|Year : 2020 | Volume
| Issue : 4 | Page : 2114-2118
Management of nonhealing venous ulcer in systemic sclerosis with leech therapy—A case report
Pooja Sharma1, Divya Kajaria2
1 MD Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India
2 Assistant Professor, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||18-Dec-2019|
|Date of Decision||25-Dec-2019|
|Date of Acceptance||12-Feb-2020|
|Date of Web Publication||30-Apr-2020|
Dr. Pooja Sharma
Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi - 110 076
Source of Support: None, Conflict of Interest: None
Systemic sclerosis (SSc) is a rare disease characterized by autoimmune pathogenesis, alterations to the vascular system, and fibrosis of the skin and internal organs. Nonhealing venous ulcers are quite common in SSc patients. A 32 years old female was brought with a foul-smelling ulcer with purulent discharge which was not healed despite using the allopathic treatment for 2 months. Even with treatment, it got worsened so the fear of amputation of leg enforced her to take Ayurvedic consultation. After 1 month of treatment with leech therapy along with Ayurvedic medicines and 3 months of follow-up, the wound got healed. It is concluded that leech therapy with Ayurvedic medicines is highly effective for the management of nonhealing venous ulcers.
Keywords: Leech therapy, nonhealing venous ulcer, systemic sclerosis
|How to cite this article:|
Sharma P, Kajaria D. Management of nonhealing venous ulcer in systemic sclerosis with leech therapy—A case report. J Family Med Prim Care 2020;9:2114-8
|How to cite this URL:|
Sharma P, Kajaria D. Management of nonhealing venous ulcer in systemic sclerosis with leech therapy—A case report. J Family Med Prim Care [serial online] 2020 [cited 2021 Feb 26];9:2114-8. Available from: https://www.jfmpc.com/text.asp?2020/9/4/2114/283402
| Introduction|| |
Systemic sclerosis (SSc) is a rare and progressive multisystem autoimmune disorder that is characterized pathologically by vascular abnormalities, sclerosis of skin, and internal organs with autoantibodies. Skin ulcers occur in 35–60% of SSc patients. The etiology of these ulcers is not well known, but these may reflect chronic vasculopathy. The treatment of chronic ulcers of the lower extremities presents a therapeutic challenge in modern medicine. In the text of Ayurveda, Rakta Dusti (Impurity of blood) is considered as one of the prime causes of skin diseases  and patients may get relief after letting out the vitiated Rakta. In the present case, the patient was managed with leech therapy along with Ayurvedic medications in a very economical way.
| Case History|| |
A 34 years old female approached OPD with a foul-smelling, nonhealing, necrotizing ulcer over the dorsal aspect of the left lower leg above the heel for 1 month. She was a known case of diffuse cutaneous systemic sclerosis for 11 years. Her leg ulcer was not healing despite using conservative treatment (linezolid, 600 mg) for the last 1 month by a dermatologist. But the wound showed no signs of improvement despite the condition worsened. Due to insignificant relief and worsening conditions of ulcer and fear of amputation of the leg, the patient came for alternative therapy in the All India Institute of Ayurveda. On local examination, the wound was of 14*6 cm in size, full-thickness skin loss with destruction of muscle and bone exposed, edges well-defined, undermined, and not attached to the base, completely covered with loosely adherent yellow slough with thick purulent discharge, surrounding skin was hyperpigmented and indurated with the rise in local temperature. Considering the history, clinical examination, and investigations, the treatment [Table 1] was given and needful interventions [Table 2] were done.
|Table 2: Timeline of events (condition of the patient and her wound with time)|
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According to Bates-Jensen wound assessment [Table 3], after complete treatment and follow-up improvement in size was 100% and undermining, necrotic tissue, exudate type, exudate amount, skin color surrounding the wound, peripheral tissue edema, peripheral tissue induration, granulation tissue, epithelization was 80% (result can be seen in [Figure 1]).
|Figure 1: Images of wound showing its condition during treatment and follow up. (a) Wound on the first day before treatment. (b) Wound during the first sitting of leech therapy. (c) The second sitting of leech therapy. (d) Third sitting at the time of Haridra dressing. (e) The wound on the day of discharge from hospital (1 month from the first day). (f) Wound during follow-up after 1 and a half months. (g) Wound during follow-up after 3 and a half months. (h) Significant hair growth over the surrounding skin|
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| Discussion|| |
There are many diseases that offer a challenge to the medical world, practitioners and also the scientific community to understand their pathophysiology and proper management. Autoimmune disorders are among such challenging diseases. Immunity plays a very determinant role in deciding the prognosis of disease as well as the outcome of management. It may be the interest of research to explore the beneficial effect of hypersensitivity response in modulating the latent immune response in the patient of autoimmune disorders. In this article, a case is discussed which is a known case of systemic sclerosis. In this case use of Jalouka (leech) is based on the concept of provoking the immune response to stimulate the stem cells of skin for regeneration supplemented with Ayurvedic medicines. Leech therapy is a painless, minimal invasive technique of controlled bloodletting(Raktamokshana). In recent studies, more than 20 bioactive molecules having anti-inflammatory, analgesic, antimicrobial, and anticoagulant properties were reported from medicinal leeches. Based on clinical presentation the patient was diagnosed as a case of Kshudra Kushtha and the treatment was planned accordingly. As per the dosha-dushya involvement and the physical condition of the patient (cachexic), it was decided to use Brimhana chikitsa (nutritional palliative treatment for restoring the natural strength), Raktaprashadaka (blood purifier) and vrana sodhaka chikitsa (ulcerated wound treatment). Details of the medicines given for the management of the patient at different stages are well described in [Table 1] and [Table 2]. Few observations are worth to be discussed such as the use of Trivangabhasma (herbomineral preparation) in exudative/oozing ulcerative wounds has a very significant role in reducing the discharge. It was observed that the secretions from the wound were all together stopping after the use of Trivangabhasma for 1 week. Similarly, the use of Madhuyasti and Kutaki churna for the management of raised total leukocyte count showed highly significant improvement. Medicated ghrita was used for easy assimilation of medicines and also for restoration of natural strength to add substantial relief in symptoms. The use of medicated ghrita was a part of immunotherapy and its role in immunity was assessed on improvement in Oja and Dehabala. (based on Oja and Dehabala assessment proforma) Acharya Sushruuta (Father of surgery and great ancient Indian physician) said that there is the presence of Krimi (microbes/pathogens) in all types of Kushtha and, therefore, Kriminashaka chikitsa (deworming treatment) was given after the suppression of discharge from the wound. Thus, at the first step, the treatment was aimed to restore the general health of the patient (nutritive and immunotherapy) and reduce the secretion from the ulcerated wound. The next step starts with the cessation of exudates from the wound with the aim to wipe out the secondary/superimposed infection and the third step concentrate on the healing of wound with proper granulation tissues with the help of Rasayana therapy. Use of Amalachurna and Shirisha chaal (Albizia lebbeck bark powder) is for reducing oxidative stress to facilitate skin regeneration. Shirisha is said to be the best antitoxin medicine in Ayurveda and researches also establish that it has potent anti-allergic, anti-inflammatory, immunomodulator, and anti-oxidant properties. Kalamegha and Sudarshan churna were used to potentiate liver functions which were assumed to be impaired due to chronic use of medicines (contemporary as well as alternative). Both medicines have proven action on liver functions and are well-documented in research studies. Improvements in terms of symptoms as well as laboratory parameters were good enough to draw the attention of the scientific community and also for Ayurvedic practitioners to reciprocate the findings. Use of Jalouka (leech) is very beneficial in primary care of ulcerative wounds as it is easily available and it can be easily applied over the wound so it uproots the disease in the primary stage. Care should be taken that the patient should not have any bleeding disorder and leeches must be medicinal.
| Conclusion|| |
The presented combination of leech therapy and Ayurvedic medications is found to be a good alternative therapy in the management of nonhealing venous ulcers. Long-term prospective studies are required to substantiate the data.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hinchcliff M, Varga J. Systemic sclerosis/scleroderma: A treatable multisystem disease. Am Fam Phys 2008;78:961-8.
Aacharya Vaidya Jadavaji Trikamji, editor. Vol. 24. Varanasi: Chaukhamba Sanskrit Sansthan; Charaka, Charakasamhita, Sutrasthana, Vidhishonitiya Adhyaya; 1990. p. 12.
Yadav CR, Guguloth R. A case study of leech therapy (Jalaukavacharana) in Khalitya W.S.R. Alopecia Int J Pharmacogn Chinese Med 2017;1:000115.
Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: Systematic review and practical recommendations. Ann Chir Plast Esthétique 2017;62:e1-13.
Ajmeer AS, Dudhamal TS, Gupta SK, Mahanta V. Topical application of Katupila (Securinega leucopyrus)
in Dushta Vrana
(chronic wound) showing excellent healing effect: A case study. AYU 2014;35:175-8.
] [Full text]
Sharma PV. Madhava Dravyaguna, Vividha aushadhi varga, Chaukhamba Vedyabhavan, Varanasi: 1st
ed; 1973. p. 8-9.
Riccioni G, Bucciarelli T, Mancini B, DiIlio C, Capra V, D'Orazio N. The role of the antioxidant vitamin supplementation in the prevention of cardiovascular diseases. Expert Opin Investig Drugs 2007;16:25-32.
Jarukamjorn K, Nemoto N. Pharmacological aspects of Andrographis paniculata on health and its major diterpenoid constituent and rographolide. J Health Sci 2008;54:370-81.
Ram VJ. Herbal preparations as a source of hepatoprotective agents. Drug News Perspectives 2001;14:353-63.
[Table 1], [Table 2], [Table 3]