記住我
CASE REPORT
Year : 2018 | Volume
: 37
| Issue : 3 | Page : 168-172
Integration of ayurveda and conventional medicine for chronic wound healing
Anupama Kizhakkeveettil, Christie Smirl, Jayagopal Parla
Ayurveda Department, Southern California University of Health Sciences, Whittier, California, USA
Correspondence Address:
Dr. Anupama Kizhakkeveettil
Southern California University of Health Sciences, 16200 E Amber Valley Dr., Whittier, CA 90603
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/asl.ASL_108_18
Background: Chronic wounds affect around 2.4 – 4.5 million patients in the United States. The burden of wound management is growing rapidly. Objective: Management of chronic wounds with integrated conventional medicine and Ayurveda treatment. Clinical Features: A 52-year-old female patient, presented with non-healing chronic wound on the right leg with pain persisting for 5 years. Initial measurement of the wound was 48 cm length × 13 cm width × 0.4 cm depth. Intervention and Outcomes: Wound depth was measured during different stages of healing along with photographic images. Patient was given Ciprofloxacin 500mg twice daily for 10 days, compression leg wraps and diuretics along with washing of the wound with Triphala decoction daily and application of wound dressing with Turmeric powder, neem bark powder and Medihoney daily were done. Marma therapy was performed once a week. Patient was also suggested kapha pacifying diet and lifestyle. Results: The wound was completely healed with normal skin coloration by the sixth week. Conclusions: This case study discusses the use of integration of ayurvedic herbs with conventional medicine for the management of wound healing. Interventional studies should be conducted to better understand the effectiveness of this integrative approach for the treatment of chronic wounds.
Keywords: Ayurveda, integrative medicine, wound healing
Chronic wounds are defined as those that fail to heal in a predictable amount of time. Chronic wounds currently affect approximately 2.4 – 4.5 million patients in the United States,[1] and approximately $50 billion is spent annually on treating chronic wounds.[2] The burden of wound management is growing rapidly as precursor conditions such as diabetes mellitus and peripheral vascular disease become more prevalent. Risk factors that delay wound healing include bacterial infections, nutritional deficiencies, certain drugs such as corticosteroids, immunosuppressant and antineoplastic and the anatomical site of the wound.[3] Over the last two decades, there has been increasing focus in the literature on various methods for healing chronic wounds. The conventional medical approach is usually aimed at proper wound base maintenance, sharp debridement, pressure prevention, vascular intervention and prevention of chronic infection. Unsuccessful wound response due to the development of resistance by microbes and side effects of medication have led many people to search for alternative treatments for chronic wounds.
Ayurveda has its own unique classification of diseases. In Ayurveda diagnosis, the analogue to such chronic wounds is called Vraṇa. These are subcategorized into Sadyo Vraṇa (acute wound) and Duṣṭa Vraṇa (chronic wound). Duṣṭa vraṇas are described in Ayurveda as “difficult to heal”. Vitiation of all three doṣas such as vāta, pitta and kapha are seen in duṣṭa vraṇa, along with the symptoms of bad odor, abnormal color with profuse discharge and severe pain.[4]
Suśruta, who is considered the father of surgery, first defined the concept of vraṇa in Ayurveda. He elaborately describes the etiopathogenesis of wounds, along with their treatments. According to Suśruta, vraṇa which has a foul smell, continuously discharges putrefied pus along with blood, has a cavity, persists for a long time, and has Vraṇa lakṣaṇas (symptoms of wound) in high intensity is considered duṣṭa vraṇa .[4] Symptoms of duṣṭa vraṇa include ati-samvṛta (excessively narrow mouths), ati-vivṛta (excessively wide mouth), ati-kaṭhina (excessively hard), ati-mṛdu (excessively soft), ati-avasanna (excessively depressed), ati-utsanna (excessively elevated), vedanāvān (having severe pain), ati-uṣṇa (excessively hot), ati-śīta (excessively cold), dāha (burning sensation), pāka (suppuration), rāga (redness), pūyasrāva (discharging pus), kaṇḍu (itching), śopha (swelling), piḍaka (boils), bhairava (frightful), Anyatamo-varṇa (various discolorations) and pūti-māṃsa-śira-snāyu (full of pus, involving muscle, vessel and ligaments).[4],[5] Suśruta describes Ṣaṣṭi upakramas (60 measures) for the management of vraṇa. His primary approach involves śodhana (purification) and ropaṇa (healing) of Vraṇa. In addition to local application, oral administration of herbs are also specified to enhance wound healing. Various medicinal plants, minerals, and materials of animal origin are prescribed for wound healing under the term vraṇa ropaka (wound healing agent).[4]
A search of the modern medical literature failed to find any studies on the use of an integrative approach which combined Ayurveda and conventional medicine for the care of chronic wounds.
Objective
To describe the integration of conventional medicine and Ayurveda treatments in the management of chronic wounds in a single patient.
Patient InformationA 52-year-old female with Vāta-Kaphaja Prakṛti (constitution), presented with a non-healing chronic wound on her right leg. She had experienced pain from this condition for the past five years, which she rated as 7/10 on a numeric pain rating visual analog scale, where zero means no pain and ten means severe pain. She also presented with morbid obesity with a body mass index of 54.9, venous reflux, and lymphedema. Previously the patient had completed multiple courses of treatment with antibiotics specific to culture and sensitivity analyses, along with compression wraps, diuretics, advanced collagen stimulating dressings and wet to dry dressings. There was no improvement in the wound with these modalities.
Clinical FindingsA physical examination revealed a foul-smelling deep wound with blood, pus and yellow slough on the anterior aspect of the right leg. Initial measurement of the wound was 48 cm length × 13 cm width × 0.4 cm depth. A culture and sensitivity swab report indicated the presence of Pseudomonas aeruginosa 
d methicillin resistant staphylococcus aureus (MRSA) infection with multiple drug resistances.
Laboratory findings included a normal comprehensive metabolic panel and complete blood cell count. MRI revealed no underlying osteomyelitis. Doppler ultrasound revealed venous reflux of the greater saphenous vein in the lower extremities bilaterally.
DiagnosisThe patient's wound met the ayurvedic diagnostic criteria for duṣṭa vraṇa, including being deep-seated, foul-smelling, and non-healing for five years.
International Classification of Disease (ICD 11) Codes include 5B81 for Obesity, BD54 for Diabetic Foot Ulcer and EB90 for Diabetic Skin Lesion.
Treatment PrinciplesAyurvedic treatment principles for duṣṭa vraṇa include Śodhana, including ābhyantara śodhana (internal purification), bahirgata-śodhana (external purification by application of medicine) and ropaṇa.[4],[5],[6]Ābhyantara Śodhana includes vamana (medically induced emesis), virecana (medically induced purgation), basti (medicated enema) and Śiro-virecana (nasal medication). Bahirgata śodhana includes abhyaṅga (therapeutic oil massage), raktamokṣaṇa (therapeutic bloodletting), vraṇa prakṣālana (wound wash), vraṇa-picu (medicated gauze), and vraṇa-lepa (application of herbal paste) and vraṇa-basti (wound irrigation). Ropaṇa is a factor which promotes or quickens wound healing process. It can be in the form of kalka (herbal paste), Kaṣāya (herbal decoctions), vartti (herbal wick), ghṛta (ghee), taila (oil), or cūrṇa (herbal powder). For this patient, we selected vraṇa-prakṣālana and vraṇa-lepa.
Therapeutic Intervention and Follow upThe patient was treated with an integrative approach which consisted of conventional and Ayurvedic medicine. Conventional medicine consisted of Ciprofloxacin, 500mg twice daily for 10 days, compression leg wraps and diuretics. Ayurvedic protocols included washing the affected area with Triphalā decoction daily and the application of wound dressing with Turmeric powder, neem bark powder and Medi honey daily, covered by gauze and a two layered compression wrap. Patient was educated to follow the Ayurvedic protocols on daily basis for six weeks. Marma therapy to the legs was performed by a practitioner once per week for six weeks. Marma therapy was performed from distal to proximal points including the following marma points: kūrcca, talaharidram, kūrccaśira, kṣipra, gulpha, indrabasti, jānu, ani and urvī. Marma strokes began distally and moved proximally to promote healing, increase reabsorption of pooled lymph fluid and increase blood circulation.
It was also recommended that the patient follow a Kapha pacifying diet and lifestyle according to Ayurveda. She was instructed to avoid kapha aggravating foods such as flour products (bread, tortillas, and pastries), dairy products (milk, ice cream, yogurt, and cottage cheese), meat, oils, butter, lard, sugar, bananas, dates, avocados and foods that are rich and heavy. She was encouraged to eat more bitter greens and raw vegetables. She was instructed to also avoid iced or cold beverages which aggravate kapha and reduce agni (energy complex that drives digestive and metabolic transformation). Drinking fluids that ranged from warm to hot was recommended. In addition, she was educated on kapha reducing lifestyle activities and encouraged to exercise to the best of her ability on a daily basis. The patient followed all these protocols for six weeks.
OutcomesWound depth was measured during the course of treatment. Photographic images were also taken during every week of treatment for six weeks. No adverse events were reported by the patient.
ResultsThe patient was compliant with following her prescribed treatment. It was observed that the deep-seated slough started to dissolve from the base and the wound started to heal after one week. At this time, she reported less drainage, odour, and pain. The margin of the wound became bluish, showing growing epithelium.
The clinical features of vraṇa were improved at the end of the sixth week [Figure 3]. Vraṇa vedana (pain and tenderness) was completely reduced at this time. Vraṇa varṇa (color of the wound) changed as the skin around affected area became pinkish and healthy tissues appeared. At the end of the sixth week, vraṇa-srāva (discharge from the wound) was completely stopped and there was no more vraṇa-gandha (smell from the wound) present. At follow-up after 9 months, the patient reported no sign of recurrence of her symptoms.
[Table 1] shows the change in wound depth during the course of treatment. [Figure 1], [Figure 2], [Figure 3] illustrate progressive stages of wound healing.
DiscussionWound management has been described in the traditional Ayurvedic literature. In Ayurveda, a non-healing ulcer is referred to as duṣṭa vraṇa. The characteristics of duṣṭa vraṇa were noted in this patient. Among the 60 measures mentioned by Suśruta for healing of wounds, a paste of herbal ingredients and decoctions of various herbs have been used most extensively. According to Suśruta, application of kalka (paste) is indicated for chronic wounds which are full of slough, deep-seated in muscle and intractable to healing.[4] The paste of the herbs used in this patient provided both śodhana (cleansing) and ropaṇa (healing) qualities for healing the wound.
In the current report, the patient had been treated for a chronic skin wound with antibiotics and other conventional medicine therapies on and off for five years prior to her presentation. She reported no improvements from those treatments. By integrating conventional treatment with Ayurvedic therapies, wound healing was achieved by us within six weeks.
Triphalā consists of three herbs: Āmalakī (Emblica officinalis), Harītakī (Terminalia chebula) and Vibhītaki (Terminalia bellirica). It balances all three doṣas. Its qualities include laghu (light), rūkṣa (dry), and uṣṇa (hot) in potency. When made into a kvātha (decoction) and used as a wound cleanser, it reduces infection and pain.[4] Studies have shown that Triphalā possess antioxidant, anti-inflammatory, analgesic, antibacterial, and anti-mutagenic qualities. Triphalā ointment reduces bacterial counts and enhances wound closure with improved levels of collagen, hexosamine and uronic acid.[7]
Rhizome of Haridrā (Curcuma Longa) is yellowish brown in color. It is tikta (bitter) and kaṭu (pungent) in taste. It possesses rūkṣa (dryness) and laghu (lightness) qualities. It is uṣṇa (hot) in potency, balances vāta and kapha, and helps in healing wounds.[8] Action includes antibacterial, antifungal and anti-inflammatory properties.[9],[10] This herb is useful in treating wounds, leprosy, skin disease and allergic conditions.[8] Rhizomes of it contain curcumin (diferuloyl-methane), turmeric oil or turmerol, 1,7-bis, 6 hepta-diene-3, 5-dione, proteins, fat, and vitamins A, B and C.[11] The anti-inflammatory properties, the presence of Vit A and proteins in turmeric results in the early synthesis of collagen fibers by stimulating fibroblastic activity.[11] Thus, Curcumin may hasten wound closure by re-epithelialization of epidermis, and increased migration of various cells including myofibroblasts, fibroblast, and macrophages in the wound bed.
Neem (Azadirachta Indica) powder is used for wound healing because it possesses antibacterial, antifungal and anti-inflammatory properties. It is tikta (bitter) in taste and possess laghu (light) and rūkṣa (dry) qualities. It is cold in potency. It is effective in moist wounds, ulcers, skin conditions and allergies.[8] The antimicrobial effects of Neem extract have been demonstrated against Streptococcus mutans ptococcus faecalis.[12],[13]
Suśruta recommends the application of Madhu (honey) for wound management.[4] It possesses rūkṣa (dryness) quality and śīta (cold) potency. It is sūkṣma mārga anusāri (able to permeate in microchannels). It has the qualities of lekhana (scraping), sandhāna (unionizing), śodhana (purification), ropaṇa (healing) and tridoṣaghna (pacifying all three doṣas).[4] The topical application of honey may be useful for treatment of wound healing.[14],[15],[16],[17] Madhu is a hyperosmolar medium, that prevents bacterial growth.[18] Raw honey consists of copious amounts of compounds such as flavonoids and polyphenols, which may function as antioxidants.[18],[19] Honey is acidic with a pH between 3.2 and 4.5, which helps to inhibit several bacterial pathogens.[20]
ConclusionsThe results of this case study show complete resolution of chronic wounds after 6 weeks of treatment. Ayurvedic methodologies were employed in addition to conventional medical treatment for wound healing. Interventional studies should be conducted to better understand the effectiveness of this integrative approach for the treatment of chronic wounds.
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
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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