Management of chronic non-healing wound by Hirudotherapy

A chronic wound is that wound which does not heal in an regular set of stages and in a expected amount of time or wounds that do not heal within three months are often considered chronic. Chronic wounds often remain in the inflammatory stage for long time. and some never heal or may take years together . Chronic wound patients most often report pain as dominant in their lives. It has been observed that Persistent pain is the main problem for patients with chronic ulcers. Many wounds shows no challenge to the body's innate ability to heal; some wounds, however, may not heal easily either because of the severity of the wounds themselves or because of the poor state of health of the individual. Keywords;-Wound, Hirudotherapy, chronic, healing, Epidermis. INTRODUCTION Wound is a sore on the skin or a mucous membrane with disintegration of tissue. An erosion or Wound can result in complete loss of the epidermis and most often portions of the dermis and even subcutaneous fat. A wound that appears on the skin is often visible as an inflamed tissue with an area of reddened skin. Wound can also be caused due to restricted movements or complete lack of mobility, which causes constant or prolonged pressure on the tissues. This stress in the blood circulation is transformed to a skin wound, commonly known as bedsores or decubitus ulcers.[9]. Patients may feel pain on the skin around the wound, and fluid may ooze from the wound. In some cases wound can bleed and, rarely patients experience fever. Ulcers develop in stages. Chronic ulcer symptoms usually include increasing pain, friable granulation tissue, foul odour, and wound breakdown rather than healing. Ulcers may also appear on the cheeks, soft palate, the tongue, and on the inside of the lower lip. These ulcers mostly last from 7 to 14 days and often appears painful. OBJECTIVE: The main objective of this study is to provide alternate and inexpensive treatment to cretin dermatological/Surgical problems. ETIOLOGY: Beyond poor circulation, neuropathy, and difficulty in moving. Factors that contribute to chronic wounds include systemic illnesses, age, and repeated trauma. Ailments that may contribute to the formation of chronic wounds include vasculitis, decreased or suppressed immunity, pyoderma gangrenosum, and some diseases that may cause ischemia. Immune suppression can be caused by illnesses or medical drugs used for long period, for example steroids. Emotional stress can also negatively affect the healing of a wound, possibly by raising blood pressure and levels of cortisol, which lowers immunity. One of the predominant factor that may lead to chronic wounds is old age. Comorbid factors include chronic fibrosis, edema, sickle cell disease, and peripheral artery disease such as by atherosclerosis. Chronic wounds and ulcers are caused by poor circulation, either through cardiovascular issues or external pressure from a bed or a wheelchair. In present day time the uncontrolled environmental pollution and contamination including bacterial, viral, fungal infections and cancers have huge influence in chronic wound predisposition. Blood disorders and chronic wounds can result in chronic skin ulcers as well. Pathophysiology: In Chronic wound healing the normal process of healing is disrupted at one or more points in the phase of haemostasis, inflammation, proliferation remodeling and may affect only the epidermis and dermis, or tissues all Arsheed et al., World J Pharm Sci 2017; 5(2): 113-120 114 the way to necrosis..Since growth factors. cytokines, proteases, and cellular and extracellular elements all pay important roles in different stages of the healing process ,alteration in one or more of these components could account for the impaired healing observed in chronic wounds. CLASSIFICATION OF WOUNDS Wounds are classified by 'stage'.  Stage 1 wounds are characterized by redness or discoloration, warmth, and swelling or hardness.  Stage 2 wounds partially penetrate the skin.  Stage 3 describes full-thickness wounds that do not penetrate the tough white membrane (fascia) separating the skin and fat from the deeper tissues.  Stage 4 wounds involve damage to muscle or bone and undermining of adjacent tissue. They may also involve the sinus tracts. The Stages of Wound Healing:All wounds heal in three stages: 1. Inflammatory Stage, occurring during the first few days. The wounded area attempts to restore its normal state by constricting blood vessels to control bleeding. Platelets and thromboplastin make a clot. Inflammation (redness, heat, and swelling) also occurs and is a visible indicator of the immune response. White blood cells clean the wound of debris and bacteria. 2. Proliferative Stage, lasting about 3 weeks (or longer, depending on the severity of the wound). Granulation occurs, which means that special cells called fibroblasts make collagen to fill in the wound. New blood vessels form. The wound gradually contracts and is covered by a layer of skin. 3. Maturation and Remodeling Stage, lasting up to 2 years. New collagen forms, changing the shape of the wound and increasing strength of tissue in the area. Scar tissue, however, is only about 80% as strong as the original tissue. Infection Delaying Wound Infection: The wound may get infected by large number of bacteria (colonization) and will slow the healing process and The difference between contamination and colonization is only the concentration of bacteria present in the wound area. Anaerobic bacteria such as bacteroides, clostridium and streptococcus may be active at deeper levels of the dermis, insulated from the healing influence of oxygen. Anaerobic bacteria are responsible for many devastating infections resulting in gangrene and are more closely identified with superficial epidermal layers but may also be involved in infective processes and include staphylococcus epidermis, corynebacteria, propionibacteria. Use of Antibiotics in non-healing wound: In patients with non-healing wound the antibiotics are broadly used to overcome the risk of local infection, systemic involvement and ultimately to save the the patient from septicemia. Approximately four million cases of non-healing wounds are diagnosed annually in Europe and are clinically felt to be given a good antiseptic or antibiotic cover to save them from spreading the infection. Non-healing wound have been considered a negligible problem in society14. But patients with non-healing wound shows excessive usage of antibiotics. As early as 1998, Tammelin et al. reported that 60.1% of all ulcer patients were treated with one antibiotic within a six-month period while as a huge percentage of patients are needed to be put on dual or combined antibiotic therapy. Microbiology of chronic non healing wound: Entities like chronic venous insufficiency, arterial insufficiency, and pressure over time, can lead to the reduced respiration capacity of skin injuries, which can lead to non-healing wound. Bacteria will colonize within the wound if the protective barrier of the skin is broken. Therefore, the appearance of a chronic wound depends on several factors. These factors also contribute to the development of infections in the ulcer.16 There are often multiple types of bacteria observed within a single wound, For example, the flora usually found in cases of venous ulcers of the legs include Staphylococcus aureus (90.5%), Enterococcus faecalis (71.7%), and Pseudomonas aeruginosa (52.2%).17 The bacterial flora found in a non-healing wound change as the wound ages. Staphylococci and streptococci bacteria are normally found in new wounds, while gram negative mixed flora are often found in older wounds. In addition, different types of ulcers are influenced by different types of bacteria. For example, a clinical infection will develop in 60% of diabetic foot ulcers but only 20% of venous leg ulcers that are colonized by Staphylococcusaureus 18. Between 1.6 and 4.4 species of bacteria are found per wound by conventional culturing methods7. However, molecular biological methods suggest that even more species of bacteria are present in the average ulcer.8 The number of ulcers with anaerobic bacterial growth is estimated to be between 25% and 82%. The most common anaerobic bacterial species are Peptostreptococcus and Prevotalla.19,20,21. Recent research has indicated Arsheed et al., World J Pharm Sci 2017; 5(2): 113-120 115 that the presence of bacterial biofilm contributes to the development of chronic wound. Studies performed by James et al. have shown that biofilm is present in 60% of chronic ulcers but only 6% of acute ulcers.22 This supports the view that biofilm probably plays an important role in the formation of chronic wounds. Systemic factors Local factors Metabolic diseases, such as diabetes mellitus Size of the ulcer Systemic diseases, such as rheumatic diseases Age of the ulcer Other forms of chronic disease, such as HIV infection Location of the ulcer Old age Local circulation Malnutrition / poor diet Necrosis Alcohol / narcotics abuse Suppuration and maceration Medicines, such as steroids, oestrogens, and vitamin K