Tinea pedis = Fusspilz
In der U.S. wird Rekruten empfohlen über ihre Füße zu pinkeln als Vorbeugung von Fusspilz.
[Prashadhna Devi Maharaj]
The Efficacy Of A Topical Naturopathic Complex (Allium sativum Ø, Hydrastis canadensis Ø, Apis mellifica D3 and Urtica urens D3) In The Treatment Of Tinea pedis.
Mini-Dissertation submitted in partial compliance with the requirements of the Master’s Degree in Technology: Homoeopathy in the Faculty of Health Sciences at the Durban Institute of Technology.
Tinea pedis, more commonly known as “Athlete’s foot”, is a common acute infection that occurs in warm, humid climates (Fitzpatrick, et al. 1992:98).
Warmth, humidity, trauma and occlusion such as non-breathable footwear increase the susceptibility to infection (Prescott, et al. 1999:814). The infection can become chronic in people who are more susceptible such as patients who are immuno-suppressed or those who have Diabetes mellitus (al Hassan, et al. 2004: 1).
The aim of this placebo-controlled double-blind study was to evaluate the effectiveness of a topical naturopathic complex comprising of
Allium sativum mother tincture (Ø),
Hydrastis canadensis mother tincture (Ø),
Apis mellifica (D3)
Urtica urens (D3) (in an aqueous cream base) in the treatment of Tinea pedis.
The complex utilized in this study is regarded as naturopathic because the remedies comprising the complex were selected for the following reasons:
Allium sativum and Hydrastis canadensis, each used in mother tincture, were selected for their antifungal properties.
Apis mellifica and Urtica urens, each utilized in D3 potency were selected because their skin symptomotology most accurately matched the symptoms associated with “Athlete’s foot”.
This study focused on individuals between the ages of 18 and 60 years residing in the greater Durban area. It was designed for 30 participants, consisting of two equal random groups, with one group receiving the complex and the second group receiving the placebo. Extra participants were, however, recruited to allow for dropouts. Data for statistical analysis was obtained from all participants who completed the trial. The final number of participants that completed the trial was 31. The treatment group comprised of 15 participants and the placebo group comprised of 16 participants.
The participants had a follow up consultation 2 weeks after the 1st consultation and a final consultation 2 weeks after the follow-up consultation.
Data for this study was obtained from the Patient Perception Questionnaire (PPQ) (Appendix D) and Visual Scale for the Assessment of the Appearance of the Feet (VS) (Appendix E).
The Visual scale provided an objective measurement and the PPQ provided a subjective measurement.
For each type of scale, the Wilcoxin’s Signed Rank test was conducted to test for a significant difference in population means within each group i.e. before and after treatment. The difference between the pre-treatment and post-treatment within each group was calculated. Frequency tables were also utilized for selected questions in the PPQ within each group. All the results were positive i.e. there were significant differences within each of the two groups on both scales where p < 0.05. When results were compared between the two groups, utilizing the Kruskall Wallis Test, no significant differences were noted (p > 0.05).
The treatment administered in this study namely, the topical naturopathic complex, was successful in reducing the signs and symptoms of Tinea pedis, but, because there was no significant difference in the effect between the topical naturopathic complex and the placebo (an aqueous cream base impregnated at a 10% volume-to-volume concentration with plain ethanol), it is concluded that the topical naturopathic complex comprising of
Allium sativum mother tincture (Ø),
Hydrastis Canadensis mother tincture (Ø),
Apis mellifica (D3)
Urtica urens (D3) (in an aqueous cream base)
was per se not effective in the treatment of Tinea pedis.
Fungi that thrive only in the uppermost tissue of the skin cause superficial fungal infections of the skin. “Tinea” is the term used generically for these fungal infections, which are usually referred to
as “Ringworm” (Fitzpatrick, et al. 1992:98). “Pedis” is a Latin word and means “foot”.
Tinea pedis is therefore a superficial fungal infection of the feet and is more commonly known as “Athlete’s Foot” (Tierney, et al. 2000:141).
Tinea pedis is a very common acute infection that occurs in warm humid climates (Fitzpatrick, et al. 1992:98). Warmth, humidity, trauma and occlusion increase susceptibility to infection (Prescott,
et al.1999: 814) It can become chronic in patients who are more susceptible such as patients who are immuno-suppressed or have diabetes mellitus (Al Hassan, et al.2004: 1).
The current trends in the allopathic treatment of “Athlete’s Foot” include the use of topically and systemically applied antifungal drugs.
Topical treatment is with drugs such as Clotrimazole and Miconazole, while oral treatment includes drugs such as Griseofulvin and Terbinafine (brand name Lamisil ®) (Prescott, et al.1999).
Generally, simple Tinea pedis responds well to the local application of cream and powder formulations of Clotrimazole (Brooks, Butel and Morse, 2001:559).
The use of allopathic medicines is however, not without complication due to shortterm effectiveness, side effects and cost implications (Tierney, et al.
This study proposed to evaluate the effectiveness of a topical naturopathic complex comprising of
Allium sativum mother tincture (Ø), Hydrastis Canadensis mother tincture (Ø), Apis mellifica D3 and Urtica urens D3 (in an aqueous cream base) in the treatment of Tinea pedis (“Athlete’s Foot”).
It focused on individuals between the ages of 18 and 60 residing in the greater Durban area.
Cutaneous mycoses or superficial fungal infections are caused by Dermatophytes (Brooks, Butel and Morse, 2001: 535).
Dermatophytes are fungi that thrive only in the superficial keratinised tissue of the skin such as the stratum corneum (figure B, pg 5), hair and nails.
The three genera are
which cause dermatophytosis, or “tinea”, a term used generically for dermatophytosis (Fitzpatrick, et al. 1992: 98).
Fungal infections of the skin can occur in different regions of the body and have been named according to the site of the infection.
Tinea capitis affects the scalp,
Tinea barbae affects the face,
Tinea unguum affects the nails,
Tinea manuum affects the hands
Tinea cruris affects the groin
(Al Hasan, et al. 2004).
Tinea pedis, otherwise known as “Athletes foot”, is a common fungal infection affecting the feet and is the focus of this study.
The principal manifestations of this condition are peeling and cracking of the skin, accompanied by pain and pruritus (itching). The condition is generally harmless but unusually irritating, producing significant discomfort to the sufferer (Anders, et al. 1999).
Athlete’s foot is found more commonly in adolescents and young adults (people using communal changing facilities, showers and swimming pools (Mackie, 1991: 145).
Causae: Trauma and contact (Brooks, Butel and Morse, 2001: 536).
Host susceptibility is increased by moisture, warmth, specific skin chemistry, composition of sebum and perspiration, youth and genetic predisposition (Brooks, Butel and Morse, 2001:536).
Incidence is higher in hot, humid climates and under crowded living conditions (Brooks, Butel and Morse, 2001:536).
Non-breathable footwear provides warmth and moisture, creating a favourable condition for the growth of fungi (Brooks, Butel and Morse, 2001:536).
An increase in immune deficiency diseases (AIDS) and an increase in the number of patients receiving chemotherapy, steroids, organ transplants, and parenteral nutrition, have resulted in an increased incidence of Tinea pedis (Al Hasan, et al. 2004). Patients who are obese, elderly, or have systemic problems such as diabetes mellitus are at increased risk (Al Hasan, et al. 2004).
Tinea pedis may manifest as one of three typical variants which are, 1st interdigital, 2nd the moccasin type and 3rd vesiculobullous type. (Fitzpatrick, et al. 1992:101)
Interdigital Tinea pedis = the most common form and usually affects the fourth and fifth interdigital spaces. The infection may spread to the underside of the toes. May be present as one of two types.
1st dermatophytosis simplex: the skin of the interdigital space is dry and scaly with low-grade peeling. This type is usually asymptomatic with only occasional pruritis.
2nd dermatophytosis complex: presents as wet, macerated interdigital spaces. Fungal infection accompanied by wet conditions increases the chance of bacterial invasion (broken skin) (Al Hasan, et al. 2004).
Moccasin type Tinea pedis:
This is a more prolonged and severe type of tinea pedis. It covers the bottom and lateral aspects of the foot and has the appearance of a slipper or moccasin covering the foot. The skin becomes dry, hyperkeratotic and scaling, with cracking and peeling. This eventually leads to pruritis, pain and bleeding (Fitzpatrick, et al. 1992:101).
Vesiculobullous type Tinea pedis:
Less common, comprises of fluid-filled vesicles occurring on the instep and plantar surfaces of the feet.
The fluid-filled vesicles are usually clear, but if pus is present then bacterial infection must be considered and ruled out by microscopy or culture (Al Hasan, et al. 2004).
The diagnosis of Tinea pedis is based on the history and clinical appearance of the feet. Al Hasan (2004) states that cultures and histological examinations are rarely required. Direct microscopy of potassium hydroxide (KOH) may accompany diagnosis through history and clinical appearance.
Scaling, maceration, vesicles or bullae formation;
Skin appears red with opaque white scales;
Usually located in the third and fourth interdigital spaces, later extending to the sole, especially the arch;
Scaling and hyperkeratosis (thickening of the skin) as the condition becomes chronic (Fitzpatrick, et al. 1992:101).
Simple dermatophyte infection is relatively asymptomatic and uncomplicated except for only mild pruritus (itching) and burning sensations (White, 1997:154 - 155).
When the infection becomes chronic, with peeling and cracking, then pain and pruritus occur (Brooks, Butel and Morse, 2001: 537).
Currnet allopathic treatment:
The allopathic treatment of “Athletes foot” involves the use of both topically and systemically applied drugs.
Topical antifungal azoles such as Clotrimazole are available in several formulations, and simple Tinea pedis responds well to the local application of creams or powders (Brooks, Butel and Morse, 2001:559). This type of treatment, regarded in naturopathy, particularly in homoeopathy, as suppression (Digby, 1997:3). By suppression it is meant that conventional medicine seeks only to treat
the symptoms of the disease, with disregard for the individual. The aim of Naturopathy is to restore the balance of the body with the use of herbal medicine, vitamins and minerals or homoeopathy. In homoeopathy, the patient is treated with substances which act in the same way as the reactive mode of the individual, in the same way as his defense mechanisms, and thus in cooperation with
the individual (Jouanny, et al. 1996:12).
Systemic antifungal therapy is employed in patients who fail to respond to topical treatment (Bell-Syer, et al. 2002).
The systemic drugs are known to have side effects.
Griseofulvin is an antibiotic formed by Penicillium.
It is given orally to treat chronic dermatophyte infections. It is thought to inhibit cell division and inhibit protein and nucleic acid synthesis. The side effects of Griseofulvin include headaches, gastrointestinal upset and allergic reactions (Prescott, Harley and Klein, 1999: 692).
Ketoconazole is a well tolerated anti fungal agent, but if used over prolonged periods, becomes hepatotoxic. Ketoconazole may also cause a variety of reversible side effects such as gynaecomastia, decreased libido, impotence, menstrual irregularity, and occasionally adrenal insufficiency (Brooks, Butel and Morse, 2001:559).
Terbanafine (Lamasil) is a more effective oral treatment than Griseofulvin (Bell-Syer, et al. 2002), but the common side effects of Terbanifine are gastro-intestinal symptoms (fullness, loss of appetite, nausea, mild abdominal pain, diarrhea), or skin reactions (rash, urticaria) (Medical Chronicle, 1995).
In cases where the infection is cleared by systemic therapy, the patient is encouraged to begin maintenance with topical therapy, as recurrences are common (Tierney, et al. 2000:142).
Allopathic antifungal drug therapy is not without side effects, it does not prevent recurrences, and it is expensive (Tierney, et al. 2000:142).
Complementary and Alternative Therapies
In milder cases of “Athletes foot”, supplements can be used as an inexpensive alternative to treating this infection (Anders, et al. 1999: 62).
Some of the alternative supplements are:
Vitamin C, which is an antioxidant, and promotes immune function, aiding the body in fighting fungal infections (Anders, et al. 1999: 62 - 63).
Tea tree oil, a natural antifungal agent. Topical preparations include creams and lotions containing tea tree oil (Anders, et al. 1999: 63).
Calendula officionalis, which is available in creams or lotions, is widely available in health shops. It relieves inflammation, soothes the skin and promotes healing (Anders, et al. 1999: 63).
Garlic oil as volatile oil
Basic feet care steps that can be followed to prevent or hasten improvement of “Athletes foot”:
The essential factor in the prevention of Tinea pedis is personal hygiene (Tierney, et al. 2000:142).
Use rubber or wooden sandals in community showers and bathing areas (Tierney, et al. 2000:142).
Keep the feet clean and dry. Wash the towel after each use (Anders, et al. 1999: 63).
Careful drying between the toes is important. A hairdryer used on a low setting may be used before dressing (Tierney, et al. 2000: 142).
Wear clean, dry socks. Air shoes after each use (Anders, et al. 1999:63).
Go barefoot when possible or opt for sandals or well-ventilated shoes that allow the feet to breathe (Anders, et al. 1999:63).
Naturopathy is defined by Yasgur (1992:95) as “system of therapeutic medical science comprising many natural healing techniques.” It is a „drugless‟? system that focuses on the use of herbal medicine, spinal and soft tissue adjustments or manipulations such as chiropractics, homeopathy, botanical medicines, hydrotherapy, acupuncture, nutritional guidance, and supplements (vitamins, glandular extracts, enzymes, etc.).”
Naturopathy focuses on the concept of Homoeostasis in relation to health and disease. Homoeostasis has been defined as the self-regulating or balancing mechanism of the body. The aim of the natural therapist is to enhance or restore the balance of the body with the use of herbology, vitamins and mineral or homoeopathy. The restoration of balance occurs on all the levels of the being, mental, emotional and physical (Jacka, 1995:3).
Topical homeopathic treatment
Kayne (1997:127), states that most topical preparations, although frequently described as „homoeopathic‟, are in essence herbal in nature, usually having been prepared by combining a Ø with a suitable vehicle such as soft paraffin, light liquid paraffin, aqueous cream or alcohol.
The complex utilized in this study contained the ingredients Allium sativum Ø and Hydrastis canadensis Ø, were choosen in tincture form to investigate their antifungal activity as herbal tinctures.
A discussion of these antifungal properties will follow in the discussion of the individual remedies.
Kayne (1997:127) also states that remedies in low potencies, typically 6x, are also used as active ingredients in most topical preparations.
The use of external homoeopathic remedies enables the remedies to act directly on the affected parts, and ensures a quicker recovery from the external dynamic disease (Rawat, 1996: Xli - XLii).
Jouanny (1996:67) states that when the medicinal similarity of the patient is at the level of the local signs, then the homoeopathic similarity is slight. In this situation, a low potency is prescribed.
Based on the above principle, two constituents of the complex utilized in this study, namely, Apis mellifica and Urtica urens, were in the D3 potency. The symptom similarity of these ingredients
in relation to the symptom picture of “Athlete’s Foot” will follow under the discussion of each remedy.
A method of prescribing whereby a number of homoeopathic medicines have been combined and prescribed simultaneously. This combination of two or more remedies is referred to as a complex (Tomlinson, 1999: 2).
Complex remedies are prescribed solely on the basis that the remedies have a degree of similarity to the disease process (Watson, 1991:71). The remedies in the complex are chosen because they
are partial similars, one covering the symptoms that the other does not (Kayne, 1997:104).
Complex prescribing differs from classical homoeopathic prescribing in that classical homoeopathy makes use of one remedy at a time and that remedy is the similimum. The similimum is the
remedy that fits all the symptoms of the disease picture (Kayne, 1997:106). The administration of complexes can be seen as increasing the chance of the correct prescription as it enables the practitioner to treat more than one symptom of the same condition (Kayne, 1997:106).
Complexes consist of remedies in low potencies generally, commonly within the range of Ø - C 6, and the prescription is usually repeated on a daily basis (Watson, 1991:71).
The decimal potency scale is prepared by adding 1 drop of Ø to 9 drops of diluent (alcohol). These potencies are designated by a number followed by the letter „x‟ or „D‟ (Kayne, 1997:50). Therefore, D3 represents a one in ten dilution that has been carried out three times. The centesimal potency scale is prepared by adding one drop of mother tincture to 99 drops of diluent (alcohol). These potencies are designated by a number followed by the letters „cH‟. This refers to the classical method of dilution formulated by Hahnemann (Kayne, 1997:50).
Off-the-shelf complexes, although not classically a very common method of homoeopathic treatment, do have a place in homoeopathy as they provide an avenue for the general public to become familiar with homoeopathy. This often provides their first experience of homoeopathy during attempts to self-treatment of common ailments. This first experience leads to consults with qualified homoeopaths where individuals can then receive proper classical homoeopathic treatment (Tomlinson, 1999: 8). Swayne (2000:42) defines classical homoeopathy as a “doctrine or school of homeopathic philosophy and therapeutics claiming to be based on strict Hahnemannian principles.” It is a therapeutic method that makes use of a single medicine in a single prescription (Swayne, 2000:42).
A combination of the following remedies was utilized in the form of a topical application.
Allium sativum (Garlic) contains a volatile oil composed of a number of sulphur-containing compounds such as allicin, ajoene, diallyl disulfide and others. Allium sativum has a wide range of pharmacological effects including, antibacterial activity, antiviral effects and antifungal activity (Murray, 1995:121 - 124).
Ledezma, E., et al., (2000) conducted a double blind and comparative study of ajoene, an organosulphur compound isolated from garlic and Terbinafine in the treatment of short term Tinea pedis.
The efficacy of the treatments, measured as mycological cure, 60 days after the end of treatment in 47 patients was 100% for 1% ajoene and 94% for 1% Terbinafine.
De Smidt (2001) used Allium sativum in vitro on Candida albicans with positive results. This study showed that Candida albicans was most sensitive to fresh garlic extract, being killed within six hours.
D.S. Arora and J. Kaur (1999) used aqueous garlic extract in a comparative study with Nystatin (Nystatinum verkäuflich in C Potenzen bei remedia.at) and found that garlic was far more effective than Nystatin in inhibiting the growth of a variety of bacterial and fungal species.
Garlic is often effective against infectious organisms such as bacteria, viruses and fungi because allicin has the ability to block the action of the enzymes that give these organisms their ability to invade and damage tissues (Anders, et al., 1999:293).
The complex utilized in this study contained Allium sativum (Garlic) in mother tincture (Ø). The reason for this was to investigate the antifungal properties of the tincture in the treatment of Tinea pedis, which is a superficial fungal infection.
Hydrastis canadensis (Goldenseal) contains the alkaloids berberine and hydrastine, which give it broad antimicrobial and immune stimulating action.
Berberine has exhibited antibiotic activity against bacteria, protozoa and fungi (Murray, 1995:162 - 167).
B.Y.Hwang et al (2003) found that berberine exhibited antibacterial activity against the oral pathogen Streptococcus mutans.
Budree (2003) used Hydrastis canadensis in vitro on Candida albicans with positive results. The study showed that Fluconazole was less effective than Hydrastis candensis in inhibiting the
in vitro growth of Candida albicans.
Hydrastis canadensis tincture is applied topically in the treatment of mouth ulcers as it promotes healing of the mucous membranes (Anders et al., 1999:303).
The complex utilized in this study contained Hydrastis canadensis (Goldenseal) in mother tincture (Ø). The reason for this was to investigate the antifungal properties of the tincture in the treatment of Tinea pedis, which is a superficial fungal infection.
Apis mellifica is indicated in conditions of the skin where there is stinging and burning sensations, with red-pink discolouration and oedema, improvement with cold application and aggravation with warmth. The common factors are the oedema and pruritus improved with cold (Jouanny, et al., 1996:29).
Apis acts on the outer parts (skin with redness) and marked sensitivity to heat and touch (Boericke, 1998:61).
Urtica urens is indicated for itching blotches; burning heat sensation with formication and itching (Boericke, 1998:662).
The skin itches and burns, being aggravated by warmth and bathing, and relieved by rubbing (Vermeulen, 1992: 404).
This remedy is indicated for oedema with stinging and burning with intolerable itching. The symptoms are aggravated by cold applications and most of all by touch (Jouanny, et al., 1996:208).
Apis melllifica and Urtica urens selected as part of this complex based on the Law of Similars, the physical symptoms of both Apis mellifica and Urtica urens are similar to those of “Athlete’s foot”.
The complex utilized in this study is regarded as naturopathic due to the following reasons:
Two of the four ingredients, namely Allium sativum and Hydrastis canadensis, having each been utilized in mother tincture, were selected for their antifungal properties.
Apis mellifica and Urtica urens, having each been utilized in homoeopathic potency, namely, D3, were selected according to the law of similars, as has been mentioned.
For the treatment group:
At consult 2 (14 days of treatment):
14 out 15 patients in the treatment group who noticed a change, reported a change ranging from „1 (getting worse) to „4 (getting much better)‟.
Only 1 patient reported no change („not at all‟).
At consult 3 (28 days of treatment): 5 out of 15 participants reported a change of „4 (getting much better)” as compared to 3 participants in consult 2.
2 participants said that their „Athlete’s foot‟ had „completely gone‟.
1 out of the 15 participants reported no change.
At consult 3 (28 days of treatment):
5 out of 15 participants reported a change of „4 (getting much better)” as compared to 3 participants in consult 2.
2 participants said that their „Athlete’s foot‟ had „completely gone‟.
1 out of the 15 participants reported no change.
For the placebo group:
At consult 2 (14 days of treatment):
All 16 participants (100%) noted a change in the appearance of the feet ranging from „2 (very slightly)‟ to „5 (very much)‟.
6 participants (37.5%) reported that the appearance of their feet had changed „very slightly‟ (2).
2 participants (12.5%) reported that the appearance of their feet had changed „slightly‟ (3).
4 participants (25.0%) reported that the appearance of their feet had changed „moderately‟ (4).
4 participants (25.0%) reported that the appearance of their feet had changed „very much‟ (5).
At consult 3 (28 days of treatment):
14 out of 16 participants (87.5%) reported a change in the appearance of their feet ranging from „3 (slightly)‟ to „5 (very much)‟.
3 participants (18.8%) reported that the appearance of their feet had changed „slightly‟ (3).
5 participants (31.3%) reported that the appearance of their feet had changed „moderately‟ (4).
6 participants (37.5%) reported that the appearance of their feet had changed „very much‟ (5).
2 participants (12.5%) reported no change in the appearance of the feet.
It is concluded that in this placebo controlled study, the topical naturopathic complex, comprising of
Allium sativum Ø,
Hydrastis canadensis Ø,
Apis mellifica D3
Urtica urens D3 (in an aqueous cream base)
was in this study, when compared with placebo, found to be ineffective in the treatment of Tinea pedis.