1General Practitioner, Department of Health, Hajtaleb Medical Complex of Alternative and Complementary, Bojnurd, Iran, Islamic Republic Of
2General Practitioner, North Khorasan University of Medical Sciences, Bojnurd, Iran, Islamic Republic Of
3Pharmacy Student, Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
Introduction: Diabetic foot ulcer is among the serious problem for diabetic patients, so that the annual incidence of this problem is from 0.1% to 4.1% in diabetic patients and the probability of its incidence is over 25% during the diabetic individual's life. Case Presentation: The patient was a 74-year-old woman with diabetes for more than 20 years and hospitalized with complaint of diabetic foot ulcers, and uncontrolled blood sugar, and sepsis at Emam Reza hospital of Bojnurd in March 2014. She was under the primary treatment of sugar control drugs and infection control. The patient's foot ulcer did not respond to current treatments, and the amputation order was made by Orthopedist's advice for patient. The patient referred to traditional medicine clinic for counseling. The patient had a sore on big toe of right foot and the severe inflammation was spread over the other fingers and continued to ankle. The wound had cyanosis and severe infection for at least two months. During this time, the patient was treated with modern medicine methods which did not have effective treatment result, so that the patient's wound and overall health situation was getting worse every day. After entering the traditional medicine clinic, the patient was under the control of health and nutrition. Pharmaceutical measures in this patient were according to disease temperament and conditions including the medicinal herbs, combination drugs, and modern blood sugar control drugs. The manual measures were utilized including full back cupping every night until the end of therapy, and leech therapy inside and around the wound with 6 medium to fine-size leeches in 10 sessions once every 3 days. The diabetic foot ulcer healed completely, the patient's physical and mental states improved, and her blood sugar is controlled after 40 days of treatment. Conclusion: Given the patient's healing process, it seems that combining the modern and Iranian traditional medicine as Iranian Effective Medicine can treat most of the common diseases and it is essential to perform a wide range of assessments and studies in different diseases based on the teachings of medicine.
Diabetic Foot Ulcer; Leech Therapy; Traditional Medicine; Modern Medicine; Iranian Effective Medicine
Diabetes mellitus is one of the oldest known human diseases  which refers to a group of metabolic disorders which more than 150 million people worldwide and nearly 3 million people in Iran have, and has significant unknown cases [2-3]. Based on the available information, it is estimated that the prevalence of diabetes will reach 300 million in 2025, so that its prevalence was 2.8% in all age groups around the world in 2000 and will reach 4.4% in 2030.  According to the deaths and disabilities caused by complications of diabetes and its enormous economic burden, this disease is considered as an important health problem [1-4]. Nowadays, more than 2.5 million people, equivalent to 6%, suffer from this disease in Iran. The prevalence of diabetes is increasing in Iran like other developing countries [2-3]. This disease causes death and disability by making multiple macro and micro vascular complications . The diabetic foot ulcer is among the serious problems in these patients. According to studies, the annual incidence of this problem is from 0.1% to 4.1% in diabetic patients, so that its lifetime risk is over 25% for diabetic person. This complication leads to amputation in 15 to 20 percent of patients . Based on a 22-year retrospective study in Iran, this figure has been increased to 30% . The features of diabetic foot ulcers include infection, wound and corruption of organ. In other words, the causes of diabetic foot ulcer include the structural deformities, peripheral neuropathy, ischemia, infection, Edema and callus. In most of the patients, a set of neuropathy, minor trauma and structural deformities lead to ulceration; and the ischemia and edema are at the later levels. The peripheral neuropathy is among the leading cause of diabetic ulcers and is seen in more than 50% of diabetics over 60 years of age with different degrees . The increased microvascular permeability and decrease in arteriolar response to various stimuli are the other mechanisms which have been proposed until now . The treatment of diabetic foot ulcer is very complicated and requires great care. Furthermore, the strategy of these treatments also requires familiarity with classification of diabetic foot ulcer. Nowadays, the comprehensive Wagner and Texas' Diabetic Wound Classification properly indicates the type of treatment and prognosis of diabetic foot. The current treatments for diabetic foot ulcers include the adequate control of blood sugar, appropriate antibiotic treatment, debridement of necrotic tissues, reduced mechanical stress, washing and dressing regularly, and improving the blood flow situation if possible [7-9]. The impaired wound healing is one of the major problems in treatment of diabetic foot ulcers despite the medical procedures and it may last for several months and even years. These chronic ulcers create disability and are also prone to infections particularly deep infections such as Osteomyelitis which may lead to amputation. Treatment of diabetic foot ulcers is one of the medical problems. Several therapies have been introduced for treatment of these wounds . On the other hand, the infection around the wound often occurs as a result of different organisms and needs to cover some kinds of pathogen. Furthermore, most of the pathogens are resistant to various antibiotics, so the use of non-antibiotic therapies may be effective in prevention of antibiotic resistance and more accepted by patient and also spend less money . On the other hand, all treatments for diabetic foot ulcers have partial effects in healing wound or preventing the amputation. Therefore, it is necessary to evaluate the new combination drugs and methods with the highest therapeutic effect in the shortest time and report them scientifically based on an integrative school of modern and Iranian traditional medicine as Iranian Effective Medicine (IEM).
Medical History andExaminationaccording to ModernMedicine
The patient was a 74-year-old woman with diabetics and a history of diabetics over 20 years and also high blood fat. She was housewife, illiterate, living and born in Bojnurd city, weighing about 80 kg and has a height of 150 cm. She was hospitalized with complaint of right foot diabetic foot ulcers, pain and wound infections along with fever, malaise and lack of blood sugar control and sepsis at Emam Reza hospital of Bojnurd City in March 2014 and was put under the early treatment including the blood sugar and infection control medicines. Her foot ulcers did not respond to current treatments and the Orthopedist ordered for patient's amputation. Guided by an acquaintance, the patient referred to Hajtaleb medical center of traditional and modern medicine for treatment. The patient had type-2 diabetes for nearly twenty years and was under the oral treatment with Glibenclamide 5 mg tablet three times daily and Metformin 500 mg tablet twice a day. She had Fasting blood sugar (FSB) of 210 and Glycosylated haemoglobin (HbA1C) of 10.5%. The patient had cardiovascular risk factors including; 1) smoking 20 cigarettes per day and consumption of opium, 2) body mass index of 35.55; in other words, obesity and hyperlipidaemia for ten years and under the treatment by Atorvastatin 20 mg once a day, 3) lack of sufficient mobility. The patient's vital symptoms were as follows: temperature: 39 °C, respiratory rate: 18 per minute, pulse rate: 90 per minute, blood pressure: systolic 140 mm Hg to diastolic 90 mm Hg. The big toe wound in the right leg (Right 1WR) which was equivalent to STAGE D/GRADE II according to clinical examination by traditional medicine physician based on the standards of Texas University diabetic wound classification system  and equivalent to GRADE 4 based on the standards of Wagner comprehensive system for wound diabetic foot . In other words, the patient had an infected wound in big toe of right foot and the severe inflammation reached the other fingers and continued to the ankle. The wound had severe cyanosis and infection started in a few months ago. The patient was treated with modern methods during this time and they had not lead to effective healing and thus the patient's health situation was getting worse every day. The wound was just as a small point and it became larger due to the lack of response to treatment over time. Furthermore, the patient suffered from anxiety and depression due to the awareness of amputation in her right leg, and she had fever, malaise and heart palpitations due to the wound infection and inflammation.
Medical History and Examinations according to Iranian Traditional Medicine
In the field of preventive medicine and maintaining health and proper lifestyle along with healthiness, the patient did not have temperament of food and drugs and the principle of balance preservation and cleaning the body and keeping the essential materials; in other words, she did not observe the treating physicians; advice on avoiding and implementing the principles of health. The patient's innate temperament (congenital) was cold and wet, and her Acquired temperament (current) was associated with melancholic and phlegmatic temperaments, so that her wetness was higher. Given that the patient was old and also drug addicted, her dry bowel was obvious. According to examinations, the patient had weak pulse with little intensity. In touching the patient's body, despite the dominance of phlegm, there was also clearly dryness and she had constipation and inappropriate defecation. She had had mental and nervous depression and was highly anxious. There was not any problem in heart Auscultation, and not any problem in abdominal examination. In general, the patient did not have any serious medical problem in clinical examination other than infectious diabetic foot ulcer.
Measures to Protect Health and Nutrition:
Remedial measures for patient started on 11/03/2015. These measures were first along with nutritional advice and essential recommendations. A CD including the nutrition practices was given to patient to help the treatment by learning manners and principles of nutrition in traditional medicine. Given that the patient had dominant cold and dry, she was prohibited from eating the cold and sour foods such as buttermilk, yogurt, vinegar, ice water, and salad. Her companions were advised to be happy with her in their commands due to her depressed state. Due to being diabetic, she was advised not to use cigarette, but since she was addicted to drug and smoking, she could not completely cut off the cigarette, but decreased the number of smoking.
The medical herbs and combination drugs were used in this patient due to her temperament and condition. In this case, the medical herbs included the chamomile, hibiscus, thyme, mint, black seed, and marigold were used as the anti-inflammatory and mucus herbs, and Rose and Securigera Varia Leaves used as cathartic; and the wound was dressed by honey every night until the end of treatment. Furthermore, the recommendations were also given to patient for modern diabetic treatment including Glibenclamide 5 mg tablet twice a day.
1- Full cupping of back every night until the end of treatment process.
2- Leech Therapy inside and around the wound with 6 medium-to-small-size leeches for ten sessions once every 3 days.
The patient underwent 10 sessions of Leech Therapy and the sensitive stages were photographed. The following cases were taken into account in Leech Therapy according to patient's age and dominated melancholic and phlegmatic temperaments:
A) Given the patient's anemia and dominated phlegmatic temperament and also to prevent phlegmatic disease due to blood loss by leeches and not added dryness to body, the patient drink was increased and smaller leeches were used.
B) To maintain physical force in patient during Leech Therapy, the periods between Leech Therapies were enhanced at two stages of Leech Therapy to give the natural reconstruction opportunity to patient's body.
Given the combination of modern and traditional medical methods, the patient's general condition was tangibly improved after the second week as there were not any fever, malaise, depression, stress and anxiety. Her vital symptoms and blood sugar were controlled and recorded at the normal range. After a week of started treatment, the granulation tissue was created in wound, and the wound was completely healed in a month. Inflammation, infection and gangrene conditions of right big toe were fully recovered after four days of treatment. Figures 1 to 4 show the treatment processes of diabetic foot ulcer. The patient situation was followed for 2 months and no recurrence was observed.
Due to hard-to-treat response, the diabetic foot ulcer is among the common problems in complications of type 2 diabetes . Morbidity and high cost of treating these injuries impose a significant burden on individual and community health system [3-2]. In this report, the examined patient had diabetic foot ulcer which did not respond to common treatments. Nowadays, all treatments of diabetic foot ulcers have partial effects on wound healing with ability to avoid amputation. Therefore, this report attempts to use the most effective and safest methods in modern and traditional medicine schools for patient's healthcare and treatment by integrating these medical schools and thus reporting them scientifically as IEM.
In summary, there is not any specific definition of diabetic foot ulcer in describing its causes in traditional medicine, so that there is not any specific diagnosis and treatment method for diabetic foot ulcer in traditional medicine based on the evidence contained in traditional medicine books. According to a major problem for diabetes in traditional medicine, it is called as diabetes mellitus which is quite different from physiopathology of diabetes. Therefore, it can be concluded that the traditional medicine does not have special definition for diabetes, but these patients can be helped by traditional medicine knowledge. In other words, if we want to treat diabetes and diabetic foot ulcer according to the texts of traditional medicine, we will not be successful. However, a physician, who knows the physiopathology of diabetes according to modern medicine and also knows the traditional medicine, can effectively combine these two schools of therapy to cure this disease and its complications.
New solutions have been introduced for treatment of diabetic foot ulcer during the past decade and they reduce the size of ulcers and treat the diabetic ulcers, so that several topical drugs have been now introduced and studied for healing diabetic foot ulcer such as the growth factor gel, Tretinoin, and Angi Pars. Furthermore, several studies have found the positive effects of herbal medicines on treatment of diabetic foot ulcers [14-23].
Several studies have found that the modified lifestyle towards a healthy lifestyle including the use of healthy diet, proper nutrition, exercise, not smoking, and living with mental health can enhance the health indices even in a diabetic person, and thus the risk factors and diabetic complications can be significantly reduced [24-27]. This study provides the nutritional advice and essential recommendations in a CD including food practices for patient to help treatment by complying with principles of eating in traditional medicine. Furthermore, the herbs such as the chamomile, hibiscus, thyme, mint, black seed, and marigold are utilized in this patient as the anti-inflammatory and mucus herbs, and rose and Securigera varia leaves as laxatives. The active ingredient is more important in choosing the treatment methods in traditional medicine of Iran, and the temperament is put on the next priority. In other words, we first select plants which are strong in terms of antimicrobial and anti-inflammatory active ingredient and are compatible with patient's temperament. In effective cleaning and reforming medicine, we do not prescribe according to the method in traditional medicine sources, but we prefer to treat the simple mis-temperament and use the active ingredients, and give the effective cleaning and reforming if necessary for treating the physical mis-temperament. We believe that the mis-temperament is simple in a majority of patients; in other words, if the mis-temperament is treated and the herbs or herbal medicines with active ingredients are then prescribed, the recovery will be achieved and there is not any need for plowing the patient temperament and we did the same in this patient. In other words, we first give the melancholic and choleric cleaning and reforming medicine according to the active ingredient, and then prescribe the laxative, and do not extend the prescribed laxative.
Honey is used in healing wounds for centuries. Despite the fact that there are numerous reported cases for effectiveness of honey in wound healing, there is a little scientific evidence which supports this treatment. Several clinical assessment have indicated the effectiveness of honey in treatment of wounds and burns, however, the use of honey is limited to non-standard treatment. Furthermore, the studies have found that the honey also prevents the growth of bacteria, but the mechanism of this effect is not fully understood. In this patient, the everyday dressing with honey accelerated the wound recovery and thus the infection was fully treated [18, 23].
Unfortunately, there is not any conducted study on leech therapy in Iran. Due to aging and lack of physical ability, we could not get more blood from this patient. Furthermore, according to the patient's phlegmatic temperament, it was not permissible to get more blood and relative contraindications were blood and leech therapy in traditional medicine. Leech therapy had a saliva therapy approach in this patient, and thus there was no need for getting blood, but since the leech do not secrete saliva until it gets blood, we had to take blood by leeches according to the following points: A) the patient's drink was enhanced and the smaller leeches used. B) The interval between leech therapies was increased at two stages of leech therapy to give the patient's body the opportunity of natural reconstruction. In this patient, the saliva of leech was helpful for treatment and the active ingredient of leech saliva treated the diabetic ulcers by its anti-inflammatory, revascularization, antimicrobial and blood flow increase properties. In conclusion, given the history of medicine over the last century, it can be concluded that there is not any perfect medical school in the world of medicine; hence, the medical schools such as Iranian modern and traditional medicine, Ayurveda in India, Chinese medicine etc are effective in protecting the human health and treatment, which are the real purposes of medicine, we well as performing the medical services, but they also numerous strengths and weaknesses due to the lack of comprehensive.
Effective medicine as a combined school of two medical schools of modern and traditional medicine can have effective clinical findings in treating some diseases such as diabetic foot ulcers, so that the use of effective medicine in treatment of diabetic foot ulcer will need lower costs and reduce the use of antibiotics in people with diabetes. Therefore, according to the principles of schools, the modern and traditional Iranian medicine can be investigated and evaluated as a new non-invasive treatment which has the largest therapeutic effect in the short term.
List of Abbreviations
IEM: Iranian Effective Medicine
FSB: Fasting Sugar Blood
MMHG: Millimetres of Mercury
CD: Compact Disk
The authors have no conflict of interest in publication of this article.
This article is the outcome of treatment measures by Dr. Hassan Hajtalebi. Dr. Hassan Khani and Hamid Hajtalebi cooperated in documenting and writing the article.
The paper authors appreciate the patient and her family's cooperation to participate and complete all treatment and healthcare processes, and all nurses in Haj-Taleb medical center of traditional and modern medicine to perform treatment processes for patient.
1- Levin ME. Pathogenesis and management of diabetic foot lesion. In: Levin ME, O’Neal LW, Bowker JH, editors. The Diabetic Foot. 5th ed. St. Louis: Mosby; 1993. 17-60.
2- Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its-complitions. Part1: diagnosid and classification of diabetes mellitus, provisional report of WHO Consulation. Diabet Med 1998; 15(7): 539-53.
3- King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21(9): 1414-31.
4- Wild S,Roglic G,Green A,Sicree R,King H.Global prevalence of diabetes.Diabetes Care 2004; 1047- 1053
5- Wieman TJ, Smiell JM, Su Y. Efficacy and Safety of a Topical gel formulation of recombinant Human platelet-Derived growth factor- BB(Beclapermin) in patients with chronic Neuropathic Diabetic ulcers. Diabetes Care 1998; 21: 822-7.
6- Larijani B, Afshari M, Bastan Hagh MH, Pajouhi M, Baradar Jalili R, Moadi M . Prevalence of
lower limb amputation in patients with diabetic foot ulcer in Imam Khomeini and Shariati hospitals, 1979-2001. J Med Council of Islamic of Iran 2005; 1(23): 29-25. Persion.
7- Larijani B, Afshari M, Darvishzade F, Bastan Hagh MH, Pajouhi M, Baradar Jalili R, et al. Lower limb amputation in patients with diabetic foot ulcer: A 22 year review. MJIRC 2006;8(3):21-24.
8- Wagner FW. Supplement: algorithms of foot care. In: Levin ME, O Neal LW, editors. The diabetic foot. 3rd ed. St.Louis, MO, CV: Mosby;1983. 291-302.
9- Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 2001; 24(1):84-8.
10- Wieman TJ, Smiell JM, Su Y. Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebocontrolled double-blind study. Diabetes Care 1998;21(5):822-7.
11- McCulloch D, Asla R. Management of diabetic foot lesions. Up To Date Ver 18.1 (updated 31 Jan 2010).
13- Wagner. The diabetic foot. Orthopedics. .l987; 10: l63-l72.
14- Kargar, Saeid; Javadzadeh-Shahshahani, Hayedeh; Tabkhi, Naeimeh. The effect of platelet gel on treatment of diabetic foot ulcers. Research Quarterly of Blood. Winter 2009, Vol. 6 (No. 4): 91-283.
15- Ardeshir-Larijani, Mohammad-Bagher; Afshari, Mojgan; Fadaei, Manijeh; Bastan-Hagh, Mohammad-Hassan; Baradar-Jalili, Reza; Pajouhi, Mohammad; "Study on the Effect of local epidermal growth factor on wound healing in diabetic foot". Iranian Journal of Endocrinology and Metabolism. Summer 2003, Vol. 5 (No. 2): 107-110.
16- Moudi, Hesam; Akbari, Asghar; Ghiasi, Fatemeh; Mahmoudzadeh-Sagheb, Hamidreza; Heidari, Zahra; Rashidi, Homeyra. "The impact of transpression Vacuum-compression therapy (VCT) on healing the diabetic foot ulcers". Scientific Journal of Zanjan University of Medical Sciences. Winter 2006, Vol. 14 (No.57): 15-22.
17- Ataei-Fashtami, Leila; Esmaeili-Javid, Alireza; Kaviani, Ahmad; Ardeshir-Larijani, Mohammad-Bagher; Razavi, Laleh; Salami, Maliheh; Fateh, Mohsen; Fatemi, Seyed-Mostafa; Mortazavi, Seyed-Mohammad-Javad. The role of laser therapy in treatment of diabetic foot ulcers: a randomized, double-blind clinical trial: Medical laser. Fall and Winter 2008, Vol. 5 (NOs. 3-4): 6-11.
18- Zahmatkesh, Mohsen; Rashidi, Maryam. Report of a treatment case of diabetic foot ulcer by topical honey and olive oil. Medicinal Plants. 2008; Vol. 8 (No. 29): 36-40.
19- Bahrami, Amir; Ali-Asgarzadeh, Akbar; Sarabchian, Mohammad-Ali; Mobseri, Majid; Heshmat, Ramin; Ghoujazadeh, Morteza. "Double blind clinical trial for evaluating the effect of oral"Angi Pars" drug on chronic diabetic foot ulcers. Journal of Endocrinology and Metabolism. March 2009; Vol. 11 (No. 6): 647-55.
20- Kashef, Nasim; Shojaeifard, Abolfazl; Esmaeili-Javid, Alireza; Mohajeri, Mohammadreza; Rezaei, Razieh; Salami, Maliheh; Ghodsi, Maryam; Fateh, Mohsen. Study on the low-power laser in treatment of chronic diabetic foot ulcers: microbiological quantitative assessment. Medical laser. Summer 2009, Vol. 6 (No. 2): 31-35.
21- Kazemikhou, Noushafarin; Khamseh, Mohammad-Ebrahim; Hashem-Dabbaghian, Fattaneh; Hajizadeh, Mitra; Akrami, Seyed-Mohammad. "The study on the effects of low-power laser in treatment of diabetic foot ulcers grades 2 and 3 (short report)". Iranian Journal of Diabetes and Metabolism (Iranian Journal of Diabetes and Lipid). 2008; Vol. 8 (No. 2): 195-202.
22- Amini, Sareh; Rezaei-Homami, Mohsen; Anabestani, Zohreh; Shaygan-Mehr, Zahra; Ardeshir-Larijani, Mohammad-Bagher; Mohajeri-Tehrani, Mohammadreza. "The effect of low-frequency ultrasound on diabetic foot ulcers with osteomyelitis in a randomized clinical trial". Iranian Journal of Diabetes and Metabolism (Iranian Journal of Diabetes and Lipid. June and July 2011; Vol. 10 (No. 5): 543-52.
23- Khadem-Haghighian, Hossein; Koushan, Yaghoub; Asgarzadeh, Akbar-Ali. Report of a treatment case of diabetic foot ulcer using propolis heated in olive oil, (brief report)". Journal of knowledge and health. Winter 2011, Vol. 6 (No. 4): 35-38.
24- Ardeshir-Larijani, Mohammad-Bagher; Afshari, Mojgan; Bastan-Hagh, Mohammad-Hassan; Pajouhi, Mohammad; Baradar-Jalili, Reza; Maadi, Mansoureh. "Study on the prevalence of lower limb amputation in patients with diabetic foot ulcer at Shariati and Imam Khomeini Hospital from 1969 to 2001". Scientific Journal of IRI Medical Council. Spring 2005, Vol. 23 (No. 1): 25-29.
25- Keshavarzi, Azam; Larijani, Bagher; Mohajeri-Tehrani, Mohammadreza. "Modern treatment of diabetic foot ulcer (reviewed article). Scientific Journal of IRI Medical Council. Winter 2011, Vol. 29 (No. 4): 90-376.
26- Alami-Harandi, Bahador; Alami-Harandi, Armin; Siavashi, Babak. "A review of diabetic foot ulcers and its new therapeutic approaches". Journal of Iranian surgery; Winter 2008; Vol. 16 (No. 4): 1-7.
27- Ghanei, Laleh; Harati, Hadi; Hadaegh, Farzad; Azizi, Fereydoun. "Study on the impact of lifestyle change on incidence of type II diabetes over a 3.5-year study: Tehran Lipid and Glucose Study". Research on medicine. Spring 2009, Vol. 33 (No. 1): 21-29.