establish positive Rheumatoid Arthritis as diagnosis.

HOMEOPATHIC ARTHRITIS MANAGEMENT

Homoeopathic Arthritis Management depends on individualisation of the patient based on present symptoms, past history, family history and constitution of the patient.

In arthritis cases it is necessary to take into account the following points (with constant search for underlying miasm and constitution type):

  • When it started, that is since how long its been there.
  • How was the onset when it appeared first time.
  • Wether the complaints had incidious progression or it was sudden.
  • Which joint is involved, wether its single joint or multiple, wether its bilateral and symetrical or diagonal.
  • Particulars like which part was affected first, which side it started first and how much time it took for progression to other side or other joints, sequence in which joints were involved.
  • How and when it gets triggered, aggravation pattern morning stiffness , aggravation on rest/ motion, relation to climate winter/monsoon/summer, relation to heat and cold, aggravation to any particular type of food.
  • Wether its constant or intermittant.
  • The joint is warmer than rest of the body or not.
  • Wether there is swelling around the joint or not.
  • Nodes or nodosities on or around any joints. or any other signs of disfigurement.
  • Movement or other disability in joint.
  • Patient has fever or not or h/o fever before or during the episode of joint pain started.
  • Presence of any concomittants or accompanying symptoms and wether those symptoms are of Psychotic, Syphilitic or Psoric nature.
  • Wether he has any other systemic complaint especially any other autoimmune or metabolic disorder.
  • History of injury, surgery especially affecting neurons or musculoskeletal structure.
  • Nature of work the patient does , postural habits, structural anomalies disfigurements.
  • Diet sleep and exercise routine water intake should also be noted carefully.
  • It is important to note family history of patient wether first degree relative had any autoimmune or metabolic disorder.
  • Wether patient was or is under any long term medication.

A careful history of all communicable ailments should be recorded in sequence as they had been contracted by patient, as it helps us evaluate when and how was the vital force deranged in past and wether the present condition is manifestation of some past ailment, that is any deep seated miasm, also it helps to establish wether its some inherited genetic condition or its acquired condition also it helps differentiate  between

  1. Vector borne conditions like post viral arthralgia/arthritis  and Group A streptococcal borne post pharyngitis systemic autoimmune condition.
  2. Other Systemic autoimmune conditions like Rheumatoid Arthritis SLE psoriatic arthritis.

These basic question will lead you towards a broader vision in the case and will let you reach upto some conclusion that under what category of arthritis it should be classified and will lead you towards some understanding of miasm and constitution.

As I have mentioned in my other arthritis articles that basically I divide all types of arthritis into four major categories based on their pathogenesis.

  1. Mechanical
  2. Immunological
  3. Metabolic
  4. Septic

After being diagnosed and classified the disease condition from one of the above group we can go further on how to manage each type of case.

Rheumatoid Arthritis falls under immunologically mediated arthritis.

Once established that its an immune mediated arthritis its necessary to rule out any damage to other organs like heart, liver, kidney, pancreas, eyes etc, as in most cases autoimmune arthritis is found to involve other system and organs or it is a part of broader systemic autoimmune condition and it is all the more necessary to find out miasmatic background, constitution and individualising symptoms, as such types of arthritis are deep seated having its own sets of aggravating and ammeliorating factors, furthermore its also observed that mental stress and emotional fluctuations have much impact on intensity and frequency of aggravations in almost all types of immunologically mediated arthritis, so its of utmost importance to take proper account of patient’s mental emotional past and present including likes and dislikes aversion and cravings, which helps us to individualise the case.

Once the we have derived constitution , miasmatic background and individuslised the case then comes medicine selection process.

I strongly recomend to go by constitution of patient in immunologically mediated arthritis rather than going theraputic remedy selection.

It should be kept in mind that the selection procedure of medicine should correspond to degree of mental PQRS , degree of systemic PQRS and degree of musculo-skelatal symptoms of the person in disease should match the degree of pathogenic action on various sphere of the specific medicine.

Though during acute exacerbations of disease it becomes necessary many a times to administer short acting acute medicines theraputically where the new symptoms desnt fall into sphere of the constitutional medicine thats been administered.

Many a times only a single dose of similimum medicine selected may suffice to cure the case  but all patients are not the same. As each case has a different constitution, miasmatic background, severity of ailment and other  external inimical factors. So in many cases before it gets cures, it may require series of medicines one after another as per case demands during progression of treatment. It all depends upon how well the physician is able to find out the similimum and type of case and its requirement.

HOMEOPATHIC MEDICINES FOR RHEUMATOID ARTHRITIS

Though the approach should always be constitutional in autoimmune disease like rheumatoid arthritis, there are certain medicines which broadly shows pathological drug picture of rheumatoid arthritis or striking peculiar so could be used as therapeutic guidance.

  • SILICEA – Rheumatoid Arthritis post exposure to fine crystalline form of silica ie silicon dioxide (an established factor that contributes in development of rheumatoid arthritis).
  • RHUS TOXICODENDRON – While repertorising I have frequently ended up Selecting this remedy in final roundction during conditional approach. Rheumatoid Arthritis has stiffness of joints on prolonged rest especially in morning last more than an hour and gradually ameliorating on motion.  Rhus tox has common symptom of aggravation on rest and amelioration on motion and also this medicine has great affinity towards joints and immune mediated disorders.
  • LEDUM PALUSTURE – This homeopathic  medicine has always given me good results in any type of inflammatory joint complaints with swelling and redness especially around ankles.
  • APIS MELIFICA – I use this medicine with great results during active phase of disease where patient has developed swelling and redness with severe pain just like Ledum  pal but more severe acute and sudden in onset.
  • CALCAREA CARBONICA – Can be used as complimentary medicine during the course of the treatment of rheumatoid arthritis especially in later stages where patients starts showing symptoms of bone erosion and reduced bone mineral density around articular surface due to prolonged inflammation and chronic autoimmune condition in body.
  • GUALTHERIA PROCUMBENS – In my experience gaultheria yields good results good results; usually in low potency and mother tincture forms; during active exacerbation of disease where in patients joint pains rheumatoid arthritis aggravates on disturbed digestion and other gastric ailments.
  • SYPHYLLINUM – indicated in later stages where patient starts showing signs of destruction of tissue, degeneratation and disfigurement and necrotising granulomatous nodules of lungs skin and bones. Especially in cases of rheumatoid arthritis with history of syphilis(treponema pellidum) infection this nosode should be administered
  • TUBERCULINUM – Patients with rheumatoid arthritis if exposed to coal for longterm, they typically develop necrotizing granulomatous nodule in lungs in such condition this medicines comes in to aid in such rare peculiar symptom. Also it should be thought of in patients with necrotising granulomatois nodule of rheumatoid arthritis on bones and skin.
  • DULCAMARA – this remedy should be thought of when Rheumatic complaints tend to increase in damp cold weather.
  • BELLADONNA – inflammation of joints during acute exacerbation of RA.

LICHEN PLANUS

Lichen Planus (LP) is believed to be autoimmune condition with an unknown causative and triggering factor. It presents itself with skin lesions characterize by 6 P’s i.e. Planar [flat topped], Purple, Polygonal, Pruritic, Papules and Plaques;
Although it may present itself with variety of other lesions as well.

The Lesions typically shows interspersed lacy white lines which are called Wicham’s Striae

It can affect anywhere on Skin Nails and Mucous membranes of any region.

The lesion may show any of the following pattern Annular, Linear, Hypertrophic, Atrophic, Bullous, Ulcerative, Pigmented.

Etiopathology

What are the causes?

It is non contagious condition and is not related to any known pathogen; it is believed to be T-cell driven autoimmune reaction which triggers apoptosis of the epithelial cells; It is believed that this process is in response to some unidentified antigenic change in oral mucosa

What is Lichenified Reaction?

There are certain conditions where the skin lesions shows similarity with Lichen Planus lesions , in both clinical appearance to naked eye as well as histopathology under microscope but unlike Lichen Planus there are known underlying causative factors such conditions are termed lichenfied reactions.

Few examples which may cause Lichenified Reaction
  • In certatin drug reactions esp. due to beta blockers quinine thiazide diuretics furosemide spironolactone metformin and penicillin
  • Reactions to metal alloy fillings
  • Graft Versus-Host disease typically presents with chronic lichenified skin lesions on palms soles upper trunk and face after several months
  • Hepatitis ; esp due to Hepatitis B virus infection ; Hepatitis C virus infection ; primary biliary cirrhosis
  • stress and lifestyle as major impact on lichen planus it may trigger erruptions
  • lichen planus may be an accompanying symptom of Grinspan’s Syndrome

Diagnosis

LP can be diagnosed clinically with brief history and character of skin lesions characterize by 6 P’s i.e. Planar [flat topped], Purple, Polygonal, Pruritic, Papules and Plaques; it typically has Lichen-like appearance; always Biopsy is Gold Standard to establish diagnosis.

HOMEOPATHIC Treatment Approach and Homeopathic Medicines for Lichen Planus.

Can LP be Cured?

Allopathy System has no cure the condition it can only relieve symptoms temporarily and does have side effects

Homeopathy is known system of medicines which can cure lichen planus without having any side effects

HOMEOPATHIC TREATMENT FOR LICHEN PLANUS WITH INDICATIONS OF COMMON HOMEOPATHIC MEDICINES.

LICHEN PLANUS

Explanation of indicated remedies on website are as follows.

THUJA OCCIDENTALIS

Thuja has main sphere of action on the skin. Acting on the skin thuja causes painful sensitiveness of skin. Very useful remedy in case of Lichen planus. Thuja is very beneficial for inverterate skin troubles and chronic or stubborn skin conditions like lichen planus, psoriasis eczema, warts. Erruptions occur only on the covered parts of the body. The erruptions burn violently after scratching. Dry sensitive skin with hyperpigmented brown spots. Skin sensitive to touch. The skin usually looks unhealthy all over body. Aggravation of complaints usually at night from heat of bed.

ANTIMONIUM CRUDUM

Antimonium crudum is one of the indicated remedies in case of Lichen planus. Acting on the skin, causes ulcerations and has a tendency to grow warts, callosities, bad nails. Hard horny excrescences grow under the nails and is extremely painful. Pustular erruptions with inflammation. Itching especially on the neck, chest, back and limbs. Erruptions chiefly appear in the evening which itch in the heat of bed and disturb sleep. Formation of thick, hard scabs with oozing. Deformed nails. Degeneration of skin. Burning and itching worse scratching at night.

CALCAREA FLOURICA

Calcarea flour is a powerful tissue remedy. Indicated in case of lichen planus. Patient usually presents with marked whiteness of skin. Cracks and fissures in the palms of hand. The skin seems hard. Useful in hard elevated edges of ulcer, surrounding skin is purple and swollen. Worse during change of weather and better by warmth.

SILICEA

Silicea is one of the frequently indicated remedy in case of lichen planus, psoriasis etc. Suited to complaints that develop slowly. Acting on the skin Silicea causes inflammation. Most scaly erruptions alternating with dry erruptions. There is hyperpigmentation of spots, coppery spots. Erruptions usually itch only in the day time. Silicea usually hastens formation of abscess. There is imperfect assimilation and defective nutrition.

SULPHUR

Sulphur is one of the widely used medicine to treat various kind of skin disorders. It is a very valuable remedy in treatment of lichen planus. Papules and erruptions with extreme dryness of skin. Intense itching of skin. Scratching of skin leads to intense burning of affected parts which is a marked indication of sulphur. Complaints are usually worse at night from warmth of bed. Burning in palms and soles is stricking feature of sulphur. Sulphur is a gneral antipsoric for almost every kind of itch. Unhealthy, dirty filthy individuals are prone to skin infections.

ARSENIC IODATUM

Ars iod is efficient remedy in case of lichen planus. Ars iod is a very good remedy for skin conditions like lichen planus, psoriasis, eczema. Marked exfoliation of skin in large scales, leaving raw exuding surface beneath. The skin is cold touch, dryness of skin. It cures all syphilitic erruptions where the symptoms agree, where erruptions have been suppressed by local treatments. There is marked excoriation, itching, burning and stinging pain with rough skin.

BORAX

Borax is often indicated in case of Oral lichen planus. Presents with ulcers inside the cheeks And on tongue. Excessive heat in the mouth. Dry hot, tender apthous ulcers usually bleed on eating or by touch. Mouth remains extremely dry. Ulcers in mouth extend to throat, even to stomach. Difficult healing of skin. Unhealthy skin, every little injury tends to ulcerate. Itching on back of finger joints. Erruptions on fingers and hands.

MERCURIOUS SOLUBILIS

Every organ or tissue of the body is more or less affected by this powerful remedy. Very often indicated in case of oral lichen planus. Presents with irregular ulcerd inside cheeks. The cheeks give a very unhealthy and dirty appearance. Salivary secretions are greatly increased. Painful raged swollen bleeding gums. Highly offenseive odour from mouth with metallic taste in mouth. Skin is almost constantly moist. Vesicular erruptions with severe itching worse from warmth of bed.

PSORIASIS

Psoriasis is an endogenous immune-mediate condition(believed to be autoimmune) where there is increased epidermal cell proliferation which is result of excessive cell division in basal layers and transit time of keratinocytes through epidermis is reduced and reduced epidermal turnover from 28days to 5-6 days; its clinically characterized by well-defined erythematous plaques with silvery scales and flakes

CAUSES

i)Genetic

A strong association has been noticed between certain loci on genome , many genes have been identified but still it remains unclearance how they all might be interelated

Most of the gene identified are related to MHC (Major Histocompatibility Complex) and T cells.

  • 9 Loci on different Chromosomes are identified by Genome-wide linkage Analysis which are supposed to be linked with Psoriasis and named Psoriasis Susceptibility 1 to 9 (PSORS1 till PSORS9) within this locus are also found genes contributing in pathways of inflamation and certain mutations in this region have been found in psoriasis. Genome Wide Association Scan identified many other non-specific genes which are responsible in expressing inflamatory protiens which affects the cells of immune system which are also involved in psoriasis.
  • PSORS1 is located on chromosome 6 in Major Histocompatibility Complex ; 3 Genes in this Locus are associated with Psoriasis vulgaris viz:- 1)HLA-C variant HLAC-w6 it encodes a MHC Class 1 Protien 2)CCHCR1 variant WWC it encodes coiled protein which if found to be overexpressed in epidermis of Psoriatic patch on skin.
  • CDSN Variant allele5 which encodes Corneodesmosin it is expressed in Granular and Cornified layers of Epidermis and upregulated in Psoriasis.
  • IL12β gene on chromosome 5q which expresses Interlukin12B(IL12B)
  • IL23R gene on Chromosome 1p which expresses interlukin23 receptor and is inlolved in T cell differentiation;psoriasis is belived to be T cell medaited inflamatory condition.
  • Both this above mentioned genes are also involved in upregulating Tumour Necrosis Factor α (TNFα) and Nuclear Factor κB.
  • Gene encoding CARD14 is found directly linked to Plaque type Psoriasis; any mutation in this gene and environmental trigger causes plaque type psoriasis.

ii)Environment and Lifestyle

Harsh environment like excess of heat and cold, extreme dry wether, irregular diet and sleep pattern, excess of mental and physical stress, substance abuse, regular exposure to excess of chemicals and other pollutants etc have been associated with aggravations in those with prexisting psoriasis and precipitates in those  genetic predesposition to develop psoriasis.

iii)Microbes

After infection with certain bacteria and virus its been observed that body develops an autoimmune state resulting into psoriasis.

iv)Medicines

Certain medicines induce it, like beta blockers, calcium channel blockers, antihyperlipidaemic medications, captopril, anti malarials,  lithium, NSAIDS, terbinafin, glyburide, interleukins, interferons, TNF inhibitors like infliximab and adalibumab, terbinafin, Granulocyte colony stimulating factor, glyburide, withdrawal of cortocosteroidal topical applications shows severe rebound aggravations.

TYPES OF PSORIASIS

  • Plaque
  • Guttate
  • Pustular
  • Erythrodermic
  • Inverse/flexural
  • Seborrheic-like
  • Oral

OTHER MAJOR SUBTYPES OF PSORIASIS :-

  • Palmo-Plantar
  • Napkin
  • Acrodermatitis continua
  • Generalised pustular psoriasis/pustular psoriasis of Von Zumbusch; during pregnancy its termed as impetigo herpetiformis
  • Annular Pustular
  • Any of above type may present with involvement of nail and joints and it will be termed as nail psoriasis and Psoriatic Arthritis respectively.

SIGNS & SYMPTOMS FOR DIAGNOSIS

Though all signs may not be present or common in every case. There are various types of psoriasis and also within each of these type the presentation may vary in each individual but still there are few signs and symptoms; the presence of which may help us in diagnosis.

  • Silvery adherent scales and flakes
  • Well defined margins
  • Itching irritation and pain restricted only on papuler/pustules /plaque
  • Red erythematous base with plaque above
  • Frequently observed cyclic pattern of eruptions
  • Extensor surface involvement
  • Auspitz’s sign ; there is pin point bleeding when the scale is removed
  • Koebner Phenomenon; in this we observe psoriatic lesions are induced at the site of trauma to the skin.

Common Homoeopathic medicines for Psoriasis

A constitutional approach is required in its treatment

Homeopathic Remedies are selected only after proper case taking and repertorisation; Few of the remedies frequently prescribed are

SULPHUR

Sulphur is an elementary substance occuring in nature as a brittle crystalline solid. Sulphur was used as a most powerful specific against itch. Sulphur is a very beneficial remedy in Psoriasis and has marked affinity towards skin. Sulphur is the greatest antipsoric remedy for almost every kind of itch. Troubles of very long standing resulting from suppressed erruptions. Skin is usually dry, rough, scaly, with voluptous itching. Itching of whole body aggravated at night from warmth. Unhealthy skin, useful in dirty filthy people who are prone to skin infections. Severe burning after scratching. Painfully sensitive to warmth of bed causes severe itching.

ARSENIC ALBUM

Arsenic album is a very deep acting remedy affecting every organ and tissue. Arsenic is useful in case of psoriasis. Acting on skin Arsenic causes intense itching, burning of skin, with dry rough scaly erruptions worse from cold and scratching. Anxiety, restlessness, prostration, burning with cadaveric odour of body are prominent characteristics of Arsenic. The surface of the body is pale, cold, clammy. Erruptions cause intense burning is the marked general of Arsenicum album.

PHOSPHOROUS

Phosphorous is suited to young people who grow rapidly and are inclined to stoop. Phosphorous causes degeneratiion and inflammation of mucus membrane. In case of psoriasis the erruptions are dry scaly with severe itching and bhrning of skin. Numbness and formication of skin. Most of the symptoms are aggravated by midnight. Phoshorous is usually suited to tall slender persons, with thin transparent skin weakened by loss of animal fluids with great nervous debility.

SILICEA

Silicea is one of the frequently indicated remedy in case of Psoriasis. The action of silicea is slow. Suited to complaints that develop slowly. Silicea is useful in psoriasis where the erruptions are dry, scaly, with coppery or silverish spots. Erruptions itch only in daytime and evening. Silicea mainly acts on constitution that are sluggish. Slow nutrition if the individual receives a slight injury it suppurates. Silicea hastens formation of abscess and boils. Sometimes Presents with moist scaly erruptions with severe itching.

NATRUM MURIATICUM

Natrum muriaticum is another deep acting remedy which is very valuable in Psoriasis. The skin is greasy, oily especially on hairy parts. Dry erruptions especially on margins of hairy scalp and bends of joints. Crusty erruptions in bends of limbs, margins of skin folds, behind the ears. Presents with severe itching. Erruptions become raw red and inflammed by scratching.

THUJA OCCIDENTALIS

Thuja has marked sphere of action on the skin. Thuja cheifly acts on the mucus membrane of skin, glands, gentitourinary tract. Remedy for soft tissue growths like warts. Thuja patient has characteristic picture in case of psoriasis. Presents with waxy shiny face often looks sick. The skin looks unhealthy everywhere about the body. Painful sensitivness of skin. Dry skin with brownish spots. Very sensitive to touch. Erruptions only on covered parts of the body which burn after scratching. Aggravation at night from warmth of bed.

CALCAREA CARBONICUM

Calcarea carbonicum is one of the polcrest remedies and usually ranks with sulphur and lycopodium at the head of antipsorics. Calcarea is a chief representative of calcium compounds. Calcarea carb is one of the efficient remedies in psoriasis. Muscles and skin of calcarea carb become lax and flabby. With tendency of patient to grow fat. There is flaccidity of skin from head to foot. Scaly or scaby erruptions. Skin is rough dry with burning pains. Very unhealthy skin, every little injury tends to ulcerate. Excoriation of skin in several areas with severe itching. Complaints worse from exertion and cold in every form.

GRAPHITES

Graphitis is a mineral carbon. The chief action of Graphitis is on skin, especially at the flexures, folds of skin, behind the ears. Graphitis produces thickening and induration of skin. Very efficient remedy in case of psoriasis. Thick crusts are formed on the skin and has tendency to produce excoriations, cracks or fissures at muco cutaneous junctions of eyes, nostrils, folds of skin etc. Erruptions are cracked, moist which bleed easily. Skin is dry rough, irritable that breaks open easily and exude a gluey moisture like discharge. Aggravation in folds and slow to heal. Moist crusty erruptions which are aggravated by heat. As per my clinical experience Very well indicated in women of climacteric age having palmoplantar psoriasis

PETROLEUM

Petroleum is one of the indicated remedies in psoriasis. Very marked skin symptoms. Skin is usually dry constricted, very sensitive, rough, cracked and leathery at times. Erruptions usually have thick, hard, yellowish green crusts. All erruptions itch violently and one must scratch until it bleeds. Parts turn cold from scratching. Great sensitiveness of skin Complaints worse during winter and relieved by warmth. Petroleum just like graphites has frequently given me very good results in palmo-plantar psoriasis.

Few solved Psoriasis cases at Dr. SHAH’s Homoeopathy with before and after pics  in links below

Also Read

Psoriatic Arthritis

PSORIATIC ARTHRITIS

Lichen Planus

LICHEN PLANUS

 

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