Overview of Leech Therapy as an Alternative Treatment for Varicose Ulcers: Mechanisms and Efficacy

 

Mohd. Maruf Khan¹, Akanksha Mishra²

¹Department of Ilaj Bit Tadbeer, H.S.Z.H. Government Autonomous Unani Medical College,

Bhopal, 462003, Madhya Pradesh, India.

²Centre of Excellence in Biotechnology, Madhya Pradesh Council of Science and Technology,

Bhopal, 462003, M.P.

 

ABSTRACT:

Varicose ulcer, the most severe and debilitating complication of chronic venous insufficiency in the lower limbs, impart substantial obstacles in medical management because of their chronicity and propensity for recurrence. About 80 percent of ulcerations on the lower extremities are triggered by varicose ulcer. Despite advances in diagnosis and treatment, varicose ulceration remains a major healthcare concern due to its potential for life-threatening complications. The morbidity has a detrimental effect on life expectancy. Venous ulceration results from persistent venous pressure brought on by venous insufficiency. Although the diagnosis is primarily clinical, it must be distinguished from other lower limb ulcer causes. Reduction of edema, enhancement of ulcer healing, and avoidance of recurrence are the objectives of treatment. Although conservative care, mechanical treatment, pharmaceutical, and surgical methods are available for the treatment of venous ulcers, but Hirudotherapy, also known as leech therapy, has grown into a prominent complementary treatment option. It has the potential to promote wound healing and alleviate varicose ulcer symptoms. The objective of this review is to accord a thorough overview of the application of leech therapy to the management of varicose ulcers. The present study emphasizes on the mechanisms of action, efficacy and safety profile of leech therapy in the context of managing varicose ulcers by synthesizing a collection of available literature, clinical investigations, and case reports.

 

 

INTRODUCTION:

Venous ulcers, also known as stasis ulcers, are typically chronic wound that often develop on the skin and are extremely painful. It accounts for 80 percent of all lower extremity ulcers.¹ Ulceration can also be caused by vascular insufficiency, prolonged pressure, diabetic neuropathy, and systemic illnesses such rheumatoid arthritis, vasculitis, osteomyelitis, and skin cancer.² Women and the elderly are more likely to develop venous ulcers.^3–5

 

Venous ulcers are frequently recurring, and open ulcers can last from a few weeks to several years. Cellulitis, osteomyelitis⁶, and malignant transformation are all serious consequences.³

 

Although the overall incidence is low, the refractory nature of these ulcers raises the risk of morbidity and mortality and has a substantial impact on patient quality of life.^7,8

 

The main risk factors of varicose ulcer include⁹-

1. Chronic Venous Insufficiency (CVI): It is a disorder in which the valves in the veins of the legs are weakened or destroyed, resulting in inefficient blood flow back to the heart. Chronic venous hypertension produces venous dilatation, which can lead to ulcer development.

2. Varicose Veins: These are swollen, twisted veins that are frequently caused by weakening vein walls and nonfunctional valves. These veins can cause blood accumulate in the lower legs, which raises the risk of ulcers.^10,11

3. Previous History of Venous Ulcers: People who have had venous ulcers prior are more likely to be affected by them again.

4. Obesity: Excess body weight exerts additional pressure on the veins, resulting in venous insufficiency and an increased risk of ulcers.

5. Age: Aging is connected with decreased flexibility of blood vessels and weakening vein walls, rendering the elderly more vulnerable to venous insufficiency and ulcers.

6. Gender: Women are more likely than males to develop varicose ulcers, which might be attributed to hormonal changes between pregnancy and menopause.

7. Prolonged Standing or Sitting: Jobs or lifestyles that require extended periods of standing or sitting might compromise blood circulation in the legs, increasing the risk of venous congestion¹², varicose vein¹³ and ulcer development.

8. Leg Trauma or Injury: Previous leg injuries or trauma can damage veins and decrease circulation, making people more likely to develop ulcers.

9. Deep Vein Thrombosis (DVT): DVT is a disorder in which blood clots form in the legs' deep veins, which can cause venous blockage and raise the risk of ulceration.¹⁴

10. Smoking: Smoking harms blood vessels and affects circulation, worsening venous insufficiency and increasing the incidence of ulcers.

11. Diabetes: Diabetes can decrease blood vessel function and wound healing, increasing the incidence of chronic ulcers, particularly varicose ulcers.

12. Peripheral Arterial Disease (PAD): PAD is a disorder characterized by constricted arteries in the legs, which reduces blood flow. Individuals with combined venous insufficiency and PAD are more likely to develop ulcers.

 

Pathophysiology:¹⁵

The body's circulatory system is a sophisticated network of blood vessels; if they are damaged or infected, skin deterioration may result or a superficial wound may not heal. Veins are frequently closer to the skin than arteries and typically transport deoxygenated blood to the heart. The majority of veins have one-way flaps or valves to stop blood from accumulating in the lower legs and from flowing backward. Blood may return when these valves become ineffective due to illness or damage. As a result, the deep vein system experiences an increase in pressure, which causes the vein walls to expand. This opens the valves and permits even more blood to fill the veins. There are two types of veins: superficial and deep. Near the skin's surface are superficial veins that lack matching arteries. The longest superficial vein in the lower leg is the saphenous vein, which connects to the femoral vein at the sapheno-femoral junction at the top of the thigh from the dorsal vein near the big toe. Deep veins are located far deeper into the leg, and they are all accompanied by comparable arteries that share names. The femoral and perineal veins are two examples. One of the primary causes of venous hypertension, deep vein thrombosis (DVT), is caused by blood clots that develop in the deep veins. One-way valves on perforator veins allow them to link the superficial and deep vein systems.

 

The Diagnosis and Clinical Presentation:

Planning for appropriate venous ulcer care requires an understanding of the etiology of the ulcer. Vein ulcers can be distinguished from other lower extremity ulcers by distinctive variations in their clinical presentation and physical examination results.² Venous ulcers are typically diagnosed clinically; however, in questionable instances, tests including venography, plethysmography, ankle-brachial index, and color duplex ultrasonography may be useful.^16–18

 

Treatment and Management:

A vascular ulcer can be healed in a lot of circumstances. Early treatment of vascular ulcers is essential for a successful outcome, as the likelihood of the ulcer healing relies on the severity to which it has grown. Conservative management, mechanical therapy, pharmaceutical, and surgical treatments are available for the treatment of venous ulcers^2,19,20. (Table 1) Reducing edema, promoting ulcer healing, and averting recurrence are the objectives of venous ulcer therapy. .

 

Management of varicose ulcers is still difficult and frequently calls for a multimodal approach, even with advancements in wound care. When it comes to wound healing, there has been a resurgence of interest in the old medical practice of leech therapy³⁶. Leech therapy is considered to be the best management method due to its high efficacy and safety.³⁷ Hirudotherapy, or leech therapy referred to as Irsal-e- Alaq in Unani Medicinal system is a blood sucking process where with the help of medicinal leeches various diseases are prevented as well as treated. Hirudo medicinalis were used to draw blood from patients in early modern and medieval medicine in an effort to balance the "biological humours." They are following four humours in Unani, or traditional Arabian medicine: phelgm, yellow bile, black bile, and blood. The concept of "biological humours" is seen as essential to Arabian medicinal philosophy.

 

Leeches are carnivorous, blood sucking annelid worms^38,39. There are roughly 45 different species of leeches in India, divided into 22 genera. Hirudinaria granulosa, an Indian leech, has therapeutic properties. Leeches can either bite or puncture the skin using their proboscis to draw blood. Because of the release of a chemical histamine-like substance, this is comparable to a mosquito bite and is painless. In order to prevent patients from feeling the bite, leech saliva also contains an anesthetic. Furthermore, saliva contains a substance that inhibits blood coagulation. The anesthetic effects of a leech bite, however, could be impacted by certain conditions including cold skin, smoking, or aging.

 

Table 1. Treatment Method of Varicose Ulcer

TREATMENT OF VARICOSE ULCER
1.      Conservative Management
a. Compression therapy	Standard of care; demonstrated effectiveness (intermittent pneumatic therapy's benefit is less evident); linked to a lower incidence of ulcer recurrence	2,19,20
b. Leg elevation	reduces edema; suggested for thirty minutes, three or four times daily; Standard of care when used with compression therapy	21,22
c. Dressing	None of the dress type is worthier	23,24
2.      Mechanical Treatment
a. Topical negative pressure (vacuum-assisted closure)	Insufficient evidence to support its use in treating venous ulcers	25
3.      Surgical Management
a. Human skin grafting	More research is required to prove the benefit.	26
b. Debridement	More research is required to prove the benefit.	27,28
c. Venous insufficiency Surgery	May be helpful in situations that are severe or resistant; linked to a lower risk of ulcer recurrence	19,29,30
d. Artificial skin	Possibly advantageous when used with compression therapy; potential for infection transmission	31
4.      Medications
a. Aspirin	Useful in conjunction with compression therapy; take 300 mg once daily.	32
b. Iloprost	The use of intravenous injection is not recommended due to insufficient data, despite potential benefits; High expense prevents use	33
c. Oral Zinc	Not demonstrated to be advantageous	34
d. Hyperbaric oxygen therapy	No evidence of benefit	29
e. Antibiotics	In situations of suspected cellulitis, oral antibiotic treatment is necessary; regular systemic antibiotic use has no healing effect; and it's unclear whether adding the topical antiseptic cadexomer iodine will be beneficial.	1
f. Pentoxifylline (Trental)	Beneficial when combined with compression therapy; could also be used alone	35

 

Mechanism of Action of Leech Therapy:

A combination of pharmacological, biochemical, and mechanical factors work together to provide therapeutic benefits in leech therapy. A wide range of bioactive compounds, such as anticoagulants, vasodilators, anti-inflammatory agents, and antimicrobial peptides, are found in leech saliva⁴⁰. These compounds work together to increase tissue perfusion, decrease inflammation, stop bacterial growth, and encourage the formation of angiogenesis and granulation tissue.

 

The effectiveness of leech therapy in the treatment of varicose ulcers has been the subject of numerous investigations and evaluations. Following are the key findings-:

1. Promotion of Blood Circulation: Through their bite, leeches encourage blood circulation, which enhances tissue oxygenation and the delivery of nutrients to the area that has been ulcerated. This improved blood flow may help wounds heal more quickly.

2. Anti-inflammatory Properties: The anti-inflammatory substances found in leech saliva may aid in lowering tissue inflammation in ulcers. The application of leech therapy has the potential to promote wound healing by reducing inflammation.

3. Antimicrobial Effects: A few leech saliva constituents have antimicrobial qualities that may aid in preventing bacterial colonization and infection, two frequent problems linked to varicose ulcers.

4. Pain Relief: Due to the analgesic qualities of some of the chemicals found in leech saliva, leech therapy has been observed to relieve pain in individuals with varicose ulcers.

5. Collagenesis: Research evidence suggest that leech therapy could increase the synthesis of collagen in the wound bed, fostering tissue regeneration and hastening the healing process.

 

Practical Issues and Future Prospects:

It is imperative to acknowledge that although leech therapy exhibits potential as an adjunctive strategy in the handling of varicose ulcers, it must not be regarded as an autonomous treatment. Usually, it is used in addition to standard wound care techniques like debridement, compression treatment, and infection control. Although leech therapy has many potential advantages, there are some practical issues to be resolved, such as the need to standardize treatment procedures, the availability of medical-grade leeches, and patient acceptability.

 

CONCLUSION:

With the potential to aid in boosting wound healing and reducing discomfort, leech therapy is a viable supplementary treatment option for varicose ulcers. Leech therapy shows potential as a component of a multimodal approach to wound care in patients with varicose ulcers, although further research is required to determine its efficacy, safety, and ideal use. Healthcare professionals can improve the management of varicose ulcers and improve outcomes for affected persons by incorporating leech therapy into clinical practice and further investigating its mechanisms of action.

 

CONFLICT OF INTEREST:

The authors have no conflicts of interest.

 

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Received on 02.04.2024           Modified on 14.06.2024

Accepted on 24.07.2024        ©A&V Publications All right reserved