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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 180-186

Integrative management of diabetic foot ulcer with Homoeopathy and standard care


1 Government Homoeo Dispensary, Ammanabrolu, Prakasham, Andhra Pradesh, India
2 Department of Materia Medica, Dr Gururaju Government Homoeopathic Medical College, Gudivada, Andhra Pradesh, India
3 Drug Standardization Unit (H), Hyderabad, Telangana Under CCRH, New Delhi, India

Date of Submission30-Jul-2017
Date of Acceptance07-Sep-2018
Date of Web Publication27-Sep-2018

Correspondence Address:
Dr. Kiranmayee G. R. Rompicherla
Flat No. 404, Bhargavi Residency, Street No. 6, Habsiguda, Hyderabad - 500 007, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_42_17

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  Abstract 


Diabetic foot ulcer (DFU) is a serious complication of diabetes associated with severe morbidity leading to poor quality of life and high cost of treatment. Many physicians are of the opinion that effective, multidisciplinary management of foot ulcer is necessary to avoid adverse consequences such as amputation and permanent disability. Homoeopathy offers an effective and safe management of these cases through its unique holistic approach. Here is one such case of chronic DFU, which has been refractory to the conventional management, treated satisfactorily with Homoeopathy. It has been observed that, with homoeopathic treatment, apart from healing of the ulcer, the general health of the patient has also improved.

Keywords: Diabetic foot ulcer, Homoeopathy, Insulin, Plastic surgery, Type 2 diabetes


How to cite this article:
Gadde P, Narasimhulu D, Rompicherla KG. Integrative management of diabetic foot ulcer with Homoeopathy and standard care. Indian J Res Homoeopathy 2018;12:180-6

How to cite this URL:
Gadde P, Narasimhulu D, Rompicherla KG. Integrative management of diabetic foot ulcer with Homoeopathy and standard care. Indian J Res Homoeopathy [serial online] 2018 [cited 2018 Dec 12];12:180-6. Available from: http://www.ijrh.org/text.asp?2018/12/3/180/242280




  Introduction Top


Diabetes mellitus is a clinical syndrome characterised by hyperglycaemia due to absolute or relative deficiency of insulin, resulting in various long-term complications affecting principally the vascular system and the nervous system.[1] Asian countries contribute to >60% percentage of the world's diabetic population as the prevalence of diabetes is increasing in these countries.[2]

Among the various organs of the body that are affected, foot is a frequent site of complications in diabetes. Peripheral neuropathy and peripheral vascular disease can lead to chronic foot ulcers, which are at high risk for infection. If left untreated, infection and ischaemia lead to tissue death, culminating in amputation.[3] The conventional management of a diabetic foot ulcer (DFU) includes blood sugar control, wound debridement, advanced dressings and offloading modalities. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management.[4] In spite of all these treatment modalities, DFU is considered as a major source of morbidity and a leading cause of hospitalisation in patients with diabetes. It is estimated that approximately 20% of hospital admissions among patients with diabetes are the result of DFU. On the other hand, once DFU has developed, there is an increased risk of ulcer progression that may ultimately lead to amputation.[4] It is estimated that approximately 50%–70% of all lower limb amputations are due to DFU.[4] The whole spectrum of treatment is costly and is not easily available to a common man.

As a system of medicine, Homoeopathy offers an effective treatment of DFUs both by reducing the symptoms and containing infection from further spread. A prospective observational study ascertaining the role of Homoeopathy in the management of DFU by Nayak et al. showed clinical benefits and healing of ulcer with integrative homoeopathic management.[5] Few case reports on homoeopathic treatment of gangrene due to diabetes have been successfully documented.[6] This case report adds to the already generated evidence of homoeopathic management of DFU and its complications.


  Case Report Top


On 13th April, 2015, a 70 year old female patient, who was a known diabetic for the past 43 years, presented with an ulcer in the sole of the left foot for 4 years, which was very painful to touch and exposure to cold air. She also complained of bleeding gums for the past 3 months.

History of presenting complaints

She was a known diabetic for 43 years and was under oral hypoglycaemic drugs till 2005. In 2005, at the time of her father's death, she developed severe rise of sugar levels up to 300 mg/dl post-prandial blood sugar (PPBS), after overuse of betnesol injections for asthma. Since then she was kept on Insulin 10 units in the morning and night.

The ulcer was triggered after an injury from a stone, in 2011. Even after 15 days, the injury did not heal and serous discharge started oozing from it. She was hospitalised, for cleansing the wound. Within 1 week after discharge from the hospital, the incised area was infected and was diagnosed to be of fungal origin by another diabetician, which was by repetition of incision and cleaning of the ulcer. Since then, she was getting repeated infection of the area, which was being incised once in every 2–3 months.

In August 2014, she underwent plastic surgery for healing of the chronic ulcer and was hospitalised for about 3 weeks. When the bandage was removed, a small slit was persistent at the site of surgery. Within a month, the slit increased gradually and got infected with discharge of pus and serous fluid. She was suggested by her endocrinologist to go for repeat surgery. But she was reluctant. She used powerful antibiotics with no much avail. After the plastic surgery, her sugar levels reached up to 330 mg/dl (PPBS) and was advised to increase the dose of insulin to 15 units twice daily.

The whole process from the time of injury to plastic surgery of the ulcer involved not only mental and physical agony but also heavy financial burden. At last, she came to our outpatient department on the advice of her neighbour.

Past history

Bronchial asthma was worse every summer from the age of 3 years. For these attacks, she used to take betnesol injections regularly till 2008.

Family history

  • Husband died due to cardiovascular attack 15 years back
  • No other significant family history.


Physical generals

  • Appetite – Satisfactory
  • Desires – fruits (+)
  • Thirst – Moderate
  • Bowels – Clay-coloured soft stool (+) for 4 years
  • Urine – D/N 5–6/1–2
  • Sweat – Profuse offensive perspiration all over the body (++), especially for the past 4 years
  • Sleep – Sleeplessness due to foot ulcer pain for 1 year (+)
  • Thermal reaction – Cannot tolerate cold in general; complaints < cold air (++).


Menstrual history

Attained Menopause at the age of 45 years.

Obstetric history

G2 P2 L2; all are full term normal delivery (FTNDs).

Life space investigation

Patient hails from a middle class Hindu family. Her children are married and settled. No specific worries are there except her health problem (DFU), to bother her.

Mental disposition

  • Irritable in nature (++)
  • Lost hope of recovery.


General physical examination

  • Built - lean and tall
  • Left inguinal lymphadenopathy +
  • Blood pressure – 140/80 mmHg, Pulse rate – 74/min, Heart rate – 74/min, Respiratory rate – 16/min, temperature – 99°F.


Local examination

The ulcer was located in the middle of left sole, deep extending up to the muscles, with shelving edge, exudated floor, severe tenderness and horribly offensive discharge. The surrounding skin was warm to touch.

Investigations

  • Fasting blood sugar – 160 mg/dl
  • PPBS – 300 mg/dl.


Clinical diagnosis

Diabetic foot ulcer.

Totality of symptoms

  • Irritable
  • Despair of recovery
  • Desires fruits
  • Perspiration profuse and offensive
  • Intolerance to cold air
  • Clay-coloured stool
  • Sleeplessness due to suffering
  • Ulcer painful with profuse foul-smelling discharge
  • Bleeding gums.


Selection of remedy

Based on the repertorisation result [Chart 1] together with the excessive sensitivity to cold air, local pathology and associated history of respiratory symptoms, Hepar sulph was selected and prescribed in the 30th potency.



General management

Calendula ф (mother tincture) was prescribed for external application. The dressing was done by herself and at our clinic. She was advised to continue insulin doses as prescribed by her endocrinologist and to take adequate rest and proper diet.

Follow-up and outcome

The ulcer and the associated symptoms were monitored as per the DFU Assessment Scale developed by Council for Research in Homeopathy [Table 1].[5] During treatment, sugar levels of the patient and the dosage of insulin were monitored by the endocrinologist once in a month. At the beginning of the treatment, due to severe infection of the ulcer [Figure 1] and high blood sugar levels (FBS 160 mg/dl; PPBS 300 mg/dl), high doses of insulin (15 units twice daily) were given. During 4th follow up, the discharge had reduced in quantity and the scoring as per DFU assessment scale reduced to 19 [Figure 2].
Table 1: Follow-up with diabetic foot ulcer assessment scale

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Figure 1: Ulcer on 13th April, 2015

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Figure 2: Ulcer on 17th August, 2015

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After 6 months of treatment with Hepar sulph, the localised infection reduced in severity which was reflected in the percentage of improvement in the ulcer (51.9% –moderate improvement) [Figure 3] along with lowering of the blood sugar levels (FBS 140 mg/dl; PPBS 220 mg/dl). Hence, the insulin doses were tapered to 10 units twice daily. The ulcer continued to show signs of healing during 9th month of treatment [Figure 4] together with persistent reduction in blood sugar levels.
Figure 3: Ulcer on 12th October, 2015

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Figure 4: Ulcer on 21st December, 2015

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After about 10 months of treatment with Hepar sulph, there was marked reduction in infection and marked healing of the ulcer (85.2% improvement as per the Diabetic Foot Ulcer Assessment Scale) [Figure 5]. The blood sugar levels were also lowered (FBS 110 mg/dl; PPBS 160 mg/dl) and hence the insulin doses were tapered to 5 units twice daily. All these parameters and required doses of insulin were monitored by endocrinologist. The facility for carrying out HbA1C was not available at the centre. Hence, it could not be done. The detailed follow-up of the case has been presented in [Table 1].
Figure 5: Ulcer on 14th March, 2016

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The Modified Naranjo Criteria, proposed by the clinical data working group of the Homeopathic Pharmacopoeia of the United States, for assigning the causal attribution between homoeopathic medicine applied to the changes occurred in the patient, have been applied to this case and the total score of outcome is 9 [Table 2].[7]
Table 2: Assessment of outcome with Modified Naranjo Algorithm

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  Discussion Top


This case report describes usefulness of homoeopathic treatment in chronic diabetic foot ulcer. Chronic DFU who has opted homoeopathic treatment due to recurrence of the ulcer in spite of effective conventional regimen. The homoeopathic remedy Hepar sulph, selected based on the tendency to suppuration, marked sensitivity to cold air, profuse perspiration and the history of respiratory affections, caused significant improvement in the local symptoms (marked improvement of the ulcer as per the Diabetic Foot Ulcer Assessment Scale) along with other symptoms such as sleeplessness, bleeding gums, constipation and the blood sugar levels of the patient [Table 1]. The total score of outcome 9 as per the Modified Naranjo Criteria, in this case, shows the definite causal attribution of homoeopathic treatment with the outcome.[7]

As per literature, Hepar sulph is an important remedy for tendency to suppuration, chilliness and hypersensitiveness.[8]

In a prospective observational study conducted by Central Council for Research in Homoeopathy, the homoeopathic drugs Silicea, Sulphur, Lycopodium, Arsenicum album and Phosphorus were found to be useful in the treatment of DFU with statistically significant results,[5] emphasising the effectiveness of Homoeopathy in the treatment of DFU. In this case report Hepar sulph, the remedy of choice as per the totality of symptoms of the patient, was found useful in the treatment of DFU.

Thus, the case shows the usefulness of homoeopathic treatment based on holistic approach in the management of DFU.


  Conclusion Top


In spite of the multidisciplinary management currently available, DFUs are still associated with considerable morbidity and disability. In this particular case, the chronic DFU which was resistant to conventional management responded well to the homoeopathic treatment with improvement in the general health apart from the healing of the ulcer. Thus, this case shows the positive role of Homoeopathy in the management of DFU.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.

 
  References Top

1.
Haslett C, Chilvers ER, Boon NA, Colledge NR, editors. Davison's Principles and Practice of Medicine. 19th ed. New Delhi: Elsevier Publishers India Ltd.; 2004. p. 641-82.  Back to cited text no. 1
    
2.
Ramachandran A, Snehalatha C, Shetty AS, Nanditha A. Trends in prevalence of diabetes in Asian countries. World J Diabetes 2012;3:110-7.  Back to cited text no. 2
    
3.
Kim PJ, Steinberg JS. Complications of the diabetic foot. Endocrinol Metab Clin North Am 2013;42:833-47.  Back to cited text no. 3
    
4.
Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes 2015;6:37-53.  Back to cited text no. 4
    
5.
Nayak C, Singh V, Singh K, Singh H, Gupta J, Ali MS, et al. A prospective observational study to ascertain the role of homeopathic therapy in the management of diabetic foot ulcer. Reprint Indian J Res Homoeopathy 2012;6:22-31.  Back to cited text no. 5
    
6.
Mahesh S, Mallappa M, Vithoulkas G. Gangrene: Five case studies of gangrene, preventing amputation through Homoeopathic therapy. Indian J Res Homoeopathy 2015;9:114-22.  Back to cited text no. 6
  [Full text]  
7.
van Haselen RA. Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline. Complement Ther Med 2016;25:78-85.  Back to cited text no. 7
    
8.
Boericke W. Pocket Manual of Homoeopathic Materia Medica and Repertory. Reprint Edition. New Delhi: B Jain Publishers (P) Ltd.; 1998. p. 325-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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