Achlorhydria or hypochlorhydria is a condition where stomach and other digestive organs stops or has reduced secretion respectively of hydrochloric acid
CAUSES OF HYPOCHLORHYDRIA / ACHLORHYDRIA
It usually is secondary to a primary condition like bacterial overgrowth like helicobacter pylori etc which neutralizes HCl; Gastro-intestinal Metaplasia; Atrophic Gastristis; Reducing Basal Metabolic Rate (BMR); autoimmune conditions where there are autoantibodies formed against gastric parietal cells that produces Gastric Acid ; frequent long-term use of antacids like H2 receptor antagonist or Proton pump inhibitors; mucolipidosis type IV, procedures like Gastric Bypass Duodenal switch RNY; Islet Cells tumors like VIPomas ( Vasoactive intestinal peptides) and Somatostatinomas; Pellagra(niacin deficiency), Pernicious anemia, deficiency of mineral and electrolytes required to produce sufficient Gastric acid like sodium chloride potassium zinc iodine etc.
So its a vicious cycle where pre-existing condition causes achlorhydria and achlorhydria further aggravates that primary cause.
SIGNS AND SYMPTOMS OF ACHLORHYDRIA OR HPOCHLORHDRIA
So along with symptoms of primary disease it will also show Gastro-Oesophageal Reflux Disease, anorexia, Early satiety while eating , weight loss, abdominal discomfort , sensation of fullness and distention of abdomen, frequent diarrhea and constipation, iron deficiency anemia due to lack of HCl, pernicious nemia due to lack of Vit B12 and many other deficiencies like that of vitamin B complex, vitamin k, vitamin C and other micronutrients minerals like magnesium sodium chloride potassium zinc etc; causes many neuro-muscular disorders like general weakness esp. lower limbs with myalgia paraesthesia ataxia and gait disorders ;also psychological disorders like weak memory, mood disorders personality disorders, hallucinations etc. these patients are prone to infection of Vibrio Vulnificus and other usually uncommon infections of organisms found in food ( more commonly from seafood); all these complaints and many other collectively may prove fatal.
DIAGNOSIS OF ACHLORHYDRIA OR HYPOCHLORHDRIA
Oesophageal pH monitoring giving 24-hour profile of gastric acid Secretion
Gastric pH at endoscopy
Extreme low levels of pepsinogen A(PgA) < 17ug/l in blood serum and high serum Gastrin Level >500-1000pg/ml supports the diagnosis
Heidelberg test is an alternate test.
Many other tests like Serum iron, serum calcium, Vit B12, Vit D, Thaimin, CBC tests for various forms of anemia elevation in serum folate level s/o small bowel bacterial growth etc can help to exclude associated conditions.
Once achlorhydria is confirmed a hydrogen breath test should be conducted to exclude bacterial overgrowth.
Acne or Pimples is a chronic skin disorder affecting pilosebaceous units caused due to clogged skin’s hair follicles by dead skin, excess sebum, dust and pollution.
It is also called Acne Vulgaris
SYMPTOMATIC CHARACTERISTICS OF ACNE/PIMPLES
It is characterised by oily skin, comedons, black-heads, white-heads, pimples and scarring and pigmentation.
It usually presents itself in region dense with sebeceous glands, like on face, chest and back.
Strong Genetic and Heredity association is found in 80% cases. During puberty surge in hormones triggers Acne in both sexes. Diet, cleanliness, medication, infections, pollution environmental factors ,sunlight exposure, stress, smoking and other lifestyle factor seems to contribute in not all but many cases in varing degrees. propionibacterium acnes a commonly found on skin which frequently outgrows in number and contribute to acne in most of the cases.
CATEGORISATION METHODOLOGY TO JUDGE SEVERITY OF ACNE/PIMPLES
Acne are categorised based on severity and there are various methods to do this Cook’s photographic scale of 0-8 grades, Leed’s scale of 0-10 with 2 modified versions of 0-11 and 0-12 and Pillsburry’s scale of 1-4 grades. A scale of mild, moderate and severe is commonly used which easily helps to quickly decide line of treatment.
Mild form has only clogged hair follicle called comedones also known as black-head(open mouth comedone) and white-head(closed mouth comedone) and very occasional pimples are found on trunk .
Moderate form has pappules and pustules forming on clogged hair follicles called pimples are found on face and trunk.
Severe form has cysts and nodules its termed severe nodular acne and is present extensively on face and trunk.
PATHOGENESIS OF ACNE/PIMPLES
Acne is a chronic skin disorder affecting pilosebaceous units caused due to clogged skin’s hair follicles due to
Excess sebum production under influence of androgen
Excess keratin deposition in hair follicle
Infection and colonization of the hair follicle by Propionibacterium acnes
Local activation of inflamatory mediators.
Dihydroxytestosterone and increased amount DHEA-S of secreted during adrenarche leads to excessive Sebum production prevents dead cells and debri to clear itself from hairfollicle causing an initial keratin and debri clog within and form microcomedon, excessive skin cell proliferation also contributes in development of clog its further complicated by colonisation of Propionibacterium Acnes which forms a slimy biofilm within the hair folicle and helps forming a comedone.
If comedone is superficial the melanin pigments gets exposed giving it dark colour so its called blackhead also called open comedone.
If the comedone is deep within the hair follicle, unexposed, it is called whitehead also called closed comedone.
Many of the comedones further progress into papules, pustules and nodules, also it may affect deeper tissue and form deep tissue nodule.
HOMEOPATHIC TREATMENT WITH INDICATED HOMEOPATHIC MEDICINES FOR ACNE/PIMPLES
Kali bromaticum is one of the most indicated remedy in case of Acne. In Kali bromaticum pimples usually begins in the teenage. Reddish pustules on the face causing grooves. Pimples usually have a depressed centre. Face is usually flushed, yellowish, cahetic look with pimples on face. In females the acne are worse prior to the menstrual period and during the time of menstruation. Exhausted look of face, lifeless and expressionless. Inflammation and great redness of face due to pimples.
It was said that in the golden age, when men lived on acorns, God lived upon walnuts and hence the name Juglans (Jupitars nut). Juglans regia stimulates the body’s defense mechanism and acts on various skin problems like pimples, eczema etc. Juglans regia is a very beneficial remedy in case of Acne. Indicated comedone of face. Reddish hard painful swelling of cheeks due to pimples. Acne filled with pus. Sharply defined depressed dark red erruptions, pus is seen through the thin skin.
Calcarea sulph is a Schussler’s connected tissue salt and most of the indications for its use are derived from his clinical experience. It has been extensively used for acne treatment based upon the biochemic theory. Very valuable remedy in case of pimoles. pimples with pustules on the face. Pale and sick looking face. Severe erruptions on face with itching. Pain in the erruptions after exposure to cold. Cold sweat on face. Useful in severe cystic acne. Lesions usually persists in one place for weeks and do not heal quickly. Yellow creamy pus drains for a long time. Unhealthy skin with yellowish scabs. Pimples on face, near hairline.
Mercurius solubilis is a powerful remedy which acts on every organ and tissue of the body.Very useful remedy in cases of acne. Earthy, puffy, dirty looking face, with constantly perspiring skin. A big pimple is surrounded by multiple smaller ones. Itchy erruptions, yellowish brown or greenish discharge from pustular pimples, often streaked with blood. Worse from extremes of temperature. Yellowish scabs with purulent pustules. Severe Burning of pimples.
Acne is by far the most commonest skin condition. Although prevalent among teens, a number of old people are also struggling with this condition. Echinecea angustifolia is the most effective remedy in case of acne. Echinecea angustifolia plant has its roots from daisy family. It makes the subcutaneous and superficial blood vessel walls stronger. This makes the skin more resistant and less penetrable from either the bacteria or free radicles that promote the development of acne. Echinecia helps to lower the inflammation levels due to its antibacterial properties. Echinecea angustifolia enhances good circulation and hence the skin will be clear and free from dead skin cells that clog the pores. It helps to accelerate the body’s natural defense mechanisms of flushing out the toxins.
Azaderechta indica has been used since decades as a traditional medicine in treatment of Acne. Azaderchta indica is known commonly as Neem. It is aaociated to Meliaceae family. Azaderchta indica detoxifies the body and acts as a blood purifier. Every part of Neem is useful with number of medicinal properties. It has been used since ancient times to treat many skin problems. It has a soothing effect on irritating skin. Very useful in acne. It acts as a nutritive tonic to skin. The antebacterial properties help to reduce the risk of infections. Azaderachta indica reudces the inflammations and puffiness of acne. Purifies blood thus gives radiance to skin. Pimples with severe redness, pus and tendency to form scars. Painful to touch.
Berberis aquifolium has a marked action on the skin producing pimples, dry, rough and scaly erruptions. Acne is the most common and psychologically distressing skin disorder which is very well managed by Berberis aquifolia, it clears acne and hence clears the skin. It also helps to erase scars on skin. Berberis aquifolia is one of the recommended medicine for its cleansing effect and helps in lightening of complexion.
Pulsatilla nigricans is a very effective remedy for acne during puberty. Especially indicated in young girls. Young girls usually suffer from various hormonal changes which lead to formation of pimples. Acne is worse during time of or around the time of menses, eating rich and fatty food. Especially indicated around time of puberty or when pimples breaks out near menstrual periods.
Hepar sulphur is one of the indicated remedies in acne. Usefull in acne in case of adolescents with unhealthy skin. Yellowish complexion. Great sensitiveness to slightest touch. Useful in pimples that are pustular in nature. The pus may be blood stained at times. The pimples are extremely painful. Tendency to form boils or abscess.
Acne like boils on face especially on cheeks. Slow healing acne which leave pitting scars. Silicea face is waxy, tired, anaemic. Pustular and vesicular erruptions spread over the face. Erruptions and crusts peel off with no healing. Useful in cases of pimples with offensive pus formation. Indicated in treating all types of skin problems. Pimples on forehead and cheeks. Silicea is usually chilly with increased sweating of palms and soles.
Nerve fibres originating from L4-S3 unites in front of piriformis muscle to form the widest single nerve in human body called the SCIATIC NERVE. Myalgia Paraesthesia in the corresponding region of supply of the Sciatic Nerve is termed as SCIATICA.
This symptom can be due to compression of /injury to /pathology of Sciatic Nerve or its nerve fibre origin.
Compression/Injury/ Pathology can be due to trauma / mechanical wear and tear / pathological changes around sciatic nerve or at origin of its fibres at lumbar and sacral region.
Patients presenting with pain along nerve path; should be tested for straight leg raise test
Further imaging tests CT, MRI, MRneurography helps to find out exact cause
Person should also be tested for any deficiency of Calcium through Bone Mineral Density ; Vitamin D levels where sciatica is due to bony degeneration or osteoarthritis of lumbar spine or osteoporosis in general.
In patients with sciatica due to spinal complaints originated from mechanical reasons
Secure lower back(lumbosacral region) and give it proper rest; mild exercises not involving lumbo-sacral region; helps by not involving lower back but still maintaining healthy equilibrium of body thus helping faster recovery.
Spinal manipulation helps to an extent in disc related pain which is contraindicated in progressive neurological deficits
Patients with sciatica due to non mechanical spinal reason / secondary to tumour / some other pathology like inflamation or abscess around; should be treated first for primary reason.
Homoeopathic Medicines for Sciatica with Indications
Magnesium phosphoricum is a great antipsoric remedy. Mag phos is a constituent of nerves, muscles, bones, spine, brain, blood corpuscles. It helps to create white fibres of muscles amd nerves. The deficiency of this salt allows the fibres to contract causing spasms, cramps and other nervous phenomenon. Magnesium phosphoricum is thought of in all maladies having origin in nerve cells and in muscle tissue. Mag phos is very well indicated in Sciatica. It is suited to tall, dark, neurotic, exhausted people. Used for neuralgic pains, having spasmodic effects and have great influence on nerves and muscles. The pains are very violent and may affect any nerve. Pain localises itself in a nerve and become worse especially in case of sciatic nerve. Pains come in paroxysms. The patient feels better in warm place where neuralgias are better. There are times when a nerve in which there is a considerable pain becomes sensitive to pressure. Stiffnness, numbness along the route of nerve from prolong exertion. Rest relieves most of the complaints.
Rhus tox is a frequently indicated remedy in rheumatic affections, and neuralgias. Rhus tox affects the fibrous tissue markedly joints, tendons, sheaths, producing pain and stiffness. Rhus tox is very useful in Sciatica. Pains usually spread over a large surface area along the route of nerve, stiffeness of limbs with paralysis. Presents with tingling in feet. Affections of nerves and spinal cord give rise to paretic effects. Symptoms appear on the eft side and go from left to right. Patient is very restless., cannot rest in one position. Complaints come on from cold damp weather aspecially to cold. Pains that run through Rhus tox are aching, tearing with numbness and paralytic weakness of limbs with loss of sensation. Presents with low back ace with stiffnness, aggravatiom on resting after excercise.
Calcarea carb is chief representative of calcium compound. Calcium metabolism is active during childhood and becomes defective in middle age. Calcarea patient can be described as fair, fat and flabby with tendency to gain weight. Calcarea carb has main action on the vegetative sphere with impaired nitrition being the keynote of its action. Calcarea carb has marked indication in case of sciatica, where there is severe pain in the lower back, lumbar spine to the buttock and down the back of leg. Excruciating pain with burning sensation. Presents with numbness tingling sensation in affected leg or foot. Associated with Weakness of extremities.
Bellis is known commonly as Wound wort, therfore like Arnica it is great traumatic remedy. Very well indicated in Sciatica. There is results of injurie to nerves with intense soreness and intolerance of cold bathing. Severe pain at the lowet back, radiatinv downwards, pains may vary widely from a mild ache to sharp burning sensation, can feel like a jolt or electric shock. Worse when you cough sneeze or due to prolong sitting aggravates the complaints. Sore bruised feeling in the pelvic region.
Hypericum perforatum is an excellent remedy for injury to parts rich in sentient nerves. Indicated in traumatic neuralgiaand neuritis.Spasms after injury.
Hypericum perforatum is considered when the sciatic pain is attended with tingling, burning and numbness in affected limb. The spine is very sensitive to touch. Walking or stooping is impossible from intense pain in back and lower limb. Aching pain in left sciatic nerve after prolonged sitting. Violent pains and inability to walk or stoop after a fall on coccyx. Excessive painfullness is the guiding symptom, associated with cramps in calves.
Arnica montana is frequently indicated remedy in case of sciatica. Patient usually presents with excessive soreness of lower limbs. Severe neuralgias with low backache and pain radiating from back through thigh to foot. Numbness and soreness after over exertion. Cannot walk erect on account of bruised pain in pelvic region. Limbs ache as if beaten. Numbness in feet. Sore lame bruised feeling all over the body, bed feels hard. Slightest tough is unbearable. Arnica is usually suited to cases when an injury however remote seems to have caused the trouble. Extreme restlessnes, patient constantly changes his position.
The sphere of action of phospahte of lime includes all neuralgic affections and bone diseases whether due to some dyscrasia or defective nutrition. Calcarea phos is One of the most important tissue remedies. Very well indicated in case of sciatica. The back pains are worse from cold stormy weather. Severe pain in the back and along the route of sciatic nerve from straining, tearing, shooting, and aching in the spine. Soreness in the sacroiliac symphysis. Pain in the lumbar region and sacrum extending to the feet.
Plantago usually affects the nerves causing nerves causing neuralgias. Patient usually presents with sharp cutting type of pain. Numbness in the affected parts. Trembling of limbs. Severe pain in the back extenxing to feet. Sharp shifting type of pains. Very useful remedy in case of sciatica.
Colocynth has a long lasting action on the nerve especially the scoatic nerve. The principle feature of colocynth is its severe tearing, neuralgic pains, pains are so severe that the patient is unable to remain still. The sciatic pains ae better feom hard pressure. Neuralgic pains are cutting, clamping, gnawing type followed by numbness and lumbar ache which is relieved by pressure. Severe pain in the back extending downwards, sensation as if heavy weight in the lumbo dorsal region lying on left side. Along with sciatica there is agonising pain in abdomen causing patient to bnd double with restlessness. Sciatic pains extend from lumbar region to limbs. Tensive lancination in lumbar region and hips especially while lying on the back. Pain while walking as if psoas muscles were too short, on stooping it caeses but commences again while walking. Usually Left sided sciatica, pain along the course of left sciatic nerve. Pain in low back radiates to toes.
Gnaphalium is an indicated medicine in sciatica, when the pain in the sciatic nerve is attended with numbness. Useful in cases of sciatica where pain is confined to calves and feet. There is intense pain in the nerve accompanied by cramps alternating with numbness. Intense pain along the route of sciatic nerve. Lumbago with numbness of parts and weight or heaviness in pelvis.
The rapidity of action of aconite determines its symptomatology. Aconite is one of the indicated remedy in sciatica. Symptoms are acute, violent and painful. They appear suddenly and remain for a short while as if a big stormwhich soon blows over. Neuralgic pains are very intense. Pain in the back. Sensation of burning, numbness, tingling, crawling semsation alon the route of nerve. Parts remain sore and numb after pains. Physical and mental restlessness with state of fear, anguish.
Belladona is very useful remedy in sciatica. Where the pains are sudden and violent with redness and heat of affected parts. Belladona acts on the nerve centres producing twitching, pains, jerks and spasms in limbs. Invluntary limping. Trembling of limbs. The lower part of the back feels as if broken. Sensation of heaviness in the buttocks and thigh. The sciatic pain is worse from heat and relieved from bending backwards and by rest. Symptoms of belladona that is pain and suffering come on suddenly pass a regular course amd subside suddenly.
Silicea is one the indicated remedy in sciatica. Presents with neurasthenic states and increased susceptibility to nervous stimuli. Sciatic pains usually start in thr back hips and run through the course of sciatic nerve through back of legs and feet. Severe cramps in calves and soles. Weak spine. Severe pain in coccyx.
Bryonia is most effective medicine for sciatica that gets worse from walking. The slightest motion may worsen sciatica., in such cases lying down absolutely still provides some relief to the patient. Heaviness in the Affected hip or leg. The general character of pain here is stitching type of pain, pains greatly aggravated by slight motion and better by rest. Usually adapted to nervous dry, alender people. Pain in small of back which becomes worse by stooping. Scaitica better by lying on painful side.
Vitiligo is believed to be an immune mediate disorder affecting skin.
It is characterized by depigmented spots with sharp well defined margins bilateral in most of the cases , usually patches appears on exposed parts, extremities, body orifices, most common sites involved are hand, wrist, lips, face, feet, umbilicus, eye lids, nostrils mucosa of nose eye and mouth are also involved.
PATHOGENESIS and GENETICS
Its cause is not known, but it’s believed to be multifactorial disease which is genetically predisposed and triggered by Environmental factors. It is frequently accompanied by other autoimmune conditions like Hashimoto’s thyroiditis, psoriasis, systemic lupus erythematoses, pernicious anaemia, alopecia areata etc.It is a non infectious condition. A strong hereditary association is noted.
Tyrosinase the enzyme of melanocyte expressed by TYR genewhich is not the component of immune system but catalyzes melanin synthesis and is a major autoantigen in generalised vitiligo. A genomewide dtudy have found around 36 loci associated with succeptibility towards generalised vitiligo, its usually due to defect in genes related to melanocytes or immune system , its doubted that there might be some autoimmune response towards melanocytes.
SYMPTOMS AND CLASSIFICATION
It can be classified into segmentaland nonsegmental types
In nonsegmental type the depigmentation appear somewhat symetrical and bilateral and usually grow with time and also appears in new areas with somewhat symetrical pattern it can start at any age and can grow to generalised or universalis where very few normal pigmented patches are left behind.
It is further categorised into
Vitiligo Universalis depigmented patches cover almost whole body with very few patches of normal pigmented patches are left behind , Micheal Jackson suffered from this type.
Generalised Vitiligo depigmented patches scattered throughout the body in somewhat symeterical fashion.
Focal Vitiligoone or few small patches in an area, commonly found in children.
Acrofacial vitiligo only fingers and periorificial areas involved
Mucosal Vitiligo only mucosal membranes involved
Segmental type usually affects segments of skin supplied by dorsal root from spinal cord. its usually nonsymetrical and unilateral, it is less frewuently associated with other autoimmune disorders as compared to segmental type, it usually is stable and static and does not grow much in size eith time.
When patches of affected skin are exposed to UV-A light it glows blue and the normal unaffected skin shows no reaction
Biopsy helps in confirmation of diagnosis
MEDICINES FOR VITILIGO IN HOMEOPATHY
BELOW MEDICINES ARE ONLY FOR QUICK REFERENCE AND THERAPUTIC HINTS.
ITS ALWAYS RECOMENDED TO TREAT SUCH AUTOIMMUNE CONDITIONS CONSTITUTIONALY, AFTER PROPER REPERTORISATION AND HOMEOPATHICALLY INDIVIDUALISED SIMILIMUM REMEDY SELECTION.
THE ABOVE MENTIONED CASE WAS TREATED WITH SINGLE SIMILIMUM DOSE FOLLOWED BY PLACEBO TILL DATE AND IT KEPT ON IMPROVING.
Psoralea corylifolia used not only in homeopathy but also is an important plant in Ayurvedic system of medicone. The seeds have a variety of traditional medicinal uses. Psoralea corylifolia is used in Homoeopathy and other system of medicines.
Psoralea corylifolia mother tincture is used therapeutically for various kinds of disorders. Psoralea corylifolia is a vedy valuable remedy in case of Vitiligo. It has a poweful action on the skin as it causes dilatation of arterioles of body leading to pigment formation which diffuses into discolorized leucodermic patches. It contains enormous biological values and is been used to treat various skin diseases from a long time like vitiligo, psoriasis, eczema. Psoralea corylifolia consists main components psoralen and iso psoralen thus it has antibacterial and anti viral properties. Psoralea corylifolea were used thousands of years ago in India for repigmentation of skin in vitiligo patients.
Ammi visnago is a natural substance used since a long time in herbal medicine. Ammi visnago is extracted from a plant in carrot family. Ammi visnago is a very beneficial remedy used in treatment of Vitiligo. Marked white patches are seen on the skin, it usually occurs when the melanocytes stop producing melanin. Usually the discoloration first shows on sun exposed areas such as hands, feet, arms, face, lips. Along with skin discoloration, there is permature greying of hair. Ammi visnago helps in repigmentation of vitiligo affected area.
Iodium is one of the indicated remedy in vitiligo. Usually presents with whitish discoloration of skin, whitish spots appear in patches. Melanocytes stop producing melanin, the pigment that gives color to skin, hair etc. Hence the involved patches become lighter. Iodium is usually suited to persons of scrofulous diathesis with dark black hair. Profound debility, great emaciation. Striking feature of iodium is eats ravenously yet emaciates.
ARS SULPH FLAVUM
ARS SULPH FLAVUM is one of the deep acting remedy which has very good results in case of vitiligo. The patient usually presents with discoloration of skin in patches that are pale white in colour. Ars sulph flavum is especially indicated when vitiligo is at the muco cutaneous junctions. Also indicated in other skin disorders such as eczema.
Sulphur is a great general antipsoric remedy widely used for various kinds of skin diseases. It is often of great use in begining the treatment of any chronic diseases. Erruptions almost of every kind. Useful in case of vitiligo. Whitish discoloration of skin. Skin is usually dry, rough, wrinkled. Unhealthy skin. Every erruption presents with great itching, sometimes itching occurs even without any erruption. Burning is the most characteristic symptom of sulphur.
When solids and particulate metabolites or salts starts depositing at any level of urinary collecting system it forms renal stones or urolithiasis
An organic matrix of mucoprotien is present in all above types of stones which acts as an additional binding matrix and it makes up almost 2.5 % of weight in all stones.
Urolithiasis is more common in males than in females
Increased concentration in urine, of the constituents of stones is associated with stone formation.
COMPOSITION AND INCIDENCE OF DIFFERENT TYPES OF RENAL STONES
1) Calcium Oxalate/Phosphate Stonescomprises 75% of every stones.
Its observed that almost 50 % of cases of Calcium Stones that have idiopathic hypercalciuria and doesn’t have hypercalcemia.
10 % of cases calcium stone cases have both hypercalcemia and hypercalciurea
5% have Enteric(4.5%) or Primary (0.5%) hyperoxaluria
20% have hyperuricosuria
15-20% have unknown metabolic anomaly
2) Struvite Stones (Magnesium, Ammonia, Calcium, Phosphate) usually due to renal infections comprises off 10-15% of all stones.
3) Uric Acid Stones comprises 6% of all stobe cases 50% of which are associated with hyperuricosuria and/or hyperuricemia and 50% are of idiopathic origin.
4) Cystine Stone comprises only of 1-2% of all the cases
5) Other and unknown types of stonescomprises of upto 10% of all the cases
An organic matrix of mucoprotien is present in all above all types of stones which acts as an additional binding matrix and it makes up almost 2.5 % of weight of all stones.
Renal caliculus, while selecting homoeopathic remedy for Kidney stones it is important to make note of all accompanying symptoms, like type of pain , character of urine, and if there are gravels in urine then its colour shape size should be noted, also other miasmatic and constitutional background should be evaluated for proper similimum remedy selection.
Dehydration, Low water intake, excess grapefruit or apple juice intake soft drinks containing phosphoric acid especially areated drinks.
Excess red meat consumption increases concerntration of certain sulfurous amino acids like cystiene and methionine which acidifies urine , decreases citrate excretion through urine and increases excretion of calcium and uric acid through urine thus increasing risk of renal stones.
Calcium suppliment tablets and VitaminD suppliment for long term may cause Calcium Stones
Studies show that low dietary calcium promotes calcium stones:- Unlike supplimental calcium , Natural dietary calcium actually protects you against renal stones. As it binds with ingested oxalate from food in gastro-intestinal tract to form calcium oxalate and thus reducing its absorption and inturn reducing oxalate concentration in urine. Oxalate is 15 times more potent in forming renal stones compared to increased levels of calcium in urine.
Sodium and fluoridated water increases urinary excretion of calcium thus increases risk of stone formation.
Low urinary excretion of citrate
Unlike supplimental calcium , Natural dietary calcium actually protects you against renal stones. As it binds with ingested oxalate from food in gastro-intestinal tract to form calcium oxalate and thus reducing its absorption and inturn reducing oxalate concentration in urine. Oxalate is 15 times more potent in forming renal stones compared to increased levels of calcium in urine
Studies show that low dietary calcium promotes calcium stones.
Magnesium inhibits stone formation.
Patassium promotes urinary excretion of citrate and citrate inhibits crystallisation of calcium and thus reduces risk of urinary calcium stones
Commonly Used Homoeopathic Remedies For Renal Caliculus
Sensation of retention of urine and urge to pass it again soon after passing, patient is thirstless, bright red mealy sediments, bubbling sore sensation in renal region, pain in urinary bladder region, pain radiating from lumbar region to pelvis and down to lower limbs while passing urine, burning in urethra even when patient is not passing urine, feequent micturation, well indicated in patients with renal caliculus with gouty diathesis and elevated uric acid levels and urate crystals in urine. Works well in patients having glomerulonephritis along with Renal Caliculus.
white amorphous salt in urine giving urine a turbid colour, white amorphous salt in urine deposits in form of gravel. Sharp pain in loins especially in left side with unquenchable thirst for large quantity water, unlike berberries vulgaris which has thirstlessness. Well indicated in patients with enlarged prostate and also having Renal caliculus.
In patients with bleeding due to renal stones, heamaturia and Nephritis, Intolerable constant urge to pass urine with paroxysmal acute cutting and burning from lumbar region to pelvis in front, urinary tract infection due to stone initially causing membranous scales giving appearance of bran in water when passed profuse urine and later on urine mixed with blood passes drop by drop jelly like shreddy urine , membranous scales giving appearance of bran in water, infection of urethra due to damage by renal stone causing irritation in urethra increasing sexual desire.
Scanty slimy flaky sandy and bloody urine, gravels in urine that passes in thin stream, this medicine should be thought of when sand-like gravels seen on daiper of children and they are cranky before and during passing urine, Kidney stones on right side.
PAREIRA BRAVA / CONDODENDRON TORMENTOSUM
great tenesmus while passing urine, constant urge to pass urine but has to strain much while passing has to bend down on his knees and press head on floor in front to pass urine causing pain to radiating till his thighs, Urine dribbles after micturating, pain in glans penis, renal stones in patient with gonorrhoeal urinary tract affections.
Small red particles in urine and on daiper of child who cries while passing urine, hot smarting pain in urethra.
Redish brown thick sediment gravels with offensive albuminuria , pain in renal angle radiating forward and downwards towards abdomen and pelvis.
its a wonderful homoeopathy know for its ability to expel foreign particle from body, for which it is also termed as surgeons knife, Red or Yellow sedimentation prostorrhoea due to tenesmus in patients with retention of urine due to renal caliculus
Heavy Red Sand Particle in urine, pain in right hypochondrium and right lumbar region , renal stones in old men with slow feeble urine with stangury, tenesmus and retention of urine.
Calcium oxalate crystals in urine, sour fetid smelling urine with dark brown colour and white sediments and haematuria.
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
Overproduction of uric acid may be due to one or more of following factors:-
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 goutand many having uric acid on higherside 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 aciddue 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 HPRT1are gene related to Purine salvage mechanism.
Phosphoribosyl Pyrophosphate Synthatase associated Protein 1(PRPSAP1).
PRPP (5-phosphoribosyl 1- pyrophosphate) is asubstrate 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).
SNPor 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 :-
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.
Medullary Cystic Kidney disease (type I and II).
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.
In patients with recurrent acute episodes of arthritis especially of great toeaccompanying hyperuricemia is sufficient to establish the diagnosis. However an episode of acute arthritis in many instances may not accompany hyperuricemia, so arthroscentesisshould 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 foodis 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 consumptionand Fructose sweetened food and drinks are strongly associated with it.
Metabolic syndrome, diabetes, cardiovascular disease, and aging process are also associated with this conditionand 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 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 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 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 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.
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 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 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 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 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 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 Acidim is a very Specific and Infallible remedy in cases of chronic and acute gout, usually given in lower potencies in frequent repetitions.
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
Low Grade Fever not necessarily in all cases.
Loss of appetite
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.
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.
Z-thumb deformity or Z deformity the interphalengeal joint gets hyperextended and there is subluxation of metacarpo-phalengeal joint with fixed flexion.
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.
Skin Symptoms of Rheumatoid Arthritis
Necrotising Granuloma or rheumatic nodule many a times appears in the skin.
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
Atrophy of finger skin
Few of above complications are due to prolonged allopathic medication.
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 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.
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
Number and type of joints involved
RA factor and ACPA tests
Acute Phase Reactants CRP and ESR
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
Vector borne conditions like post viral arthralgia/arthritis and Group A streptococcal borne post pharyngitis systemic autoimmune condition.
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.
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 (LP) is believed to be autoimmune condition with an unknown causative and triggering factor. It presents itself with skin lesions characterize by 6 P’si.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.
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
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.
Explanation of indicated remedies on website are as follows.
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 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 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 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 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.
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 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.
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.
Psoriasisis 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
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 Chromosomesare 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.
PSORS1is 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 allele5which encodes Corneodesmosin it is expressed in Granular and Cornified layers of Epidermis and upregulated in Psoriasis.
IL12β geneon chromosome 5q which expresses Interlukin12B(IL12B)
IL23R geneon 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 CARD14is 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.
After infection with certain bacteria and virus its been observed that body develops an autoimmune state resulting into psoriasis.
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
OTHER MAJOR SUBTYPES OF PSORIASIS :-
Generalised pustular psoriasis/pustular psoriasis of Von Zumbusch; during pregnancy its termed as impetigo herpetiformis
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 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 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 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 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 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 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 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.
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 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