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Wound healing activity of Arjuna bark powder in Dushta vrana (Non healing venous ulcers) -A Case Report

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Tukaram Sambhaji Dudhamal at Institute of Teaching & Research In Ayurveda
Tukaram Sambhaji Dudhamal
  • Institute of Teaching & Research In Ayurveda
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Abstract

A non-healing ulcer or chronic wound is defined as a wound that does not improve after four weeks or does not heal in eight weeks. These wounds include diabetic foot ulcers, venous-related ulcerations (varicose ulcers), pressure ulcers etc. Venous ulcers develop at medial part of lower leg and above the medial malleoli of foot and occur as a result of recanalization of DVT (deep vein thrombosis). These ulcers are often large in size, non-healing, tender and recurrent with secondary infection. In this case report a 65 years old male patient of non-healing multiple ulcers at left lower leg visited in OPD. Patient had complaints of severe pain, serous discharge, swelling of leg and multiple ulcers largest one ulcer (6cm x 4cm) at medial aspect of right leg. The pus culture report showed absence of microorganism (Bacteria and fungus). So this case was diagnosed as multiple varicose ulcers and was successfully treated with Arjuna bark powder (Terminalia arjuna) mixed with coconut oil. Wound was cleaned with normal saline and then applied paste of Arjuna bark powder mixed with coconut oil daily once in the morning. All wounds healed completely within one and half month of treatment without any complication. Hence this case highlighted that varicose ulcer can be treated with local application of Arjuna bark powder.
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102
Journal of Ayurvedic and Herbal Medicine 2016; 2(4): 102-103
Case Report
J. Ayu. Herb. Med.
2016; 2(4): 102-103
July- August
© 2016, All rights reserved
www. ayurvedjournal.com
*Corresponding author:
Dr. T.S. Dudhamal
Associate Professor, Department
of Shalyatantra, I.P.G.T. & R.A.,
Gujarat Ayurved University,
Jamnagar, Gujarat-361 008, India
Email:
drtsdudhamal[at]gmail.com
Wound healing activity of Arjuna bark powder in Dushta
vrana (Non healing venous ulcers) - A Case Report
T.S. Dudhamal
Associate Professor, Department of Shalyatantra, I.P.G.T. & R.A., Gujarat Ayurved University, Jamnagar, Gujarat-361
008, India
ABSTRACT
A non-healing ulcer or chronic wound is defined as a wound that does not improve after four weeks or does not heal in
eight weeks. These wounds include diabetic foot ulcers, venous-related ulcerations (varicose ulcers), pressure ulcers
etc. Venous ulcers develop at medial part of lower leg and above the medial malleoli of foot and occur as a result of
recanalization of DVT (deep vein thrombosis). These ulcers are often large in size, non-healing, tender and recurrent
with secondary infection. In this case report a 65 years old male patient of non-healing multiple ulcers at left lower leg
visited in OPD. Patient had complaints of severe pain, serous discharge, swelling of leg and multiple ulcers largest one
ulcer (6cm x 4cm) at medial aspect of right leg. The pus culture report showed absence of microorganism (Bacteria and
fungus). So this case was diagnosed as multiple varicose ulcers and was successfully treated with Arjuna bark powder
(Terminalia arjuna) mixed with coconut oil. Wound was cleaned with normal saline and then applied paste of Arjuna
bark powder mixed with coconut oil daily once in the morning. All wounds healed completely within one and half
month of treatment without any complication. Hence this case highlighted that varicose ulcer can be treated with local
application of Arjuna bark powder.
Keywords: Ayurveda, Arjuna, Terminalia arjuna, Venous ulcers, Wound.
INTRODUCTION
Management of Vrana (wounds/ulcers) has been dealt since the period of Veda to current era. Non-
healing wounds present serious problems for patients, family and clinicians. Most of the wounds are
associated with a small number of underlying disorders such as Diabetes mellitus (DM), leprosy and
peripheral vascular diseases. The vast majority of chronic wounds can be classified into three categories
i.e. venous ulcers, diabetic ulcers and pressure ulcers. [1-2] A non-healing ulcer or chronic wound is defined
as a wound that does not improve after four weeks or does not heals within eight weeks. These wounds
includes diabetic foot ulcers, venous-related ulcerations (varicose ulcers), pressure ulcers, wounds related
to metabolic disease, wounds that repeatedly break down and non-healing surgical wounds.
In developed countries, the most common chronic wounds are leg ulcers. The prevalence of varicose veins
increases with age which is in age group 55-64 (55.7%).[3] Venous ulcer commonly develops at around and
above the medial malleoli, medial aspect of lower leg because of presence of large number of perforators
which transmit pressure changes directly into superficial system. Ulcer is often large, non-healing, tender
and recurrent with secondary infection. It presents with complications of venous diseases like eczema,
ulceration, lipodermato sclerosis and venous ulcers. [4]
In this regard, Sushruta also mentioned the non-healing wounds in the similar manner and mentioned the
prognosis of that wounds.[5] The signs of Dushta Vrana (chronic wounds) mentioned in the classics are
Ativivrita (broad based), Bhairava (ugly looking), Putipuyamansa (purulent pus discharge), Gandha (foul
smell), Vedana (pain), Dirghakalanubandhi (chronic in nature). [6] Arjuna (Terminalia arjuna) is plant found
nearby river in Uttar Pradesh, Madhya Pradesh, West Bengal and south and central India. [7]
CASE REPORT
A 65 years old male patient visited outpatient department IPGT&RA Ayurved Research Hospital, Jamnagar
with multiple right lower leg ulcers at medial aspect of right leg. Patient had complaints of severe pain,
serous discharge, swelling of leg and multiple ulcers largest one ulcer (6cm x 4cm) at medial aspect of right
leg (Figure 1). Above complaints had since last 2 months and patient taken medicine and local dressing
with antiseptic solution from local doctor but did not get relief so he consulted to Ayurved hospital.
Patient’s occupation was news paper distribution by using bicycle since last ten years. Patient had
addicted to tobacco chewing daily 10-15 times. Prominent varicosity at medial side of both lower limbs
J Ayu Herb Med ǀ Vol 2 Issue 4 ǀ July- August 2016
103
was observed. Patient had no history of diabetic mellitus,
hypertension, tuberculosis, venereal diseases, bronchial asthma,
anemia, cardiac diseases and any other major illness. He did not
reported any surgical history in past. Routine blood investigations for
complete blood count (CBC), blood sugar level and serum creatnine
were normal except increased white blood corpuscles (WBC) and
neutophils. The pus culture report was negative for micro-organism
both gram positive and gram negative and for fungal also. So this case
was diagnosed as multiple venous ulcers and admitted in Shalya male
ward for further management. Wound cleaned with normal saline and
then applied Arjun (Terminalia arjuna) bark powder mixed with
coconut oil daily once in the morning. After seven days patient
discharge from hospital and called daily for dressing on OPD basis.
Assessment of wound was done on the basis symptomatic relief in sign
and symptoms of wound and photographed by weekly interval up to
complete wound healing.
RESULT AND DISCUSSION
In first consultation patient had severe pain, mild swelling, serous
discharge and large wound at medial malleolus. As wound was big and
multiple sufficient amount of prepared Arjuna bark powder and
coconut oil was applied on all wounds (Figure-2) and bandaged. The
symptoms like pain, swelling and discharge were markedly reduced
and wound became clean with mild slough after 7 days. Treatment
continued daily on OPD basis and weekly assessed where wound base
became clean due to increased circulation and neo-vascularisation
after 15 days (Figure-3). Day by day wound size reduced due to
epithelisation and wound contraction where wound remained half of
the size after one month. Those multiple non healing venous ulcers at
medial aspect of right lower leg healed completely after one and half
months without complication (Figure-4).
According to Sushruta, among 60 measures of comprehensive wound
management, Kalka (paste) is indicated in cases of chronic wounds
which are reluctant to heal. [8] The paste performs both the functions
of cleansing as well as healing of wounds. Previous reports shown that
coconut oil has the property of antiulcer so it may accelerate the action
of healing in this case.[9] Arjuna has wound debridement activity and it
is essential in initial stage as wound has slough, oedema and discharge.
Vagbhata mentioned that Arjuna is to be topically applied in the
treatment of wounds, hemorrhages and ulcers. Drug has neo-
vascularisation property (improve circulation) which plays important
role in cases of varicose ulcer as there is hampered blood circulation.
Wound was quite big so in surgery the skin grafting is advisable which
is expensive and sometimes not acceptable due to old age. The take-
away message from this case report is non-healing varicose ulcer can
be treated with Ayurveda herbal powder of Arjuna (Terminalia arjuna).
CONCLUSION
This single case study highlighted that paste of Arjuna and coconut oil
has healing potential in management of venous ulcers which need
further study in more number of patients.
Acknowledgement
Prof. P.K. Prajapati, Director, IPGT&RA, Gujarat Ayurved University,
Jamnagar.
REFERENCES
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7. https://en.wikipedia.org/wiki/Terminalia_arjuna#/media/File:Terminalia_
arjuna-1.jpg Accessed on 30.05.2016.
8. Shastri A. Sushruta Samhita with Ayurved Tatva Sandipika Commentary,
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1/55.
9. Srivasta va P, Durgaprasad S. Burn wound healing property of Cocos
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HOW TO CITE THIS ARTICLE
Dudhamal TS. Wound healing activity of Arjuna bark powder in Dushta vrana
(Non healing venous ulcers) - A Case Report. J Ayu Herb Med 2016;2(4):102-
103.
Figure 1: Varicose ulcer (6cm x
4cm) at medial aspect of right leg
Figure 2: Applied Arjuna bark
powder and coconut oil on wound
Figure 3: Wound status after 15
days
Figure 4: Healed scar after one and
half month
... Keeping this view the concentrate efforts are needed to make the available compound more potent against disease and safer to environment by way of improved formulations [26]. As per WHO reported about 80% of world population relayed on traditional medicine in India [1,2,21] . The main Indian traditional system of medicine is primarily plant based system [3] . ...
... Bark paste of T. Arjuna is applied for bone bandage in fractures. T. Arjuna bark powder is effective in tubercular cough by stopping blood in cough and healing the ruptured arteries in lungs [9,20,21]. T.Arjuna act as diuretic helps to flush out the small stones formed in the kidneys. T.Arjuna reversing dysfunction an early event of antherosclerosis through oxidative stress process [16]. ...
... T.Arjuna reversing dysfunction an early event of antherosclerosis through oxidative stress process [16]. Juice of leaves is used in ear ache (otalgia) and Leaves also used to cure ulcers and sores externally [21]. ...
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... Several bioactive compounds such as arjunolic acid (King et al., 1954;Tsuyuki et al. 1979Tsuyuki et al. , 1979bSingh et al., 2002a;, arjunic acid (Row et al., 1970b;Singh et al., 2002a;, arjungenin (Honda et al., 1976;Tsuyuki et al., 1979;Singh et al., 2002a;, gallic acid (Singh et al., 2016), ellagic acid (Row et al., 1970a), β-sitosterol (Row et al., 1970a;Wang et al., 2010a), terminoic acid (Ahmad et al., 1983), casuarinin (Lin et al., 1996;Kuo et al., 2005) were isolated and characterized from the bark of T. arjuna. The bark of T. arjuna (BTA) showed various medicinal properties such as hypocholesterolemic (Ram et al., 1997), anti-cancer (Scassellati-Sforzolini et al., 1999;Kaur et al., 2002;Kuo et al., 2005;Saxena et al., 2007), antimicrobial (Rahman and Sultana, 2012;Mandal et al., 2013;Gupta and Kumar 2017;Kumar et al., 2018;Bano et al., 2020;Kumar et al., 2021), anti-viral (Cheng et al., 2002), antioxidant (Sultana et al., 2007;Shastry Viswanatha et al., 2010;Shahriar et al., 2012;Mandal et al., 2013;Kumar et al., 2016;Kumar et al. 2018;Kumar et al. 2021), hepatoprotective (Manna et al., 2006;Haidry and Malik, 2014;Doorika and Ananthi, 2012;Toppo et al., 2018), anti-allergic, anti-anaphylactic activity (Prasad et al., 2004); anti-diabetic (Manonmani et al., 2002;Raghavan et al., 2006;Borde et al., 2018;Shengule et al., 2018a, b), and wound healing effects (Chaudhari and Mengi, 2006;Dudhamal, 2016). BTA was also used in the food industry as a source of natural colorant (Bhuyan et Sinha et al., 2016;Rangi and Jajpura, 2017) and food preservatives (Kalem et al., 2017;Birla et al., 2019). ...
... Chaudhari and Mengi (2006) reported significantly high tensile strength of the incision wounds and enhanced epithelialization of the excision wounds by a tannin-rich fraction of T. arjuna as compared with the control. A mixture of BTA and coconut oil was found to be potentially effective against chronic wounds (Dudhamal, 2016). However, further studies based on in vivo studies with different extracts/phytocompounds of BTA are required to validate its wound healing potential. ...
Therapeutic potential and industrial applications of Terminalia arjuna bark
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Ethnopharmacological relevance: Terminalia arjuna (Roxb. ex DC.) Wight & Arnot (Combretaceae) is one of the most frequently used medicinal trees in Indian traditional medicinal systems. It is used for the treatment of a variety of diseases including cardiovascular disorders. Aim of the study: The purpose of this review was to provide a comprehensive overview of the phytochemistry, medicinal uses, toxicity, and industrial applications of T. arjuna bark (BTA), as well as to identify gaps in research and applications of this important tree. It also aimed to analyze trends and future research paths to utilize the full potential of this tree. Materials and methods: Extensive bibliographic research on the T. arjuna tree was carried out using scientific research engines and databases such as Google Scholar, PubMed, and Web of Science, covering all relevant English-language articles. The database "World Flora Online (WFO)" (http://www.worldfloraonline.org) was used to confirm plant taxonomy. Results: To date, BTA has been traditionally employed for several disorders such as snakebites, scorpion stings, gleets, earaches, dysentery, sexual disorders, and urinary tract infections along with the cardioprotective activity. About 38 phytocompounds were identified from BTA and were classified as triterpenoids, tannins, flavonoids, and glycosides. A wide range of in vitro and in vivo pharmacological effects of BTA were reported such as anti-cancer, antimicrobial, antiviral, anti-inflammatory, antioxidant, hepatoprotective, anti-allergic, anti-diabetic, and wound healing activities. The oral administration of BTA (500 mg/kg) per day did not result in any toxicity in humans. The in vivo acute and sub-acute toxicity analysis of the methanol extract of BTA and one of its major compounds, 7-methyl gallate, did not produce any adverse effects up to a dose of 1000 mg/kg. Conclusions: This comprehensive review highlights various aspects of traditional knowledge, phytochemicals, and pharmacological significance of BTA. The review covered safety information on employing BTA in pharmaceutical dosage forms. Despite its long history of medicinal benefit, more studies are needed to understand the molecular mechanisms, structure-activity relationship, and potential synergistic and antagonistic effects of its phytocompounds, drug administration, drug-drug interactions, and toxicological effects.
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... The activity of tincture made from flowering tops and fresh leaves was more effective after oral administration than the topical administration of tincture of Calendula flowers and leaves [40]. [42]. ...
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Being an ancient system of medicine, Unani system is diagnosing and treating human ailments since antiquity. This system is serving mankind since the time when there were no sophisticated equipped tools of diagnosis. Ancient Unani scholars have described diseases on the basis of their particular and peculiar sign and symptoms ((aḥwāl) aiding in quick diagnosis and assistance. Irony, with an age of 4000 years, still anemia is the most common nutritional deficiency disorder in the world, especially in developing countries. Although exact description of iron deficiency anemia is not available in ancient Unani literature, but Razi (Razes, 841-926 AD) and Abul Hasan Ahmad Bin Mohammad Tabri (10th century AD) have mentioned that sū'-i-mijāz kabid bārid-o-raṭab (Deranged cold and wet temperament), leads to the development of features of iron deficiency anemia, which they have described as sū'al-qinya (Kantoori, 1303; Tabri, 1995) that has been used as its synonym. Great Unani scholars had mentioned some aḥwāl (sign and symptoms) related to this disease. They have given detailed description and explanation about these aḥwāl; and at what stage of the disease, these will accompany. This study was to validate the facts in classical Unani literature described as aḥwāl-i-sū'al-qinya.
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A detailed review of ancient texts of Ayurveda connotes tremendous information on wound healing potentials of herbs being utilized by their different forms. This brings curiosity to learn more about the creative applications of herbs in various types of wounds. Probably this could be one among the several reasons which honors Sushruta, an Ancient Indian Surgeon as Father of Surgery. Wound dressing in various systems were compared not only on the basis of the rate of granulation tissue formed or the rate of wound healing but, also on the cost and duration of hospital stay of the patient which was considered as a measure of the morbidity of the patient. As per Ayurvedic texts, Wounds, Ulcers, Burns and Incision all are grouped under one term as ‘Vrana’, a defect in skin or mucous membrane being common in all of them. On the basis of stages of pathogenesis Vrana or ulcer has been divided as Dushta Vrana (Chronic / non healing / infected ulcer), Shuddhavrana (Healthy wound), Ruhyamana Vrana, Rudha Vrana (healed Vrana). Sushruta indicates eight pearls for Infective ulcer, these eight being the eight forms of medical therapeutics used locally to cleanse the ulcer and bring to healthy state.
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The development of new therapies for treatment of chronic wounds has not matched the availability of treatment modalities forecast by the pharmaceutical industry. This is attributable in large part to difficulties encountered in clinical trials as well as in isolating study design variables. Our hypothesis attempts to address this shortcoming. We are proposing that chronic wound pathogenesis is based on 3 fundamental factors: the cellular and systemic changes of aging, repeated ischemia-reperfusion injury, and bacterial colonization with resulting inflammatory host response. The derivation of this hypothesis is founded on the observation that the 3 primary categories of chronic wounds--pressure ulcers, diabetic ulcers, and venous ulcers, which are the overwhelming majority of chronic wounds--have these common causative factors. Our hypothesis incorporates major implications for treatment modalities based on these factors. Addressing the first issue, the cellular and systemic changes of aging, Regranex (Ortho-McNeil Pharmaceutical, Inc, Raritan, NJ), a platelet-derived growth factor drug, has shown great promise. Additional treatment modalities that address the second and third problems, repeated ischemia-reperfusion injury and bacterial colonization, include vacuum-assisted closure, warming of local tissue, and water irrigation using pulsed lavage. Additionally, treatment comprising a combination of these approaches has demonstrated success.
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Sushruta Samhita with Ayurved Tatva Sandipika Commentary, Sutrasthana.Varanasi: Chowkhambha Sanskrit Sansthan
  • Jan 2009
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Shastri A. Sushruta Samhita with Ayurved Tatva Sandipika Commentary, Sutrasthana.Varanasi: Chowkhambha Sanskrit Sansthan; 2009. 98 Su.Su.23/7.
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Williams NS, Christopher JKB, O'Connell PR. Baily and love's Short Practice of surgery. chapter 57 venous disorders 25 th ed. UK Hodder Arnold part of Hachette. 2008. pp-901.