A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and...

[Full title: A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu]

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ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 109 A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu Dr. Shruthi P, 1 Dr. Shailaja SV 2 1 Post Graduate Scholar, 2 Professor & HOD, Department of Shalya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Medical College, Hospital & Research Centre, Bangalore, INDIA. I NTRODUCTION In present days the complications of diabetes mellitus like diabetic foot ulcer is often quite dreaded disability cause of lower extremity amputation. It occurs in 15% of all patient with diabetes mellitus and precedes 84% of patients with diabetic foot ulcer which needs lower leg amputation. Three factors play to produce diabetic ulcer are diabetic neuropathy, diabetic atherosclerosis causing ischaemia and Glucose laden tissue is quite vulnerable for infection and thus ulcer is formed [1] The pathogenesis of foot ulcer is complex. Common Address for correspondence: Dr. Shruthi P. Post Graduate Scholar, Department of Shalya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Medical College, Hospital & Research Centre, Bangalore, INDIA. E-mail: drshruthipgowda 77@gmail.com Submission Date: 13/01/2019 Accepted Date: 22/02/2019 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.4.1.22 sites are Foot - plantar aspect, leg, upper limb, back, scrotum, perineum [2] The management of Diabetic foot ulcer requires diabetes should be controlled, Antibiotics, Excision of the ulcer, debridement and skin grafting once healthy granulation tissue is formed [3] Diabetic ulcers might end up in amputation of the limb, if not treated properly. Majority of these amputations are preceded by non-healing ulcers. Only two-thirds of ulcers eventually heal. Hyperbaric oxygen therapy, electrical stimulation can be used as adjacent therapies for rapid healing of Diabetic foot ulcer. In Ayurvedic literature, Acharya Sushruta has described sixty treatment modalities for Vranas, [4] for any Vrana foremost management is Vrana Shodhana and Ropana Acharya Vagbhata has explained that Vranas which are caused by Madhumeha can be treated with Aragwadhadigana Dravyas. [5] Acharya Susrutha says Doopana is useful for the Vranas which are having Srava and Vedana. [6] Hence in the present study for Vrana Shodhanartha Prakshalana with Aragwadhadi Qwatha and Vrana Dhoopana by Guggulu, Nimba Choorna, [7] Haridra, Jatyadi Ghrita were selected and for Vrana Ropanartha Jatyadi Taila [8] was selected. A B S T R A C T In present scenario due to the sedentary lifestyle, diabetes mellitus has become common disease. Diabetic foot ulcer is a complication of diabetes mellitus which is the leading cause of lower limb amputations. It occurs in 15% of all patient with diabetes mellitus and precedes 84% of patients with diabetic foot ulcer which needs lower leg amputation. The management of diabetic foot ulcer requires blood sugar control, debridement, advanced dressing and offloading modalities. In Ayurvedic literature, Acharya Sushruta has described sixty treatment modalities, He has given more importance to Vranashodhana and Ropana . Acharya Vagbhatta has explained that Vranas which are caused by Madhumeha can be treated with Aragwadhadigana Dravyas, hence in the present study for Vrana Shodhanartha Prakshalana with Aragwadhadi Qwatha and Vrana Dhoopana by Guggulu, Nimba Choorna, Haridra, Jatyadi Ghrita were selected and for Vrana Ropanartha Jatyadi Taila was selected. Key words: Diabetic foot ulcer, Vrana Shodhana, Vrana Ropana.

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 110 C ASE R EPORT A 61 years female patient visited the Shalya Tantra OPD of SKAMCH & RC with the complaints of Nonhealing ulcer over medial side of plantar aspect of right foot and pain over right foot since 2½ months. H/O present illness Patient was said to be apparently healthy 2½ months before, she noticed a wound in the medial side of plantar aspect of right foot which occurred spontaneously after a swelling. The wound was painful, pain was pricking in nature, increases on long standing and walking for long hours and relieves after taking analgesics. Occasionally tingling sensation and numbness over right foot was present. For these complaints she visited diabetes center and foot clinic. Where they advised investigations and advised to continue the insulin therapy along with antibiotics for 5 days and wound dressing on alternative days. The wound was not healed even after 2 months of treatment. So, for further management she came to Shalya Tantra OPD of SKAMCH & RC. Purva Vyadhi Vruttanta ▪ Patient is a known case of Type 2 Diabetes mellitus for 10 years. ▪ P/H/O wound caused due to burn on the medial side of plantar aspect of right foot on 4/11/2016. ▪ P/H/O wound caused due to trauma on plantar aspect of right great toe on 9/5/2017. ▪ P/H/O blister over dorsal aspect of 5 th digit of the right foot on 1/6/2017. Family history: All other family members are said to be healthy Vayaktika Vruttanta ▪ Diet - Mixed ▪ Appetite - Moderate ▪ Sleep - Good, 7-8 hours/night, 2-3 hours in the afternoon ▪ Micturition - 5-6 times/ day; 3-4 times/night ▪ Bowel - Regular, once /day, constipated sometimes ▪ Habits - Tea - 2 cups/day Rogi Pareeksha General Examination ▪ Tongue - Uncoated ▪ Pulse - 72 beats/ min ▪ BP - 130/90 mm of Hg ▪ Temperature - 98.6°F ▪ Respiratory rate - 18 cycles/min ▪ Height - 157 cm ▪ Weight - 64 kgs ▪ BMI - 26 Systemic Examination Cardio Vascular System Examination: S 1, S 2 heard, no added murmurs. Respiratory System Examination: NVBS heard. Per Abdomen Examination: Soft, Nontender, No Organomegaly. Central Nervous System Examination: Conscious, Orientation to time, place, person - Intact Vrana Pareeksha Darshana ▪ Vaya : Vruddhavastha ▪ Sthana : Dakshina pada ▪ Sankya : One ▪ Akruti : Vrutha ▪ Varna : Pandu ▪ Srava : Puya, Pandu varna, Putigandha, Sandra, picchila ▪ Shareera : Madhyama Sparshana : Sheeta, Katina Prashna ▪ Hetu : Guru, Madhura, Snigda Ahara Sevana, Mamsa Sevana, Dadhi Sevana, Divaswapna, Atichankramana, Atichinta. ▪ Vedana : Present - Chumachumayana Vat, Todha.

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 111 ▪ Kala : Chirakalina Examination of Ulcer History 1 Mode of onset : Spontaneous 2 Duration : 2 months 3 Pain : Present 4 Discharge : Pus 5 Associated disease : Diabetes Local Examination 1. Inspection ▪ Size : 3.5 cm x 2.5 cm x 3 mm, cavity was present at the anterior part of the ulcer which measures about 2.5 cm ▪ Shape : Circular ▪ Number : One ▪ Position : Plantar aspect of right foot ▪ Edge : Slightly indurated ▪ Floor : Slough is noted ▪ Discharge : Purulent o Amount : Scanty o Smell : foul ▪ Surrounding area : Hyper pigmented Palpation ▪ Edge : Slightly indurated ▪ Margin : Slightly thickened ▪ Base : Slightly indurated ▪ Depth : 3 mm ▪ Bleeding : Bleeding on touch absent ▪ Surrounding skin : No marked increased temperature o Tenderness : Present at the medial aspect of the wound o Fixity to deeper structures : Absent ▪ Examination of vascular insufficiency : Popliteal pulse, Dorsalis pedis pulse, Posterior tibial pulse - present Investigation ▪ Blood urea - 30 mg/dl ▪ Serum creatinine - 1.0 mg/dl ▪ Glycosylated Hemoglobin - 8.2 % ▪ FBS : 173 mg/dl ▪ PPBS : 336 mg/dl Right lower limb venous doppler study Impression - Patent deep venous system right lower limb. Competent saphenofemoral and saphenopopliteal junctions. Mild diffuse soft tissue edema of the lower leg and foot. Right lower limb Arterial doppler study Impression - Diffuse atherosclerotic changes. M ATERIALS AND M ETHODS Preparation of Aragwadhadi Qwatha : Required quantity of Aragwadhadi Qwatha Choorna was taken and boiled in 8 parts of water and was reduced to one fourth and filtered in a clean vessel. The filtrate was used luke warm for Prakshalana. (Fig.1) Fig. 1: Aragwadhadi Qwatha Choorna with Water

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 112 Fig. 2: Aragwadhadi Qwatha Preparation of Kshara Picchu ▪ 4-5 strands of gauge was taken. ▪ Mrudu Chitraka Kshara was smeared over the strands of gauge and a Pichu was prepared. ▪ And kept for drying in the Kshara Sutra cabinet. Fig. 3: Chitraka Kshara Pichu Treatment 1. Vrana Prakshalana with Aragwadhadi Qwatha 2. Vrana Doopana with Guggulu, Nimba Choorna, Haridra, Jatyadighrita 10 Days 3. Dressing with Jatyadi Taila Fig. 4: Vrana Dhupana Other medicines: Inj. Insugen 30/70 According to sliding scale Internally ▪ Cap. GP 500 1-0-1 A/F ▪ Tab. Gandhaka Rasayana 1-0-1 A/F ▪ Mahamanjistadi Kwatha 15 ml-0-15 ml with 30 ml of warm water B/F ▪ Tab. Nishamalaki 1-0-1 B/F ▪ Triphala Guggulu 1-1-1 A/F on 10 th day - Pus discharge was noted from the cavity of the ulcer Treatment from 11 th day onwards 1 Vrana Prakshalana with Aragwadhadi Qwatha 2 Kshara Pichu insertion to the ulcer cavity 7 days. (Fig. 5) 3 For the remaining healthy granulation tissue dressing with Jatyadi Taila. Treatment from 18 th day onwards 1. Vrana Prakshalana with Aragwadhadi Qwatha 2. Jatyadi Taila Picchu insertion to the ulcer cavity. 10 Days 3. Dressing with Jatyadi Taila

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 113 Fig. 5: Kshara Picchu insertion O BSERVATION AND R ESULTS Fig. 6: On the day of admission Fig. 7: Wound on 5 th day - The healing was started with the formation of healthy granulation tissue.The wound started to contract by filling of tissue from the base of the wound day by day. Fig. 8: Wound on 10 th day - Roohyamanavrana - Kapota Varna Pratima, Kledavarjita , Sthira , Pitikavanto. Fig. 9: Depth of the cavity - 1 cm on 15 th day Fig. 10: On 20 th day - It was observed that wound size was markedly reduced.

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 114 Fig. 11: On 27 th day - The wound completely healed DISCUSSION Aragvadhadhi Gana Dravyas are having the properties of Vrana Shodhaka, Shothahara, Vedanasthapana, Ropaka and Mehahara . And Acharya Vagbhatta has explained Aragvadadhi Gana Dravyas can be used in Madhumeha Vrana . As it has anti inflammatory, analgesic, antibacterial hypoglycemic effects, hence for the Vranashodhanartha Prakshalana was done with Aragvadadhi Kwatha . Acharya Sushrutha while explaining about the wound care, has given importance to Dhoopana, Dhoopana is indicated in Vranas which are having Ruja, Srava, Durgandha the drugs like Guggulu, Nimba Patra, Haridra, Jatyadi Ghrita are Shothahara, Vedanasthapana and Ropaka , which are important requirements for the healing of wound. Pus discharge was noted from the cavity of the ulcer hence Kshara Picchu treatment was started as the Kshara is having Lekhana property, and the Vrana Shodhana, Ropana properties of Kshara are helpful in the healing of discharge wounds. Most of the ingredients used in Jatyadi Taila are Shothahara, Vedanasthapana and Ropaka , the drugs like Nimba, Daruharidra are having antibacterial effect which promotes healing. CONCLUSION Diabetic ulcers might end up in amputation of the limb, if not treated properly. In our classic’s importance was given to Vranashodhana and Vranaropana . The present study was carried out giving importance to Vranashodhana and Ropana . Acharya Vagbhatta has explained that Vranas which are caused by Madhumeha can be treated with Aragwadhadigana Dravyas . Aragvadhadhi Gana Dravyas are having the properties of Vrana Shodhaka, Shothahara, Vedanasthapana, Ropaka and Mehahara , hence for the Vrana Shodhanartha Prakshalana was done with Aragvadadhi Kwatha . Acharya Susrutha says Doopana is useful for the Vranas which are having Srava, Vedana, Durgandha . The drugs like Guggulu, Nimba Patra, Haridra, Jatyadi Ghrita are Shothahara, Vedanasthapaka and Ropaka , which are important requirements for the healing of wound. Pus discharge was noted from the cavity of the ulcer, hence Kshara Picchu treatment was started as the Kshara is having Lekhana property, and the Vrana Shodhana, Ropana properties of Kshara are helpful in the healing of discharge wounds. Most of the ingredients used in Jatyadi Taila are Shothahara, Vedanasthapana and Ropaka , the drugs like Nimba, Daruharidra are having antibacterial effect which promotes healing. REFERENCES 1 Somen Das; A manual on clinical surgery, SD Kolkata, 9 th edition, 4 th chapter, Pg-70,Pp-650. 2 Sriram Bhat M; SRB’s manual of surgery, Jaypee Brothers’ Medical Publishers (P) LTD,4 th edition,1 st chapter, pg-25, pp-1335. 3 S. Das : A concise textbook of surgery , SD Kolkata 2012, 7 th edition, 11 th chapter, Pg – 161-162, Pp- 1358. 4 Sushrutha: Sushrutha Samhita with commentary of Dalhana, edited by Vaidya Jadavaji Trikamji Acharya, Chowakhamba Surbharti Prakashan, Varanasi, reprint 2009, Chikitsa Sthana, 1 st Chapter, Verse 8, Pg-397, Pp- 824. 5 Vagbhata; Astanga Hrudayam with commentary of Arunadatta and Hemadri, Chaukhambha Orientalia Varanasi, Uttara Sthana, 25 th chapter, verse 41,Pg- 867,Pp-956.

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Dr. Shruthi P. et.al. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu ISSN: 2456-3110 CASE REPORT Jan-Feb 2019 Journal of Ayurveda and Integrated Medical Sciences | Jan - Feb 2019 | Vol. 4 | Issue 1 115 6 Sushrutha: Sushrutha Samhita with commentary of Dalhana, edited by VaidyaJadavaji Trikamji Acharya, Chowakhamba Surbharti Prakashan, Varanasi, reprint 2009, Chikitsa Sthana, 1 st Chapter, Verse 80, Pg-404, Pp-824. 7 Sushrutha: Sushrutha Samhita with commentary of Dalhana, edited by Vaidya Jadavaji Trikamji Acharya, Chowakhamba Surbharti Prakashan, Varanasi, reprint 2009, Sutra Sthana, 5 th Chapter, Verse 18, Pg-21, Pp- 824. 8 Pandit Sharangadharacharya; Sharangadhara Samhita, Madhyama khanda, 9 th chapter, verse 168-171,Pg- 229,Pp-398. ******************************* How to cite this article: Dr. Shruthi P, Dr. Shailaja SV. A Single Case Study of Diabetic Foot Ulcer treated with Vrana Dhoopana and Kshara Picchu. J Ayurveda Integr Med Sci 2019;1:109-115. http://dx.doi.org/10.21760/jaims.4.1.22 Source of Support: Nil, Conflict of Interest: None declared.

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Sthira, Durgandha, Daruharidra, Shothahara, Vedanasthapana, Vranashodhana, Nimbapatra, Vranaropana, Family history, Right foot, Wound dressing, Wound management, Wound healing, Sedentary lifestyle, Palpation, Acharya Sushruta, Analgesic effect, Jatyadi taila, Anti-inflammatory, Local examination, Systemic examination, Acharya Vagbhata, Type 2 Diabetes Mellitus, General examination, Diabetic Foot Ulcer, Lekhana property, Vrana Pareeksha, Non-healing ulcer, Vascular Insufficiency, Healthy granulation tissue, Antibacterial effect, Pus discharge, Wound care, Diabetic neuropathy, Blood sugar control, Wound size, Vrana ropaka, Electrical stimulation, Lower Limb Amputation, Vrana Shodhaka, Nonhealing ulcer, Hyperbaric oxygen therapy, Purulent discharge, Diabetic Atherosclerosis, Inspection, Wound treatment, Plantar aspect.