The global prevalence of diabetics is estimated to increase from 4.0% in 1995 to 5.5% by the year 2025. The chances of secondary infection are more in diabetics as the immunity of the patients is compromised and needs prolonged hospitalization, psychological and social problem for the patients and family. In Madhumehi the vessels of lower limb become weak and is unable to expel the Doshas (along with other Dushyas) leading to Prameha Pidakas more in lower extremities, which eventually burst open precipitating an ulcer. &nbsp;Avachoornana is one among the Shashti Upakrama, explained by Acharya Sushrutha for management of Vrana. Numerous studies are done in the management of Dushta Vrana with the internal medication and external therapies. Here a preliminary attempt to study the effect of Avachoornana with Lakshadi Choorna in the management of the same was taken for the study

K M Sweta

Swathi C Nair

English

Journal of Ayurveda and Integrated Medical Sciences (JAIMS)

                                                     CASE REPORT          October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 196  To evaluate the role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to Diabetic Ulcer : A Case Study Swathi C Nair1, K M Sweta2 1Post Graduate Scholar, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India. 2Professor & HOD, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.                  INTRODUCTION The global prevalence of diabetics is estimated to increase from 4.0% in 1995 to 5.5% by the year 2025.[1] India is facing with galloping diabetes epidemic which is progressing at a greater speed.[2] Diabetes Mellitus is a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrate and elevated levels of glucose in the blood. Slight injury to glucose laden tissue may cause chronic infection and ulcer formation. Ulceration in diabetes may be precipitated  Address for correspondence:  Dr. Swathi C Nair Post Graduate Scholar, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India. E-mail: swathiappu.cnair@gmail.com  Submission Date: 12/08/2022 Accepted Date: 21/09/2022 Access this article online Quick Response Code Website: www.jaims.in  Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA by ischaemia due to diabetic atherosclerosis. More prone to infection of glucose laden tissue may cause ulceration. Diabetic polyneuropathy or peripheral neuritis may also cause ulcer formation.[3] An ulcer is a break in the continuity of the covering epithelium-skin or mucous membrane. It may either follow molecular death of the surface epithelium or its traumatic removal.[4] Prameha is a Tridoshaja Vyadhi which affects the Kleda Dhatus of the body. On Kaalantara, Prameha converts to Madhumeha Vyadhi, a type of Vataja Prameha which is Asadya.[5] The 10 types of Prameha Pidakas which are Sarvadosha Samuthana occur as the Upadrava of Prameha.[6] If Pramehi is left untreated Doshas get aggravated and by vitiating Mamsa and Shonitha causes Shopha, which should be managed with Shodhana and Siramoksha. Shopha further advances severely and produce Ruja and Daha.[7] With respect to the above-mentioned facts Ayurvedic line of treatment (Shodhana and Ropana) will play an important role.[2] Avachoornana is one among the Shashti Upakrama, explained by Acharya Sushrutha for management of A B S T R A C T  The global prevalence of diabetics is estimated to increase from 4.0% in 1995 to 5.5% by the year 2025. The chances of secondary infection are more in diabetics as the immunity of the patients is compromised and needs prolonged hospitalization, psychological and social problem for the patients and family. In Madhumehi the vessels of lower limb become weak and is unable to expel the Doshas (along with other Dushyas) leading to Prameha Pidakas more in lower extremities, which eventually burst open precipitating an ulcer.  Avachoornana is one among the Shashti Upakrama, explained by Acharya Sushrutha for management of Vrana. Numerous studies are done in the management of Dushta Vrana with the internal medication and external therapies. Here a preliminary attempt to study the effect of Avachoornana with Lakshadi Choorna in the management of the same was taken for the study. Key words: Dushta Vrana, Avachoornana, Diabetic Ulcer, Lakshadi Choorna.     Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 197  Vrana. On Avachoornana Upakrama, adequate research has not been done, but it has efficacy in treatment of Vrana accompanied with symptoms like Sama Sthiramamsa, Twak Sthana Vrana.[8] Acharya Sushrutha has mentioned Lakshadi Gana in Dravya Sangrahaneeya Adhyaya which is having predominantly Tikta Kashaya Rasa, Laghu Rooksha Guna, Ushna Veerya, Katu Vipaka, Kaphapittahara, Arthi Nashanam and indicated in Dushta Vrana, Kushta and Krimi. Hence this current study is an attempt to validate role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to diabetic ulcers. AIM AND OBJECTIVE To evaluate the role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to Diabetic Ulcer MATERIALS AND METHODS  Properties of Lakshadi Choorna Drugs   Botanical name & Family  English name  Kannada name  Hindi name   Parts used   Laksha[9] Laccifer lacca  Lac  Aragu Laakh  Resin  Aragwadha[10]  Cassia Fistula Linn.  Caesalpinioideae  Purging Cassia   Phalus   Amaltas   Root bark   Kutaja[11]  Holarrhena  Antidycentrica  (Roth) A.DC.  Apocyanaceae  Conessi Tree   Korachi   Kuda   Stem bark   Aswamara[12]   Nerium indicum  Mill.  Apocyanaceae  Indian Oleander   Kanagalu   Kaner   Root bark   Katphala[13]   Myrica Nagi Buch.  Myricaceae  Box  Myrtle  Kirishivani   Katphala   Stem bark   Haridra[14]  Curcuma longa Linn.  Zingeberceae  Turmeric   Arishina   Haldi   Rhizome   Daruharidra[15]  Berberis aristata DC.  Berberidaceae  Indian berbery   Bagisutra   Daru haldi   Stem   Nimba[16]  Azadirachta indica A.Juss.  Meliaceae  Neem tree   Bevu   Nim   Stem bark   Saptaparna[17]  Alstonia scholaris  R.Br.  Apocyanaceae  Indian devil tree   Maddale   Satouna   Stem bark   Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 198  Jati[18]  Jasminum grandiflorum Linn.  Oleaceae  Common jasmine  Mallige   Chameli   Root  Leaf  Trayamana[19]  Gentiana kurroa Royle.  Gentianaceae  Indian gentian   Karadihanni   Kadu   Root    Drugs  Rasa  Guna  Virya  Vipaka  Karma  Indication  Laksha[9]  Kashaya  Laghu  Sheeta  Madhura  Kaphapitta Doshaharam  Vrana Jwara Urakshatham Aragwadha[10]  Madhura   Mrdu  Guru  Snigdha  Sheeta   Madhura   Kaphapittahara  Sramsana  Kustha  Prameha  Sula  Jwara  Kutaja[11]   Tikta Kashaya   Laghu Ruksha   Sheeta   Katu   Kaphapittahara  Grahi  Dipana  Raktarsas  Kustha  Krimi  Visarpa  Vatarakta  Jwara  Aswamara[12]   Katu  Tikta  Laghu  Ruksha  Ushna   Katu   Kaphavatahara  Kusthaghna  Vranahara  Caksusya  Dushta Vrana  Upadamsa  Kustha  Krimi  Kandu  Katphala[13]  Kashaya Tikta Katu   Laghu Tiksna   Ushna   Katu   Kaphavatahara  Sandhaniya  Vedanasthapana  Jwara  Raktapitta,  Arsas  Mukharoga  Haridra[14]  Tikta  Katu  Ruksa  Laghu  Ushna   Katu   Kaphavatahara  Lekhana  Vishaghna  Varnya  Prameha  Kusta  Krimi  Kandu  Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 199  Vrana  Daruharidra[15]  Tikta Kashaya   Laghu Ruksha   Ushna   Katu   Kaphapittahara  Chedana  Prameha  Kustha  Sveta Pradara  Vrana  Visarpa  Nimba[16]  Tikta Kashaya   Laghu Ruksa   Sheeta   Katu   Kaphapittahara  Dipana  Grahi  Krmighna  Netrya  Jwara  Kustha  Krimi  Prameha  Vrana  Visa Roga  Kandu  Saptaparna[17] Tikta  Kashaya  Laghu  Snigdha  Ushna   Katu   Tridosahara  Dipana  Hrdya  Krimi  Kustha  Vrana  Amavata  Sula  Jati[18] Tikta Kashaya   Laghu  Snigdha  Mrdu  Ushna   Katu   Tridosahara  Vrana Ropana  Vrana Sodhana  Vrana  Netraroga  Siroroga Karnapuya  Mukhapaka  Trayamana[19]  Tikta  Kashaya  Laghu Ruksa   Ushna   Katu   Pittakaphahara  Visaghna  Recaka  Jwara  Hrdroga  Gulma  Bhrama  Sula  Visa roga  Case Study It is a case study of a 42-year male patient who presented with the chief complains of ulcer over big toe of right leg since 2 months (K/C/O DM for last 8 years and under medication). He was being treated with oral medications and dressings. Study was done after obtaining an informed consent from the patient. He was treated with the Lakshadi Choorna for dressing Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 200  daily and Triphala Guggulu 2 BD before food, Amritadi Vati 2 BD after food as internal medication. Intervention Lakshadi Choorna was prepared with all aseptic measures, as per the classical reference of Choorna Kalpana. After proper cleaning the drugs, it made into small pieces by chopping. Using pulveriser it was made into fine powder with mesh size of 80 to 120 range. Packing done under aseptic precaution and sterilization done under UV for 20 minutes.  Figure 1: The method of Lakshadi Choorna preparation.  Raw drugs for Lakshadi Avachoornana   Final product With all aseptic measures ulcer was cleaned with normal saline and Avachoornana was done uniformly over ulcer site. Dressing was done with sterile gauze and pad. Avachoornana was done with the Lakshadi Choorna once daily and observations were done on 7th, 14th, 21st and 40th day of the treatment.   Figure 2: The method of Lakshadi Avachoornana    Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 201   0th Day  Avachoornanam  7th Day  14th Day  21st Day  40th Day Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 202   Follow-up Table 2: Subjective symptoms assessed on 0th, 7th, 14th, 21st, 40th day. Pain Assessment 0  No Pain  1-3  Mild pain  4-6  Moderate pain 7-10  Severe pain 0th day  +   7th day  +   14th day +    21st day +    40th day +    Burning Sensation  Grade 0 No burning  Grade 1 Mild burning  Grade 2 Moderate burning  Grade 3 Severe burning  0th day   +  7th day  +   14th day  +   21st day +    40th day +    Table 3: Objective symptoms assessed on 0th, 7th, 14th, 21st, 40th day. Item   Assessment   0th day Score  7th day Score  14th day Score  21st day  Score  40th day Score  1. Size   1 = Length x width <4 sq. cm  2 = Length x width 4--<16 sq. cm  3 = Length x width 16.1--<36 sq. cm  4 = Length x width 36.1--<80 sq. cm  5 = Length x width >80 sq. cm  3 3 3 3 2 2. Depth   1 = non-blanchable erythema on intact skin  2 = Partial thickness skin loss involving epidermis &/or dermis  3 = Full thickness skin loss involving damage or necrosis of subcutaneous tissue; may extend down to but not through underlying fascia; &/or mixed partial & full thickness &/or tissue layers obscured by granulation tissue  4 = Obscured by necrosis  5 = Full thickness skin loss with 3 3 3 3 3 Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 203  extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures  3. Edges   1 = Indistinct, diffuse, none clearly visible  2 = Distinct, outline clearly visible, attached, even with wound base  3 = Well-defined, not attached to wound base  4 = Well-defined, not attached to base, rolled under, thickened  5= Well-defined, fibrotic, scarred or hyperkeratotic  2 2 2 1 1 4.Undermining   1 = None present  2 = Undermining < 2 cm in any area  3 = Undermining 2-4 cm involving < 50% wound margins  4 = Undermining 2-4 cm involving > 50% wound margins  5 = Undermining > 4 cm or Tunnelling in any area  1 1 1 1 1 5.Necrotic Tissue Type   1 = None visible  2 = White/grey non-viable tissue &/or non-adherent yellow slough  3 = Loosely adherent yellow slough  4 = Adherent, soft, black eschar  5 = Firmly adherent, hard, black eschar  3 3 2 2 1 6.Necrotic Tissue Amount   1 = None visible  2 = < 25% of wound bed covered  3 = 25% to 50% of wound covered  4 = > 50% and < 75% of wound covered  5 = 75% to 100% of wound covered  2 2 2 2 1 7.Exudate Type   1 = None  2 = Bloody  3 = Serosanguineous: thin, watery, pale red/pink  4 = Serous: thin, watery, clear  5 = Purulent: thin or thick, opaque, tan/yellow, with or without odour  3 3 1 1 1 8.Exudate Amount   1 = None, dry wound  2 = Scant, wound moist but no observable exudate  3 = Small  4 = Moderate  4 3 2 2 2 Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 204  5 = Large  9.Skin Colour  Surrounding  Wound   1 = Pink or normal for ethnic group  2 = Bright red &/or blanches to touch  3 = White or grey pallor or hypopigmented  4 = Dark red or purple &/or non-blanchable  5 = Black or hyperpigmented  1 1 1 1 1 10.Peripheral  Tissue Edema  1 = No swelling or edema  2 = non-pitting edema extends < 4 cm around wound  3 = non-pitting edema extends > 4 cm around wound  4 = Pitting edema extends < 4 cm around wound  5 = Crepitus and/or pitting edema extends >4 cm around wound  2 2 1 1 1 11.Peripheral  Tissue Induration  1 = None present  2 = Induration, < 2 cm around wound  3 = Induration 2-4 cm extending < 50% around wound  4 = Induration 2-4 cm extending > 50% around wound  5 = Induration > 4 cm in any area around wound  2 1 1 1 1 12.Granulation Tissue   1 = Skin intact or partial thickness wound  2 = Bright, beefy red; 75% to 100% of wound filled &/or tissue overgrowth  3 = Bright, beefy red; < 75% & > 25% of wound filled  4 = Pink, &/or dull, dusky red &/or fills < 25% of wound  5 = No granulation tissue present  3 2 2 2 2 13.Epithelialization   1 = 100% wound covered, surface intact  2 = 75% to <100% wound covered &/or epithelial tissue extends to > 0.5cm into wound bed  3 = 50% to <75% wound covered &/or epithelial tissue extends to <0.5cm into wound bed  4 = 25% to < 50% wound covered  5 = < 25% wounds covered  5 5 5 4 3 Total Score 34 31 26 24 20 RESULTS Reduction of Symptoms of ulcer was achieved within 14-21 days of Lakshadi Avachoornana and later complete healing was achieved without any other complications. Swathi C Nair et al. Lakshadi Avachoornana in the management of Dushta Vrana ISSN: 2456-3110                                                               CASE REPORT October 2022  Journal of Ayurveda and Integrated Medical Sciences | October 2022 | Vol. 7 | Issue 9 205  DISCUSSION Lakshadi Gana with the properties of Tikta Kashaya Rasa, Laghu Rooksha Guna, Ushna Veerya, Katu Vipaka, Kaphapittahara and Arthi Nashanam is indicated in Dushta Vrana, Kushta and Krimi. Acharya Susrutha has included this Gana in Dravya Sangrahaneeya Adyaya and indicated in Dushta Vrana. In the present situation, due to hampered foot habits and physical exertion, life style disorders are more along with its complications. Lakshadi Avachoornana helps in reducing the symptoms of Dushta Vrana, thereby helps in getting desired result. Tikta Kashya Rasa helps in promoting healing of wound and it has Pittahara property, thereby helps in reducing the burning sensation. Due to its Usha Veerya, it helps in Vatashamana, thereby reducing the pain. This Gana also possess, Krimighna, Kushtagna property, hence its Vranasodhana and Ropana nature in Dushta Vrana is highlighted.  Further clinical study is needed to evaluate the effectiveness in larger sample. CONCLUSION Significant relief on symptoms of Dushta Vrana including Poothi Pooya, Srava, Athigandha etc was being observed in the course of treatment. There was better healing and sustained symptomatic relief in this patient with the Lakshadi Avachoornana. Due to its easy and convenient mode of application it makes the procedure significant. REFERENCES 1. Amit Jain’s triple assessment for foot in diabetes- a rapid screening tool (Internet). Clinical practice. 2018 November;  2. 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Dravyaguna Vijnana, Varanasi: Chaukamba orientalia; 2012.p.850-1.    How to cite this article: Swathi C Nair, K M Sweta. To evaluate the role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to Diabetic Ulcer : A Case Study. J Ayurveda Integr Med Sci 2022;9:196-205.  Source of Support: Nil, Conflict of Interest: None declared. 

To evaluate the role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to Diabetic Ulcer : A Case Study

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To evaluate the role of Lakshadi Avachoornana in the management of Dushta Vrana with special reference to Diabetic Ulcer : A Case Study

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