International Journal of Innovative Pharmaceutical ... ARTICLE Asutkar et.al / IJIPSR / 4 (1), 2016,...

REVIEW ARTICLE Asutkar et.al / IJIPSR / 4 (1), 2016, 15-28

Department of Ayurveda ISSN (online) 2347-2154

Available online : www.ijipsr.com January Issue 15

A CONCEPTUAL OVERVIEW ON INFLAMMATORY

MARKERS IN PATIENTS OF CELLULITIS (VRANASHOPHA)

AND ITS MANAGEMENT WITH LEECH THERAPY

1Asutkar Sheetal G*, 2Varshney Subhash Chandra

1Professor, Dept of Shalyatantra, Shri Ayurved College, Nagpur (Maharashtra), INDIA

2MD PhD, Professor & HOD, Dept of Shalyatantra , MGAC, Sawangi (Meghe) Wardha, INDIA

Corresponding Author:

Asutkar Sheetal G

Professor, Dept of Shalyatantra,

Shri Ayurved College,

Nagpur (Maharashtra), INDIA

E-mail: [email protected]

Phone: +91- 9766811974

International Journal of Innovative

Pharmaceutical Sciences and Research www.ijipsr.com

Abstract

Vrana is the most important disease in the field of Shalya tantra and term ‘Shopha’ refers to

swelling disorders. Vranashopha is the preliminary stage of Nija Vrana. Sthanika Shopha is termed as Vranashopha. According to the signs and symptoms of Vranashopha it can be correlated with Cellulitis. Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial

skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender. The Samprapti of Vranashopha is characterized by Rakta dushti and localized accumulation of

dushita Rakta. In Sushruta Samhita, the procedure of Raktamokshana has been hailed as one of the most effective therapies of Vranashopha. In Ayurvedic literature, Acharya Sushruta has mentioned that bloodletting is an ideal treatment in the treatment of many conditions. Leech

Therapy (Jalloukavacharan) is a well known and admired therapy in the treatment of Cellulitis (Vranashopha).

Keywords: Jalloukavacharan, Vranashopha, Samprapti, Cellulitis.

mailto:[email protected]




INTRODUCTION

The aim of all Medical Sciences is to provide better health to every human being so as to have a

disease free life. Ayurvedic medical science with its holistic approach has to play a vital role in

this direction. Numerous therapeutic modalities have been advocated by our Acharyas in the

management of each and every disease. But their efficacy needs re-establishment by the means of

thorough and intensive researches.

Vrana is the most important disease in the field of Shalya tantra. All the types of Shalya and

Shastra karma ultimately result into Vrana formation [1]. Vranashopha i.e. Inflammation is a

symptom complex and this condition exists since time immemorial. Centuries of immense

observations and tireless efforts have revolutionized the treatment approach in this condition [2].

Vranashopha is the preliminary stage of Nija Vrana. The term Shopha refers to swelling

disorders. Sthanika Shopha is termed as Vranashopha. Vedana(pain), Utseda(swelling), Sthanika

Ushma(raised local temp) Vruddhi(increase in size)and Vivarnata(change in colour of skin)

characterize Vranashopha. Epidemiological studies reveal that the incidence of Vranashopha is

almost the same for both sexes and for all age groups [3].

According to the signs and symptoms of Vranashopha, it can be correlated with Cellulitis.

Cellulitis (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. Cellulitis

appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts

of the body. Skin on lower legs is most commonly affected, though cellulitis can occur anywhere

on your body or face. Cellulitis might affect only your skin's surface. Left untreated, the spreading

infection can rapidly turn life-threatening. It's important to seek immediate medical attention if

cellulites symptoms occur. Possible signs and symptoms of cellulitis, which usually occur,

include: Red area of skin that tends to expand, Swelling, Tenderness, Pain, Warmth, Fever, Red

spots, Blisters, Skin dimpling [4]. It can be correlated to Vranashopha according to Ayurveda.

Jalloukavacharan Therapy

The Samprapti of Vranashopha is characterized by Rakta dusti and localized accumulation of

dushita Rakta [5]. In Sushruta Samhita, the procedure of Raktamokshana has been hailed as one

of the most effective therapies of Vranashopha [6]. Raktamokshana is considered as half of the

treatment in Shalya tantra [7]. Among various methods for Blood Letting, Jalloukavacharana is

described as the supreme therapy because of its safety and high efficacy in the disorders involving

the vitiation of blood. It is safely indicated even for the king, rich, old, fearful, weak, women and




the people of tender nature [8]. Jalloukavacharana procedure by its mechanism arrests the

progress of Vranashopha and removes the vitiated Rakta from the disease site [9]. The first

description of leech therapy, classified as Blood Letting, was found in the text of Sushruta

Samhita (dating 800 B.C.) written by Acharya Sushruta, who was also considered the father of

surgery. Diseases where leech therapy was indicated were skin diseases, sciatica, and

musculoskeletal pains etc. [10]. Medicinal leeches have been found to secrete saliva containing

about 60 different proteins. These achieve a wide variety of goals useful to the leech as it feeds,

helping to keep the blood in liquid form and increasing blood flow in the affected area. Several of

these secreted proteins serve as anticoagulants (such as hirudin), platelet aggregation inhibitors

(most notably apyrase, collagenase, and calin), vasodilators, and proteinase inhibitors. It is also

thought that the saliva contains an anesthetic, as leech bites are generally not painful and enzymes

containing analgesic and anti inflammatory properties. Medicinal leeches are any of several

species of leeches, but most commonly Hirudo medicinal is the European medicinal leech [11].

Hence Leech Therapy has been established as one of the most efficacious therapies in the

management of various skin conditions like psoriasis, Eczema, cysts, abscess, Cellulitis etc. [12].

Clinical Approach on Significance of Raktamokshana (bloodletting)

In Ayurvedic literature, Acharya Sushruta has mentioned that bloodletting is an ideal

treatment in the treatment of many conditions.

A. According to Acharya Sushruta, bloodletting (Raktamokshana) cures skin diseases,

granthi (cysts), shopha,(inflammation),raktapradoshaja vikara(bleeding disorders) [13].

B. As Basti given in adequate dose and to the indicated person is of prime importance in

Ayurvedic medicine, bloodletting is of utmost importance and is termed ‘half of the

treatment. In the treatment of visarpa, it is said that Raktamokshana alone is equivalent to

all the other procedures [14].

C. Snehana, Swedana, Shamana, lepana etc. procedures does not yield quick results as

Raktamokshana does [15].

D. When Raktamokshana is done in proper way and quantity the person with shuddha (pure)

rakta gets prasanna varna (fresh complexion), his indriyas (sense organs) grasp their

subjects attentively, the digestion is improved. The Bala (strength) and Sukha (happiness)

are increased and mana santosh(self satisfaction) is achieved [16].

E. Aacharya Vagbhata has mentioned that bloodletting is useful to reduce redness and pain of

skin conditions [17].

https://en.wikipedia.org/wiki/Bloodletting

https://en.wikipedia.org/wiki/Sushruta

https://en.wikipedia.org/wiki/Anticoagulant

https://en.wikipedia.org/wiki/Hirudin

https://en.wikipedia.org/wiki/Platelet_aggregation#Adhesion_and_aggregation

https://en.wikipedia.org/wiki/Apyrase

https://en.wikipedia.org/wiki/Collagenase

https://en.wikipedia.org/wiki/Vasodilation

https://en.wikipedia.org/wiki/Protease

https://en.wikipedia.org/wiki/Anesthetic

https://en.wikipedia.org/wiki/Species

https://en.wikipedia.org/wiki/Leeches




F. Aacharya Sushruta has mentioned Avsechana karma (Raktamokshana) as second most

treatment in the treatment of Vranashotha [18].

Inflammatory markers

The Erythrocyte Sedimentation Rate (ESR),C-reactive Protein (CRP) Red Blood Cell (RBC)

aggregation and plasma viscosity are blood tests that detect inflammation and these are certain

useful blood tests to help diagnose and monitor the activity of certain diseases like diabetes,

osteoarthritis, Alzheimer’s disease Myocardial Infarction, Osteoarthritis, Diabetes Mellitus,

Cellulitis etc.

It was revealed from numerous researches that CRP(C - reactive protein) and ESR (Erythrocyte

Sedimentation Rate) are important inflammatory markers and found to increase in various

conditions like osteoarthritis, Alzheimer’s disease, Myocardial Infarction, Osteoarthritis,

dermatitis, Cellulitis etc. Leech Therapy has been proved as an important anti inflammatory

therapy by certain variety of researches worldwide [19-34].

Rationale of Leech Therapy Application

There is prevalence of 24.6/1000 persons of Cellulitis per year with higher incidence in males

aged 45 to 65 [35]. Available treatment forms are antibiotics, narcotics, local steroid application,

elevation of the affected part, and critical care in patients of impending sepsis in primary cases.

Presently, no formal practice guidelines or consensus statements exist for management of first or

subsequent episodes of cellulitis, nor there is good evidence on prognosis [36] along with high

recurrence rate.. Remarkably, cellulitis recurs among 15-29% of patients within 3 years and 50%

of patients sometime later in life [37]. Leech Therapy (Jalloukavacharan) is a well known and

admired therapy in the treatment of Cellulitis (Vranashopha).

REVIEW OF LITERATURE

A. Ayurvedic Treatise

a) Charaka Samhita: In 18th chapter ‘Trishothiya Adhyaya’ of Sutra sthana, and in 12th

chapter ‘Shwayathu Chikitsa’ of Chikitsa sthana [38]

b) Sushruta Samhita: In Sutra sthana 17th chapter, ‘Aamapakwashniya Adhyaya’, and is

also explained in 23rd chapter ‘Shophanam Chikitsa’ of Chikitsa sthana [39]

c) Hareeta Samhita: In Tritiya sthana, 25th chapter explanation about Shotha vyadhi is

available [40]




d) Bhela Samhita: In Chikitsa sthana, ‘Shwayathu chikitsa’ 17th chapter is dedicated for

explaination of Shopha [41]

e) Astanga Hradaya: In Nidana sthana 13th adhyaya, ‘Panduroga Shopha Visarpa Nidana’

the details about VranaShopha have been mentioned. 17th adhyaya of Chikitsa sthana

named is as ‘Shwayathu chikitsa [42]

f) Astanga Samgraha: Nidana sthana 13th adhyaya, ‘Panduroga Shopha Visarpa Nidana’

contains details about VranaShopha [43]

g) Bhavaprakasha: VranaShopha is explained in 42nd chapter of Madhyama Khanda,

‘Shophadhikara adhyaya [44]

h) Sharangadhara Samhita: Prathama Khanda 7th chapter, ‘Rogaganana adhyaya’,

description of Vranashotha is available [45]

i) Madhava Nidana: 41st chapter is titled as ‘VranaShopha Nidana’ and indetail description

is available [46]

j) Kashyapa Samhita: In the Chikitsa sthana 14th chapter and Khila sthana 17th chapter

detail explaination is available [47]

k) Yoga Ratnakara: VranaShopha is described in Poorvaradha ‘Shopha Nidana Prakarana’.

Also different formulations are mentioned [48]

l) Bhaishajya Ratnavali: 42nd chapter is for the explaination and treatment of Shopha in

‘Shopha roga chikitsa Prakarana [49]

m) Chakradatta: In 39th adhyaya, Shopha chikitsa description regarding treatment of Shopha

is found [50]

n) Vangasena: In ‘VranaShophadikar Adhyaya’, description of Lakshana, and Chikitsa of

VranaShopha is found.[51]

B. Disease Review: Vranashopha

Granthi(tumor),Vidradhi(abscess),Alaji(kind of skin disease),and such other diseases of many

shapes generally arise with shopha (swelling/oedema).

Apart from this swelling there is another kind of swelling with different features, which is a thick

elevated mass, even or uneven, residing in the skin and muscles, having accumulation of Doshas

and arising in any part of the body (localized) called as Vranhopha (inflammatory swelling) [52].




Vranashopha Symptoms

Guruta (Heaviness in the affected part), Utsedha (Swelling), Asthirta (instability), Ushnata(Local

Warmth), sira roga(Dilatation of vessels),and Vaivarnya (discoloration of overlying skin) [53].

Vranashotha Avastha (Stages)

Aamavastha

Mild pain, mild rise in temperature, mild and immovable swelling,(vatdoshadhikya)

Pachyamanavastha

Pain as if pricking or bitten by ants, or pain like cutting, burning locally and all over the body,

swelling resembles the bag of air, patient doesn’t find comfort on sitting or lying down, change in

skin colour, increase in swelling, fever, thirst, loss of appetite(Pittadoshadhikya)

Pakwavastha

Pain subsides, appearance of wrinkles, cracking of skin, itching, subsiding of complications

(Kaphadoshadhikya)

Vranashopha Treatment

First Vimlapana (softening by kneading with fingers),second Avasechana (Bloodletting), Third

Upanaha (Warm poultices),Fourth Patana (Incising),Fifth Shodhana(Cleaning),Sixth Ropana

(Healing),and seventh Vaikrutapaham (removing off the abnormalities), these are the seven

successive treatments to be followed for Vranashotha (swelling leading to an ulcer) [54].

C. Review of Leech Therapy

The first description of leech therapy, classified as bloodletting, was found in the text of Sushruta

samhita (dating 800 B.C.) written by Acharya Sushruta, who was also considered the father of

surgery.

He described 12 types of leeches (6 poisonous and 6 non-poisonous). Diseases where leech

therapy was indicated were skin diseases, sciatica, and musculoskeletal pains [55].

A recorded use of leeches in medicine was also found during 200 B.C. by the Greek physician

Nicander in Colophon. Medical use of leeches was discussed by Avicenna in The Canon of

Medicine (1020s) and by Abd-el-latif al-Baghdadi in the 12th century.

The use of leeches began to become less widespread towards the end of the 19th century [56].

Jalloukavacharana has been an established therapy of Raktamokshana by Anushastras, others

being Ghatiyantra,, Shringa karma and Alabu Karma.[57].

https://en.wikipedia.org/wiki/Bloodletting

https://en.wikipedia.org/wiki/Sushruta

https://en.wikipedia.org/wiki/Nicander

https://en.wikipedia.org/wiki/Colophon_(city)

https://en.wikipedia.org/wiki/Avicenna

https://en.wikipedia.org/wiki/The_Canon_of_Medicine

https://en.wikipedia.org/wiki/The_Canon_of_Medicine

https://en.wikipedia.org/wiki/Abd_al-Latif_al-Baghdadi_(medieval_writer)




It is said that Raktamokshana should be done as a treatment in all those patients in whom

Snigdha, ruksha (oily and dry Therapy) or Shit and Ushna (Cold and Hot Therapy) couldn’t

render expected Results [58].

Leeches Description

Kingdom: Animals

Phylum: Annelida

Class: Clitellata

Order: Hirudinea

Family: Hirudinadae

Genus: Hirudo

Species: H.Medicinalis,H.Manillensis

There are many other species of leeches in medicinal use. In Asia H. Manillensis is used for

treatment and in Europe H.Medicinalis is used for treatment. Along with this other species like

H.Verbana, H.Orientalis are also used for treatment purpose.

Indications for Raktamokshana [59]

Vranashopha( Cellulitis)

Kushtha (Skin Diseases),

Visarpa (Erysipelas)

Pidaka (Skin eruptions)

Raktapitta(Bleeding disorders)

Gudapaka(Proctitis)

Pleeha(Splenomegaly)

Vatarakta(Gout)

Arsha(Hemorhoids)

Vidradhi(Abscess)

Arbooda(tumor)

Shwitra(Leucoderma)

Dadru(ring worm) etc

Types of Jalloukas (Leeches) [60]

I. Savisha(Poisonous) 6 in number

II. Nirvisha(non poisonous) 6 in number




Savisha(Poisonous) Jalloukas are not indicated to treat the patients.

Complications of Jalloukavacharan (Leech Therapy)

Shotha (swelling),Kandu (Severe Itching), Murcha (Shock),Jwara (fever), Daha (local Burning),

Chhardi (Vomiting) [61].

Cellulitis Review [62]

Cellulitis may be defined as a spreading infection of the dermis or epidermis. It is thereby

distinguished from the more localized folliculitis and furunculosis. The most prevalent organisms

associated with cellulitis are beta hemolytic streptococci.

Epidemiology

Cellulitis in 2013 resulted in 30,000 deaths worldwide. In the United Kingdom, Cellulitis was the

reason for 1.6% of hospital admissions in 2013.Cellulitis is common among dense populations

sharing hygiene facilities and common living quarters, such as military installations, college

dormitories, nursing homes, oil platforms and homeless shelters. Along with abscess, its

evaluation accounted for 158 visits per 10,000 patient risk-years in 1991 British medical practice.

Starting in the 1970s, there was a shift in the disease from its classical appearance on the face to

the lower extremities, now the location of more than 80% of cases. Remarkably, cellulitis recurs

among 15-29% of patients within 3 years and 50% of patients sometime later in life. Recurrent

disease is associated with specific host risk factors among which are diabetes, alcoholism, trauma,

dermatophyte infections (athlete’s foot), and lymphedema. Case control studies show highest risk

exists with lymphedema, skin breaks such as tinea infection and wounds, venous insufficiency,

leg edema, and being overweight. The current epidemic of obesity certainly seems to be

facilitating cellulitis incidence. Tinea pedis is a common predisposing condition for leg cellulitis.

Risk factors for breast cellulitis include hematoma drainage, presence of lymphedema, the amount

of breast tissue resected, previous number of biopsies, and number of breast seroma aspirations.

Clinical Features

1) Rubor-redness

2) Tumor-swelling

3) Calor-heat (rise in local temperature)

4) Dolor-Pain

5) Tenderness

6) Impaired function of the affected part




The clinical features of recurrent cellulitis differ little from the first episode except that the limb

or breast may show scarring or other residue. The first symptom is usually pain, followed soon by

redness and warmth in the affected skin. The inoculation site may be occult or obvious and is

usually somewhat distal to the center of the spreading erythema or pain. Often the patient has

initiated self-therapy with antibiotics. Differential diagnosis is usually limited to deep vein

thrombosis, insect venom, trauma, and overuse.

Differential diagnosis.[63]

Venous stasis

DVT.(deep vein thrombosis)

Impetigo.

Eosinophilic cellulitis.

Pyoderma gangrenosum.

Necrotising fasciitis.

Urticaria.

Burns.

Erythema nodosum.

Papular urticaria (insect bites).

Allergic contact dermatitis.

Folliculitis.

Specifically of the face: acne fulminans, rosacea fulminans, lupus erythematosus, sunburn,

eczema, angioedema, fifth disease, granuloma faciale, lupus pernio, Jessner's lymphocytic

infiltrate, pseudofolliculitis barbae, photodermatoses

Complications of Leech Therapy [64]

Infection is the most common complication of leeching and occurs in 2-36% of patients. Several

bacterial strains like Acromonas sp., pseudomonas sp. And vibrio sp. Agent in the gram positive

rods, Aeromans hydrophilla with can cause pneumonia, Muscular necrosis, flap failure and even

septicemia. Because hydrophilla are resistant to Penicillins and the first generation of

cephalosporins.

Local hypersensitivity reaction itching, blister forming, ulcerative necrosis and even local tissue

damage (flap death) due to existence of some toxins in leech saliva. Proper treatment will be

given if these symptoms occur. Skin marks (scar) – due to impaired healing of leech bites.




CONCLUSION

Jalloukavacharana has been an established therapy as one of type in Raktamokshana. Leech

Therapy (Jalloukavacharan) is an effective and admired therapy in the treatment of Cellulitis

(Vranashopha). Leech Therapy has been proved as an important anti inflammatory therapy by

certain variety of researches worldwide. Leech is approved by FDA of US also for medical use in

various conditions as it helps in enhancing micro flow of blood in conditions like diabetic foots,

various nerose ulcers etc. The Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP)

Red Blood Cell (RBC) aggregation and plasma viscosity are blood tests that detect Inflammation.

As these methods have certain effect on blood tests to help diagnose such conditions like cellulitis

it also help in prognosis as well as management. It was revealed from numerous researches going

on worldwide that CRP(C-reactive protein) and ESR (Erythrocyte Sedimentation Rate) are

important inflammatory markers and found to be increase in various conditions like osteoarthritis,

Alzheimer’s disease, Myocardial Infarction, Osteoarthritis, dermatitis, Cellulitis etc. It will be

cost effective and new way to detect early prognosis for further management.

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