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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 70-73

Management of pilonidal sinus using homoeopathic medicine in combination with Kshar Solution: A case report of a novel approach


1 Department of AYUSH, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Department of Homoeopathy, State Homoeopathic Dispensary, Ghazipur, Uttar Pradesh, India

Date of Submission18-Jul-2022
Date of Decision25-Aug-2022
Date of Acceptance27-Aug-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Ashish Kumar Dixit
All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_9_22

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  Abstract 


Pilonidal sinus (PNS) occurs beneath the skin in the gluteal cleft just above the anus. It continues to pose a number of therapeutic challenges and its treatment is mostly surgical. A 33-year-old male shopkeeper consulted the homeopathy outpatient department of AYUSH with complaints of mild pain and bloody pus (serosanguinous) from the sinus tract and intermittent mild fever, for the past 2 years. The patient was apprehensive about the surgery and did not want it. We devised a therapy strategy for the patient. Depilation of the tract followed by the adding of a Kshar solution to spontaneously cauterize the scar tissue was performed. Finally, the homeopathic drug Silicea 200 was given for 3 months period, and the case was followed for more than 9 months. The case exhibited a marked reduction in probing of the tract (1.7–0 cm), Visual Analog Scale (VAS) for pain (3-0), and discharge (+++ to NIL) after 3 months of treatment. The Outcome in Relation to Impact on Daily Living scale score was +4, indicating that he is back to normal in terms of both the main complaint and overall well-being. At the final visit, the Modified Naranjo Criteria for Homeopathy score was +8 on a scale of −6 to +13. Homeopathy in combination with the Kshar solution can be an effective alternative approach to the management of PNS. As a result, controlled clinical trials are warranted.

Keywords: Ayurvedic medicine, Homeopathy, Kshar solution, pilonidal sinus, Silicea


How to cite this article:
Dixit AK, Javed D, Giri N. Management of pilonidal sinus using homoeopathic medicine in combination with Kshar Solution: A case report of a novel approach. J Surg Spec Rural Pract 2022;3:70-3

How to cite this URL:
Dixit AK, Javed D, Giri N. Management of pilonidal sinus using homoeopathic medicine in combination with Kshar Solution: A case report of a novel approach. J Surg Spec Rural Pract [serial online] 2022 [cited 2023 Feb 2];3:70-3. Available from: http://www.jssrp.org/text.asp?2022/3/3/70/364434




  Introduction Top


Pilonidal disease is an infection that occurs beneath the skin in the gluteal cleft just above the anus. Pilonidal means "nest of hair."[1] Pilonidal sinus (PNS; 2022 edition of International Classification of Disease-10-CM Diagnosis Code L05.92) track runs between the buttocks in a vertical orientation. The majority of cases affect young adult males. It affects an estimated 26 per 100,000 persons, with a 3:1 male predilection.[2] The clinical presentation varies, and it might be an acute abscess or a chronic PNS cavity with recurrent discharge due to infected residue and retained hair. In some studies, nonoperative treatment like shaving the hair around the gluteal cleft has been emphasized.[3] On the other hand, postsurgical recurrence is common, necessitating regular and time-consuming wound care.

Kshar sutra therapy is a minimally invasive ayurvedic parasurgical process for the treatment of anorectal diseases; regarded to be safe, sure, and cost-effective.[4] However, regardless of any kind of surgery, patients are always apprehensive about it.

In homeopathic clinical practice, few case reports have been published in this regard and further documentation is required in this direction.[5],[6]

As a result, it is necessary to assess the role of alternative strategies to reduce recurrence and enhance acceptability. Thus, this case report has been conducted to evaluate the effect of homeopathic medicine in combination with Kshar solution in the management of PNS.


  Case Report Top


A 33-year-old male shopkeeper UHID 201901**** consulted the homeopathy outpatient department of AYUSH with complaints of mild pain and bloody pus (serosanguinous) from the sinus tract and intermittent mild fever since January 2020. His build was lean, thin, and thermally; chilly and experienced pain aggravation from cold application and his complaints were relieved by wrapping and warm things. During fever, he did not want to be uncovered. The patient was constipated and always had the sensation of an incomplete void. He had no history of any other comorbidities but a family history of diabetes and hypertension. The patient was apprehensive about the surgery and did not want it. On the day of the first visit, his Pulse was 82 beats per minute, blood pressure monitoring was 130/85 mmHg, and body mass index was 17 (underweight); all other routine tests were normal.

Physical examination and diagnosis

On local examination, a scar measuring 4.2 cm at the 5 O'clock position was found with two external openings on either end of the scar, at the natal cleft about 9 cm away from the anal verge. Intraoperatively, a dye was injected through the external opening and it was shown to be flowing from the natal cleft, confirming the diagnosis of PNS instead of fistula-in-ano.

Case analysis

The patient complaints were recorded after taking the case thoroughly as per the principles of homeopathy. After analysis and evaluation, the "totality of symptoms" was prepared.

Repertorial analysis

Each symptom forming totality was converted into rubrics and the case was repertorized with the help of Homoeopathic Repertorium (Android version 3.9.5.7 developed by Soft Solutions available on the Play Store) [Figure 1].
Figure 1: Repertorization sheet

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The following rubrics were considered for the repertorization:

  • Extremities, fistulous, opening the hip
  • Fever, uncovering, aversion to
  • Generalities, fistulae, openings, hip
  • Generalities, fistulae, ulcers of skin with,
  • Generalities, uncovering, agg
  • Generalities, warm, amel
  • Rectum, constipation, insufficient, incomplete stool
  • Rectum, moisture, bloody
  • Rectum, ulceration
  • Skin, ulcers, discharges, bloody.


Therapeutic intervention

We jointly made a treatment plan for the patient. The surgeon suggested depilation of the tract and adding a Kshar solution to it to naturally cauterize the scar tissues. Finally, orally homeopathic medicines will be given based on the totality of symptoms, repertorization, consulting Materia Medica books, and mutual consent with a separate homeopathic practitioner, having experience of 8 years.

Parasurgical (Kshar therapy)

The PNS was treated under local anesthesia with the help of mosquito forceps by manual depilation of hair tufts from its cavity through its opening followed by washing with Kshar solution; prepared by dissolving Apamarg Kshar (Achyranthes aspera) in normal saline (1:10 w/w ratio). After this, a normal saline wash was given. We did not use any other antiseptic lotion for cleaning. Similarly, daily dressing and cleaning were done until the sinus opening was completely closed.

Medical

The repertorization results suggested the medicine Silicea. On the day of the first visit, Silicea 200, a single dose (4 pills, 30 numbers), followed by a placebo for 15 days, was given for oral intake and advised for follow-up in terms of homeopathy medicine every 15 days.

Outcome assessment and follow-ups

Assessment of the case has been done by physical anorectal examination with probing of the sinus tract, discharge from sinus, and for pain with Visual Analog Scale (VAS). The patient was asked to mark their current pain level on the VAS consisting of a 100-mm long horizontal line with the anchors "no pain" on the left side (0 mm) and "worst imaginable pain" on the right side (100 mm).[7] Two validated outcome measuring scales were used to examine patient-rated outcomes. The patient's perception of how the outcome of care has impacted his daily life was assessed using the Outcome in Relation to Impact on Daily Living (ORIDL) scale.[8] The patient's ORIDL score for his main complaint and overall well-being was recorded at each follow-up. The ORIDL score for both components was +4 at the end of the treatment [Table 1].
Table 1: Follow-up details

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  Results Top


After 3 months of treatment, the sinus pain on the VAS score decreased from +3 to 0, with no discharge. The sinus tract completely healed, which was 1.7 cm deep at the first visit. The ORIDL score also increased to +4 in both its components indicating the patient's return to his normal healthy condition.


  Discussion Top


PNS continues to pose a number of therapeutic challenges.[1] The treatment of PNS is mostly surgical; simple incision, excision, plastic surgery techniques, marsupialization, and fistulotomy are various commonly used procedures nowadays.[9]

In this case, we tried to explore integrated and alternative management by incorporating homeopathic medicine in combination with the Kshar Solution. Apamarga (Kshar) (A. aspera), Snuhi (Euphorbia nerufolia) latex, and Haridra (Curcuma longa) powder are all used in the Kshar Sutra.[10]

In pursuance of repertoriszation, Silicea covered maximum symptoms with the highest marks (23/10) and was distinguished from the other top three medicines in the following characteristics: Phosphorus (16/8) patient has a greater thirst for cold water and a significantly larger discharge toward fresh blood; Hepar sulph (16/7) was ruled out because this patient did not have such a sensitivity to touch and cold. Calcarea carb (13/7) was not suited for this case due to the absence of a peculiar constitution, perspiration, cravings, and aversions and discharges. Keeping all these, Silicea was prescribed in a potentized form. Silicea specifically affects the function of connective tissue, the reticuloendothelial system, and leukocytes.[11]

After treatment, the VAS and ORIDL scales showed that he was back to his normal condition. However, due to the possibility of PNS recurrence, the case was monitored for more than 9 months, during which time no such recurrence was found.

The Modified Naranjo Criteria for Homeopathy (MONARCH) algorithm was used to assess the likelihood of attributing causal linkages between a homeopathic intervention and a clinical improvement.[12] The MONARCH score at the final visit (+8 on a scale of −6 to +13) indicates a strong likelihood of the same [Table 2].
Table 2: Causality assessment by the Modified Naranjo Criteria for Homeopathy

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The Pearson correlation coefficient (+0.939) shows a substantial, positive, and linear relationship between the ORIDL score of the major complaint and the patient's overall well-being [Table 3].
Table 3: Correlation of Outcome in Relation to Impact on Daily Living score for the main complaint and overall well-being

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The coefficient of determination (R2 = 0.882) indicates that the improvement in the patient's main complaint is attributable to 88.2% in the patient's overall well-being [Figure 2].
Figure 2: Scatter plot diagram, showing a linear correlation of "Outcome in Relation to Impact on Daily Living" score for the main complaint and overall well-being

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  Conclusion Top


Homeopathic medicine Silicea in combination with Kshar solution is found useful in reducing pain and discharge, as well as improving tract healing and ORIDL in a patient with PNS. As a result, it could be regarded an alternate therapy for the management of PNS. For better validation of this, rigorous controlled clinical trials are warranted.

Patient consent

The authors obtained the patient's written informed consent to publish his case details and images without disclosing his identity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg 2011;24:46-53.  Back to cited text no. 1
    
2.
Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10:39-42.  Back to cited text no. 2
    
3.
Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am 2010;90:113-24.  Back to cited text no. 3
    
4.
Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical evaluation of Kshara sutra therapy in the management of Bhagandara (Fistula- in-Ano)- A prospective study. Anc Sci Life 2009;28:29-35.  Back to cited text no. 4
    
5.
Singh L, Reddy M. A case of recurrent perianal abscess with fistula-in-ano treated with homoeopathy: A case report. Indian J Case Rep 2021;6:656-8.  Back to cited text no. 5
    
6.
Dutta A. A Case of anal fistula treated by individualized homeopathic medicine. Innovare J Med Sci 2019;7:1-2.  Back to cited text no. 6
    
7.
Katz J, Melzack R. Measurement of pain. Surg Clin North Am 1999;79:231-52.  Back to cited text no. 7
    
8.
Reilly D, Mercer SW, Bikker AP, Harrison T. Outcome related to impact on daily living: Preliminary validation of the ORIDL instrument. BMC Health Serv Res 2007;7:139.  Back to cited text no. 8
    
9.
Varnalidis I, Ioannidis O, Paraskevas G, Papapostolou D, Malakozis SG, Gatzos S, et al. Pilonidal sinus: A comparative study of treatment methods. J Med Life 2014;7:27-30.  Back to cited text no. 9
    
10.
Dwivedi AP. Management of pilonidal sinus by Kshar Sutra, a minimally invasive treatment. Int J Ayurveda Res 2010;1:122-3.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Gutman W. Silicea. J Am Inst Homeopath 1965;58:136-41.  Back to cited text no. 11
    
12.
Lamba CD, Gupta VK, van Haselen R, Rutten L, Mahajan N, Molla AM, et al. Evaluation of the Modified Naranjo Criteria for Assessing Causal Attribution of Clinical Outcome to Homeopathic Intervention as Presented in Case Reports. Homeopathy 2020;109:191-7.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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