A Case Study on Dushta Vrana w.s.r to Venous Ulcer

Radhika Pachamalai

doi:10.21760/jaims.9.8.43

A Case Study on Dushta Vrana w.s.r to Venous Ulcer

Pachamalai R^1*

DOI:10.21760/jaims.9.8.43

^1* Radhika Pachamalai, Assistant Professor, Dept. of Shalya Tantra, KTG Ayurvedic Medical College, Bengaluru, Karnataka, India.

Vrana in Ayurveda is defined as a structural deformity in the skin and deeper structures, it’s of 2 types - Dushtavrana and Shudhavrana. Dushta Vrana with foul smell has abnormal color with profuse discharge from wound, intense pain and takes long period to heal is said to be Dushta Vrana. The features will vary according to the predominant Dosha. It can be correlated to Chronic wound based on underlying pathology. Chronic wounds are termed ulcers and can be defined as wounds with full thickness in depth and slow healing tendency. In this single case study Dusta Vrana is considered as venous ulcer is one among 4 types of Chronic wound. Venous Ulcer occurs due to abnormal hypertension in the lower third of the leg, ankle and dorsum of foot. Acharya Sushruta has mentioned Shashti Upakrama for the management of Vrana. Here to evaluate the combined effect of Shodhana and Shamana Chikitsa, Classical Virechana, Jalaukaavacharana as a Shodhananga, Shamanaushadi by Kaishora Guggulu, Triphala Guggulu, Gandhaka Rasayana, and Manjishtadi Kashaya, Sthanika Chikitsa by Panchavalkala Kashaya Pariseka and Jathyadi Ghrita. The medicines having Tridosha Shamaka, Vrana Shodhana, Ropana, Vedana Shamaka, Shothahara, Rasayana property showed successful result in treating Dushtavrana.

Keywords: Dushtavrana, Venous ulcer, Kaishora Guggulu, Triphala Guggulu, Jathyadi Ghrita

Corresponding Author	How to Cite this Article	To Browse
Radhika Pachamalai, Assistant Professor, Dept. of Shalya Tantra, KTG Ayurvedic Medical College, Bengaluru, Karnataka, India. Email:	Pachamalai R, A Case Study on Dushta Vrana w.s.r to Venous Ulcer. J Ayu Int Med Sci. 2024;9(8):280-286. Available From https://jaims.in/jaims/article/view/3747

Introduction

Vrana is derived from the verbal root ‘Vrana Gatravichurnane’ which means splitting/tearing of the body tissues. Since it causes discontinuity of the Dhatu it is called Vrana. Vrana is so called as it covers the site and the scar even after healing does not disappear lifelong.

Vrana is concerned the main Nidana includes both Nija and Aganthuja factor. Nija Vrana is vitiation of Doshas due to faulty dietary habits, mode of living, seasonal variations and such deranged Doshas after going through series of pathogenesis get lodged in particular site resulting in formation of Vrana.

Thus, Nija Vranas are the ulcers formed after suppuration. Acharya Charaka has defined Nija Vrana as Vrana formed after derangement of doshas and discharge their contents outwards.^[1]

Agantuja Vrana caused due to thermal injuries, Pressure injuries with blunt or Sharp instruments, Chemicals as strong acids, Kshara, poisons of vegetable and animal origin, supernatural factors (Mantra, Shapa), fall from trees, fight with stronger fellow, bite by animals, insects etc are other factors leading to Agantuja Vrana.^[2]

Vrana Ropana last point in any kind of surgery, it’s equally important and true that without proper healing the art of surgery remains incomplete. Acharya Sushruta explained Shanmoola, Asta Parigrahee, Pancha Lakshana Lakshita; Vrana, Srava, Gandha, Vedana, Aakruti to diagnose the Vrana and also scientific explanation about Shastiupakrama (60 procedures)^[4] and many other formulations for Vrana Shodhana and Ropana.

Etiology and pathogenesis of Dushtavrana as described by Hareetha Samhita and Ashtanga Hridhaya are contaminated food drinks, carrying of heavy load, severe exercise and emotional factors like anger, fear etc. Defective surgical procedure like Mithya Bandha, Atisneha, Roukshya are the cause for vitiation of Raktha.^[3]

Raktha Dhatu associated with Rasa Dhatu in its path of perfusion causes the vitiation of other Dhatu i.e., Mamsa and Meda which leads to Dushta Vrana.

Doshas being aggravated by their respective causative factors gets lodged in any of Vrana Sthana to give rise to Dushta Vrana.

Table 1: Samprapti Ghatakas of Dushtavrana

SN	Samprapti Ghatakas of Dushtavrana
1.	Dosha	Tridosha
2.	Dushya and Adhisthana	Twacha, Mamsa, Sira, Snayu, Sandhi, Asthi, Kostha and Marma
3.	Srotas	Annavaha, Rasavaha, Raktavaha, Mamsavaha, Swedavaha
4.	Agni	Manda, Vishama
5.	Marga	Antarmarga, Madhyamamarga, Bahyamarga
6.	Udbhavasthana	Anywhere in the body
7.	Pratamya Lakshana	Gatra Vichurna along with Pancha Lakshana i.e., Vedana, Akruthi, Gandha, Vrana and Srava

Venous ulcer

Spontaneous ulcer due to lipodermatosclerosis or following minor injury. Occur at the rate 3/1000 at age 61-70 and 20/1000 at >80 years, 2/3 of ulcer are due to chronic venous insufficiency and 1/3 due to arterial disease, diabetes, rheumatoid disease etc. Venous 40-50% of ulceration is due to superficial venous insufficiency alone. Usually, ulcer occurs in chronic venous disorders in the age group of 40-60 years. Women are affected more than men. Venous Ulcer occurs due to abnormal hypertension in the lower third of the leg, ankle and dorsum of foot. Varicose ulcer, Post thrombotic ulcer or Gravitational ulcer used as synonyms of it. The main pathway of the venous drainage of the ankle skin in the erect posture is via the ankle perforating veins. When the valves of this vein are damaged there will be local venous hypertension. This condition is aggravated by obstructed main deep veins. Post canalization of the thrombosed deep vein leads to destruction of the valves of the veins and this becomes the main contributing cause for ankle venous hypertension. Location of the perforating veins from the malleolus up to the lower half of the leg determines the predilection of the area for the development of stasis changes and ulcers.^[5]

Venous leg ulcer (VLC) found in lower part of the leg on its medial side, majority vertically oval, can be any shape and size. The edge is sloping and pale purple blue in color. Margin is thin and blue of growing epithelium. The floor is formed by pale granulation tissue. The ulcer usually shallow, flat and never penetrates the deep fascia. The discharge is seropurulent with occasional trace of blood. The base fixed to the deeper structures. Surrounding skin in chronic venous hypertension shows pigmentation, induration and tenderness.^[6]

Treatment of Ulcer due to superficial venous insufficiency: varicose ulcers respond well to surgical treatment of varicose veins and ulcer heals with medical treatment but recurrence can’t be avoided. Standard treatment of ulcer due to deep venous insufficiency- Debridement of ulcer, keeping it clean, foot end elevation, adequate compression; elastic stocking, multilayer bandage technique.^[5]

Case Study Parameters

Inclusion Criteria

Patients irrespective of age, sex, occupation, was selected for the study.
Patients having clinical features of Nija/Agantuja Dushta Vranae., pain, foul smell, pus discharge, pain, burning sensation, edema was selected for study.
Dushta Vrana with maximum history of four weeks.

Exclusion Criteria

Patients suffering from systemic diseases like uncontrolled Diabetes mellilitus, Tuberculosis etc. was excluded from the study.
Patients suffering from grave conditions like malignant ulcer and other severe illness like HIV, HbsAg was excluded
Patients having pre-gangrenous or gangrenous changes.
Patients suffering from Osteomyelitis

Assessment criteria
The assessment of result is based on signs and symptoms presented before and after completion of treatment. Objective parameters as Size of ulcer, Discharge, Sloughing, Foul smell, Granulation, discoloration, edema and Subjective parameters as Pain, Burning sensation, Itching are used as assessment criteria. On basis of degree of relief and condition of patient clinical features of Vrana assessed in form of scores as follows:

Table 2: Objective and Subjective Parameters

SN	Objective Parameters	Subjective Parameters
1.	Size of ulcer	Pain
2.	Discharge	Burning Sensation
3.	Sloughing	Itching
4.	Foul Smell
5.	Granulation
6.	Discoloration
7.	Edema

Table 3: Objective and Subjective Parameters Scale

Parameters	Nil - 0	Mild - 1	Moderate - 2	Severe - 3
Size of ulcer	Healed	Upto 4x4 cms	Upto 6x6 cms	More than 8x8cms
Granulation tissue	More than 50% wound surface covered with granulation tissue.	25-50% wound surface covered with granulation tissue.	Upto 25% wound surface covered with granulation tissue.	No granulation tissue.
Slough tissue	No slough tissue.	Upto 25% wound surface covered with slough tissue.	25-50% wound surface covered with slough tissue.	More than 50% wound surface covered with slough tissue.
Pain	No pain	Localized pain during movement & not during rest	Localized pain during rest but no disturbed sleep due to it	Continuous pain
Discharge	No discharge	Scanty occasional	Often discharge with blood on dressing	Profuse, continuous
Smell	No smell	Bad smell	Tolerable unpleasant	Foul smell which is intolerable
Burning sensation	No Burning	Little localized and sometime felling of burning sensation	More localized and often burning sensation which does not disturb sleep	Continuous burning with disturbed sleep
Itching sensation	No itching	Slight, localized itching sensation which is relieved by rest	More localized and often itching but not disturbed sleep	Continuous itching with disturbed sleep
Edema	No edema	Slight edema, which is relieved by rest.	More localized edema with non-pitting edema	Continuous edema with pitting edema

Case History

A 45 year old, non-diabetic, non-hypertensive male, working as Corn seller resident of Bengaluru, he visited OPD of Shalya Tantra at KTGAMC Hospital, Bengaluru On 21/7/2023 with C/o non healing ulcer, watery discharge with red color, foul smell,

mild pain while walking since 1 year, c/o blackish discoloration in left leg since 3 years. This was the first occurrence of such an ulcer on his leg, and the patient did not have any family history of the same.

Clinical Findings

The patient examination results; Bowel, appetite and micturition were normal. He had disturbed sleep due to ulcer with discharge. His systemic and vital signs were within normal limits. A vertically oval shaped ulcer with 8cm x 6cm x 1.4 cm (Length, Breadth, Depth) was present on the lower lateral aspect of the left leg above and on the lateral malleolus.

Rogi Pariksha (Examination of the patient)

Patient with Vata Pitta Prakruthi, Alpa Upalipta Jihwa (slightly coated tongue), Vataja Nadi, Anavabadha Mala (normal bowel movements), normal Shabda and Sparsha.

Roga Pariksha (Examination of the disease)

Dushta Vrana on the lateral aspect of the left leg. The characteristics of Dushta Vrana are Ativivrita (broad base), Bhairava (ugly look), Vedana (pain), Dirghakalanubandhi (chronicity).

Table 4: Local Examination.

SN	Stanika Pareeksha of Dushtavrana
1.	Vrana - Type	Nija Vrana
2.	Parigraha	Twak, Raktha, Sira, Mamsa & Medas
3.	Rogadishtana	Adhakaya - Vaamapada
4.	Avastha	Pakwa
5.	Prognosis	Krichrasadhya

Vrana Pareeksha

Number: 1

Site: above and on lateral malleolus of left leg

Size: Length: 8 cm, Width: 6cm & depth 1.4cm

Edge and margin: Sloping, irregular margin,

Floor: Covered unhealthy granulation tissue

Base: Indurated

Discharge: Seropurulant Surrounding area: Pigmented with black colour. (Ref. Table 8).

Tenderness: Slightly was Present.

Edema: Pitting edema of dorsum of left foot.

A few varicose veins were present in lower left leg. Varicosity on the calf region tested positive for Trendelenburg test and negative to Mose’s sign. A palpable pedal pulsation confirmed that varicose ulcer and differentiated it from a deep vein thrombotic ulcer. Doppler study confirmed the absence of DVT and left sapheno-femoral and sapheno-popliteal vein incompetent.

Treatment

The patient was prescribed the following procedures and Ayurvedic medicines. Classical Virechana followed by Jalaukacharana to Ulcer edges. Vrana Prisheka with Panchavalkala kashaya and Vrana Pichu with Jathyadi Ghrita.

Table 5: Treatment chart

Procedure	Medication	Dose	Duration
Deepana, Pachana	Chitrakadi Vati	1BD	3 days
Snehapana	Panchatikta Guggulu Ghrita	Day 1 - 30ml Day 2 - 60ml Day 3 - 90ml Day 4 - 120ml	4 days
Sarvanga Abhyanga Bashpa Sweda	Ksheera Bala Taila	Qs	3 days
Virechana	Trivrut lehya	50gm	On 8th day, 9 Vegas
Paschatkarma	Rice gruel	On 8th, 9th, 10th days	3 days

Table 6: Oral medications are:

Kaishora Guggulu	2 BD Before food	Duration of 3 months along with location treatment
Triphala Guggulu	1 TID After food
Gandhaka Rasayana	1 BD After food
Manjishtadi Kashaya	10ml BD with warm water Before food

Table 7: Local treatment medicines

Panchavalkala Kwatha	Vrana Pariseka QS 2 days once	Local treatment done for 4 months from day 1 to till complete healing
Jathyadi Ghrita	Vrana Pichu QS 2 days once

Figure 1: Before treatment

Figure 2: During treatment

Figure 3: After treatment

Table 8: Local Assessment Parameter with results

Assessment Parameter	Before Treatment	After Treatment
Number	1	Nil
Site	Left leg lower lateral aspect of the lateral malleolus above and on it.	Fibrous Scar mark
Wound Size	8cm x 6cm x 1.4 cm (Length, Breadth, Depth)	Healed
Granulation tissue	Upto 25%	More than 50%
Sloughing	Upto 25%	Nil
Pain	Localized pain during movement & not during rest	No pain
Discharge	Seropurulent- Moderate	No discharge
Burning Sensation	Localized to ulcer site with felling of burning sensation	No
Itching	Slight, localized itching sensation	No
Edema	Pitting edema	Not present
Discoloration	Peripheral black color of Skin	Mild lightening

Discussion

In venous ulcer discomfort and tenderness of the skin, pigmentation and eczema exist for months or years before a venous ulcer to develop. The ulcer is painful in its beginning but once it chronic becomes painless. Healing of wounds whether internal or external involves a series of overlapping events viz inflammation, cell migration, agiogenesis, matrix synthesis, collagen deposition and re-epithelization. Vrana with Nija Kaarana, Parshwa Sthana, Dushta Avastha, Chathurasra Akruthi, Dirgakaalanubandhi, Kruchra Sadhya, Pancha Lakshanas of Vedana, Akruthi, Gandha, Vrana and Srava having Pitta and Vata predominant features. Virechana helped to detoxify the body making Dosha in normal status, followed by Jalauka Avacharana in ulcer edges so that leech saliva containing Hirudin, Fibrin, Hirustasin, Bdellins, Hyaluronidase, Tryptase inhibitor, Eglins, Factors Xa inhibitor, Carboxypeptidase A, Acetylcholine etc. which Inhibits blood coagulation by binding to thrombin and acts as thrombolytic, anti-inflammatory, vasodilator etc. Oral medication Kaisora Guggulu indicated for Vatarakta, Sarvavrana, Rasayana, Kantikaraka, skin diseases with discharge by elimination of toxins, relieving inflammation and swelling.

Triphala Gugglu is Agroushadi of Vrana with anti-inflammatory and anti-infective action of Guggulu. Triphala^[8] is Vatashamaka, Vedanasthapana, Vrana shodhana, Vrana Ropana, Shothahara, Vatanulomaka, Kledahara, deepana and Amahara properties. Gandhaka Rasayana acts as Rasayana and Agnideepaka which is essential for Amapachana and Strotoshodhana. Mahamanjistadi Kashaya is Ushna Tikshna Guna and its Rakta Shuddhikara Guna indicated for Vataraktha. Panchavalkala Kwatha Parisheka is effective in relieving the symptoms such as Srava, Daha, Gandha and Vedana. Jathyadi Ghrita^[7] contains leaves of Jati, Nimba, Patola, Katuki, Daruharidra, Haridra, Madhuka, Manjishta, Abhaya, Karanja, Sariva. Tutta, Madhuchista each 1 parts, Go Ghrita 4 part, water 16 part. Indicated for Vrana Shodhaka, Vrana Ropaka, Dushtavrana.

Conclusion

In Dushtavrana treating Systemic disease improving local circulation with combination of internal medication and local application showed significant result of ulcer healing. By applying knowledge of Shastiupakrama in Dwivrana Chikitsa of Acharya Sushruta helped Dushta Avastha of Vrana to Suddha, Ruhyamana and Roodha Vrana i.e., edges firmly adhere, no pain, no swelling, leaving cicatrices of the same line with surrounding skin.

References

1. Agnivesha, Charaka Samhitha Varanasi, Chaukhambha Sanskrit Sansthan, 2001, Chi.25/10, 738pp, pg.no.592
2. Sushruta, Sushruta Samhita, Varanasi, Chaukhamba Orientalia, 2002, Chi.1/3, 824pp, pg.no.396
3. Ashtanga Hridaya Uttratantra edited by Sreekantha Murthy Chaukambha Sanskrit Pratishthan, Delhi, 2003: Verse 25/2 ,Pp 1295, Pg 1068
4. Sushruta, Sushruta Samhita, Varanasi, Chaukhamba Orientalia, 2002, Chi 1/8 Pp 824, Pg no 397.
5. Clinical Surgical Case Manual, Kanchana Sundaramurthy, Jaypee Brothers Medical Publishers (P) LTD, First Edition; New Delhi,2009; chapter 26, Pp.849, Pg no. 150-153.

6. Somen Das, A manual on clinical Surgery Published by Dr S. Das, eleventh edition; Kolkata; 2015 Chapter 4, Pg no.73
7. Sarngadhara, Sarngadhara Samhita A Treatise on Ayurveda, Translated in English by Ayurveda Vidwan Prof.K.R.Srikantha Murthy, Reprint Edition 2012,Chaukhamba Orientalia, PP 335,Pg No. 109
8. L.N.Sastry, Illustrated Dravyaguna Vijana, Published by Chaukhamba Orientalia, 2012,Varanasi PP 1134,Pg No.211,222,217,454,115.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2024-07-09	2024-07-19	2024-07-29	2024-08-09	2024-08-19
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
None	Nil	Yes	13.32

Case Report

Dushta Vrana

Journal of Ayurveda and Integrated Medical Sciences

A Case Study on Dushta Vrana w.s.r to Venous Ulcer

Pachamalai R^1*

Introduction

Case History

Discussion

Conclusion

References

Case Report

Dushta Vrana

Journal of Ayurveda and Integrated Medical Sciences

A Case Study on Dushta Vrana w.s.r to Venous Ulcer

Pachamalai R1*

Introduction

Case History

Discussion

Conclusion

References

Pachamalai R^1*