1.       Introduction

This case highlights a singular successful treatment of chronically fissured feet in a child diagnosed with Juvenile Plantar Dermatosis (JPD), atopic dermatitis, and verruca simplex using homeopathic medicine. JPD, sometimes referred to as ‘Sweaty Sock Syndrome’ or ‘Forefoot Eczema’ is a painful condition of the anterior plantar foot and toes that most commonly affects children ages 3-15, often resolving with puberty [1,2]. The severe chapping, desquamation, and fissuring of JPD is often attributed to footwear that doesn’t allow for proper ventilation. However, it is likely that there is a predisposition to the condition, as the footwear of affected children doesn’t differ greatly from the footwear of unaffected children [3]. JPD has been histological associated with other forms of eczema [4]. Though recent research on etiology suggests that while the majority of children who get JPD have other forms of ‘Atopy’, it is only about 52%, and the two remain distinct diagnoses [2]. JPD can have a similar appearance to some forms of tinea pedis, more commonly known as athlete’s foot [5]. Specifically, the chronic, hyperkeratosis (Moccasin) form can present with fissures and peeling of the soles of the feet [6]. However, tinea pedis is rare in pre-pubertal children, and since JPD is not fungal in nature, negative skin scrapings are often used to rule out tinea as an etiology. Conventional treatment of JPD with topical steroids and lubrication is palliative at best, and can be taxing for the patient. Lubricating creams or ointments must be applied several times per day, and the feet are typically covered with plastic wrap at bedtime. Occlusive footwear should be removed at school, and socks should be changed twice per day [3]. Topical steroids can exacerbate thinning and cracking of the skin [1]. Tacrolimus a topical macrolide immunosuppressant ointment was shown to be effective in one study [5]. However, this drug is generally reserved for severe cases, as long term use is associated with development of skin malignancies and lymphoma The therapeutic value of homeopathy is typically regarded as a safe, effective treatment for a variety of skin conditions (i.e., allergic, inflammatory, infectious, etc.) and has been thoroughly documented in the literature [7-10].The value of homeopathy lies in its ability to not only reduce the severity of immediate symptoms, but to lessen the predisposition toward flares [11,12]. The following case illustrates the effectiveness of homeopathic Petroleum oleum in resolving a singular case of debilitating fissures in the soles of the feet of a pediatric patient which had been chronically present at least four years prior to treatment.

2.                   Presenting Concerns

A nine-year-old Caucasian female presented with chief concerns of deep, painful cracks in the soles of her feet with accompanying diffuse, dry, flaking skin and warts (Figure 1A). The deep fissures were on the balls of the feet bilaterally, extending through the webs and pads of the toes. The plantar surfaces appeared dirty, even though they were clean, and the skin was peeling. She reported constant pain from the fissures under the toes and along the ball of the foot. Pain from the other fissures was exacerbated by sweating and walking. Pain with walking was 8/10 on a scale of 1-10, with 10 being the most severe. She described a stinging sensation as if “Stepping on little needles,” but denied itching on the soles of her feet. In her past, the fissures would bleed and become inflamed, though that was not present at the time of intake. Initial onset was approximately four years prior, around the age of five years old. The patient could not remember when she didn’t suffer from this condition. Her father reportedly suffers from severely cracked feet as well. She was assessed by her pediatrician a few years prior, but no recommendations were given. A variety of lotions, creams, olive oil, and essential oils were tried without success. Upon intake, she was using an over-the-counter ointment containing 8-hydroxy quinolone sulfate 0.3% in a petrolatum lanolin base. This treatment had been partially effective, except during the summer months when symptoms were at their worst. Based on clinical presentation, personal history of atopy, and family history of chronic foot dermatitis, the patient was diagnosed with juvenile plantar dermatosis. The presence of tine a pad is was also considered, but a skin scraping was not performed. The patient also presented with accompanying concerns, including eczema, warts and distractibility, with inattention. The eczema began a few months prior, after being dormant since infancy. There was dry, flaking skin on her face, specifically on the cheeks and below her eyes. The skin of her knees was rough and thickened, with whitish flaking upon excoriation. There were three excoriated, dry patches on the lower leg, the largest being about 3cm in diameter. The lesions were puritic. She could not resist scratching, though it would exacerbate the itch. She denied scratching until bleeding or waking at night to scratch. The pruritus was aggravated by bathing and ameliorated with emollient lotion. A 3mm wart, present for three years, was noted on the right fifth digit, at the distal interphalangeal joint. A 2mm wart was noted on the flexor surface of the right second digit at the proximal interphalangeal joint. A 2mm wart was noted on the right calf. Other pertinent medical history included past ear infections, frequent epistaxis, exercise induced asthma, and distractibility, with inattention demonstrated at home and school.

        3.       Intervention

Homeopathic medicine and non-pharmacological topical agents were utilized as the only treatments in this case. The topical agents were palliative, providing some immediate comfort to the patient and lessen the occurrence of secondary infection. The patient’s mother was instructed to mix the ointment she was currently using with a calendula based salve in a 1:1 ratio, along with a few drops of tea tree oil, applying nightly in the usual manner, underneath socks. Topical emollients alone are not curative in a case such as this and do not prevent recurrence of the fissures, as evidenced by the patient’s four-year history of utilizing them. In this case, the primary method of treatment used to treat the patient’s painful skin condition was homeopathic medicine. The goal of homeopathic treatment is to choose a specific substance, based on the patient’s unique presenting symptoms that will best stimulate self-healing mechanisms within the patient. In the system of homeopathy, as symptoms improve or change over time, it may become necessary to change the potency of the medicine, or change the substance itself, in order to maximize the healing process. The most distinguishing features of this case were repertorized. The totality of the patient’s symptoms (Organ on Aphorism 153) [13] was most similar to the recorded effects of Petroleum oleum in the material medicate. The patient was initially prescribed Petroleum oleum 6C, 2 pellets dissolved sublingually, daily. Other remedies considered for this patient included Sarsparilla, Sulphur and Graphite’s. A more complete list of symptoms, most similar to our patient’s, found in the material medicine include:

Petroleum - Hahnemann’s Chronic Diseases: [14] Lips cracked; Cracked, fissured skin of the hands, full of chaps (aft.13 d.) Petroleum - Allen’s Encyclopedia: [15] Tips of the fingers rough, cracked, fissured, with sticking-cutting pain (after eight days); Skin of the hands cracked and rough, [_a1]. Petroleum-Hering’s Guiding Symptoms: [16] Chapping and cracking of the skin; Thick, greenish yellow crusts; burning and itching; redness, rawness and moisture; soreness and swelling of the scalp; cracks bleeding easily; thick, yellowish exudation; Scrofulous ophthalmia; great difficulty in opening eyes in the morning; skin deeply cracked and slowly healing; Eczema; heavy, greenish-yellow crusts; skin cracked, with tendency to bleed; Herpetic itching, redness and moisture on the scrotum; skin cracked, rough and bleeding; extending to perineum and thighs; Skin of hands cracked and rough; Deep, bloody rhagades on hands, thick crusts; Tips of fingers rough, cracked, fissured; sticking, cutting pain; eczema, excoriations, cracked, bleeding rhagades; Eczema; vesicular eruption forming thick scabs and oozing pus; skin harsh and dry; deep cracks and fissures which bleed and suppurate.

Petroleum - Morrison’s Desktop Guide: [17] the conditions which respond to Petroleum are almost always very dry and it is the first homeopathic remedy considered when the patient complains about tremendous dryness of the skin, so dry that no cream or salve is of any benefit.

4.       Outcomes

Over the course of 12 months following the initial intake, the patient presented for monthly follow up visits, at which time 1) the same remedy was continued, 2) the potency of the same remedy was increased, or 3) the remedy was changed. Unlike conventional treatment protocols, these decisions could not be determined ahead of time, but were based on the unique set of symptoms which surfaced with each follow up visit.

·         Month 1: The patient reacted very well to the Petroleum oleum 6C initially prescribed. She reported improvement in several symptoms, and this was confirmed by physical examination. The severity had dropped from 4/4 to 2/4 (Figure 1B and Figure 2). The fissures were still painful, but walking was easier, as it no longer felt like needles. The skin appeared softer, but still dirty looking, and with noticeable odor. The peeling skin had completely resolved. The patches of eczema had fully resolved, and the skin in those areas was smooth. Two of the three warts were gone, and the long-standing wart on the right index finger was more flattened in appearance. The accessory symptom of epistaxis, however, had worsened. The patient reported eleven nose bleeds over the course of the month, which typically occurs between 10am and 2pm. The distractibility had not changed. The patient rated difficulty maintaining focus in school as 7/10 (scale of 1-10, with 10 being most severe). The potency of the Petroleum oleum was increased to 30C at this follow up, after four weeks on the 6C potency, since the patient’s mother was unsure that she would be able to recognize a plateau. The remedy did not appear to affect the epistaxis or distractibility, so it was noted that a different prescription may be required in the future to address those symptoms. Homeopathic Sulphur was also noted as a future consideration, due to the strong foot odor noted on physical examination in office.

·         Month 2: The patient did not improve with the increased potency of Petroleum. The fissures had deepened slightly and appeared dirtier than the previous visit (Severity 3/4) (Figure 1C and Figure 2). There was a new wart on the sole of her right foot, and the eczema had worsened with new dry patches on the thighs and arms. The patient’s teachers had contacted the mother expressing concerns that the patient’s ability to focus and listen attentively was declining and that she had lost some of her joy and self-confidence. Based on her dry, cracked skin, tendency to get warts, and distractibility, the patient was prescribed Sepia officinalis 30C, 3 sublingual pellets daily. Other remedies that were considered at this time were Sulphur, Lycopodium, Calcarea, and Medorrhinum.

·         Month 3: The patient reacted partially to Sepia as evidenced by very mild improvement in the fissures of her feet, though one of the fissures was bloody (Severity 3/4) (Figure 1D and Figure 2). She reported that summer weather was always much more difficult for her, which was the present time of year. Her left foot was no longer painful to walk on and the wart was smaller. She developed a return of an old symptom - cracks in her fingertips. Based on the lack of adequate response, the patient was prescribed another round of Petroleum at a higher potency of 200C, 3 sublingual pellets daily. This was based on a past clinical experience of petroleum oleum failing at the 30C potency, even when well indicated. Medorrhinum remained a future consideration based on symptoms of feeling hot, difficulty concentrating, history of acute illnesses since birth, painful soles of the feet, and warts on the soles of the feet.

·         Month 4: The patient reacted positively to Petroleum 200C. The toes appeared nearly normal, and most of the deep fissures were healing (Severity 2/4) (Figure 1E and Figure 2). The pain when walking was completely resolved. The eczema had improved, with some mild patches remaining on her inner left calf. She was instructed to continue on Petroleum 200C, 3 sublingual pellets daily.

·         Month 5: The patient’s feet continued to improve, though they remain cracked (Severity 1/4) (Figure 1F and Figure 2). Her eczema and warts had not improved. She continued to have a very difficult time remaining focused and completing any task asked of her. She reported that she gets headaches under stress and they are ameliorated in the “Freezing” cold temperature of classroom. She reported sweating on her face at typical room temperatures. Based on the belief that the patient may have plateaued on the Petroleum oleum 200C potency, she was prescribed an increased potency of Petroleum 1M, 3 sublingual pellets daily. Other remedies considered at this time were Sulphur and Lycopodium.

·         Month 6: The patient’s feet continued to improve, with no pain upon walking (Severity 1/4) (Figure 1G and Figure 2). However, the eczema and warts remained the same. She continued to have a difficult time remaining focused and completing tasks, feeling too distracted or “Rushed.” Based on her symptoms of cracks in the skin, warts, eczema, sweating on the face, feeling rushed or hurried, and aggravation by heat, the remedy was changed to Sulphur 30C, 3 sublingual pellets daily.

·         Month 7: The patient reacted negatively to Sulphur and was considerably worse (Severity 4/4) (Figure 1H and Figure 2). The fissures were much deeper, accompanied by flaking, with a dark, dirty appearance to the skin. There was an episode of bleeding inside one of the fissures. The warts remain unchanged and the epistaxis was significantly worse. There was a very mild improvement in her ability to complete tasks at home. Based on the worsening of her physical symptoms, it was recommended that she return to Petroleum at a potency of 1M, with instructions to increase to 10M potency if there is no improvement after one week.

·         Month 7.5 - Acute illness: Midway through the month, the patient returned to the office and was diagnosed with acute otitis media. Based on the new symptom picture, she was instructed to stop the Petroleum and start Pulsatilla 200C, 3 sublingual pellets every 3-4 hours, in addition to other supportive treatments, including vitamin A, garlic and mullein ear drops, children’s immune support drink mix, and acetaminophen as needed for pain relief. Over the course of the next few days, the patient’s mother consulted the physician every other day, and alternated homeopathic Pulsatilla with Belladonna until the ear pain resolved.

·         Month 8: At this visit, the patient’s acute ear infection had completely resolved. However, according to teacher reports, the patient’s distractibility at school had significantly worsened over the recent couple of weeks. Patient was instructed to return to Petroleum 1M.

·         Month 8.5: It was learned at this visit that the patient’s mother accidentally gave Petroleum oleum 200C instead of the 1M potency as was intended. The rash on the patient’s arms was worse and both of her knees were red, burning, and itching. Since this appeared to be an aggravation, she was instructed to stop taking the remedy and do no treatments for two weeks.

·         Month 9: The patient’s reaction to the remedy was unclear and has been clouded by a premature trial of Sulphur, a subsequent acute illness, and use of an incorrect potency of Petroleum with aggravation. At this visit, there was a new fissure on the right heel that was bleeding (Severity 3/4) (Figure 2). Walking was very painful. The wart on her foot was gone, but the wart on her right fifth digit (Which has previously resolved) had returned. Eczema had erupted on the flexor surfaces of her knees and elbows. The skin on her hands was dry and rough. Teachers continued to report on the patient’s failure to finish assignments. It was decided to start again with a “Clean slate” of Petroleum 10M, 3 sublingual pellets, dosed once weekly to avoid aggravation.

·         Month 10: The patient reacted positively to Petroleum 10M. The pain and fissures had improved, without episodes of bleeding (Severity 2/4) (Figure 1I and Figure 2). The patient required less topical emollients. The eczema had flared again behind the knees. There was a new area of seborrhea dermatitis behind the left ear, which was a return of old symptoms she had when she was very young. She was instructed to continue with Petroleum 10M, 3 sublingual pellets, weekly.

·         Month 11: The patient continued to react positively to Petroleum 10M (Severity 0/4) (Figure 1J and Figure 2). The soles of her feet were smooth, without cracking. There was slight peeling on her toes. Otherwise, her condition had completely resolved.

·         Month 24: Twelve months after discontinuing treatment, the patient’s symptoms continued to remain improved (Severity 0/10) (Figure 1K and Figure 2).                     

        5.       Discussion 

This case suggests the possibility that homeopathic medicine, specifically Petroleum oleum, contributed to the reversal of chronic, debilitating fissures on the soles of a child’s feet, which had been a source of suffering for four years. The success of homeopathic treatment is dependent on the prescriber’s ability to match the patient’s unique symptoms with the actions of the chosen medication [13]. A marked improvement of symptoms is usually indicative of a correct prescription. As long as those symptoms continue to improve, there is no need to change the remedy. Sometimes though, as the patient heals, the symptom profile changes such that it becomes necessary to change the potency, or the remedy itself, in order to continue the facilitation of healing. Homeopathic prescriptions are individualized for the patient and no two cases are completely alike. Each decision to either continue or change the course of treatment is a judgment call made by the prescribing physician. 

In this case, the patient clearly reacted positively to the initial administration of Petroleum, as evidenced by dramatic improvements in symptoms overall. However, when the potency was raised to 30C, the rate of improvement halted. There are a few possible reasons for this, including 1) the medication was pharmacologically inactive, 2) an acute illness or stress interfered with the reaction to the medication, or 3) the medication chosen was not the best remedy for the presenting symptoms. Assuming that the medication chosen was not the best remedy, Sepia was subsequently prescribed, to which the patient partially reacted, but not nearly as well as she had with Petroleum 6C. Since the case was still well covered by Petroleum, and it was possible that the previously prescribed potency of 30C was not pharmacologically active, a new potency of 200C was prescribed. For three months, the patient’s skin continued to improve on Petroleum 200C and 1M. However, the lack of attention problems at home and school continued. In an effort to treat the totality of symptoms, which included distractibility, the patient was prescribed Sulphur, which has an affinity for skin and mind conditions like hers. However, upon follow up, it was immediately clear that Sulphur was not the correct prescription, for it made the patient worse, nearly returning her to original baseline symptoms. During the following month, the case was convoluted by an acute illness and the patient’s accidental use of an old potency of Petroleum. Only after a break in treatment, followed by prescribing a higher potency of Petroleum (10M), dosed weekly rather than daily, did the patient regain the improvements she had previously made and continued on toward a complete recovery. 

The patient’s recovery should not be attributed to the application of the topical preparation, as this less than optimal treatment was consistently used prior to intake and throughout the homeopathic treatment for palliative purposes only. Furthermore, it was not likely that the condition healed spontaneously, as it had been stubbornly present for four years prior to treatment. A lesson that can be learned from this case is the importance of patience in homeopathic prescribing. When chosen correctly, homeopathic medicine is thought to stimulate the body to heal itself in the quickest, most efficient way possible. However, occasionally the case contains too few characteristic symptoms to clearly direct the physician to one specific remedy. In these cases, Hahnemann suggested that the case be retaken, and a different remedy be selected, or used in succession for the best therapeutic effect [18]. Twice the physician in this case abandoned Petroleum prematurely, which produced temporary states of relapse for the patient. Fortunately, in homeopathy, these “Errors” can have a positive outcome. The symptoms which emerge or become enhanced following an inaccurate prescription often lead the physician to the correct remedy with unprecedented clarity [19]. In this case, the physician was continually redirected to Petroleum, which resulted in long-term stabilization of this patient’s debilitating skin condition. 

Figure 1(A-L): Photographs of the patient’s feet over the course of treatment. A-initial intake; B-month 1; C-month 2; D-month 3; E-month 4; F-month 5; G-month 6; H-month 7; I-month10; J-month 11; K-month 24. 

Figure 2: Graph representing the severity of symptoms on the patient’s feet over the course of treatment. Scale ranges from 0-4, with 4 being severe pain and extensive skin fissures, 0 being a complete lack of pain and skin fissures. The course and changes in treatment protocols is shown. 

1.       Kalia S, Adams SP (2005) Derma case Can you identify this condition? Juvenile plantar dermatosis. Can FAM Physician51: 1203-1213.

2.       Kumar H, Keerthi SN (2016) Juvenile plantar dermatosis: A barrier disease beyond eczema: An open prospective uncontrolled study in a teriary care hospital of South India. Indian Journal of Pediatrics Dermatolog 17: 17-13.

3.       Habif T. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Fifth Edition. St. Louis: Mosby, 2010.

4.       Zagne V, Fernandes N, Cuzzi T (2014) Histopathological aspects of juvenile plantar dermatosis. The American Journal of Dermato pathology 36: 359-361.

5.       Shipley D, Kennedy, C. Juvenile plantar dermatosis responding to topical tacrolimus ointment. Clinical and Experimental Dermatology 31: 453-454.

6.       Durdu M, Ilkit M, Tamadon Y, Talooe A, Rafati H, et al. (2017) Topical and systemic antifungal in dermatology practice. Expert Review of Clinical Pharmacology 10: 225-237.

7.       Itamura R, Hosoya R (2003) Homeopathic treatment of Japanese patients with intractable atopic dermatitis. Homeopathy: The Journal of the Faculty of Homeopathy 92: 108-114.

8.       Lawrence CN (2011) Seborrheic dermatitis and homeopathy. Nasza Dermatology Online 4: 208-210.

9.       Wiessner A. Psoriasis. Health & Homeopathy. September 2009: 25-27.

10.    Simonart T, Kabagabo C, De Maertaelaer V (2011) Homeopathic remedies in dermatology: a systematic review of controlled clinical trials. British Journal of Dermatology 165: 897-905.

11.    Fisher P. SPOTLIGHT ON Skin. Health & Homeopathy. Summer 2005: 17-20.

12.    Medhurst R (2014) Is there a role for homeopathy in psoriasis? J AustTradit Med Soc 2014- 20: 268.

13.    Hahnemann S. Organ on of Medicine. 5^th ed. Translated by Dudgeon RE (1833). Indian reprint, New Delhi; B. Jain Publishers 1996: 153.

14.    Hahnemann S (1895) In: The Chronic Disease, Their Peculiar Nature and Their Homoeopathic Cure. 2^nd ed. Translated by Tafel LH. Indian reprint, New Delhi: B. Jain Publishers; 2011.

15.    Allen TF. Encyclopedia of Pure Materia Medica: A Record of the Positive Effects of Drugs upon the Healthy Human Organism (1874). Indian reprint, New Dehli: B. Jain Publishers; 2000.

16.    Hering C. The Guiding Symptoms of our Materia Medica (1879) Indian reprint, New Dehli: B. Jain Publishers; 1997.

17.    Morrison, R. Desktop Guide to Keynotes and Confirmatory Symptoms. Mumbai, India: Homoeopathic Medical Publishers, 1993.

18.    Hahnemann S. Organon of Medicine, ibid. Aph 164-177.

19.    Hahnemann S. Organon of Medicine, ibid. Aph 180.