Research Article International Ayurvedi c Medical Journal ISSN:2320 5091
A HISTOPATHOLOGICAL STUDY ON LEECH APPLICATION IN THE MANAGEMENT OF VICARCIKA (ECZEMA) Shankar Pratap K. M.1 Rao Dattatreya 2 Sai Prasad 3 1Dept. of Shalya Tantra , Santhigiri Ayurvedic College , Palakkad, Kerala, India 2Dept. of Shalya Tantra, S.V. Ayurvedic College, Tirupati , Andhra Pradesh , India 3Dept. of Pathology, S. V. Medical College, Tirupati, Andhra Pradesh, India
ABSTRACT To assess the efficacy of Leech application in the management of Vicarcik a (Eczema) with Histopathological study, the present study with 10 patients having the classical symptoms of Vicarcika, were randomly selected as per the inclusion and exclusion criteria from O.P.D. & I.P.D. sections of Shalya department, S.V. Ayurvedic Hospital, Tirupati. Minimum 4 sittings of Leech application was carried out with seven days interval. Total duration of treatment was 6 weeks. Biopsy samples were collected from the lesion site before and after treatment. Histopathological examination was done by the pathologist. In eczema (dermatitis) the leech application therapy gives excellent response by reducing the inflammatory component, hyperkeratosis, spongiosis, irregular acanthosis and by evoking a granulation tissue response in the dermis and in most of the cases with complete recovery from the lesion. Most of the cases in the study were chronic dermatitis and sebhoric keratosis, almost all local/focal pigmented lesion is totally relieved by leech therapy especially in cases of sebhoric keratos is. In the present study it was found that, leech application evokes significant changes at histological level specifically in reduction of inflammatory component, hyperkeratosis, spongiosis and irregular acanthosis. It was also found that there was a considerable formation of granulation tissue, which helps in formation of healthy new tissues. Keywords: Eczema, leech application, hyperkeratosis, spongiosis, acanthosis
INTRODUCTION quality of life, including physical, emotional Skin is an extraordinary structure. It and financial consequences. is frequently damaged because it is directly Eczema or dermatitis is a pattern of in the 'firing line' and, for this reason, skin inflammatory respons e of the skin , which is diseases are very common. There are more characterized by erythema, edema, than 3000 known diseases of the vesiculation, exudation and crust skin.1Although most of the chronic skin formation. 2Acute eczema presents with conditions, such as eczema, psoriasis, weeping, crusting and vesicle formation and vitiligo and leg ulcers, are not immediately sub acute or chronic with dryness, scaling, life-threatening, they are recognized as a fissurin g and lichenification. considera ble burden on health status and Histologically, dermatitis is characterized by inflammation of the Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika epidermis i.e. perivascular lymphohistocytic bloodletting, leech application was selected infiltrate. The hallmark of acute dermatitis is as it is specifically indicated for Tvak dosha spongiosis (intraepidermal vesicles) and (skin disease) 9 and biochemicals released exocytosis of lymphocytes. In sub acute from leech saliva have antinflammatory, dermatitis, apart from the features of acute antibiotic, thrombolytic actions etc., further dermatitis, parakeratosis (increase in leeches can be easily administered with less thickness of stratum corneum) and complication and are cost effective. Many acanthosis (thickened epidermis) are clinical studies have already proved the prominent. As eczema becomes more efficacy of leech application in skin diseases chronic, there is tendency for it to become especially in eczema, but still effect of leech more acanthotic and less spongiotic 3 application on histological level was not accompanied by T-helper lymphocytic explored. Hence this study was designed to infiltration in the upper dermis.4 prove the efficacy of leech application in Management of eczema involves eczema at the tissue level through topical applications like emollients, Histopathological examinations. antipuritic lotions, steroids, coal tar and zinc MATERIALS AND METHODS paste etc, oral antibiotics, sedative Selection of Patients: antihistamines, corticosteroids and Ten patients having the classical immunosuppressive agents.5Even after their symptoms of Eczema were randomly use relapses, recurrences and other selected from O.P.D. & I.P.D. sections of complications are very common. Dept. of Shalya , S.V. Ayurvedic Hospital, Indiscriminate use of these drugs can cause Tirupati. The inclusion criteria included vomiting, diarrhea, stomach upset, allergic patients of age group 16 to 70 yrs (as reaction, peptic ulcer, neuropsychiatric bloodletting is indicated for this age reactions, diabetes, diminution of libido, group). 10 The exclusion criteria included, Cushing’s syndrome etc. patients having secondary infections, In maximum cases, failure of bleeding disorders, Diabetes Mellitus, Heart contemporary medicine in the treatment of diseases, Tuberculosis, Leprosy and eczema push them to chronic state and Generalized eczema. A specific case sheet hence report to Ayurvedic system in the later was prepared and the patients of the present stage. Vicarcika has been mentioned in study were examined in detail as per case Ayurvedic classics under Kshudra Kustha 6 sheet. Routine hematological investigations and also under Kshudra roga .7 According to and urine examinations were carried out Ayurveda, Rakta dushti (vitiation of blood) before and after treatment to rule out the is one of the prime causes of skin diseases, other associated pathology. The patients among the Shodhana karma (purificatory were included for study after taking written treatments); bloodletting is considered as the consent for ethical clearance. best treatment for skin diseases. According Treatment: Minimum 4 sittings of leech to Sushruta , if a person regularly undergoes application therapy were carried out with bloodletting, he can develop resistance seven days interval. Number of leeches against all types of skin diseases.8 In the applied was decided on the basis of the size present study, among the various methods of 2 www.iamj.in IAMJ: Volume 1; Issue 4 ; July – Aug 2013
Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika of lesion. Procedure of leech application was separate pot containing pure water and used under taken in the following stage: for the same patient after a gap of 7 days. Pre operative procedure : Non poisonous The frequency of leech application will vary Leeches were identified and collected from according to the severity of disease. fresh water sources; they were stored in mud Generally leeches should be applied once in pots. On the day of application, the patient a week up to 4-6 sittings. Leeches should be was placed on proper position according to reserved for a particular patient to avoid the site of lesion. Leeches (no. as required) cross infection. were kept in turmeric water to make them Contra indication of leech therapy active, increase appetite and free from 1. Blood clotting disorder. natural urges, after keeping the leeches for 2. Severe anemia. 45 minutes they were put in fresh water. 3. Allergic reaction to active substances Operative procedure: Lesion is cleaned by of the leech such as hirudin, water and dried with cotton. After this, hyaluronidase, egline, apyrase, rubbing of skin was done as per need. For destabilase, etc. this purpose, either sterilized cotton bandage 4. Human with weak constitution. pad or thick thread of jute was used. The 5. Pregnancy. activated leeches were applied over the Precautions during leech application lesion site. Leeches become elevated like a 1. Bleeding and clotting time of the horse shoe or raised in arched position from patient should be normal. its neck which indicates that they are 2. Gentle handling of the leech. sucking the blood vigorously or strength 3. Cover the leech with wet cotton. fully. After catching the site, leeches were Histopathological analysis covered by wet cotton pad and regularly Skin biopsy (Incisional biopsy) was sprinkled with cold water. The leeches taken from the lesion site before and after usually detach from the site after sucking the the treatment. Sample was transported to the vitiated blood or have to be removed by pathology lab in a fixative (10% formalin sprinkling salt over it when the patient solution). For the histological examinations, complains pain or itching. paraffin-embedded tissue sections of the Post operative procedure : After skin (5 µm) were stained with hematoxylin- detachment of leeches, wound was cleaned eosin (HE). The tissue samples were then with anti septic solution and after that tight examined and photographed under a light bandage was applied for prevention of microscope (Olympus CX31, Olympus, secondary hemorrhage. After falling off, the Japan), for observation. The leeches were dusted with rice powder and Histopathological parameters were fixed as turmeric powder was applied on the mouth follows: Acute dermatitis – Spongiosis and to make it vomit the sucked blood exocytosis of lymphocytes; Sub acute (otherwise it may cause death of leeches). dermatitis – Parakeratosis, acanthosis, Leeches after vomiting were put in fresh Spongiosis and exocytosis of lymphocytes; water and when they move freely without Chronic dermatitis - Irregular acanthosis, sinking down were considered as properly papillary dermal fibrosis and focal vomited. Used leeches were kept in a superficial epidermal necrosis. 3 www.iamj.in IAMJ: Volume 1; Issue 4 ; July – Aug 2013
Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika
RESULTS Effects of Leech application in Eczema in Histopathological alterations
Figure 1.A (40X mag) Figure 1.B (10X mag) Figure 1.A (before treatment histopathology Figure 1.B (after treatment histopathology photo of Case 1) shows hyperkeratosis, photo of Case 1) shows decrease in spongiosis, irregular acanthosis with acanthosis, mild hyperkeratosis, decreased bluntening of the rete ridges and presence of inflammatory component and decrease in lymphocytes in the epidermis. spongiosis.
Figure 2.A (40X mag) Figure 2.B (40X mag) Figure 2.C (40X mag) Figure 2.A (before treatment histopathology Figure 2.B (after treatment histopathology photo of Case 2) shows hyperkeratosis and photo of Case 2) shows decrease in the irregular acanthosis of epidermis with focal hyperkeratosis, melanin pigmentation is areas of spongiosis with irregular rete ridges decreased, irregular widening of rete ridges (with widening of retephages) and is decreased and the inflammatory prominent presence of melanocytes. Shows component is reduced. Figure 2.C (after collection of non specific inflammatory cells treatment histopathology photo of Case 2) in the sub epidermis and dermis reveals shows the presence of granulation tissue in fibrocollagenous tissue with few adnexa. the dermis.
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Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika
Figure 3.A (40X mag) Figure 3.B (40X mag) Figure 3.A (before treatment histopathology photo of Figure 3.B (after treatment histopathology photo of Case 3) shows hyperkeratosis increase in collection Case 3) shows decrease in hyperkeratosis, spongiosis of inflammatory cells and spongiosis. and collection of inflammatory cells.
Figure 4.A (40X mag) Figure 4.B (40X mag) Figure 4.A (before treatment histopathology Figure 4.B (after treatment histopathology photo photo of Case 4) shows the presence of of Case 4) shows decrease in hyperkeratosis, hyperkeratosis with keratin plug. spongiosis and collection of inflammatory cells.
Figure 5.A (10X mag) Figure 5.B (10X mag) Figure 5.A (before treatment histopathology photo of Figure 5.B (after treatment histopathology photo of Case 5) shows hyperkeratotic epidermis with Case 5) shows hyperkeratotic epidermis with no irregular rete ridges and mild spongiosis. Dermis irregular rete ridges and decrease in spongiosis. reveals collagenised fibrous tissue and collection of Dermis reveals granulation tissue. inflammatory cells.
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Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika
Figure 6.A (10X mag) Figure 6.B (10X mag) Figure 6.A (Case 6) shows that a focal part of Figure 6.B (Case 6) shows the gap being filled epidermis is removed probably by leech bite. with healthy cells in the latter stage.
Figure 7.A (40X mag) Figure 7.B (40X mag) Figure 7.A (before treatment histopathology photo of Figure 7.B (after treatment histopathology photo of Case 7) shows hyperkeratosis, spongiosis and mild Case 7) shows hyperkeratosis, decrease in spongiosis acanthosis with collection of leucocytes. and acanthosis. The sub epidermal zone reveals formations of granulation tissue.
Figure 8.A (40X mag) Figure 8.B (40X mag) Figure 8.A (before treatment histopathology photo of Figure 8.B (after treatment histopathology photo of Case 8) shows irregular pattern of epidermis. Case 8) shows mosaic pattern (normal pattern) of epidermis with normal intra epithelial component.
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Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika
Figure 9.A (10X mag) Figure 9.B (40X mag) Figure 9.C (40X mag) Figure 9.A (before treatment histopathology Figure 9.B (after treatment histopathology photo of Case 9) shows hyperkeratosis, photo of Case 9) shows decrease in irregular acanthosis, extensive spongiosis hyperkeratosis, no spongiosis and acanthosis and collection of non specific inflammatory and absence of inflammatory cells. cells in the epidermis. Dermis reveals Figure 9.C (after treatment histopathology bundle collagens with inflammatory photo of Case 9) shows normal mosaic components and intra epithelial collection of pattern arrangement of epidermal cells. inflammatory cells.
Figure 10.A (10X mag) Figure 10.B (40X mag) Figure 10.C (40X mag) Figure 10.A (before treatment Figure 10.B (after treatment histopathology histopathology photo of Case 10) shows photo of Case 10) shows decrease in hyperkeratosis, spongiosis and acanthosis hyperkeratosis, spongiosis and acanthosis, with more collection of melanin pigments. with decrease in melanin pigments. Normal Epidermis shows collection of inflammatory mosaic pattern of epidermal cells is noted. cells. Dermis reveals collagen bundles, Inflammatory components in the epidermis congested vessels and a few collections of are decreased. Figure 10.C (after treatment non-specific inflammatory cells. histopathology photo of Case 10) shows normal pattern of epidermis and presence of granulation tissues.
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Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika DISCUSSION one of the oldest surviving animals on earth. In eczema or dermatitis the leech The first documented accounts of the use of application gives excellent response by Leeches for medicinal purpose is from the reducing the inflammatory component, time of extreme antiquity, more than 2500 hyperkeratosis, spongiosis, irregular years before in Ayurvedic texts, then long acanthosis and by evoking a granulation later during the period of Hippocrates. tissue response in the dermis. Dhanvantari , the Indian God of Ayurveda Spongiosis is mainly intercellular hold a leech in one of his hand. This simply edema between the keratinocytes in suggests the importance of Leeches in the epidermis, and is characteristic of medicinal field by ancient Indian science. eczematous dermatitis. Leech saliva releases Leeches have and will always be thought of anti inflammatory components like as the ‘wonder doctors’ of science. Hylaurinadase, Eglins and Bdellins, they Although leeches may not be safe for may reduce the intercellular edema and people with diseases that impair blood hence spongiosis was found to be clotting or for those with compromised remarkably reduced in most of the cases. immune function, it is believed to be safe for Hyperkeratosis is a thickening of the most of other people. The saliva of leeches outer layer of skin, producing a tough, often contain a variety of substances such as dry area that may be discolored. Hirudin, Hylaurinadase, histamine like Hyperkeratosis can trigger localized hyper vasodilators, Eglins, Bdellins, Collagenase, pigmentation in the stratum corneum of the destabilize, 11 inhibitors of Kallikerin, super epidermis, along with an increased oxide production and poorly characterized production of protective keratin. anesthetic and analgesic compounds.12 Hyperkeratosis can be treated by removing These substances reach epidermis the thickened layer of skin (containing and dermis by the action of enzyme keratin) to be replaced with a normalized Hylaurinadase. It has been proved through layer of cells. Hyper pigmentation Laser Doppler flowmetry that there is a associated with hyperkeratosis can be significant increase in superficial skin effectively treated by combining a strategy perfusion following leech application, to stimulate melanocyte degeneration and especially 16mm around the bitting promote skin repair through hydration and zone.13 Therefore a regional antiphlogistic, collagen production. Leech therapy induces thrombolytic and antibiotic effect by these granulation tissue formation which in turn substances enforced by hylaurinadase might results in collagen formation causing be the possible reason of improvement by keratolysis. There is also remarkable treatment with leeches. The jaws of the decrease in local/focal pigmented lesion leech pierce the skin so that potent which causes considerable reduction in biologically active substances can penetrate hyper pigmentation especially in case of in to the deeper tissues. Hylaurinadase Sebhoric keratosis. (spreading factor), an enzyme in leech The medicinal leech is a beautiful saliva, further facilitates the penetration and symbol of ‘give and take’ and is sustainable diffusion of these pharmacologically active resource management. Hirudo medicinalis is substances in to the tissues. 8 www.iamj.in IAMJ: Volume 1; Issue 4 ; July – Aug 2013
Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika Leech saliva contains variety of Dermatology Association and the Society biochemicals which are anti inflammatory, for Investigative Dermatology. J Am Acad thrombolytic, antibiotic, analgesic, Dermatol [Internet]. 2006 Sep; 55(3): 490- vasodilator etc. These pharmacologically 500. Available from: http:// active compounds causes normalization and www.ncbi.nlm.nih.gov/pubmed/16908356 improvement of capillary as well as 2. Sehgal NV. Eczema. In: Text book of collateral blood circulation, anti- clinical dermatology, 4 th ed. New Delhi: inflammatory effect, analgesia and Jaypee Brothers medical publishers (P) Ltd: anesthesia effect through saliva, Immune- 2004.p.19. stimulation and Immune-modulating effect 3. Barnhill RL, Neil CA: Text book of and early wound healing effect. Dermatopathology, 2 nd ed. USA: The In conclusion, the Histopathological Mcgraw-Hill Company; 2004.p. 17. study done from the samples of eczematous 4. Schofield OMV, Rees JL. Skin disease. lesion before and after leech application In: Chilvers ER, Boon NA, Colledge NR, therapy proves that there are significant editors. Davidson’s Principles and Practice changes at histological level specifically in of Medicine, 19 th ed. India: Churchill reduction of inflammatory component, Livingstone; 2002.p.1072. hyperkeratosis, spongiosis and irregular 5. Dermnetz.org [Internet]. Newzealand: acanthosis. It was also found that there was Newzealand Dermatological Society; c2013 a considerable formation of granulation [created 1996, updated 22 may 2013]. tissue, which helps in formation of healthy Available from: http:// dermnetnz.org new tissues. Hence the application of /dermatitis/treatment.html leeches in the established cases of eczema 6. Yadavji TA, editor. Susrutha Samhita. can be handy and effective measure of Varanasi: Chaukamba Krishnadas Academy; treatment from the ever relieving problems 2008.p.283 of eczema particularly in the chronic cases. 7. Yadavji TA, editor. Susrutha Samhita. The study proves the utility of leech Varanasi: Chaukamba Krishnadas Academy; application further in other inflammatory 2008.p.318 disorders can also be considered and further 8. Yadavji TA, editor. Susrutha Samhita. research is also required to know the exact Varanasi: Chaukamba Krishnadas Academy; protocol for complete cure. 2008.p.65 ACKNOWLEDGEMENTS 9. Harishastri PV, editor. Vagbhata’s The authors are grateful to Dr. T. Astanga Hridaya. Varanasi: Chaukamba Vijaya PhD, Associate Professor, Dept of Krishnadas Academy; 2006.p.323 Botany, S.V University, Tirupati, for 10. Murthy KRS, translator. Sarangadhara providing facility for Histopathological Samhita. Varanasi: Chaukamba orientalia; Micro Photographs. 2006.p.255 REFERENCES 11. Zavaloc LL, Baskova IP, Lukyanova 1. Bickers DR, Lim HW, Margolis SA. Destabilase from the medicinal leech is D, Weinstock MA, Goodman C, Faulkner E a representation of novel family of et al . The burden of skin diseases: 2004 a lysosome. Svedlov Biochemica et joint project of the American Academy of Biophysica Acta 2000; 1478: 69-77. 9 www.iamj.in IAMJ: Volume 1; Issue 4 ; July – Aug 2013
Pratap Shankar et. al: Histopathological Study on Leech Application in the Management of Vicarcika 12. Baskova IP, Nikonov GI. Destabilase CORRESPONDING AUTHOR ‘An enzyme of medicinal leech salivary Dr. K. M Pratap Shankar gland secretion the hydorolyse isopeptide Asst. Prof. of Shalya Tantra, bonds in stabilized fibrin’. Biochemia 1985; Santhigiri Ayurvedic College, 50: 363-75. Palakkad, Kerala, India 13. Connor NP, Conforti ML, Heisey DM, Email: [email protected] Vanderby R, Kunz D, Hartig GK. Augmented blood removal after Source of support: Nil medicinal leech feeding in congested tissue Conflict of interest: None Declared flaps. J Rehabil Res Dev 2002 Jul-Aug; 39(4):505-12.
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