Study of Papaya Dressing in Wound Bed Preparation of Diabetic Wound A Review

Transcription

1 International Journal of Advances in Health Sciences (IJHS) ISSN Vol-4, Issue-1, 2017, pp1-6 Research Article Study of Papaya Dressing in Wound Bed Preparation of Diabetic Wound A Review Javed Alam 1, Manzoor Ahmad 2, Ansari Mohd Imran 3, Khurshid Alam 4, Akhtar Husain Chaudhary 5 and Jalis Ahmad 6 1,3 P.G. Scholar Dept. Ilmul-Jarahat (M.S.), 2 Asstt. Prof. Dept. Ilmul Jarahat, 4 HOD Dept. of Ilmul Jarahat, 5 Prof. Dept. Of Ilmul Jarahat, 6 Principal, Z.V.M. Unani Medical College and Hospital, Pune ABSTRACT: This paper reviews the role of papaya (papita/carica papaya) dressing in wound bed preparation of diabetic ulcer, during healing procedure of diabetic wound in relation to ancient Unani Medicine. Diabetic foot ulcers are common complication of diabetes mellitus. Diabetic foot ulcers are usually caused by well-known triad of complications of diabetes mellitus known as Neuropathy, Ischemic changes and Infection resulting in poor wound healing with presence of gangrenous slough over diabetic wound. Therefore, it is difficult to treat even sometimes it needs amputation of foot because of gangrenous slough collection over the diabetic ulcer. In fact, the gangrenous slough over the diabetic wound doesn t allow healing of that ulcer. Hence, there is need to debridement of wound or clear all gangrenous slough material to allow healing of the wound. The regular papaya dressing clears all gangrenous sloughs, due to its enzymatic action. In other words enzymatic action of papaya dressing provides wound debridement naturally and gives a clean wound for healing process. In this way, the papaya dressing provides wound bed preparation. Details will be discussed in full length paper. Keywords: Unani advia (Papita -Carica papaya) Diabetic wound, Papaya dressing, wound bed preparation. INTRODUCTION Diabetic foot ulcer is one of the commonest chronic complications Awariz of diabetes mellitus, Ziabetusshakary Which have a major long-term impact on the morbidity, mortality and quality of patients lives 1,2,3. Individuals who develop a diabetic foot ulcer are at greater risk of premature death, myocardial infarction and fatal stroke than those without a history of diabetic foot ulcer. 4,5,6 It is estimated that approximately 15% of diabetic people world-wide will at some stage develop diabetic foot ulceration. The prevalence of active foot ulceration varies from approximately 1% in certain European and North American studies to more than 11% in reports from some African countries. Although there have been many developments in recent years which encourage optimism for future improvement in diabetic foot care, there is still much to be done; the recent data from the Netherlands show that with a concerted team approach, it is possible to increase the numbers of foot clinics with the provision of podiatry services by more than 100%. 7,8,9,10 In general, in diabetic patients, the incidence of diabetic foot ulcers ranges from 1.0% to 4.1%, and the incidence of lower-extremity amputations ranges from 2.1 to 13.7 per ,11,12,

2 Diabetic foot Ulcers have become more prominent with advance in diabetic treatments which have increased the life expectancy of these patients. Hyperglycemia or glucose laden in the tissues lowers the resistance to infection in diabetic patients. Which leads to tissue putrification and ultimately ulcer formation? Diabetic foot ulcer a etiology is well-known triad of neuropathy, ischemia, and infection. 13,14. Due to the impaired metabolic mechanisms in diabetes mellitus, there is an increased risk of infection and poor wound healing due to a series of mechanisms which include decreased cell growth factor response, diminished peripheral blood flow and decreased local angiogenesis 14,15. Thus, the feet are predisposed to peripheral vascular disease, damage of peripheral nerves, deformities, ulcerations and gangrene. Neuropathy causes more than 60% of the foot ulcers. 14,16 An imbalance between excessive pressure on the sole of the foot and repetitive stress from walking results in foot ulcer. Normally harmful pressure or motion against the skin will set off a protective pain alarm but unfortunately in people with diabetic 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,17,18,19,20 The most common sites for ulcer are toes, followed by the plantar metatarsal heads and the heel. Foot risk factors include peripheral neuropathy, peripheral arterial disease and foot deformities. Arterial disease was present in 48% of foot ulcers in Germany, but only 11% in Tanzania and 10% in India. In the United States, the incidence of diabetes is increasing 1% per year 21,22 In the U.S, diabetes is the seventh leading cause of death, mainly secondary to cardiovascular complications. It was estimated in 2000 that there were 32million people with diabetes in India, a number that is predicted to increase to nearly 80 million by ,23. Peripheral neuropathy is present in 60% of patients with diabetes and 80% of patients with diabetes who have diabetic foot ulcers. Neuropathy in these patients is a multifactorial process and is thought to result from a combination of vascular disease occluding the vasa nervorum, endothelial dysfunction, deficiency of myoinositol-altering myelin synthesis and diminishing sodium-potassium adenine triphosphates activity, chronic hyperosmolarity, and effects of increased sorbitol and fructose. Decreased sensation in the foot predisposes the patient with diabetes to unnoticed injuries and fractures that overload the skin and lead to ulceration. 24,25, The incidence of foot complications, among patient with diabetes mellitus is1-2% per year, The diabetic wound of foot forms due to combined influence of vascular insufficiency mechanical disruption of tissues peripheral and autonomic neuropathy and impaired tissue healing ulceration of the Calcaneum and Bones of forefoot especially the great toe and 1 st metatarsal head is common leading to deep extension of wound and osteomyelitis of under lying bone. Because of impaired wound healing and deep extension of wound healing slough formation within the wound is induced. All these barriers of healing are usually interrupting the healing process. 3,7,26 About half of the all patients with diabetes have developed the complications of supplying vessels to foot causing ischemia or neuro-ischemic changes of foot which ultimately, turns to amputation of foot or limb. Therefore, to save the lower extremities there must be a therapy to save the foot. In the management of diabetic foot early recognition of infections, control of diabetes, appropriate and effective antibiotic selection, early surgical intervention and debridement, wound washing, appropriate dressings and definitive wound closure are the key components 27, Safe and effective debridement method for the patient with a chronic diabetic wound is yet to be elucidated. Different strategies including honey dressings, medicated dressings, povidone iodine dressings, platelet rich plasma dressings, saline dressings, vacuum dressings and papaya dressings are available in the management of diabetic foot ulcer,28,29. Carica papaya is widely known as a Javed Alam, et al. 2

3 medicinal fruit 30. Several observations point to the hypothesis that treatment with papaya preparations may help facilitate wound-healing responses 31. Papaya has been studied from a pharmacological perspective. Green papaya is rich in two enzymes (papain and chymopapain) that have very strong digestive properties, with an ability to dissolve dead tissue and also have antiinflammatory activity 28,32, The Indian papaya (Carica papaya) known to have de-sloughing Wizr and wound healing properties due to have protease enzyme, This is clinically seen as slough on the wound bed or unhealthy granulation tissue prevents angiogenesis and re-epitheliazition of the wound. Therefore papaya dressing in considered de-sloughing the wound and providing healthy wound bed for reepitheliazation and angiogenesis within the wound and healthy granulation tissue for healing of wound. 33 As mention by Ibn-ul-quf Al Masihi that Physician (Tabib) is responsible to diagnose the cause of weakness Tabiyate- Aam and Tabiyate- Khass.Latif-Fuzla(liquid excretory products) is producing liquid pus and Ghaliz-Fuzla(semi liquid Wagner s classification for diabetic foot disease Grade 0 High risk foot and no ulceration. Grade 1 Superficial Ulcer Grade 2 Deep Ulcer ( Cellulitis ) Grade 3 Grade 4 Grade 5 Osteomylitis with Ulceration or abscess. excretory products) producing GhalizRatubat (semi liquid ) which is known as(slough) Wizr. 34,35 In this condition both Tabiyate-Aam and Tabiyate- Khas are depends on Tabib,Tabiyat-e-Amma can be help by decreasing in diet to reduce the approach of Madda to Uzooaffected structure) but Ratubate-Ghaliz- Wizr. (Slough) requires cleaning (De-sloughing). In this way the Papaya dressing needs de-sloughing or debridement of the Wizr 34,35. MATERIAL AND METHODS This experimental study was conducted in the Surgical Unit of Punjab Employees Social Security Institution Islamabad and Ahmed Teaching Hospital of Islamabad Medical & Dental College, from 1st September 2011 to 30th June Patients (n=43), with diabetic foot of all grades, were included. Age of the patients ranged from 40 to 70 years. Grades of diabetic foot were classified according Wagner s classification system. Gangrenous Patches. Partial foot gangrene. Gangrene of entire foot. METHODS Patients with co-morbid conditions like peripheral arterial disease, chronic renal failure, ischemic heart disease, hepatitis and malignancy were excluded from this study. Wagner s classification of Diabetic Foot Grading was taken. Initial management included empirical antibiotics, surgical wound debridement or amputation and control of glycemic levels. Further the wound care and de-sloughing was with the help of papaya dressings, which was easily available. It is being performed in our hospital for more than three decades. Unripe fruits of papaya (Caarica papaya) were collected locally, The paste was prepared according to the method explained by IhtashamMohmood Ch. et al. The fruit was cleaned with distilled water and superficial layer and seeds of the papaya were removed and the flesh of the raw fruit is grated. The grated fruit is prepared freshly every day and applied to the wounds and covered with sterile gauze pieces for dressing. We educated the patients and also the attendants for the dressing. Javed Alam, et al. 3

4 Dressings were changed every 24 hours. The wounds were considered healthy when they were covered with healthy granulation tissue and had epithelial growth on their edges. Once the wound was healthy, grated papaya dressing was discontinued and simple saline dressing without any medication was carried out till the complete healing of the wound. Some patients with large ulcers underwent skin grafting as a part of further management. DISCUSSION The present study was randomized single blind standard controlled trials accomplish to evaluate the safety and efficacy of a topical Unani drug in the management of diabetic foot ulcer on scientific basis and modern parameter. The diabetic foot ulcers are caused, because of macro and micro vascular changes, the neuropathy and Glucose laden tissues of the Lower extremity. One major factor is sensory neuropathy, which may lead to painless trauma, ulceration and infection. Macro vascular and micro vascular changes produce tissue ischemia and skin changes that can cause ulcerations and infections and prevent healing. The inter relationship of all these factors results in gangrene and ultimately amputation of foot. 22,23 The diabetic foot ulcers have become more prominent with advances in diabetic treatments which have increased the life expectancy of these patients. Hyperglycemia or glucose laden in the tissues lowers the resistance to infection in diabetic patients.which leads to tissue putrefaction and ultimately ulcer formation. The papaya dressings are most effective for desloughing and wound healing properties in diabetic foot ulcer problem. The research has been published to prove the same fact as Ihtasham Muhammad Ch, et al (2014) have mentioned the significant effect of papaya dressing in the management of diabetic foot ulcer. CONCLUSION Treatment of Diabetic Foot Ulcer with multidisciplinary approach can overall change the clinical outcome in Diabetic Foot Ulcer. A wide variety of advanced treatments for diabetic foot ulcers, such as Ultrasonic debridement, Topical growth factors, honey dressing, plasma dressing, iodine dressing, but In this study it has been observed that Diabetic Foot Ulcer shows more fast de-sloughing wizer with papaya dressing which is being attributed to different bioactive enzymes present in Papaya (Carica papaya), which are known as papain and chympapain. and is also a cost effective choice for diabetic foot management. REFERENCES 1. Huzinga MM, Rothman RL. Addressing the diabetes pandemic: A comprehensive approach. Indian journal Med Res 2006; 124: Herrison s text book of medicine 3. API text book of medicine 8thed, vol, 2 pg, National Institute for Health and Clinical Excellence. Diabetic foot problems: inpatient management of diabetic foot problems. Clinical guideline 119. London: NICE, Available at: uk / diabetic-foot-problems-cg119. Accessed March International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, Available from, Published by Wounds International A division of Schofield Healthcare Media Limited Enterprise House 1 2 Hatfields London SE1 9PG, UK 6. Abetz L, Sutton M, Brady L, et al. The diabetic foot ulcer scale: a quality of life instrument for use in clinical trials. PractDiabInt 2002; 19: BardiaFarzamfar, Reza Nazari and SaeedBayanolhagh, Bardia Farzamfar1, Reza Javed Alam, et al. 4

5 Nazari2 and Saeed Bayanolhagh3 *Address all correspondence to: PUBLISHED BY World's largest Science, Technology & Medicine Open Access book 8. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003 May 3;361(9368): Boulton AJ. The diabetic foot: a global view. Diabetes Metab Res Rev 2000 Sep- Oct;16Suppl 1:S Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005 Nov 12;366 (9498): Bartus CL, Margolis DJ. Reducing the incidence of foot ulceration and amputation in diabetes.currdiab Rep 2004 Dec;4(6): RagnarsonTennvall G, Apelqvist J. Healtheconomic consequences of diabetic foot lesions. Clin Infect Dis 2004 Aug 1;39Suppl 2:S Pendsey SP (2010) Understanding diabetic foot. Int J Diabetes DevCtries 30: Simerjit Singh*, et al. Singh S, Pai DR, Yuhhui C (2013) Diabetic Foot Ulcer Diagnosis and Management. Clin Res Foot Ankle 1: 120. doi: / X Brem H, Tomic-Canic M (2007) Cellular and molecular basis of wound healing in diabetes. J Clin Invest 117: Clayton W, Elcasy TA (2009) A Review of the Pathophysiology, Classification, and Treatment of Foot Ulcers in Diabetic Patients. Clin Diabetes 27: National Institute for Health and Clinical Excellence. Diabetic foot problems: inpatient management of diabetic foot problems. Clinical guideline 119. London: NICE, Available at 18. Abetz L, Sutton M, Brady L, et al. the diabetic trials. PractDiabInt 2002; ArsheedIqbal et al. AASCIT Journal of Health 2016; 3(1): 1-5 Published online February 2, 2016 ( /health) ISSN: (Print); ISSN: (Online) Hirudotherapy in Diabetic Foot Ulcer - A Natural Way of Wound Debridement. 20. Young MJ, McCardle JE, Randall LE, et al. Improved survival of diabetic foot ulcer patients : possible impact of aggressive cardiovascular risk management. Diabetes Care 2008; Gibbons WG. Lower extremity bypass in patients with diabetic foot ulcers.surgclin N Am 2003;83: DrAmit Kumar C Jain* The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 1, No. 1, Pages 1-5 All rights reserved. A NEW CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS: A SIMPLE AND EFFECTIVE TEACHING TOOL. 23. Morbach S, Lutale JK, Viswanathan V, et al : Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabet Med 2004;21(1): Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med 351(1):48-55, American Diabetes Association: Diabetes statistics. Available at: ArsheedIqbal, Arjum and Shah et al, Journal of Diabetes and Health. Photon 107 (2014) photon foundation organization/home/journal-ofdiabetes-and-health 27. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvages team. J Vasc Surg. 2010; 52: BapurapuRajaram, MadipeddiVenkanna et al. The Role of Papaya Dressings in the Management of Diabetic Foot Ulcers: A Prospective Study. Journal of Evidence Javed Alam, et al. 5

6 based Medicine and Healthcare; Volume 2, Issue 42, October 19, 2015; Page: , DOI: /jebmh/2015/ Moura LI, Dias AM, Carvalho E. Recent advances on the development of wound dressings for diabetic foot ulcer treatment--a review. ActaBiomater. 201l; 9: Anuar NS, Zahari SS, Taib IA, and Rahman MT. Effect of green and ripe Carica papaya epicarp extracts on wound healing and during pregnancy. Food ChemToxicol, 2008; 46: Telgenhoff D, Lam K, Ramsay S, Vasquez V, Villareal K, Slusarewicz P, Attar P, and Shroot B. Influence of papain urea copper chlorophyllin on wound matrix remodeling. Wound Repair Regen, 2007; 15: Owoyele BV, Adebukola OM, F unmilayo AA and Soladoye AO. Anti-inflammatory activities of ethanolic extract of Carica papaya leaves. Inflammopharmacology 2008; 16: Norman s. Willian Christopher at all Bailey and love s. short practice of surgery. 26thAdition.p AminuddaulaAbulFarajIbnulqaf-al-Masihi Kitab-ul-Umda fill JarahatUedu translated by CCRUM New Delhi.p Anuar NS, Zahari SS, Taib IA, and Rahman MT. Effect of green and ripe Carica papaya epicarp extracts on wound healing and during pregnancy. Food ChemToxicol, 2008; 46: Javed Alam, et al. 6