AASCIT Journal of Health

2016; 3(1): 1-5

Published online February 2, 2016 (http://www.aascit.org/journal/health)
ISSN: 2381-1277 (Print); ISSN: 2381-1285 (Online)

Hirudotherapy in Diabetic Foot

Ulcer - A Natural Way of Wound
Debridement
Arsheed Iqbal1, *, Naquib ul Islam1, M. A. Wajid1, Afroza Jan2,
Sheikh Tariq3
1
Regional Research Institute of Unani Medicine, Faculty of Unani Medicine, Department of
Central Council for Research in Unani Medicine, Srinagar (J&K), India
2
Kashmir Tibbya Collage (KTC), Faculty of Unani Medicine, Department of Kashmir Tibbya
Collage and Research Centre, Srinagar (J&K), India
3
JLNM Hospital, Department of Plastic Surgery, Kashmir University, Srinagar City, Jammu and
Kashmir, India
Keywords Email address
Diabetic Foot, iarsheed@yahoo.com (A. Iqbal)
Debridement,
Ulcer, Citation
Bioactive Substance, Arsheed Iqbal, Naquib ul Islam, M. A. Wajid, Afroza Jan, Sheikh Tariq. Hirudotherapy in Diabetic
Hirudotherapy Foot Ulcer - A Natural Way of Wound Debridement. AASCIT Journal of Health.
Vol. 3, No. 1, 2016, pp. 1-5.

Abstract
Foot ulcers are caused by an imbalance between excessive pressure on the soul of the
Received: December 23, 2015
foot and repetitive stress from walking. Normally harmful pressure or motion against the
Revised: January 4, 2016
skin will set off a protective pain alarm but unfortunately in people with diabetic
Accepted: January 6, 2016
neuropathy, this pressure goes undetected and can cause serious injury. In diabetic
patients, foot ulcer is estimated to effect 15% of people at some time in their lives. The
increasing prevalence of diabetes and its associated complications represent a global
health care problem, estimated. Diabetic foot ulcer (DFO) can become infected and lead
to osteomyelitis cellulitis and even amputation resulting in morbidity, mortality and very
high cost of the health care system. In DFU the debridement is the prime modality of
choice. In the DFU debridement, the removal of dead, damaged, infected or callused
tissue in being done to ensure the proper blood flow of the affected area and to heal the
ulcer. Leaching / hydrotherapy is the natural non surgical way of wound debridement by
virtue of bioactive substances present in the leech saliva including natural steroids.
Following are the actively involved substances to deride the diabetic foot ulcer naturally.
Calin - which binds to collagen and neutralises its capacity to induce clotting. Inhibits
blood coagulation and inhibits colagin and mediated platelet aggregation. Destabilase – a
monomerizing activity which is to solve vibrind, this enzyme therefore givens leeches
the ability to lyse clots, this is therefore no longer simply an anticoagulant process but a
fibrinolytic supply process. Bdellins - Anti-inflammatory effects plus the skin, can
reduce skin inflammation, swollen skin, and itchy skin. Hyaluronidase – an antibiotic to
prevent infection. An enzyme that splits hyaluronic acid and so lowers its viscosity and
increases the permeability of connective tissue and the absorption of fluids. This is what
they use in the cosmetics and creams. Egllins – Anti-inflammatory effects plus effects
the skin the anti-swollen substance. The other bioactive substance are hirudin, hirustasin,
Anesthatic substance, triptase inhibitor, xa inhibitor factor – histamine-like substance
collagenase, apyrase, A prostaglandin, esterase, lipase, endorphins and neurotransmitters.

1. Introduction
An imbalance between excessive pressure on the soul of the foot and repetitive stress
2 Arsheed Iqbal et al.: Hirudotherapy in DIABETIC Foot Ulcer - A Natural Way of Wound Debridement
from walking results in foot ulcer. This is usually found in
diabetic patients with peripheral neuxpathy as the pressure
goes undetected and can cause serious injury. Debridement is
the removal of dead, damages, infected and callused tissue
from the wound, the infection and its responsible for the
delayed wound healing the debridement is preventive as well
as curative method of treatment for DFU, the debridement
methods can be autolytic e.g. hydrogels hydrocolloids and
transparent films and biological e.g. maggots leeches and
mechanical enqymentic or surgical. DFU are complex,
chronic wounds, which have a major long-term impact on the
morbidity, mortality and quality of patients lives [1-2].
Individuals who develop a DFU are at greater risk of
premature death, myocardial infarction and fatal stroke. It has
been estimated that every 20 seconds a lower limb is limb is
emputated due to complications of diabetes [3]. In Europe,
the annual amputation rate for people with diabetes has been
cited as 0.5-0.8% [1, 4], and in the US it has been reported
that around 85% of lower-extremity amputations due to
diabetes begin with foot ulceration [5, 6]. Mortality following
amputation increases with level of amputation [7] and ranges
from 50-68% at five years, which is comparable or worse
than for most malignancies [8, 9]. DFUs are complex,
chronic wounds, which have a major long-term impact on the
morbidity, mortality and quality of patients libes [1, 2]. It
have been estimated that every 20 seconds a lower limb is
amputated due to complications of diabetes [14]. In Europe,
the annual amputation rate for people with diabetes has been
cited as 0.5-0.8% [1, 15] and in the US it has been reported
that around 85% of lower-extremity amputations due to
diabetes begin with foot ulceration [16, 17]. Mortality
following amputation increases with level of amputation [18]
and ranges from 50-68% at five years, which is comparable
or worse than for most malignancies [13, 19].
Table 1. Countries with the highest numbers of estimated cases of diabetes for 2000 and 2030.
Ranking Country People with diabetes (millions)
01. India 31.7
02. China 20.8
03. Indonesia 17.7
05. Japan 6.8
06. Pakistan 5.2
07. Russian Federation 4.6
08. Brazil 4.6
09. Italy 4.3
10. Bangladesh 3.2
Globally as of 2010 an estimated 285 million people had
diabetes, with type 2 making up about 90%of the cases. [1]
In 2013, according to International Diabetes Federation, an
estimated 381 million people had diabetes [2]. Its prevalence
is increasing rapidly, and by 2030, this number is estimated
to almost double [3]. The greatest increase in prevalence is,
however, expected to occur in Asia and Africa. The increase
in incidence in development countries follows the trend of
urbanization and lifestyle changes, perhaps most importantly
a “Western-style” diet.
AUSTRALIA: In Australia, the age-standardised
2. Prevelance
The Asia-Pacific region is at the forefront of the current
epidemic of diabetes. There are currently more than 30
million people with diabetes in the Western Pacific region
alone. The World Health Organization predicts that this
number will rise dramatically by the year 2025, by which
time India and China may each face the problem of dealing
with 50 million affected individuals. Asia also contains the
world’s second largest country, India, with a population of 1
billion and fourth largest country, Indonesia, with a
population of about 200 million. Thus, the Asia-Pacific
region is of prime importance to the epidemiology of
diabetes. The region combines a high proportion of the
worlds population with rapidly rising diabetes prevalence
rates. The Western Pacific region, along with the Indian
subcontinent, is at the forefront of the current epidemic of
type 2 diabetes mellitus. In 1998 it was estimated that
globally, there were already 140 million people with
diabetes. Predictions compiled by Dr Hilary King of the
World Health Organization (WHO) indicate that this figure
will rise to 300 million will be in Asia. The prevalence of
diabetes for all age-groups worldwide was estimated to be
2.8% in 2000 and 4.4% in 2030. The total number of people
with diabetes is projected to rise 171 million in 2000 to 366
million in 2030. The prevalence of diabetes is higher in men
than women, but there are more women with diabetes than
men. The urban population in developing countries is
projected to double between 2000 and 2030. The most
imported demographic changed to diabetes prevalence across
the world appears to be the increase in the proportion of
people 65 years of age.
Country People with diabetes (millions)
India 79.4
China 42.3
Indonesia 21.3
Pakistan 13.9
Brazil 11.3
Bangladesh 11.1
Japan 8.9
Philippines 7.8
Egypt 6.7
prevalence of self-reported diabetes in indigenous Australians
is almost four times that of nonindiagenious Australians.
CHINA: Almost one Chinese adult in ten has diabetes. A
2010 study estimated that more than 92 million Chinese
adults have the disease, with another 150 million showing
early symptoms. [5] The incidence of the disease is
increasing rapidly; a 2009 study found a 30% increase in 7
years. (6) Indigenous nomadic people like Tibetans and
Mongols are at much higher susceptibility than Han Chinese.
INDIA: India has more diabetics than any other country in
the world, according to the International Diabetes
 AASCIT Journal of Health 2016; 3(1): 1-5
Foundation, [7] although more recent data suggest that China
has even more. [5] According to the Indian Heart
Association, India is the diabetes currently effects more than
62 million Indians, which is more than 7.1% of India’s adult
Population [9]. An estimate shows that nearly 1 million
Indians die due to Diabetes every year [7] The average age
on onset is 42.5 years. [7]The high incidence is lifestyle by
India’s growing middle class. [10] Additionally, a study by
the American Diabetes Association reports that India will see
the greatest increase in people diagnosed with diabetes by
2030. [11]
UNITED KINGDOM: About 3.8 million people in the
United Kingdom have diabetes mellitus, but the charity
Diabetes U.K. and about 10% of the primary care prescribing
budget is spent on treating diabetes. [12]
UNITED STATES: In 2010, nearly 26 million people had
diabetes in the United States, of whom 7 million people
remain undiagnosed. Another 57 million people are estimated
to have prediabetes. [16, 17] About 5%-10% of diabetes
cases in North America are type 1, with the rest being type 2.
The Merican Diabetes Association (ADA) cites the 2003
assessment of the National Center for Chronic Disease
Prevention and Health Promotion that one in three Americans
born after 2000 will develop diabetes in their lifetimes. [20,
21] 4.9% of American adults had diabetes in 1990. By 1998,
that number rose by a third to 6.5%. The prevalence of
diabetes increased for both sexes and every racial group.
American women have suffered. Weight is also a strong
factor in one’s likelihood of becoming diabetic, with 13.5%
of people at a healthy weight had the disease. According to
the ADA, about 183% (8.6 million) of Americans age 60 and
older have diabetes.
3. Wound Healing in Diabetic Foot
Diabetes influence foot wound healing by an impairment
of the peripheral circulation, altered leukocyte function,
disturbed balance of cytokines and proteases and even
chronic hyperglycemia itself. [15, 16] Recently, it has been
suggested that levels of matrix metalloproteinase’s (MMP)
are important in predicting the likelihood of healing and a
high level of MMP-1 seems essential to wound healing. [17]
3.1. Management of Infected and
Non-infected Diabetic Foot Ulcers by
Different Treatment Modalites
Where ulcers are not infected and predominantly
neuropathic (UT grade 1A, 2A), the use of antibiotics may be
withheld as Chantelauet al [18] have shown that with
appropriate wound management, patients do equally well
with or without systemic antibiotics in a randomized
controlled trial. Nevertheless, frequent review, debridement
and callus removal together with offloading are essential
parts of management of neuropathic foot ulcers and if signs
of infection develop, antibiotics may be needed. For those
ulcers with an ischemic component which do not have gross
sign of infection (UT 1C, 2C) antibiotics should infection and
3
ischemia in the diabetic foot are a common cause of ultimate
lower extremity amputation.
Hyperbarlc Oxygen: Hyperbaric oxygen (HBO) has been
promoted for the management of non- healing diabetic foot
ulcers in ischemic diabetic foot wounds. Though the
systematic review of the International working group
considered HBO accepted, that there was some evidence to
support its use.
Negative pressure Wound Therapy: Over the past several
years negative pressure wound therapy (NPWT)
usingvacuum- assisted closure has emerged as the treatment
of complex wounds of the diabetic foot. [19] It decreases
local tissue edema and removes excessive fluid and pro-
inflammatory exudates from the wound bed.
Bioengineered Skin Substitutes: Tissue engineered skin,
Apligruf comprises of cultured living dermis and sequentially
cultured epidermis. Dermagraft is dermis derived from
human fibroblasts used for treatment of non-infected
neuropathic ulcers.
Larval Therapy: The use of sterile maggots, the larvae of
the common green bottle fly, is not new. Sterile maggots are
useful in desloughing wounds that are resistant to surgical
debridement. It is believed that they secrete a broad spectrum
of powerful enzymes that break down dead tissue. Limited
evidence also suggests that they do not harm healthy tissue
because the enzymes are inactivated by inhibitors present in
normal skin. [20]
Charcot Neuroarthropathy: Charcot neuroarthropathy (CN)
is a non- infective arthropathy which occurs due to result of a
combination of motor, autonomic, and sensory neuropathies
in which there is muscle and joint laxity that lead to changes
in the arches of the foot. Further, the autonomic denervation
leads to bone demineralization via the impairment of vascular
smooth muscle, which leads to an increase in blood flow to
the bone with a consequential osteolysis. The exact
mechanism underlying the development of CN remains
unclear. Bisphosphonates are potent inhibitors of osteoclast
activation and intravenous Pamidronate has been shown to be
useful in reducing disease activity in acute CN [21] Injected
liquid Silicone: injected liquid silicone in the diabetic foot
has confirmed that silicone injections were associated with
increased soft-tissue thickness under the metatarsal head,
decreases foot pressure, and reduced callus formation.
3.2. Case Presentation
In this presentation we have experienced the effeciacy of
Hirudotherapy in a middle aged male patient with history of
type 2 diabetes mellitus from past ten years. The patient was
constantly on oral hypoglycemic and was getting his foot
ulcers debrided at tertiary care hospital following latest
techniques. The patient was then given the leech therapy for
a period of three months after regular intervals at regional
research institute of unani medicine (CCRUM). The ulcers
were completely healed leaving the skin surface smooth and
the foot ulcers did not show any recurrence after one year of
continuous follow ups.
4 Arsheed Iqbal et al.: Hirudotherapy in DIABETIC Foot Ulcer - A Natural Way of Wound Debridement

4. Discussion
Foot ulcers in diabetic patients are common. It is estimated
that 15% of diabetes patients will develop Diabetic foot ulcer
once in their life time, and approximately 14% of diabetic
ulcers lead to amputation [10]. Factors that affect
development and healing of diabetic patient’s foot ulcers
include the degree of metabolic control, the presence of
ischemia or infection, and continuing trauma to feet from
excessive plantar pressure or poorly fitting shoes.
Appropriate wound care for diabetic patients, addresses their Figure 2. Diabetic foot ulcer with application of leech.
issue and provides optimal local ulcer therapy with
debridement of necrotic tissue and provision of a moist
wound healing environment by dead tissue should be
removed from the wound by sharp nipper, scalpel or a curette
finger pressure may be applied to the wound to help control
bleeding. After adequate debridement the would should be
dresses properly to check the infection. Negative pressure
wound healing and is the controlled application of sub-
atmospheric pressure to a wound using an electrical pump
and specialized wound dressings. The application of negative
Figure 3. Diabetic foot ulcer with application of leech.
pressure help by, Optimization of the flow of blood,
Reduction of swelling in local tissue and Removal of
potentially damaged wound fluid. The physiological changes
give rise to a most environment for healing and facilitate the
removal of bacteria from the ulcer. In past leeching has been
used in various ailments from headache to very delicate
plastic surgery. Galen – (129-189 AD) promoted leeching
because he believed that bloodletting by leeching will
remove different substances from the body responsible for
various diseases. Von Rosenstein (1776) advocated leeching
for difficult dentition, scarlet fever, pleurisy, throat diseases Figure 4. Healed up diabetic foot ulcer after multiple leech applications.
and rheumatism. Now a days leeching again has been revived
to be used for various ailments of cardiovascular system, 5. Conclusion
dermatology, necrology, gynaecology and musculoskeletal
disorders. Foot ulcers in diabetic patients are common. It is estimated
This study of leeching in Diabetic Foot Ulcer was done that 15% of diabetes patients will develop Diabetic foot ulcer
with the concept that leech contain numerous biologically once in their life time, and approximately 14% of diabetic
active substance which have powerful anti-inflammatory ulcers lead to amputation [10]. Factors that affect
effect and also effect of facilitating the blood perfusion. The development and healing of diabetic patient’s foot ulcers
patient was given multiple applications of leech therapy and include the degree of metabolic control, the presence of
the foot ulcer were completely healed up and did not show ischemia or infection, and continuing trauma to feet from
any recurrence even after following the patient at regular excessive plantar pressure or poorly fitting shoes.
intervals, for a period of one year. The patient also shows Appropriate wound care for diabetic patients addresses there
significant decrease in blood sugar level during period of issue and provides optimal local ulcer therapy with
leech application. debridement of necrotic tissue and provision of a moist
wound healing environment. Chronic Diabetic Foot Ulcer is
one of the very important but most neglected complication of
Diabetes. More than 80, 000 amputations are performed each
year in diabetic patients in the United States, and around 50%
of the people with amputations will develop ulcerations and
infections in the contra lateral limb within 18 months. An
alarming 58% will have a contra lateral amputation. Mc
Neely et al [10] found that a transcutaneous oxygen tension
(TcPO2) of less than 30 mmHg, absence of the Achilles'
tendon reflex, and foot insensitivity are 3 factors that are
strong predictors of ulceration. The pathogenesis of
Figure 1. Diabetic foot ulcer with application of leech.
 AASCIT Journal of Health 2016; 3(1): 1-5
ulceration is complex and involves the interaction of
angiopathy, neuropathy, and immunopathy. Briefly, vascular
impairment has been found to correlate with the development
of diabetic foot ulcers, [11] Neuropathy is the most
significant risk factor for diabetic foot ulcers and is present in
over 80% of patients with diabetes and foot lesions. [12, 13,
14] Treatment of chronic non healing Diabetic Foot Ulcer
with multidisciplinary approach can overall change the
clinical outcome in nonhealing DFU. A wide variety of
advanced treatments for diabetic foot ulcers, such as
Ultrasonic debridement, Topical growth factors,
Bioengineered skin grafts (BATs), VAC (Vacuum Assisted
Closure) Therapy, and hyperbaric would healing. In this case
report it has been observed that DFU shows more fast healing
with Hirudotherapy which is being attributed to different
bioactive enzymes present in leech including Steroids,
Histamine and Serotonin.
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