An individualized homoeopathic approach in a case of palmar wart: A case report

Background: Palmar warts are benign skin and mucous membrane lesions, caused by human papilloma virus (HPV) infection. In this case a 32 years old woman visited our clinic for the complaint of outgrowths over the palm of right hand which was clinically diagnosed to be palmar warts. Methods: After detailed case-taking and repertorization, at first individualized homoeopathic medicine, calcarea carbonica 1M was given and thereafter other drugs as per the indication were given. Within about three to four months of homoeopathic treatment, the patient started improving and continues to be free from her complains at the time of last follow-up visit in our clinic leaving a clear smooth skin demonstrating a positive role of individualised homoeopathic treatment in a case of verruca vulgaris. Results: Modified Naranjo Criteria for Homoeopathy tool was used to assess the causal relationship between homoeopathic intervention and clinical outcome. The MONARCH score (+9) suggested that the clinical improvement was likely attributable to the homoeopathic treatment, which is also evident from photographic images. Conclusions: This case study shows the utility of individual homoeopathic treatment in case of palmar wart. More studies and evidenced based clinical verification is required to establish the efficacy of homoeopathy in such cases.


Introduction
Warts are benign growths of epithelial tissue that are typically associated with an infection caused by the Human Papillomavirus (HPV) [1] .There are over 100 distinct varieties of HPV, with new types continually being identified.HPVs are known to infect epithelial cells found in various parts of the body, including the skin, mouth, oesophagus, larynx, trachea, and conjunctiva, and they can lead to the development of both non-cancerous and cancerous lesions.Palmar warts, specifically, are predominantly induced by certain strains of the human papillomavirus, particularly HPV types 1, 2, 4, and 63.Palmar warts typically manifest as small, elevated growths appearing on the palm of the hand or the fingers.They often possess a coarse texture and may exhibit a greyish or brownish hue.The size of these warts can vary, ranging from a few millimetres to more than a centimetre in diameter.In some instances, multiple warts may cluster together, forming a larger lesion referred to as a mosaic wart.These viruses can gain entry into the body through minute breaks or cuts in the skin, which are commonly found on the palms of the hands due to everyday activities like gardening, handling rough objects, or coming into contact with surfaces in public areas.Palmar warts can be painful or tender, especially when subjected to pressure, such as during activities that involve gripping or squeezing [2] .Warts are a common occurrence, most frequently seen in children and young adults, although they can manifest at any age.It's not uncommon to observe warts in close proximity to one another, often referred to as "kissing lesions."These growths tend to emerge in areas that have experienced some form of physical trauma, such as the hands, around the nails due to nail-biting habits, and on the soles of the feet [3] .In a notable historical case series report published in the Lancet, McLaughlin and Edington demonstrated that a container of adhesive, specifically bone glue, served as an effective medium for preserving the wart virus.Their research revealed that a single container of this bone glue was the source of infection in nine out of 11 women who had come into contact with it.
~ 393 ~ A significant cross-sectional survey, the initial NHANES conducted in the United States, indicated a 78% prevalence of warts in both sexes.However, in subsequent years, Rea et al. and Kumarsinghee et al. reported lower prevalence rates of 3.43% and 3%, respectively [4] .According to a case study conducted by Chan et al. [5] , it was observed that palmar warts might be associated with type-1 diabetes in the paediatric age group.Although warts are seldom a serious health concern, they can lead to physical discomfort and psychosocial distress [1] .Treatment options vary depending on the location, type, and size of the lesion.Commonly employed treatments include cryotherapy and electrocauterization; however, these methods can be painful, may leave scars, and have relatively high rates of treatment failure and recurrence.Other approaches encompass surgical removal with curettage, laser ablation using CO2 or dye lasers, keratolytic agents such as salicylic acid, acetic acid, tretinoin, or 20%-50% trichloroacetic acid, cytostatic like 1% podophyllotoxin or 5-fluorouracil, and immuneresponse modifiers like imiquimod and Polyphenol E, a commercial extract derived from green tea leaves [6] .The topical application of acetic acid solutions is considered one of the treatment options for HPV infections.However, the accessibility of over-the-counter acetic acid solutions for medical purposes raises concerns about potential misuse [1] .Managing warts remains a significant challenge in contemporary dermatology, as there is currently no fully effective treatment regimen that can guarantee complete recovery without the risk of recurrence [7] .Upon conducting an extensive review of the available literature, we discovered only a limited number of recent reports focusing on the homeopathic treatment of various types of skin warts, including flat warts and filiform warts [8][9][10][11][12][13][14][15][16] .Furthermore, a double-blind, randomized, placebo-controlled clinical trial conducted by Manchanda RK and colleagues [17] has provided evidence demonstrating that homeopathic remedies exhibit therapeutic effects beyond that of a mere placebo.In light of this context, the current case report, which concerns a patient with palmar warts, was successfully managed using individualized homeopathic treatments, thus highlighting the beneficial role of homeopathy in the treatment of palmar warts.

Case report
A 32year aged women came to our clinic with some out growths over her right palm of hand which on clinical examination supposed to be verruca vulgaris i.e., wart.

History of present complaints
The patient was suffering from this warty out growths from last 3 years.Although she had not consulted any kind of treatment for that.

Other complaints
There is whitish discolouration along with fissures over the tongue.

Past history
Intra-uterine history: Pre-eclampsia Chicken pox-at an age of 13 years-allopathically recovered History of recurrent urinary tract infection.Regarding the Obstetrical history (P 1+1 ) there was a history of abortion followed by onset of irregularity of menstruation.

Family history
Regarding family history father has hypertension.

Clinical diagnosis
Based on the clinical presentation the patient was diagnosed to have palmar wart.

Generalities
The patient cannot tolerate hunger and drinks while eating.The patient has desire for egg, sweet, raw salt, and lukewarm food.She has unquenchable thirst.She perspires profusely over the scalp.Stool is hard and not clear.Thermally she is chilly besides that there is irregularity of menses which can be traced to abortion as previously mentioned.In the mental generals the patient has got fear of darkness, her memory is also weak, besides that patient is short-tempered too, which is aggravated from consolation.

Analysis and evaluation of symptoms
Mental general  Fear of darkness. Short-tempered, which is aggravated from consolation. Weakness of memory.

Physical general
 Irregularity of menses  The patient has desire for egg, sweet, raw salt, and milk. She has unquenchable thirst. The patient cannot tolerate hunger.drinks while eating. She perspires profusely over the scalp. Thermally she is chilly. Stool is hard not clear.

Particular
 Warts over the dorsum of right palm. Whitish discolouration of tongue along with cracked tongue.

Totality of symptoms
 Fear of darkness. Short-tempered, which is aggravated from consolation. Weakness of memory. Irregularity of menses.
 The patient has desire for egg, sweet, raw salt, and milk. She has unquenchable thirst. She perspires profusely over the scalp. Stool is hard not clear. Whitish discolouration of tongue along with cracked tongue.
The miasmatic evaluation of the symptoms of this case was done and the predominant miasm was found to be Psoric.
Considering the above-mentioned characteristic symptoms, Kent's Repertory was preferred and using HOMPATH software, systemic repertorization was done.The Repertorization chart is given in Fig 1.

Modified Naranjo algorithm Yes No
Not sure or N/A Was there an improvement in the main symptom or condition for which the homoeopathic medicine was prescribed?+2 Did the clinical improvement occur within a plausible timeframe relative to the medicine intake?+1 Was there a homeopathic aggravation of symptoms?0 Did the effect encompass more than the main symptom or condition (i.e., were other symptoms, not related to the main presenting complaint, ultimately improved, or changed)?+1 Did overall well-being improve?+1 Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease?0 Direction of cure: Did at least one of the following aspects apply to the order of improvement of symptoms: From organs of more importance to those of less importance?-From deeper to more superficial aspects of the individual?-From the top downwards?0 Did 'old symptoms' (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during improvement?0 Are there alternative causes (i.e., other than the medicine) that -with a high probabilitycould have produced caused the improvement?(Consider known course of disease, other forms of treatment and other clinically relevant interventions) +1 Was the health improvement confirmed by any objective evidence?(e.g., investigations, clinical examination, etc.) +1 Did repeat dosing, if conducted, create similar clinical improvement?+2 0 Total +9

Discussion of the case
When as a physician we come across some hyperkeratotic papules with irregular surface on skin then besides the wart we should also consider other conditions like seborrheic Keratosis, molluscum, squamous cell carcinoma etc. Let's know the difference.Distinctive "stuck on" appearance of hyperpigmented papules with a greasy surface and keratinous plugs is the characteristic feature of seborrheic keratosis, whereas the squamous cell carcinoma is characterised by verrucous plaque or shallow ulcer with red granular floor, surrounded by a wide, elevated, often everted, and indurated border with the base indurated, often attached to underlying structures along with regional lymphadenopathy.Regarding this case, patient came to us with the typical characteristic features of viral wart in palmar region as evidenced from the photographic images taken prior to treatment (Fig 2).The miasmatic evaluation [18][19] of the symptoms of this case was done and the case was found to be multi-miasmatical with psoric predominancy.Considering the past history family history personal history individualised characteristic symptoms and consulting our authentic [20] materia madica, final selection for this case was calcarea carbonica 1M, 2 dose on 10/1/2023.Following which there was marked improvement seen in the patient the details of which has been mentioned in [Table no : 1].The Modified Naranjo Criteria [21] were applied to this case for ascertaining the causal attribution between the homoeopathic medicine applied and the changes in the symptoms/signs of the patient [Table -2].As per the modified Naranjo Criteria, the total score of the outcome is (+9).

Conclusion
This case report is a testimony of effectiveness of homoeopathic remedies in case of palmar wart which is a challenging problem in modern dermatology.Further rigorous clinical, observational studies, randomised controlled trials etc are necessitated for establishing the effectiveness.Through prognostic factor research we can evaluate the effectiveness of the symptoms given in totality of symptoms for calcarea carbonica.

Financial support Not available
Consent of the patient: Written consent has been obtained from the patient.

Table 1 :
Follow up marked improvement in the symptoms of the patient especially the cutaneous warts which are seen to be disappearing and menstrual irregularities is also better than before and hardness of stool is much better than before.in the symptoms of the patient especially the cutaneous warts which have completely disappeared and menstrual irregularities and hardness of stool is much better than before. A