E-ISSN:2456-3110

Brief Report

Vranashopha

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 9 SEPTEMBER
Publisherwww.maharshicharaka.in

Ayurvedic management of Vranashopha w.r.t. Cellulitis: A Single Case Study

Javali JA1*, Anusha K2
DOI:10.21760/jaims.9.9.46

1* Jeetendra A Javali, Assistant Professor, Department of Shalya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College and Hospital, Koppal, Karnataka, India.

2 Anusha K, Post Graduate Scholar, Department of Shalya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College and Hospital, Koppal, Karnataka, India.

Cellulitis is a spreading inflammation of dermis and subcutaneous tissue. It is commonly due to Streptococcus pyogenes and gram positive organisms. These organisms usually gain access through a wound or scratch. It is generally treated with Antibiotics, anti-inflammatory, antipyretic and analgesic medications. The disease can progress and complicates to Abscess formation, gangrenous cellulitis or necrotizing fascitis. Vrana Shopha can be associated with Cellulitis. According to Ayurveda, Ekadasha/Saptopakrama treatment have been explained. A 36 year old male Right hemiplegic patient presented with indurated swelling and redness over lateral aspect in Right foot region & was treated with Chedana Karma, Lepana and Shamana Aushadi, where he showed good progression in this condition.

Keywords: Vranashopha, Cellulitis, Lepana, Surgical Debridement

Corresponding Author How to Cite this Article To Browse
Jeetendra A Javali, Assistant Professor, Department of Shalya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College and Hospital, Koppal, Karnataka, India.
Email: 		Javali JA, Anusha K, Ayurvedic management of Vranashopha w.r.t. Cellulitis: A Single Case Study. J Ayu Int Med Sci. 2024;9(9):287-293.
Available From
https://jaims.in/jaims/article/view/3584

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-08-15 2024-08-27 2024-09-07 2024-09-17 2024-09-27
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 14.32

© 2024by Javali JA, Anusha Kand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Jeetendra A Javali et al. Ayurvedic management of Vranashopha w.r.t. Cellulitis

Introduction

Cellulitis is a non-suppurative spreading inflammation of dermis and subcutaneous tissue that is usually caused by bacterial infection like Streptococcus pyogenes, Staphylococci pyogenes and gram positive organisms. These organisms usually gain access through a wound or scratch or insect bite. The organisms on skin and its appendages gain entrance to dermis and multiply to cause Cellulitis.[1] The prevalence rate of cellulitis is 24.6 per 1,000 person. The most common site of infection was lower extremity (39.9%), Face and Scrotum.[2] Diabetes, Cancer and Immuno-compromised persons are the risk factors for Cellulitis. The main cardinal signs of cellulitis are Pain, erythema, swelling, warmth with other symptoms like fever, malaise and chills. Most common complications are Abscess formation, gangrenous cellulitis or necrotizing fasciitis. Based on the symptoms cellulitis is treated with Antibiotics, anti-inflammatory, antipyretic, analgesics, limb elevation and if necessary debridement.[3]

According to Ayurveda, Vranashopha can be associated with Cellulitis. The definition of Shopha given by Acharya Sushruta is a localised swelling in part of the body involving Twak and Mamsa Dhatu which may be even or uneven, massive and knotty in consistency.[4] It is the prodromal stage of Vrana. The Samanya Lakshana are Gaurava (Heavyness), Anavasthitva (Mobile), Utsedha (Swelling), Ushama (Heat), Siratanutva (Increases vascular permeability), Romaharsha (Horripilation) and Vivarnata (Discoloration).[5]

Acharya Sushruta while explaining the treatment aspect of Vranashopha he has told Ekadasha and Saptopakrama.[6] Among them Patana (Chedana) and lepa places an important role in the management of Cellulitis as it may alleviate local inflammation, temperature, edema and redness. So, Chedana and Lepa were chosen for this study to treat cellulitis.

Case Report

Chief Complaints

C/O Indurated swelling and redness over lateral aspect of Right foot since 2 days. Associated with fever since 2 days.

History of Present Illness

A 36 year old male N/K/C/O T2DM, Hypertension, Thyroid disorders on 10-06-2024 morning had a sudden fall in his washroom with loss of consciousness for 5 min followed by slurred speech for few minutes, later he developed loss of strength in Right upper and lower limb was approached to Hubli hospital for treatment and was bedridden. On 26-06-2024 patient attender noticed swelling and redness over lateral aspect of Right foot associated with Fever. As patient didn’t find any improvement approached Kayachikitsa department of SJG Ayurvedic Medical College and Hospital for Pakshagata treatment and he was referred to Shalya Tantra department for management of swelling in Right foot.

History of Past Illness

No H/O T2DM, Hypertension, Thyroid disorder or any other comorbidities.

Examination of Patient

Personal History

Diet: Mixed
Appetite: Poor
Bowel: Constipated
Micturition: 4-5 times a day
Sleep: Sound
Habits: Tobacco chewing, Smoke, Alcohol since 10 years.

Vitals

BP: 120/80 mmHg
Respiratory rate: 18 cpm
Pulse rate: 72bpm
Temperature: 99.8°F

Systemic Examination

CVS: S1 S2 Heard, No murmurs.
RS: Equal air entry B/L Lung fields, NVBS +
P/A: Soft, Non tender, No organomegaly.

Examination of Foot

  • Swelling over Right lateral malleolus region extending from Right ankle to foot
  • Reddish Discoloration over Right lateral malleolus region
  • On Palpation: Raised temperature over the swelling
  • Induration over lateral aspect of ankle joint

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  • Tenderness + + over induration part

Table 1: Examination of Ulcer

After 1st Surgical DebridementAfter 2nd Surgical Debridement
Inspection
§ Site: Right lateral malleolus
§ Size: 2 x 2cm
§ Shape: Oval
§ Discharge: Seropurulent
§ Edge: Punched out
§ Floor: Covered by thick slough
§ Margin: Irregular, inflamed and oedematous
§ Foul smell: Present
§ Surrounding area: erythematous swelling
Palpation
§ Local Temperature: Raised
§ Tenderness: Present in and around the wound
§ Induration: Present in and around the wound
§ Base : lateral malleolus of Fibula
§ Pulsation: dorsalis pedis felt feeble, Anterior and Posterior tibial artery felt well. No distal neuro-vascular deformity.		Inspection
§ Site: Right lateral malleolus
§ Size: 6 x 8cm
§ Shape: Oval
§ Discharge: Serous
§ Edge: Punched out
§ Floor: dull, dusky red granulation < 25% of wound
§ Margin: Irregular, inflamed and oedematous
§ Foul smell: Absent
§ Surrounding area: erythematous swelling
Palpation
§ Local Temperature: Raised
§ Tenderness: Present in and around the wound
§ Induration: Present in and around the wound
§ Base : lateral malleolus of Fibula
§ Pulsation: dorsalis pedis, Anterior and Posterior tibial artery felt well. No distal neuro-vascular deformity.

Investigation [Date: 01-07-2024]

Hb: 15.2 g/dl
TC: 13,700 Cells/Cu mm
Platelet count: 4.82 Lacks/cumm
RBS: 127 mg/dl
ESR: 55 mm/hour
HIV: Non Reactive
HCV: Non reactive
HBSAG: Negative
Diagnosis : Vranashopha

Treatment

Table 2: Treatment timeline

DateProcedure
29-06-2024 to 30-06-2024Dashanga Lepa BD
01-07-20241st Chedana Karma (Surgical Debridement)
02-07-2024 to 04-07-2024Nimba Patra Kalka over the wound for 6 hours and Dashanga Lepa around the wound for 1 hour,
Dressing with Jatyadi Taila
05-07-20242nd Chedana Karma (Surgical Debridement)
06-07-2024 to 11-07-2024Nimba Patra Kalka over the wound for 6 hours and Dashanga Lepa surrounding the wound for 1 hour,
Dressing with Jatyadi Taila.

Oral medication

Amrutottara Kashaya 15ml TID AF for 8 days. Later Guggulu Tiktaka Kashaya 15ml TID AF, Tab.Triphala Guggulu 1 TID AF and Tab. Gandhaka Rasayana 1 TID AF for 15 days. Limb elevation.

Assessment

Table 3: Assessment of parameters

ParametersDay 1(Before Treatment)Day 3(After 1st Chedana)Day 7(After 2nd Chedana)Day 14Day 28Follow up after 45 days
Pain1085320
Size-2x26 x 84x6cm2x2
Depth-0.5110.50.5
Granulation tissue-
DischargeGrade 5
Purulent		Grade 4
Serous		Grade 3
serosanguineous		Grade 1Grade 1Grade 1
Peripheral tissue edemaGrade 4
Pitting edema <4cm around wound		Grade 3
Non pitting edema >4cm		Grade 2
Non pitting edema <4cm		Grade 2Grade 1
No swelling or edeme		Grade 1
Peripheral tissue IndurationGrade 5
Induration >4cm in any area around wound		Grade 4
Induration 2-4cm extending >50% around the wound		Grade 3
Induration 2-4cm extending <50% around wound		Grade 2
Induration <2cm around the wound		Grade 1
None present		Grade 1
None present

Wound assessment done according to Bates-Jessen wound assessment tool[7] and for Pain VAS[8] scale was used.

Table 4: Granulation tissue

Grade 1Skin intact or partial thickness wound
Grade 2Bright, beefy red; 75% to 100% of wound filled &/or tissue overgrowth
Grade 3Bright, beefy red; < 75% & > 25% of wound filled
Grade 4Pink, &/or dull, dusky red &/or fills < 25% of wound
Grade 5No granulation tissue present

Table 5: Discharge

Grade 1None
Grade 2Bloody
Grade 3Serosanguineous: thin, watery, pale red/pink
Grade 4Serous: thin, watery, clear
Grade 5Purulent: thin or thick, opaque, tan/yellow, with or without odor

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Table 6: Peripheral tissue edema

Grade 1No swelling or edema
Grade 2Non-pitting edema extends <4 cm around wound
Grade 3Non-pitting edema extends >4 cm around wound
Grade 4Pitting edema extends < 4 cm around wound
Grade 5Crepitus and/or pitting edema extends >4 cm around wound

Table 7: Peripheral tissue induration

Grade 1None present
Grade 2Induration, < 2 cm around wound
Grade 3Induration 2-4 cm extending < 50% around wound
Grade 4Induration 2-4 cm extending > 50% around wound
Grade 5Induration > 4 cm in any area around wound

Table 8: Pain

Grade 0No pain
Grade 1-3Mild pain
Grade 4-6Moderate pain
Grade 7-9Severe pain
Grade 10Worst pain

jaims_3584_01.JPG
Figure 1: Day 1

jaims_3584_02.JPG
Figure 2: After 1st Chedana Karma

jaims_3584_03.JPG
Figure 3: After 2nd Chedana Karma

jaims_3584_04.JPG
Figure 4: Application of Nimba Kalka over the wound and Dashanga Lepa around the wound

jaims_3584_05.JPG
Figure 5: On day 14

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Figure 6: After 45days

Discussion

Vranashopha is managed in early stages to avoid more tissue damage. Acharya Sushruta has described management required for different stages of Vranashopha in Saptopakrama: Like in Amawastha the Upakrama told are Vimlapana (massage or rubbing over swelling), Avasechana (Blood letting), Upanaha (Poultice). In Pakwawastha, Patana (Draining or incising), For Vrana Chikits: Shodhana (Cleaning) and Ropana (Healing) are told. Later Vaikritapaha (Repairing the scar) has been mentioned.[9] As Acharya Sushruta has said if doshas are eliminated in stage of accumulation itself, the disease will not progress to further stages.


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So in this case when the shopha was noticed, Dashanga Lepa was applied to make Shopha from Amavastha to Pakwavastha later Chedana Karma (surgical debridement) was done to drain out all pus and slough. After Chedana Kriya, for Vrana Chikitsa- Nimba Kalka was applied over the wound and Dashanga Lepa surrounding the wound followed by Wound dressing with Jatyadi Taila.

In this case after application of Dashanga Lepa, Shotha turned to Pakwavastha so Chedana Karma (Surgical debridement) was planned. In 1st Chedana Karma, during the procedure patient couldn’t tolerate the pain and he was anxious, even his vitals went above the normal range, so Chedhana Karma was not done completely. For 3 days Nimba Patra Kalka over the wound and Dashanga Lepa application surrounding the wound was done, then again he was took for 2nd Chedana Karma and thorough surgical debridement was done with all vital within the normal range. After this, the granulation tissue was seen developing over wound floor.

Chedhana Karma comes under Patana which is one among the Ashtavidha Shastra Karma. It is absolute indication in Pakwavastha Vranashopha. It drains the collected exudates & pus from the cavity, which helps in wound healing. Dashanga Lepa.[10,11] reduces Inflammatory edema as most of the ingredients are Kashaya and Tikta Rasa so it allivates vitiated Kapha and due to Sheeta Virya it constricts blood vessels & reduces erythema. Nimba Patra[12] has Tikta Kashaya Rasa and is both Shodhana and Ropana , it reduces itching, foul smell and acts as antimicrobial helps in healing the wound faster. Jatyadi Taila[13] is Shothahara, Vedanasthapana and Vrana Shodaka & Ropaka. It has Tikta, Madhura, Katu Rasa and Ushna Veerya which helps in wound healing.

Internally Amrutottara Kashaya 15ml TID AF for first 8 days was given later Guggulu Tiktaka Kashaya 15ml TID AF, Tab.Triphala Guggulu 1 TID AF and Tab. Gandhaka Rasayana 1 TID AF for 15 days was given. Amrutottara Kashaya[14] is having properties like Antipyretic, anti-inflammatory and anti-bacterial. Triphala Guggulu[15] has Dahasamana, Vedanahara, Vrana Sodhana and Ropana properties. It is Tridoshagna, it also has anti-inflammatory and anti-microbial action. Acharya Vagbhatta has mentioned Triphala Guggulu as Agryaaushadha for Vrana.

Gandhaka Rasayana [16] is Tidoshashamaka, Vatamaya Nivaraka, Agnivardhaka and Shoolahara. It has anti-inflammatory, anti-bacterial action and is also said to promote wound healing.

Conclusion

Acharya Sushruta has explained the management of every stages of Vranashotha in detailed. Vranashotha results in vitiation of Tridosha. In Vranasthotha, Avastha Chikitsa should be followed. Here in Amavastha, Lepa was used to make it Pakwavastha, Chedhana was used in Pakwavastha to drain out all pus and Dressing with Jatyadi Taila was used to heal vrana by achieving granulation tissue. All these Lepana, Chedana Karma, Ropana are indicated in Saptopakrama. An early intervention should be done in view of early suppuration and prevention of further complications.

References

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2. Ellis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, Lyon JL. Cellulitis incidence in a defined population. Epidemiol Infect. 2006 Apr;134(2):293-9. doi: 10.1017/S095026880500484X. PMID: 16490133; PMCID: PMC2870381.
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7. Bates-Jensen BM, Vredevoe DL, Brecht ML. Validity and reliability of the Pressure Sore Status Tool. Decubitus. 1992 Nov;5(6):20-8. PMID: 1489512.


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8. Dugashvili, Giorgi & Van den Berghe, Linda & Menabde, Giorgi & Janelidze, Marina & Marks Prof. dr, Luc. (2016). Use of the universal pain assessment tool for evaluating pain associated with TMD in youngsters with an intellectual disability. Medicina Oral Patología Oral y Cirugia Bucal. 22. 10.4317/medoral.21584.
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13. Kanjiv Lochan, Bhaisajya Ratnavali of Govinda Dasji Bhisagratna, vol-2, Chapter no-47, Varanasi Chaukhambha Sanskrit Sansthan, Reprint 2009, pg.761.
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