A case of Hidradenitis suppurativa treated with Hyoscyamus
Dr. Meghna Shah (BHMS, FCAH)
The following is a case of a 27-year-old male diagnosed with a skin condition Hidradenitis suppurativa (HS). He consulted Dr. Meghna Shah on the 7th April 2018 via Skype.
(*Hidradenitis suppurativa (HS), also known as acne inversa, is a long term skin disease characterized by the occurrence of inflamed and swollen lumps. These are typically painful and break open releasing fluid or pus. The area’s most commonly affected are the underarms, under the breasts, and groin.)
Below is a summary of his past complaints and few notable symptom from his case record form:
His complaint started with an abscess in the back and groin. He received treatment for Tuberculosis which aggravated his abscess. He also had an anal fistula which resolved with treatment. He had undergone 3 surgeries for the same in the past. He had colonostromy (reversed). He had consumed Isotroin for 2.5 years and since 2015 he was doing fine.
Besides he had profuse perspiration in humid weather on the back, head, axilla and between thighs. He had complaint of snoring and drooling of saliva in sleep. He feared dark, being alone and was anxious about his health especially when alone.
(Observations- patient was obese.)
He complaints of minor boils, discharging in nature, recurrent, slightly painful. These would culminate into small abscesses that would discharge, while he was sitting for long hours and when stressed.
His complaint worsened in hot weather. He has undergone multiple surgeries for the same.
(Looks up and talks with hand at the back of his head while talking)
After much struggle with AKT treatment for 4 months and undergoing multiple sugeries, he got diagnosed with Hidradenitis suppurativa – an autoimmune condition in 2015, after which gained a lot of weight and was weighing about 104 kilograms.
His abscess took long to heal. He had overgrowth of skin with occasional discharge worse when stressed. He experienced burning between groin and private parts and would use T-bact ointment. The appearance was like that of a scar tissue. It oozed during summers, stressful situations and under pressure when sitting long hours. The discharge was whitish yellow and occasionally burned. The other abscesses had watery discharge, they were painful after rupturing. He was definitely better after washing with cold water, and worse with heat, even the body heat.
When asked about the effect of this disease on him he said, ‘it depressed him a lot. He could not socialize, his circle was restricted. It was like a state of crisis. He had to undergo surgery almost every semester.
(Obs- he avoided eye contact. He mainly looked up while talking with hands behind the head)
(The further conversation is in the Doctor & Patient manner in order to make it comprehensive and give understanding of the questioning pattern in case taking. The case is compressed and translated for brevity. The abbreviations D=Doctor and P= Patient)
D- Tell more about crisis?
P- I don’t socialize much. I don’t talk to people or express my feelings. I feel lonely, depressed. I keep things to myself.
D- Tell more?
P- I have a lot of thoughts. At times I discontinue taking medication thinking there is no cure to it. I feel I will remain in the same state. I don’t hang out. I seldom go to college. I’ve spent two years running to hospital and undergoing surgeries.
(So far we have understood the effect of the problem on him, and it is now important to understand his deeper experience to this.)
D- How did it feel to you?
P – depressed and sad. The treatment is giving me a lot of pain. There is bleeding, surgeries, abscesses and so much pain. Earlier I had confidence but lately it is very aggressive in nature, frequent. I am unable to walk properly. It has affected my behavior.
I cannot socialize, cannot swim or get into water. I cannot go out with friends.
D- Describe this feeling a bit more? (He was not asked for a specific feeling but the choice is left open to him to talk)
P- Felt sad and depressed. I lost my mother in 2012 and my complaint started in 2009. I was an outgoing and jovial person. I enjoyed going out with friends but have restricted myself. I feel lonely now. I stay alone most of the time. I have now got used to it as this is a part of my life I have to live with.
D- How was your nature earlier to the problem? (It became more obvious that this problem changed a lot in him, and he was not going deeper than this. I think there was something very painful about the experience because of which he was not going deeper.. I tried to then take him to a point that would be easier for him to experience..)
P- I was very jovial, always hanged out with friends and family. I was a friendly person, talkative. I could socialize easily.
my complaint is very painful and that’s why I avoid people. I have to sleep in specific position. The pain worsens on pressure, touch, friction and heat. I only feel better with cold water.
D- talk more about your original nature?
P- Very talkative with friends and family. I liked playing cricket.
(At this point it again came to a halt. Then I decided to take another route..)
D- Tell me what are the things you are sensitive to?
P- I don’t get angry easily (spontaneous). When someone makes fun of it or mocks at me. If I am in a good mood I mock back but at times I get very angry. In anger I shout but that is rare. I only get angry in front of parents and sister. I never show emotions in front of strangers or outsiders.
D- What are your interests and hobbies?
P- cricket. I play for 6-7 hours on weekends. I like watching movies, going out with friends. I used to talk a lot and not restrict myself. I tend to speak too much. I don’t feel strange. The moment I am introduced to someone, I can immediately start a conversation. I don’t get into a quarrel or fight easily, nor do I get very angry.
D- Tell more?
P- If I find someone cunning or vengeful, I move away. I try not to engage in fights. I prefer to ignore them.
(This was an interesting projection and I chose to then explore this.)
D- Tell about cunning and vengeful?
P- When people project themselves differently but later show their true color. I get stressed when I think of them. I don’t like two faced people. They talk differently in front of you and behind your back they show their true colors, I feel bad. They are selfish. They take credit for someone else’s work; steal their pride.
(Now we begin to see his areas of sensitivity)
Such people are jealous looking at others success. They show something and act entirely different. They can influence you in a bad way.
Sometime ago, an office colleague instigated me to fight against another colleague. I ignored him and later got to know he had done the same to a couple of others. He was very pleasing on face, but he rubbished about me behind my back.
(What you see in others or what you are sensitive to about others is who you are. This is what you call ‘Projection’)
D- What was the feeling?
P- Betrayed. I could not judge his nature. I could not recognize his true color. I felt second handed, inferior. I felt bad that I was influenced by someone and could not take the right decision.
D- Talk about this betrayed feeling.
P- I trusted him, but he turned his back at me. He made me fall in a trap. I felt trapped. He was the source of the problem. It was difficult to identify his true nature. I was influenced to take a wrong decision.
Another incident where my sister was having post marital problems especially with her mother in law. She would often cry. They would hurt her with derogatory words. This would stress her. They’d verbally abuse her while she was pregnant.
My mother was asked to apologize to them with no fault of her. This happened a couple of times. My mother had to stoop below her self esteem in order to improve my sisters life. This made me very angry, although I couldn’t express. I felt inferior and helpless, as I couldn’t help my mother. Moreover my personal health was also affecting her. I wondered for what should I live, I have not done anything wrong. I don’t have any bad habits of drinking alcohol or smoking. Why do I have to undergo this suffering, surgeries? I have suicidal thoughts. At times, I feel I will never be cured.
D- What dreams do you get?
P- I get dreams of going out with friends and my things getting stolen. Another dream is that of losing my way and I am stranded in between nowhere.
D- What is the experience in the dream?
P- Terrified, I don’t know how will I get back. I feel restless, freaking out, crying. There are lot of thoughts and I am not able to arrive on a decision. I don’t know where I am stranded.
P- Alone, without help, no friends. Stranded when something is going out of my hands and not in my control. (This is indicative of the miasm in the case)
D- What is the fear?
P- Being alone and in dark. In childhood, I had fear of ghosts.
D- Tell more about the fear?
P- Fear lonely, dark. Something is going to happen to me; either someone will get me; something bad may happen; a ghost will come and get me especially when I am sleeping alone.
While travelling I always keep the lights on.
D- Tell more?
P- It will trouble me, kill me, torture me, harm me.
D- What other fears do you have ?
P- Fear snakes. I don’t fear cats or dogs.
(Obs- The patient avoided eye contact throughout the case, he was looking up. He didn’t realize when the video was turned off.)
In the above case, we evidently see a strong theme of ‘fear’. He is afraid of the dark, ghosts, being alone and snakes. These elements are not only a part of his imaginations but also appear in his dreams. For instance, he has dreams of being lost. When we ask about his experience, he described it as terrifying, freaking out, restless, crying, stranded. Further on, in the same dream, he felt as though he was losing control of things and they were going out of his hands. This typically describes the miasm of the patient. Interestingly, for him every difficult situation is a state of ‘crisis’. For instance, in his disease condition, he had to undergo a multiple surgeries practically every semester. And each time it was like a state of crisis, wherein things went beyond his control.
It is also important to understand the effect of the disease on the patient. On account of his condition, he avoided meeting people or socializing, not wanting to go out with friends, not talking much. Here, we see the patient in a compensated state. However it is important to examine his original self in order to unfold his original unaltered picture. This information will help us derive to the right similimum. Former to this ailment, patient was a jovial, very talkative, out-going person; liked watching movies, playing cricket, meeting friends, in other words overtly social person.
Now when we examine the area of sensitivity in this patient, we come across a strong fear or sensitivity to being betrayed by family or colleagues. He was sensitive to cunningness, vengeance, maliciousness and his experience in there was of being trapped. This feeling came up in two different life incidences; one with the colleague and the other with the brother- in –law. The remedy suitable for the patient must cover all the different aspects discussed above.
In order to treat this patient, along with the above symptoms we need a remedy with tendency to multiple recurrent abscess. Let us list the totality of both his physical and mind symptoms:
mind; LOOKING; constantly in one direction (2)
mind; LOQUACITY (267)
mind; DECEITFUL, sly (56)
mind; JEALOUSY (124)
mind; FEAR; betrayed, being (2)
mind; FEAR; alone, being (146)
mind; FEAR; dark, of (106)
mind; FEAR; ghosts, spectres, of (67)
mind; CHILDISH behavior (96)
mind; NAIVE (17)
mind; DELUSIONS, imaginations; wrong; suffered, has (23)
mind; SUICIDAL disposition; despair, from (20)
generalities; OBESITY (205)
generalities; ABSCESSES, suppurations (542)
When we simply repertorize the above, we get:
From the above repertorization chart we get Hyoscyamus, Arsenic. Sulphur, Belladona, Veratrum alb and Stramonium. Interestingly Hyoscyamus, Belladona and Stramonium belong to the same family viz Solanaceae.
As derived by Dr. Rajan Sankaran, the theme of Solanaceae family is to do with sudden and unexpected danger, violence, explosion triggering a your fright and flight mechanism.
The patients mental state coincides with the theme of ‘Solanaceae’. Interestingly we have 3 remedies from the same family covering his symptoms. However, there is a marked sensitivity towards being betrayed upon, and this is covered only by Hyoscyamus. The main feeling of Hyoscyamus as given in Dr. Sankaran’s ‘Soul of Remedies’ is being let down, disappointed, betrayed and deserted by whom he is dependent on. Besides, there is also tremendous fear of being alone and facing danger of outside world.
Another interesting aspect in his case was that for most part of his first case, he just looked up. and hardly gave me any eye contact. This when I looked in the repertory, I saw: mind; LOOKING; constantly in one direction (2) : 3Brom., 3Hyos.
Interestingly, out of the two remedies, one was Hyoscyamus.
He received Hyoscyamus 1M followed by LM8 for 1 month. Gave him LM since he had a progressive and chronic pathology.
Follow up dated 3rd May 2018:
Observation- Gives a better eye contact, yet looks up at talks.
Not getting abscesses, earlier it was every month. The existing one drains, at times the discharge is more and sometimes less. But overall feeling better.
Feeling less tired. He is sleeping well. Feeling more energetic. He was able to wake up on time. earlier he would start work at 1pm and then feel very tired and exhausted.
Mentally much better. No dreams. Sleep is sound. Earlier would get intermittent disturbance, would wake up 3-4 hours.
Burning sensation on scar tissue has reduced.
Not yet had session with dietician. But have stopped rice in night. Not taking junk food. Have started walking regularly for 30 minutes, sometimes even for an hour.
Rx: Hyoscyamus 1M 1 dose followed by Hyoscyamus LM8 daily for 1 month.
Skype follow up on 6th October 2018:
Developed 2-3 abscess this time. No pus, when they broke only blood.
Discharge from earlier scar tissue – no pattern. Some days no discharge, and some days more than normal. After waking feels some discharge, after walking for long. (gives better eye contact)
Moods are ok. sleeping pattern is ok. Just notice some behavioral change. Getting more short tempered. Getting more angry than normal.
D: Tell more about this?
P: When having conversation even if they do friendly it irritates me, earlier I would ignore. But nowadays getting more short tempered. I am shouting back at them. Not sure if it’s some kind of job stress.
D: What do they do exactly?
P: Little things friends mock at. For instance my weight, and I would mock at them. If I make a mistake while speaking. For eg. Change in accent, or words I use that is inappropriate. We used to have this mocking they now comment on my behavior. At times when they touch certain topics my temper rises. Even father mocked at me and I lost my temper and shouted at him.
P: Anger. Mostly anger. One or two times its fine but when it repeatedly happens I lose it and give back by shouting or talking in a loud voice. I don’t scream just raise my voice.
D: Internally any sensations?
P: Used to get headache for some time. I would lose my control. Usually when I speak I’m aware of what I’m saying but in anger I say certain words which I should not be using. It’s in the heat of the moment and later I feel bad and regret it. I feel I should have controlled myself. Normally I don’t show my emotions to other people. When someone is provoking you, beyond a point you cannot control yourself and lose your temper.
P: Things which happen in recent past..
D: How are your fears?
P: Nowadays after watching horror movies I don’t experience the same fear I had earlier.
Recently watched the Nun. After watching for 2-3 days I had slight fear again, when in dark or lonely places. In the movie, the ghost possessed one character and a scene was picturised, wherein a guy is standing in dark near the graveyard. A girl was hung on tree and comes down. Such thrilling scenes. While watching the scene, I felt thrill which lasted in my mind for couple of days. When I cross from my living room to bedroom, I walk quickly. In my mind I have a thought something may appear like a ghost as it is dark, it could be around. When switching off the lights, if hear dog howling/barking, I get scared.
P: Fears have definitely reduced. Earlier I would turn on lights and sleep with my father. If he was out of town keep lights on. Those things are not happening now.
Weight – 116 (reduced). Walking every day. Planning to now join gym.
Rx: Hyoscyamus 1M f/b LM10
At this point I raised the LM potency to LM10.
Follow up on 10th November 2018:
I am doing better this month. I can see improvement this month. Had less drains, no new abscess.
Exercise not much. Dad is admitted in the hospital. I didn’t increase any weight, maybe reduced half a kg. Earlier would sit for hours in office.
(gives better eye contact)
I feel more energetic this time compared to earlier times. Even after waking from sleep last 15-20 days more refreshed. Sleep patterns are good. Earlier it would take 3-4am, at times 5. Now I can sleep around 11-11:30. Having good sleep.
P: I get short dreams related to whatever has happened during course of week. Like catching cab and going to office. Nothing threatening. On one occasion dream of spending time with mother (who is no more).
D: How is your mind state compared to last month?
P: Last 10-15 days I spent in the hospital taking care of my father. Not much work pressure. Was feeling bit refreshed. When started going to office last week was feeling good, compared to last month. No temper, no emotions since last 2-3 weeks. 1-2 occasion when he was diagnosed was feeling worried about him.
About father – was having bacterial pneumonia. Now he is better.
Now will start going to gym.
Rx: Hyoscyamus 1M f/b LM10
Follow up on 16th February 2019:
(Observation – gives much better eye contact)
Doing good. No new abscess. Worried about March to May (last year) as that is the time I used to get abscess. I have been exercising. Lost 2 kgs. He was weighing 120kg during 1st consultation. Regularly going to gym. Working out at least one hour. I have oozing when I am continuously working for 6-7 hours. When sleeping or walking, that time it has reduced the drains. Earlier drains would wet my innerwear, now it has reduced.
Sleep has regularized. Not much of dreams. Mind state good. Not much of fears.
Rx: Hyoscyamus 1M f/b LM10