Featured Case

BIOMEDICAL DIAGNOSIS: Varicose ulcer

ABOUT THE DISEASE:

Venous ulcer is a severe clinical manifestation of chronic venous insufficiency (CVI). It is responsible for about 70% of chronic ulcers of the lower limbs, i.e. those which do not heal within 6 weeks. Other causes of chronic ulcers include arterial insufficiency, diabetes mellitus, rheumatoid arthritis, trauma, chronic osteomyelitis, sickle cell disease, vasculitis, and skin tumor. Nearly 3.5% of patients do not have the cause of ulceration identified and in some cases the cause is multifactorial.

“Varicose ulcer”, “gravitational ulcer”, “stasis ulcer” and “hypostatic ulcer” have been used as synonyms for venous ulcer. It is not recommended that these terms be used as the commonly agreed upon term is “venous ulcer”.

The venous ulcer is an irregularly shaped wound, initially superficial but with the potential to deepen, with well-defined borders. The surrounding skin is erythematous or hyperpigmented with variable degrees of induration (acute or chronic lipodermosclerosis). Yellowish exudate is usually observed. The size and site of ulcers vary, but they usually occur in the distal portion of the lower limbs. Varicose veins and ankle oedema are common. Venous ulcer is typically not painful. When the patients have severe pain, one should consider the possibility of another cause of the ulceration, such as arterial disease`

Diagnosis: Diagnosis is based on classical clinical presentation of venous ulcer and on supporting examinations. Non-invasive examinations such as Doppler, plethysmography, and duplex scanning are used to characterize venous abnormalities.

In this case report, a 63-year-old male patient had a history of varicose vein since many years. Now he was suffering from a non-healing wound in the lateral aspect of heel with severe pain in the left leg in the last 3 years. Based on the medical history and clinical evaluation, this was diagnosed as Varicose ulcer.

Image 1. The wound in the left lateral heel taken during Jalaukavacaranam added below

Treatment: The target of treatment is to heal the lesion and to avoid a recurrence. Wound care is very important. Surgical removal of fibrin and devitalized tissue from the base and the borders of the ulcer is needed. This procedure reduces the risk of infection and favours healing. Afterwards the wound must be kept humid by using occlusive dressing, for instance hydrocolloid dressings, hydro gels and alginate, which favour autolytic debridement. If there is a suspicion of infection, that has to be addressed. The patient did regular wound dressing with medicated strips. This gave only temporary relief, and the complaints would again recur.

Prognosis: The main complications of chronic venous ulcers are osteomyelitis and more rarely neoplastic transformation, i.e. squamous cell carcinoma (SCC). Leg ulcers of atypical presentation (elevated and everted boarders, with excessive production of exudate and necrotizing tissue) and those that fail to heal can acquire a malignant status. In this patient, there is a long history of varicose vein and varicose ulcer since 3 years, that did not yield a satisfactory outcome with conventional medicines.

Reference:  

Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Luciana P Fernandes Abbade , Sidnei Lastória. Int J Dermatol 2005 Jun;44(6):449-56.  doi: 10.1111/j.1365-4632.2004.02456.x

Image 1. The wound in the left lateral heel taken during Jalaukavacaranam

AYURVEDA DIAGNOSIS: Dusta vrana

ABOUT THE DISEASE:

Ayurveda Diagnosis: Dusta Vrana

About the Disease

The definition of Vrana is:

व्रण गात्र विचूर्णने व्रणयति इति व्रणह….(AH.Utt.25.22)

There is a destruction, break, rupture or discontinuity in the body tissue, it is called as Vrana.

वृणोति यस्मात् रूढे'अपि व्रनवस्तु न नश्यति ।आदेह धारणात्तस्मत्व्रणैत्युच्च्यते ॥

Susruta explains Vrana as that which retains the scar even after complete healing of the wound, and the imprint remains the entire life. (Su.Ci.1.6)

दोषैरधिष्ठितो दुष्टः…..

When it becomes the seat of the vitiated dosa then it is called as Dushta Vrana.

In Dushta Vrana, there is severe pain, profuse discharge having putrified smell, and irregular base and margin.

पूतिगन्धान् विवर्णाञ्च बहुस्रावान्महारुजः॥८३॥

Dushta Vrana is difficult to heal and heals very slowly in spite of the best efforts by Cikitsa Chatuspada.

Lakshanas of Dushta Vrana 

तत्रातिसंवृतोऽतिविवृतोऽतिकठिनोऽतिमृदुरुत्सन्नोऽवसन्नोऽतिशीतोऽत्युष्णः
नगन्धात्यर्थदाहपाकरागवेदनावानिति पित्तेन, शेषाः कफेन; उन्मार्गी मुखात् मुखान्तरवान्, उत्सङ्गः कोटरः’ इति चक्रः; कृष्णरक्तपीतशुक्लादीनांवर्णानामन्यतमवर्णो भैरवः पूतिपूयमांससिरास्नायुप्रभृतिभिः पूर्णःपूतिपूयास्राव्युन्मार्ग्युत्सङ्ग्यमनोज्ञदर्शनगन्धोऽत्यर्थंवेदनावान्दाहपाकरागकण्डूशोफपिडकोपद्रुतोऽत्यर्थं दुष्टशोणितास्रावी दीर्घकालानुबन्धी चेतिदुष्टव्रणलिङ्गानि | (Su.Su 22/7)

Management of Vrana 

Treatment varies depending on the type of vrana and the management is given till the complete removal of scar tissue. In the treatment of nija vrana, i.e., those ulcers which recur due to aggravation of doshas, Sushruta explained the 60 upakrama, Charaka explained 36 upakrama and Vagbhata mentioned 26 upakramas. Seven modalities of Vrana Vimlapana, Avasecana, Upanaha, Patana kriya, Shodhana, Ropana, Vaikritapaham are explained by Acarya Sushruta. Sapta upkrama are a principal line of treatment which is explained in detail as Shashti upakrama.

A 63-year-old male patient presented with a chronic non-healing varicose ulcer in the lateral aspect of the left heel with severe pain and oedema for 3 years. The onset of the wound was before 3 years, which gradually increased in size, depth and intensity of pain. Based on the clinical presentation and evaluation, the ayurvedic diagnosis was made as Dusta vrana.

The patient opted for Ayurvedic treatment, after trying conventional management and did not et satisfactory outcomes.

Treatment rationale: As the doshas are deep-seated, to eliminate them completely jalaukavacarana was done. As this condition has been correlated to dusta vrana, initiating the blood purification and improving the circulation was the aim of treatment.
Kaishora guggulu was given to heal the dusta vrana. Sudarshanam Tab is pittahara, cures the infection and acts as an anti-inflammatory agent. Avipatti curnam is pittahara, initiates mild nitya virecanam to correct the bowels. Tab Radix was prescribed to increase blood circulation.
Amrita guggulu was prescribed to heal vrana as an anti-inflammatory agent, and also to control infection.

Reference

1. Vagabhata, Astangasangraha, Atridev Gupta,Krishnadas Academy, Varanasi UP Ed., 1993; 846:225.35.
2. Madhavakara, Madhavanidan With MadhukoshaCommentary By Vijayarakshita And Srikant Data,Vinal Madhukar Hindi Commentary By Dr.Brahmanand Tripathi Choukhamba SanskritSansthan, Varanasi, 520:

Traditional and contemporary appraisal of dushta vrana w.s.r to venous ulcers. Available from: https://www.researchgate.net/publication/324156242_traditional_and_contemporary_appraisal_of_dushta_vrana_wsr_to_venous_ulcers#fulltextfilecontent[accessed apr 01 2023].

OUTCOME MEASURES

A 63-year-old male patient had a history of varicose veins since many years. Now he was suffering from a non-healing wound in the lateral aspect of the heel with severe pain in the left leg past  3 years. This was diagnosed as  Varicose ulcer. Wound dressing with medicated strips used to be done. This gave only temporary relief, and the complaints would again recur. After 3 years in 2022, the patient consulted Dr Soumya, who diagnosed this condition as dushta vrana. The line of treatment followed was jalaukavacarana for rakta shodhana, and inner medications for pacifying the pitta and healing the vrana.

Subjective parameters: A significant reduction in pain was observed after the first and second sitting of Jalaukavacarana. In the third follow-up after 4 months of Ayurvedic treatment, the wound healed completely and there was no pain and oedema. The patient is in remission.

Assessment criteria: Images taken pre and post-ayurvedic treatment were the assessment criteria.

Image 1. An image of the wound in the left leg before and after treatment added below

I

Disease-modifying effect: Patient is in remission