Management of an Infective Ulcer: A Case Study

K Prashanth; Annet Thomas

The development of wound infection depends on the complex interplay of many factors. Nowadays, leg ulcers are at a rise due to increase in elderly population, life style changes and has been a common feature associated with infection, malignancy, adverse drug reaction, trauma and haematological disorders. Hence timely and effective management of ulcer is necessary. A patient of infected leg ulcer aged 62 years female presented with ulcer over right lower limb. The patient was treated with Panchavalkala Kashaya Parisheka followed by Yashtimadhu Ghrita dressing for 1 week following which the ulcer healed completely within 2 weeks and no recurrence in the 2 months of follow up.

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Annet Thomas, Final Year Post Graduate Scholar, Dept of PG Studies in Shalya Tantra, Shri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.
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K Prashanth, Annet Thomas, Management of an Infective Ulcer: A Case Study. J Ayu Int Med Sci. 2022;7(7):155-158.
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2022-06-28

2022-06-30

2022-07-07

2022-07-14

2022-07-21

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Introduction

Ulcer in the lower limb is fairly common among middle aged people whose symptoms include pain, oedema, oozing and bleeding. The incidence of ulceration is rising as a result of the ageing population and increased risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes. In the course of lifetime, almost 10% of the population will develop a chronic wound with a wound related mortality rate of 2.5%. Chronic leg ulcers affect 0.6-3% of those aged over 60 years, increasing to over 5% of those aged over 80 years.^[1] The potential for infection depends on patients variables such as state of hydration, nutrition and existing medical conditions as well as extrinsic factors.^[2]

Wound infection is defined as the presence of replicating microorganisms within a wound with a subsequent host response that leads to delayed wound healing. The signs and symptoms of local infection are redness (erythema), warmth, swelling, pain and loss of function. Eventually, the local bacteria burden will increase further and become systematically disseminated resulting in sepsis which if not actively treated could progress to septicaemia and multi organ failure.^[3] Factors affecting on ulcer are slough, infection and foreign body, which can delay the normal process of healing. These are several factors known to affect the bacterial burden of chronic wounds and increase the risk of infection. To date the management of infective ulcer is a challenging problem because of prolonged healing and recurrence. Clinically, infective ulcers can result in serious consequences for patients, health care systems and society.

Dushta Vrana is a commonly encountered problem faced in clinical practice. The presence of Dushta Vrana can damage the condition of the patient with different complication and may become fatal. Acharya Sushruta has mentioned 60 Upakramas for the treatment of Vrana. Among these Upakramas, Kashaya, Varti, Kalka, Sarpi, Taila, Rasakriya, Avachoornana are used for Vrana Shodana and Ropana.^[4] One among them is Nyagrodhadhi Varga mentioned in Vrana Ropana kashaya which includes Panchavalkala.^[5] Kashaya prepared with Panchavalkala drugs when used topically found to be effective in treating an infective ulcer located on the leg.

Case Report

A 62 year female patient K/C/O HTN since 5 years, under medication and asthma since 20 years came with a history of recurrent fever with chills for 3 days. She then noticed painful swelling of her right leg with red coloured rashes associated with itching. By the end of the week the rash turned into two ulcers. Day by day ulcers increased in size with distal scaling of the skin. Pain was intense and continuous with burning character that it disturbed her sleep. Her systemic examinations were not significant for any major systemic disease. Her vitals were stable with BP - 120/80mmhg, respiratory rate - 20/min, pulse rate - 86 bpm, temperature - 98.6^°F. Laboratory investigations revealed Hb - 10.4 gm%, TC - 6800 cells/cumm, DC – Neutrophils - 75%, ESR - 90mm/hr, RBS - 88mg/dl, serum creatinine - 1.0 mg/dL .

Ulcer Examination: Local examination revealed two ulcers over posterior side of right leg measuring 10 x 4cm and 4 x 5cm in size with punched out edge of ½cm depth. The shape of ulcers was irregular with well-defined margin, floor covered with red granulation tissue along with serous discharge. The surrounding area was oedematous and red scaly skin. On palpation, there was rise in temperature over the affected limb and mild tenderness. Bleed on touch and lymph node enlargement were absent with no signs of vascular insufficiency. A diagnosis of infective ulcer / Dushta Vrana was made.

Intervention: Duration of treatment - 15 days

The treatment included

1. Local wound care
2. Internal medicines
3. Supplementary care

1. Local wound care

a. Panchavalkala Kashaya Parisheka - 300ml of Kashaya was prepared by Chathurhasta (1/4^th of heating) which was made cool. The cotton balls soaked in Kwatha were squeezed all over the ulcer and surrounding inflamed skin continuously for 5 min.

b. The area of intervention was mopped and allowed to dry for 15 minutes. Then Yastimadhu Ghrita soaked with sterile gauze was applied over the ulcer followed by light bandaging using sterile gauze and pads.

Result

Local symptoms like pain, itching, burning sensation, and swelling were significantly reduced with complete healing of the ulcer in 2 weeks. It was observed that after the Parisheka there was significant and immediate reduction in the burning sensation. The combination of complete rest, limb elevation, Panchavalkala Kashaya Vrana Parisheka and Yashtimadhu Ghrita bandaging reduced the symptoms and showed reduction in signs of inflammation within a week. Complete healing of ulcers was observed in two weeks.

Discussion

Acharya Susrutha advocated that based on the condition of the wound appropriate treatment needs to be selected among Shasti Upakrama. In this study, Vrana Parisheka with Panchavalkala Sheetha Kashaya was adopted as there was spreading ulcer with burning pain and discharge due to dominance of Pitta and Vata. Further alleviation of the symptoms were achieved by control of inflammation with Yashtimadhu Ghrita as topical application due to its Raktaprasadana Karma. Parisheka has to selected on the basis of Doshic dominance which helps to reduce the symptoms of Vrana with associated Shopha. When Vata and Pitta are the dominating Dosha in Vrana, the ideal topical formulation should be Ghrita as directed by the text. Hence these two formulations were selected based on the condition of the wound and dominance of the Doshas. These interventions have significantly controlled the spreading inflammation and the symptoms without requiring the prescription of analgesics / NSAIDS. However, antibiotics were prescribed owing to the systemic manifestation of the infection like fever associated with chills for a period of 5 days. Internal medications were prescribed considering the Vyadhi and Koshta of the patient for a period of 2 weeks. Patient’s compliance to all the interventions was good and no adverse reactions were noted during the treatment.

Reference

1. Shubhangi Vinayak Agale, “Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management”, Ulcers, vol. 2013, Article ID 413604, 9 pages, 2013. https://doi.org/10.1155/2013/413604

2. Vijayakumar, A comparative study of Kaseesadi Avachurnana and Jatyadi Ghrita application in the management of Dushta Vrana, Ph.D thesis, Bengaluru: Rajiv Gandhi University of Health Sciences;2015

3. Bhat KS, Vishwesh BN, Sahu M, Shukla VK. A clinical study on the efficacy of Panchavalkala cream in Vrana Shodhana w.s.r to its action on microbial load and wound infection. Ayu. 2014 Apr;35(2):135-40. doi: 10.4103/0974-8520.146216. PMID: 25558157; PMCID: PMC4279318

4. Acharya Sushruta, Sushruta Samhitha, Dalhana, Nibandhasangraha Commentary, Edited by Jadavji Trikamji Acharya and Naarayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2012; Chikitsa Sthana 1/7,Pp 820,p397

5. Acharya Sushruta, Sushruta Samhita, Dalhana, Nibandhasangraha Commentary, Edited by Jadavji Trikamji Acharya and Narayana Ram Acharya; Varanasi: Chaukhambha Sanskrit Sansthan; Reprint 2012; Sutrasthana 37/22,Pp 820,p162

Case Report

Infective Ulcer

Journal of Ayurveda and Integrated Medical Sciences