Issue : 01 DOI :
INTERNATIONAL
JOURNAL
OF
DIAGNOSTICS
AND
RESEARCH
Volume : 02
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Abstract
Background: Venous ulcers are develop as a result of improper venous valve function, primarily in
the legs. Overall incidence rates for men and women are 0.76% and 1.42%, respectively. The
malleolar zone on the medial and lateral portions of the ankle is where venous ulcers typically
develop. In Ayurveda, this condition is considered as Duṣṭa Vraṇa. It can be managed with the specific
Shodhana therapy followed by ropan therapy. So, the same treatment protocol was used to treat the
case discussed here, like Manjishtadi Kshar Basti, Triphala Kwath Dhavan, Jatyadi Tail dressing, and
internal oral medication.
Material & Methods: This is a case study of an 41-year-man with an exposed chronic infectious wound on the
front of his left leg and the front of his left foot, which was followed by pain, discharge (slough), foul odor,
edema, and blackish skin discoloration, along with tortuous and dilated veins, swelling at left lower limb below
knee joint since 2 years. This case was successfully managed with Ayurved Approach.
Results: The significant changes were observed in the form of complete wound healing, and associated
symptoms also got resolved entirely.
Discussion: Encouraging results were obtained due to both local & systemic effects, i.e., anti-microbial,
antiseptic, scrapping actions & wound healing properties of Triphala kwath, Jatyadi tail & Manjishtadi Kshar
Basti and oral medications.
Conclusion: Formulations offers promising results without causing any undue effects. In this case which
showed that both Jatyadi Tail and Triphala kwath Dhavan along with Manjishtadi Kshar Basti are effective &
safe in the management of Chronic Varicose Ulcer.
Keywords : Ayurveda, Dushta Vran, Varicose Ulcer, Jatyadi Tail Dressing, Triphala Kwath Dhavan,
Manjishtadi Kshar basti.
Corresponding author: Dr. Vedika Bhoir
Article Info: Published on : 15/10/2024
P
Publisher
ROGANIDAN VIKRUTIVIGYAN PG ASSOCIATION
FOR PATHOLOGY AND RADIODIGNOSIS
DOI
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Reg. No. : MAHA-703/16(NAG)
Year of Establishment – 2016
INTERNATIONAL JOURNAL OF DIAGNOSTICS AND RESEARCH
Management of Varicose Ulcer with combine Ayurvedic approach
- A Case Report
Dr.Damini Raut
1
, Dr. Vedika Bhoir
2
1
First Year PG, Department of Shalyatantra, D. Y. Patil School of Ayurveda Navi Mumbai,
2
Associate professor, Department of Shalya Tantra, D. Y. Patil School of Ayurveda Navi Mumbai.
Cite this article as: - Dr. Vedika Bhoir (2024) Management of Varicose Ulcer with combine Ayurvedic approach - A Case
Report; Inter.J.Dignostics and Research 2 (1) 35-42, DOI: 10.5281/zenodo.13936650
G
A
R
V
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36
Introduction:
Varicose veins are a highly prevalent issue. They can
cause disability and worse quality of life. Varicosity
may also be found in the rectum (haemorrhoids),
oesophagus (esophageal varices) and in spermatic cord
(Varicocele) etc., but their twisted, bulging, superficial
appearance on the lower extremities makes them
easily identifiable.
[1]
Definition:Varicose veins are
tortuous, enlarged, palpable, usually blue or dark
purple in the subcutaneous tissues of the legs, ankle
and are often easily visible. All of these veins possess
one-way valves to ensure that the blood flows towards
the heart; however, when their valves are normally
defective, blood reflux occurs, resulting in venous
hypertension, which can produce symptoms.
[2
]
About
47,928,177 people in India have varicose veins that
can be informed about, according to statistics. Another
estimate places the prevalence of vein disease in
India's population between 15 and 20 percent.
[3]
Patient’s Information:
41 year old man came to OPD No. 3 with complaints
of varicose vein and ulcer present at left lower limb.
Details of Chief & associated complaints with
duration are given in Tables 1.
Table no. 1: Details of chief complaints with duration
Progress Of Disease:
The patient was well before 2 years but later he suffer
from swelling at left lower limb below knee joint,
blackish discoloration, infectious wound, pain at ulcer
region, pus discharge from ulcer, foul smell from ulcer
region, tortuous and dilated veins along with increased
swelling at left lower limb in long standing position.
Patient’s History:
Details of the patient‘s history are given in Table no.2.
Table No.2: History of patient
S.N.
Head
Details of the patient
1
Past History
No H/o similar episode
No any Major illness
No allergy
No drug history
No previous operation done
No history of any
trauma/tuberculosis (TB)
2
History of
present
illness:
Onset- Before 2 years
Duration – since 2 years
Progress- Gradual
3
Family
History
Mother –K/C/O/ DM) HTN and
IHD
Father –HTN, IHD, and
osteoarthritis (knee)
Siblings: one brother –
K/C/O/HTN.
4
Personal
History
Diet: vegetarian, Daily intake of
oily, sweet food items despite
being diabetic nature
Sleep: interrupted due to burning
sensations and pain overwound
No history of any addiction
Examinations:
Figure 1: Local examination of the affected part is
depicted
S. N.
Nature of Chief
complaint
Severity
Durati
on
1
swelling at left lower limb
below knee joint
4+
2
years
2
blackish discoloration at left
lower limb at left foot
4+
2 years
4
Tortuous and dilated veins
present at left lower limb
along with increased
swelling at left lower limb in
long standing position.
3+
2 years
3
infectious wound present at
left lower limb
3+
1.5
years
5
pain at ulcer region present
on left lower limb
2 +
1 year
6
pus discharge from ulcer
present at left lower limb
2+
15days
7
Foul smell from ulcer region
present at left lower limb,
2+
15 days
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Table No. 3 : Local examination of patient
Sr.
No.
At Left Lower Limb:
At Multiple
Ulcers:
1
Ulcer present at anterior
side of left lower limb
Slough- +++
2
Blackish
Hyperpigmentation
present at left lower
limb.
Pus Discharge-
+++
3
Dilated and tortuous
veins are present at left
lower limb.
Tenderness- ++
4
Edema- +++
Foul Smell- +
5
Tenderness - ++
No active
Bleeding
Table No. 4 : Local Laboratory of patient
Reports done outside on 14/02/2023. (Venous doppler
study of left lower limb.)
Sr.
No.
Findings
1
Deep Vein Thrombosis: few strands of
echogenic thrombus seen in popliteal vein.
2
Sup Venous System: Great saphenous vein
is dilated in leg region. Short saphenous
vein seen normal in leg region.
3
SSV (Short Saphenous Vein): popliteal
junction is incompetent.
4
Few varicosities seen at post medially and
post laterally in calf.
Diagnosis :
Varicose Ulcer (Siraj Vrana / Dushta Vrana).
Therapeutic Intervention:
The line of treatment was adopted, as shown in Table
No.5.
Table No. 5 : Line 0f Treatment
Observation And Result : (Diagnostic Assessment)
Table No.6: Assessment of Subjective Criteria
S.N.
Type of
Symptom
Before
Treatment
(on 1
st
day)
On
15
th
day
After
Treatment
(on 60
th
day)
1
Pain(VAS)
3+
2+
0
2
Slough
3+
1+
Absent
3
Tenderness
3 +
1+
Absent
4
Pus
discharge
Severe
Absent
Absent
5
Foul smell
2+
Absent
Absent
6
Itching
over
affected
part
2+
Absent
Absent
S.
N.
Type of
intervention
Time of
administrati
on
Anu-
pana
Dura
-
tion
1
Local
Applic-
ation
Triphala
Kwath
Dhawan
Twice daily
NA
15
days
Jatyadi
Taila
Twice daily
followed by
Gomutra
Dhawan &
bandaging
NA
15
days
2
Inter-
nal
Admini
stration
Gokshuradi guggulu 350
mg 2BD AF
Kaishore Guggulu
350mg 2BD AF
Punarnava Mandoor
2BD AF
Avipattikar +
Hingwashtak Churna
3gm BD AF with warm
water.
Khadirarishta 30ml BD
AF with equal amount of
water
Warm
water
60
days
3
Panchk
-arma
Proced
-ure
A. Yoga Basti-
i. Anuvasan Basti
with
Dhanwantar tail
ii. Nirooh Basti
with Manjishtadi
kshar basti
NA
8
Days
4
Advice
• Two pillow leg
elevation for lt
lower limb.
• Crepe
Bandaging at lt
lower limb in
day time.
NA
15
Days
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Table No.7: Assessment of Objective Criteria
S.N
.
Sign
Before
Treatment
After 15
days
After
Treatmen
t (On 60
th
day)
1
Size of
wound
1.Anterior
side of left
lower limb.
It is
irregular
and about
4*7 cm
length.
2.Multiple
small Ulcers
present at
lateral side
of left lower
limb at
lateral
malleolus
about 2cm
and 4 cm
dia.
Decrease
in size
No wound
2
Quantit
y &
color of
discharg
e
Profuse
deep-seated
fresh wound
& pus
discharge at
the base of
the wound
Pus
discharge
stopped &
the
Formatio
n of the
crust
No
discharge
and
Complete
healing of
Wound
3
Edema
around
wound
Significant
edematous
edges
Edema
was
minimal,
pinkish-
red edges
showing
growing
epitheliu
m
Absence of
edema
4
Appeara
nce and
color of
the base
of the
wound
Redness and
the presence
of the
wound's raw
surface
The crust
separates,
and the
granulatio
n tissue
appears.
Pinkish
white skin
with no
contraction
s
The diagnostic assessment was carried out using
subjective & objective criteria, as shown in Tables 6 &
7. At the end of the 15
th
day, the clinical features of
Siraj/Dushta Vrana had improved, and the wound had
healed fully by the end of the 60
th
day. There was no
proof of infection. Healthy granulation tissue present
after five days. Regular dressing was continued for 15
days. The percentage of wound contraction increased
drastically. It was determined by keeping track of how
the wound area plan improved over time. The progress
of the injury after treatment is shown in the fig.no.2.
Discussion:
Venous ulcer or varicose ulcer is the commonest ulcer
of the leg. It is usually found on the medial portion of
the lower third of the limb. These ulcers are frequently
connected with varicose veins in the upper region of
the limb. Varicose veins are convoluted, enlarged
veins in the subcutaneous tissues of the legs that are
frequently apparent. Their valves are frequently
defective, causing blood reflux and venous
hypertension, which can produce symptoms. Legs are
the primary area for varicose veins because to the
force of gravity, pressure from body weight, and the
work of delivering blood from the bottom of the body
to the heart. Compared to other veins of the body, leg
veins have the toughest job of carrying blood back to
the heart. Various terms have been used for this ulcer
e.g. varicose vein, post thrombotic ulcer, gravitational
ulcer etc. CVI may develop due to obstruction, blood
Before
Treatment
After 8
Days
After 15
Days
After
Treatment
Figure 2: Wound Progress During & After
Treatment
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reflux or a combination of both mechanisms, causing
micro- and- macro-circulatory dysfunction. Major risk
factors for development of venous leg ulcer include
long standing, old age, pregnancy, sex, athlets, trauma,
immobility etc. pathophysiology of venous leg ulcer
includes DVT, perforator insufficiency, calf muscle
pump insufficiencies etc. leads to distal venous
hypertension leads to ulcer.
[4]
According to Ayurvedic classical texts the complete
explanation of varicose vein is not found. It is
available in scattered manner. On the basis of signs
and symptoms the varicose vain, it shows close
resemblance with Siragat Vata, Vataj Vatrakta, Siraj
Granthi. On detailed review of available literature we
found that symptoms of varicose vein lies in close
proximal with siraj granthi. It also has close
resemblance with siragat vata as described by Acharya
charaka. Majority of symptoms of vataj type of
vatarakta also coincides with the symptoms of
varicose vein. Concisely it can be understood as an
outcome of vitiation of all the three Doshas along with
Rakta, Mamsa, Medo Dhatu Dushti. Acharya
Vagbhata alters the physical indicators by adding
Vakreekarana (tortuosity), which clarifies the clinical
picture and also states that Sirajagranthi will be
Nishphura (nonpulsatile) and Neeruja (painless).
A.H.A.U.29/10-11.
[5]
According to Ayurvedic classics
varicose ulcer can be correlated with Siraj Vran or
Dushta Vran. Dushta vrana, according to Acharya
Sushruta, is a chronic ulcer, manifested in any part of
the body, caused either by the Doshas or trauma.
Susruta Samhita, Sutra sthana, Ch.23 Ver.6.
[6]
When
caused by Doshas, it is known as Nija vrana; when
caused by trauma, it is known as Agantuja vrana.
Sushruta Samhita provides a detailed account of the
numerous characteristics of a Dushta vrana. The one
that is Atisamvrita (excessively covered), Ativivrita
(excessively uncovered), Atikathina (too hard),
Atimrudu (too soft), Utsanna (excessively elevated),
Avasanna (excessively depressed), Atyushna (calor),
Atisheeta (cold to touch), differently coloured, ugly
looking, suppurative, painful, associated with different
types of discharges, and chronic; is called a Dushta
vrana. (Su. Su, 22/7).
[7]
A 41-year-old male Patient came to OPD No. 3.
Department of ShalyaTantra, D. Y. Patil Ayurvedic
hospital for his treatment. Admitted in Shalya Male
ward on 17/05/2023 and got discharged on
24/05/2023. Patient was having Following Complaints
since 2 years: Swelling at left lower limb below knee
joint, Blackish discoloration at left lower limb,
Infectious wound present at left lower limb, Dilated
and tortuous veins present at left lower limb, swelling
at left lower limb. Increased on standing, Pain at ulcer
site, whitish slough present at ulcer. Location of ulcer
present on left lower limb at anterior side of left lower
limb. It is irregular and about 7 cm length and multiple
small Ulcers present at lateral side of left lower limb at
lateral malleolus about 2cm and 4 cm dia. The patient
was advised for treatment of Panchkarma procedure
Yoga Basti For 8 Days.Anuvasan Basti with
Dhanwantar tail, Nirooh Basti with Manjishtadi
Kshar Basti, Triphala Kwath Dhavan, Jatyadi Tail
Dressing. Oral medications are given for 1 month-
Gokshuradi Guggulu 350 mg 2BD AF, Kaishore
Guggulu 350mg 2BD AF, Punarnava Mandoor 2BD
AF, Avipattikar + Hingwashtak Churna 3gm BD AF
with warm water, Khadirarishta 30ml BD AF with
equal amount of water.
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Mode Of Action Of Internal Medication :
Gokshuradi Guggulu- having Shothahara,
kaphanisarak and Lekhan property.
Kaishore Guggulu- having blood purifying
effect (Raktaprasadak)
Punarnavadi Mandoor- Shothahara,
vranropak and krimighna property
Khadirarishta- antioxidant property,
antimicrobial, antifungal, Shothahar and helps
to purify blood etc.
Guggulu - Guggulu is having Pidanashak,
Shothhara, Vedananashak, Vrana Shothahar
and Vranropan property.
Yoga Basti Krama is given in Table no 8 as follows:
Table No.8: Yoga Basti Krama
Days
1
2
3
4
5
6
7
8
Basti
M
MK
M
MK
M
MK
M
M
MK- Manjishtadi Kshar Basti
M- Matra Basti with Dhanvantar Tail.
In the context of Vraṇa Cikitsā, Basti Chikitsā is
mentioned as a Śodhana therapy where medicines are
administered through rectal route. The Vāta Doshaja
Vraṇa and Adhaṇkāyaja Vraṇa (ulcers prone to lower
limbs) are treated with Basti karma or Āsthāpana Basti
administered through rectal route. Mahamanjishtadi
Kwath made of Manjishtha, Triphala, Kutaki,
Guduchi, Nimba, Vacha, Daruharidra. Method of
preparation of Manjishtadi Kshara Basti. The different
components of Basti should be mixed in following
pattern: Gomutra- 100 ml, Madhu- 30ml, Saindhava
Lavana- 3gm, Dhanvantar Taila- 100ml, Manjishtadi
Kwatha- 500ml, Mishri- 2gm all ingredients are
thoroughly mixed and a preparation in the form of
emulsion was obtained, this was made Sukhoshna by
keeping it inside the Ushnajala.
Probable mode of action of Manjishtadi Kshar Basti is
given in table no 9.
[8]
Sr.
No.
Drug
Probable Mode of Action
1
Manjishtha
It has properties like Tikta- Kashāya
Rasa, KaṭuVipāka, Uṣṇa-Vīrvya,
Kapha-Pitta-Shāmaka; Shleshma-
Śotha Nāśaka. Also, a study proved
the significance of Mañjiṣṭhā in
chronic wound healing.
2
Triphala
Triphala contains a number of
antioxidants that perform protective
functions in the body.
3
Kutaki
Rasa-Tikta, Guna- Laghu Ruksha,
Veerya- Sheeta, Vipaka-Katu.
Balances Pitta Vata.
4
Guduchi
Tikta-Kaśāya Rasa; Madhura
Vipāka; Uṣṇavīrya; Tridośaśāmaka;
Dīpanīya, and Dāhanāśaka are its
properties.
5
Nimba
Rasa : Tikta, Kashaya, Guna :
Laghu, Ruksha, Virya : Shita,
Vipaka : Katu Kaphapittahara,
Grahi (reduce excessive discharge),
Sothahra (anti-inflammatory),
Arshoghna (useful in piles),
Krimighna (anti-helminthic),
Kusthaghna (useful in skin
disorders)
6
Vacha
Rasa : Katu, Tikta, Guna : Laghu,
Tikshna, Virya : Ushna, Vipaka :
Katu, Vatakaphahara, Lekhaniya
7
Daruharidra
Rasa : Tikta, Kashaya, Guna :
Laghu, Ruksha, Virya : Ushna,
Vipaka : Katu
Kaphapittahara, Chedan (scarpping
of Kapha humor and Meda Dhatu),
Pramehahara (anti-diabetic),
Kusthaghna (useful in skin
disorders), Vranropana (wound
healing)
8
Gomutra
Rasa : Katu, Tikta, Kashaya, Lavan,
Vranropak, Lekhaniya,
Svarnatwakrit (normalize the skin
colour), Tikshna (helps is deeper
penetration), Malashodhak.
9
Dhanvantar
Tail
Vatahara, shothahara,
vedanashamak, antioxidant
property, acts as a neuroprotective
etc.
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Manjishtadi Kshar Basti by its Strotoshodhak and
Rakta Prasadak property reduces the inflammation
and purifies the blood. The Kshar Basti by its
Strotoshodhak property helps in clear the obstruction.
Triphala Kwath Dhavan and its Probable mode of
action:
According to Acharya Sushruta, among the 60
measures of comprehensive wound management,
Parisheka (pouring of liquids) for reduction of Shopha
and Kashaya (Cleansing Deccoction) for
Durgandhanam (Smelling), Kledavatam (Sodden),
Picchila (Slimy) wounds. The Kashaya Parisheka
performs both the functions of Shodhana (cleansing)
and Ropana (healing) in cases of Dushta Vrana.
Triphala consist of Amalaki, Haritaki and Bibhitaki. It
balances all three Doshas. It has Vranropak,
Vranshodhak, Kushtaghna and Rasayan properties. It
is Stravhara and Vedanashamak too. It is reported to
be an effective antimicrobial, blood purifier and
immunomodulator action. Triphala Kwatha contains
active compounds in them such as Gallic acid,
Chebulinic acid, Ellagic acid, Flavonoids, Tannins and
Polyphenols which are responsible for its effective
immune stimulatory action. It is reported to be an
effective antibacterial agent against Gram-positive and
Gram-negative bacteria, antifungal agent.
[9,10]
Jatyadi tail dressing and its Probable mode of
action in wound healing-
Jatyadi Taila is having Tikta, Kashaya Rasas, Laghu,
Ruksha Gunas, Pitta Kapha Hara and have the
properties of Vrana Shodhana, Ropana, Pootihara,
And Vedanasthapana with Antibacterial, anti-
inflammatory, and antifungal properties. In order to
make Jatyadi taila, Tila Taila is used. Tila Tail Have
Ushna, Teekshna, Madhura, Vataghna, Vyavayi,
Vikasi, and Sukshma Gunas. As a result, its Sukshma,
Vyavayi, and Vikashi Gunas may assist in reaching the
minute channels and minimizing Vedana. As a result,
it may aid in the elimination of slough, Because
Jatyadi Taila contains medications with both
Shodhana and Ropana properties, it aids in the proper
healing of Dustha Vrana. Overall, the healing effect is
caused by the combined impact of the substances.
[11]
Conclusion:
An attempt was made to treat varicose ulcer (Dushta
Vrana) like condition with Ayurvedic management. As
varicose ulcer is caused due to the Doshas and can be
compared with the Dushta Vrana in Ayurveda. The
combine treatment of internal medications and
Manjishtadi Kshar Basti (explained by Chakradatta).
External application of Triphala Kwath Dhawan along
with Jatyadi Tail dressing shows effective results
against the varicose ulcer (Dushta Vran) which is
difficult to cure.
References:
1. Jones RH, Carek PJ. Management of Varicose
Veins. Am Fam Physician
2008;78(11):1289 1294
2. National Clinical guidelines centre. Varicose veins
in legs: The diagnosis and management of varicose
veins; Commissioned by the National Institute for
Health and Care Excellence. July 2013.
3. Statistics by country for varicose veins. Available
from: http://www.curesearch.com/v/varicose
veins/stats.html. Accessed 24 may 2017
4. Meissner, M.H., Eklof, B. and Smith, P.C. 2007a.
Secondary chronic venous disorders. J. Vasc. Surg.
46(Suppl. S): 68S–83S
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5. Vaidya Harisastri Paradakara Acharya (2011)
Ashtanga Hridaya, with commentaries of Sarvanga
Sundari of Arunadutta and Ayurveda Rasayana of
Hemadri, 10th edn, Varanasi. Uttara Sthana Chp,
2011; 29/10-11.
6. Acharya Yadavji Trikamji Susrutha Samhita with
Nibandhasangraha Commentary of Dalhanacharya
and Nyayachandrika Panchika of
GayadasaVaranasi, Chaukamba Orientalia, Nidana
Sthana Chp, 2009; Sutra Sthana Chp: 23/6.
7. Acharya Yadavji Trikamji Susrutha Samhita with
Nibandhasangraha Commentary of Dalhanacharya
and Nyayachandrika Panchika of
GayadasaVaranasi, Chaukamba Orientalia, Nidana
Sthana Chp, 2009; Sutra Sthana Chp: 22/7.
8. Chakradatta, Indradeva tripathi chaukambha
Sanskrit sansthan Varanasi, 005 pp- 542, page
no.455.
9. Ambikadattashastri sushruta samhita-1 varanasi
chaukhamba Sanskrit sansthan reprint 2005
chikitasthan 1/8.
10. Bhavprakash niganthu edited by G. S. Panday
Chaukhamba bharti academy 221001 reprint-2015
Haritkyadi vagra 12-13.
11. Shailajana Sunita, Menonv Sasikumar, Pednekara
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