INTRODUCTION:

Charcot neuropathic osteoarthropathy (CNA), commonly known as Charcot foot, is a condition that impacts the bones, joints, and soft tissues of the foot and ankle. It is categorized by inflammation, especially in its early stages. While Charcot foot can arise from various types of peripheral neuropathy, diabetic neuropathy is the generalized cause. The condition results from the association of multiple factors, including diabetes, sensory-motor neuropathy, autonomic neuropathy, trauma, and disorders of bone metabolism. These factors create a localized acute inflammatory response that can lead to different degrees of bone destruction, subluxation, displacement, and deformity. One of the most notable deformities associated with this condition is midfoot collapse, often referred to as “rocker-bottom” foot. Although this deformity is primarily observed in the midfoot, it can also affect other joints and manifest in different ways¹.

The deformity primarily affects the midfoot and is often characterized by a rocker-bottom shape, which crucially increases the risk of ulceration. The initial management after the acute phase involves gradually introducing weight-bearing and providing continued offloading through specially made footwear to prevent repeated ulceration. In patients with Charcot foot, ulceration rates have been reported to be between 49% and 65% during a follow-up period of 4 to 9 years². The prevalence of Charcot arthropathy is variably reported in the literature, varying from 0.08% to thirteen percentage³. Clinically, Charcot's feet typically appear painless, swollen, flushed, and overheated. Conventional X-rays usually show progressive bone decay that leads to foot deformities. These deformities can result in a variety of complications, including ulcers, soft tissue infections, and osteomyelitis, with surgical treatment sometimes necessitating amputation⁴. In Siddha medicine, the World Health Organization's International Standard Siddha Terminologies denotes Charcot neuropathic osteoarthropathy as being correlated with "Vaḷi nōy," while non-healing chronic ulcers are referred to as "Āṟāppuṇ." Āṟāppuṇ may also be known as "pōkā viraṇam," "paṇṭai viraṇam," or "aẕiyāta viraṇam ". Chronic non-healing ulcers, frequently seen in the lower extremities, are described by Āṟāppuṇ and can result from several factors affecting the wound healing process⁵. Siddha literature describes various preparations for the management of Āṟāppuṇ.

This case study presents details of a Charcot foot accompanied by a non-healing ulcer that was successfully treated with Siddha Sastric medications. The patient experienced complete recovery from the non-healing ulcer after eight weeks of Siddha medications. Additionally, further clinical features such as itching, hyperpigmentation, pus discharge, and swelling also resolved entirely. This case demonstrates the effectiveness of Siddha medicines in managing chronic non-healing ulcers.

Patient Information:

On March 6, 2023, a 72-year-old female patient visited the Siddha Clinical Research Unit in New Delhi. She presented with a non-healing ulcer placed in the medial compartment of her left foot, near the left ankle joint (see Figure 1). The ulcer was accompanied by symptoms of itching, hyperpigmentation, mild pus discharge, pain, and swelling in the left foot region, which made it difficult for her to walk for the past five months. The patient has a history of systemic hypertension, which has been managed with allopathic medications for the past 22 years. There are no other reported comorbidities. At the age of 53, the patient was diagnosed with Charcot's foot. In 2022, the patient began experiencing itching and ulceration in the left foot, along with swelling and an enlargement of the ulcer. Subsequently, the patient visited a nearby allopathic hospital for further evaluation. After a thorough examination, the diagnosis was confirmed as Charcot's foot with a non-healing wound in the left foot. Following two months of allopathic treatment, the ulceration and other clinical symptoms improved. However, after three months, the patient began to experience a recurrence of the previous symptoms and ulcerations. Once again, the patient sought allopathic treatment, but no improvement was observed. Consequently, the patient decided to visit our Siddha Clinical Research Unit in New Delhi for further treatment. The patient had no family history related to this condition and follows a vegetarian diet.

Clinical Findings:

In the last five months, patient had a clinical features of chronic ulcer in left foot, itching, swelling, hyperpigmentation in left foot region and difficult to walk. On examination, 1.6 * 1.9* 0.6cm chronic ulcer, mild pus discharge and mild oedema present in left foot region. During the general examination, the body temperature- 98.6°F, Pulse rate was 80/min, Blood Pressure was 124/82 mmHg, and the Respiratory rate was 22 breaths/min; all were within normal limits. The systemic examinations, including cardiorespiratory, Gastrointestinal and urogenital system examinations, were normal. On examination of the Skin, the lesion is characterized by blackish patches with an irregular configuration. The colour is reddish and blackish, the texture is rough, and the distribution is asymmetrically located in the medial compartment of her left foot near the left ankle joint. The nails appear normal, and swelling is present.

According to Siddha medicine, the patient was examined using the eight-fold diagnostic method known as Eṇvakai tērvu. The assessments conducted were as follows: Nāṭi (pulse examination)- Pittavātam, nā (tongue examination)- normal, Niṟam (examination of the colour of the body) – Affected (Hyperpigmentation present in around the ankle joint), Sparicam (examination of skin) -affected (Ulceration present in left foot), Moḻi (speech examination)– normal, Viẕi (eye examination) - normal, Malam (stool examination) - normal, Mūttiram (urine examination)- normal. Yākkai ilakkaṇam (assessment of body constitution)- Pittakapam. As per Siddha medicine examination methods Overall, the Niṟam and Sparicam were affected.

Timeline:

Table 1 outlines the timeline of episodes in this case report, detailing all the clinical features experienced by the patient, before treatments administered, and the results obtained.

Table 1: Chronological Overview of Events in the Current Case Study

Year	Incidence/ Intervention
April 2022	Itching and ulceration was present in near left ankle joint. Patient diagnosed as Charcot foot with chronic non healing ulcer.
April 2022 to June 2022	The patient was treated with allopathic medication and clinical features has improved. Patient feels better.
July 2022 to September 2022	Occasionally mild itching present.
October 2023	Itching was increased and ulceration has formed.
October 2023 to February 2023	Hyperpigmentation in left ankle joint, itching, swelling, difficult to walk and ulceration size has been increased.
March 2023	The patient visited Siddha Clinical Research Unit in New Delhi for further management.
06.03.2024 to 11.05.2023	The patient administered with the Siddha therapeutic regimens. The clinical features has gradually reduced and completely recovered in 2 months of Siddha management.
May 2023 to October 2023	Follow-up period. No recurrence was observed

Diagnostic Findings:

Patient has a previous history of Charcot's foot ulcer. Considering the clinical features, previous medical history, and blood investigations, the patient was diagnosed with a non-healing Charcot foot ulcer (Āṟāppuṇ).

Subjective Parameters:

The following subjective parameters were used to assess the prognosis of clinical features. They reflect various grades: 0 indicates no pain and absence, while mild, moderate, and severe pain are represented by 1, 2, and 3, respectively.

· Itching

· Hyperpigmentation

· Pain

· Pus Discharge

· Swelling

OBJECTIVE PARAMETERS:

The severeness of the ulcer was evaluated using the Diabetic Ulcer Severity Score (DUSS). The ulcer classification was conducted using the Wagner Ulcer Classification System (WUCS)⁶. Additionally, the ulcer characterization and satisfaction of patients were assessed with the Leg Ulcer Measurement Tool (LUMT)⁷. Haematological tests and a routine urine examination were performed, as detailed in Table 3.

Treatment Schedule:

In Siddha literature, various therapeutic regimens are described for the management of Āṟāppuṇ. They are Cūraṇam: Paraṅkipaṭṭai Cūraṇam, Elathy Cūraṇam, Civaṉārvēmpu Cūraṇam. paṟpam: Caṇṭaraca paṟpam, Rasa paṟpam, Palakarai paṟpam, Caṅku paṟpam, Gandhaga paṟpam. Centuram: Āṟumuka Centuram, Rasa Centuram, Veḷḷi Centuram. Pataṅkam: Paraṅkipaṭṭai Pataṅkam. Meẕuku: Rasa Meẕuku, Rasagandhi Meẕuku, Idivallathi Meẕuku, Gandhi Meẕuku. Iracāyaṉam: Gandhaga Iracāyaṉam. Eṇṇey (Medicated Internal oils): Rasa tailam, Karappāṉ tailam, Mēkanāta tailam. Tailam (Medicated External oils): Vīraṇa cañcīvi tailam, Ūṇpūccu tailam, Mattaṉ tailam, Arukaṉ tailam. External wash: Tiripalā Cūraṇam, Paṭikāra Nīr⁸.

The selected Siddha therapeutic regimens for this case report adhere to the guidelines prescribed for Āṟāppuṇ. A combination of three unique Siddha medicines, referred to as Combination Cūraṇam, includes the following: Paraṅkipaṭṭai Cūraṇam (100 grams), Palakarai paṟpam (10 grams), and Caṅku paṟpam (10 grams). The patient was instructed to take 2 gm of this combination twice a day after meals, along with milk. Additionally, Gandhaga Iracāyaṉam was administered at a dosage of 5 gm twice a day after meals, also with milk. For external treatment, Tiripalā Cūraṇam was used as a wash twice daily. The patient was instructed to add five grams of Tiripalā Cūraṇam to two fifty ml of water, boil it for ten minutes, and then wash and clean the ulcerated parts thoroughly. Lastly, Mattaṉ tailam was externally applied to the ulcerated parts.

The patient was directed to a follow-up visit once every fifteen days, during which clinical assessments and prognosis were recorded. Furthermore, the patient was instructed to adhere to the Pattiyam (dietary guidelines) throughout the treatment process.

Outcomes and follow-up:

Throughout this Siddha medications, the patient completed the medication without any complications, and there were no reports of adverse drug reactions (ADRs). Each visit recorded the prognosis and symptoms, which are detailed in Tables 2. Before treatment, the patient appeared with a non-healing ulcer on the left foot, along with itching, swelling, and hyperpigmentation in the same region, which made walking difficult. After 30 days of treatment, the margins of the ulcer showed slight healing, and the swelling, hyperpigmentation’s, and other clinical symptoms were mildly reduced. After 8 weeks of treatment, the ulcer had recovered completely, and additional clinical symptoms had fully recuperated. This information is outlined in Table 2 and illustrated in Figure 1.

Baseline of the treatment, the DUSS score was 1, and the patient presented with chronic ulcer in the left foot region. Following treatment, the DUSS score improved to nil. Based on the Wagner Ulcer Classification method, the ulcer was classified as grade two (ulcer has deeper and full thickness extension) before treatment, but after medications, it improved to grade zero. The features of the ulcer and satisfaction of the patient were valued using the Leg Ulcer Measurement Tool (LUMT), which includes 16 assessment questions. In the Clinician Rated Domain, the score before treatment was 21 out of 56. The Patient Rated Domain (PRD) consists of 3 assessment questions rated by the patients, with a score of 7 out of 12 prior to treatment. Baseline and after therapeutic interventions, haematological investigations were normal except for ESR and CRP levels. The ESR level was 29 mm/hr before treatment and decreased to 12 mm/hr after treatment. Similarly, the CRP level was 19 mm/hr before treatment and reduced to 7 mm/hr after treatment.

Table 3: Haematological investigations in Baseline of the Treatment and After Treatment

Investigations	Baseline of the treatment	After Treatment
Blood Investigations
Neutrophils	52%	50%
Total WBC Count	7200 cells/ cu.mm	8100 cells/ cu.mm
Lymphocytes	31%	24%
Platelet count	3.20 lacs cells/ cmm	3.70 lacs cells/ cmm
Eosinophils	7%	4%
Monocytes	05%	02%
Basophils	0%	0%
ESR	29 mm/ hr	12 mm/ hr
Random blood sugar	126 mg/dl	112 mg/dl
FBS	102 mg/dl	98 mg/dl
Haemoglobin	13 g/dL	14 g/dL
RBC Count	4.80 millions/cu. mm	5.10 millions/cu. mm
CRP	19 Mg/l	7 Mg/l
Total Bilirubin	0.7 mg/dl	0.6 mg/dl
Direct Bilirubin	0.3 mg/dl	0.2 mg/dl
Indirect Bilirubin	0.4 mg/dl	0.4 mg/dl
SGOT	24 U/L	21 U/L
SGPT	39 U/L	33 U/L
Alkaline phosphatase	96 U/L	83 U/L
Total Protein	7.15 gm/dl	7.10 gm/dl
Globulin	2.25 gm/dl	2.26 gm/dl
Albumin	4.35 gm/dl	4.17 gm/dl
Total Cholesterol	228 mg/dL	187 mg/dL
Triglycerides	106 mg/dL	105 mg/dL
Serum Urea	13 mg/dL	11 mg/dL
Serum Creatinine	0.7 mg/dL	0.6 mg/dL
Serum Uric Acid	4.3 mg/dL	3.6 mg/dL
Urine Routine Analysis
Appearance	Clear	Clear
Colour	Pale yellow	Pale yellow
pH	5.4	5.0
Specific Gravity	1.022	1.020
Glucose	Nil	Nil
Protein	Nil	Nil
Bile Salt	Absent	Absent
Bile Pigments	Absent	Absent
Urobilinogen	Normal	Normal
Urine Microscopic Examination
Crystals	Absent	Absent
RBC’S/ Hpf	Absent	Absent
Pus Cells/ Hpf	3-4/hpf	2-3 /Hpf

Before Treatment

After Treatment

Figure 1: Prognosis of Chronic Non-healing ulcer during Siddha management

DISCUSSION:

The development and progression of foot ulcers are influenced by various interrelated factors, including peripheral vascular disease, neuropathy, structural deformities, and changes in soft tissues. Peripheral neuropathy involves a progressive loss of nerve fibers—sensory, motor, and autonomic—which can lead to complete sensory loss. This usually starts at the tips of the toes and spreads in a pattern resembling a stocking or glove. In advanced cases of peripheral neuropathy, patients may not notice minor injuries. Motor neuropathy can cause muscle imbalances, resulting in increased pressure and tissue breakdown in specific weight-bearing areas. Autonomic neuropathy reduces the supply of nutrients and oxygen to the foot's soft tissues by diverting blood flow away from the capillaries that nourish them. Structural deformities of the foot, such as hallux valgus, hammertoes, equinus, hallux limitus, and Charcot foot, play a notable part in the development and persistence of foot ulcers by increasing pressure on certain areas. Treatment options for foot ulcers are varied. Chronic, non-healing ulcers are often managed through debridement, which can be surgical, enzymatic, mechanical, or biological. Mechanical debridement involves using wet-to-dry dressings to remove non-viable tissue during dressing changes. Enzymatic debridement typically utilizes collagenase to help break down collagen. Surgical debridement involves the physical removal of fibrotic and necrotic tissue using sharp instruments. In cases of severe ulcers that are deep or have led to gangrene, amputation may be necessary. Proper wound care and management are essential, particularly because peripheral neuropathy is a major contributor to ulcer formation. Additionally, nitric oxide plays a critical role in managing peripheral vascular and neuropathic conditions, making its induction vital for ulcer treatment. Topical nitric oxide has also been used for painful peripheral neuropathies. Supplements like B6, B12, and folate are often utilized in managing peripheral neuropathies, while oral medications, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and antiarrhythmics, can provide symptomatic relief for those affected⁹.

Non- Healing Chronic ulcer is called “Āṟāppuṇ” in the Siddha system of medicine. For effective management of chronic non-healing ulcers, the Siddha medicine advocates a comprehensive approach that includes both internal and external therapies. Embracing this holistic method can significantly enhance healing outcomes. Paraṅkipaṭṭai Cūraṇam is a traditional Siddha therapeutic regimen that is indicated for the treatment of vascular diseases and various skin conditions. Paraṅkipaṭṭai (Smilax China Linn) and Karuntuḷaci (Ocimum tenuiflorium) is the major ingredients of Paraṅkipaṭṭai Cūraṇam. The anti-inflammatory, anti-microbial, immunomodulatory, anti- Oxidant properties of Paraṅkipaṭṭai Cūraṇam is known to reduce inflammations and healing ulcers. A systematic review conducted by Deepa and colleagues on the effects of Paraṅkipaṭṭai Cūraṇam in treating ulcers has demonstrated its effectiveness¹⁰. Palakarai paṟpam, a Siddha herbo-mineral therapeutic regimen, exhibits anti-inflammatory, wound healing, and antimicrobial properties¹¹. Palakarai (Cypraea moneta Linn) contains 91.35% calcium, which may act a crucial part in the development of granulation tissue. Calcium, a free metal-containing mineral, is essential for cell migration and remodeling in skin wounds¹². Caṅku paṟpam is another herbo-mineral therapeutic regimen designed to treat peptic ulcers, urinary tract infections, skin diseases and arthritis. It possesses anti-inflammatory¹³, antioxidant¹⁴, and antiulcer properties¹⁵.

Gandhaga Iracāyaṉam is a Siddha herbo-mineral preparation that is used to treat wounds, skin diseases, hemorrhoids, peptic ulcers, and urinary tract infections. Gandhaga Iracāyaṉam exhibits antibacterial, antifungal, antiviral, analgesic, and anti-inflammatory properties¹⁶, as well as antioxidant effects¹⁷. A study by Shetty et al. demonstrated that Gandhaga Iracāyaṉam works by activating fibroblasts and modulating the proteins involved in tissue remodeling during the wound healing process¹⁸.

Tiripalā Cūraṇam is a unique polyherbal Siddha formulation. It contains three key ingredients: Kaṭukkāy (Terminalia chebula), Nellikkāy (Emblica officinalis), and Tāṉṟikkāy (Terminalia bellirica). For many years, Tiripalā Cūraṇam has been used as an external wash to treat ulcers. This formulation exhibits several beneficial properties, including antioxidant, anti-inflammatory, immunomodulating, antibacterial, and antineoplastic effects. A study by Muthusamy Senthil Kumar and colleagues revealed that Tiripalā Cūraṇam demonstrates good wound healing activity and reduces the incidence of infections¹⁹.

Mattaṉ Tailam is a distinctive Siddha therapeutic regimen that is generally prescribed for external application in various conditions, including wounds, non-healing external ulcers, bedsores, folliculitis, anal fistulas, carbuncle ulcers related to diabetes, perianal abscesses, and burn wounds²⁰. The components of Mattaṉ Tailam contains Tēṅkāy eṇṇey (coconut oil), Turucu (copper sulfate), Ūmattai (Datura metel), and Kuppaimēṉi (Acalypha indica). Histopathological studies have shown an increase in fibroblast proliferation and neovascularization in wounds treated with Virgin Coconut Oil compared to controls. The extract of Datura metel has shown significant inhibition of the bacteria Staphylococcus aureus and Pseudomonas aeruginosa. Copper is a key mineral that acts a pivotal role in angiogenesis, skin regeneration, and the expression and stabilization of extracellular skin proteins. Furthermore, the herbal extract of Acalypha indica exhibits notable wound healing properties²¹. Selvaraju et al. showed that Mattaṉ Tailam has excellent rejuvenating effects on wound gaping and is highly effective in wound healing and rejuvenation²².

The DUSS is a regularized classification system that categorizes wounds into specific severity subgroups for the purpose of comparing results. The assessment utilizing the DUSS system effectively evaluates key factors such as the presence of pedal pulses, the ability to probe the ulcer down to the bone, and the number and location of the ulcers. The total points assigned from this comprehensive evaluation decisively determine the severity of the condition, with scores ranging from 0 to 4²³. The Wagner Ulcer Assessment Scale is used to classify ulcers, specifically diabetic foot ulcers, into six grades based on the depth of the ulceration. Grade 0 represents healthy skin, grade one indicates a superficial ulcer, grade two describes an ulcer progressing toward deeper tissue, grade three denotes a deep ulcer with possible involvement of underlying structures, grade four indicates the presence of gangrene in the forefoot or part of the limb, and grade five represents gangrene affecting the entire foot²⁴. The LUMT scale is a unique assessment tool used to analyzed chronic leg ulcers, particularly in research contexts. By comparing evaluations from baseline to after treatment, non-healing ulcers can demonstrate adequate improvement based on assessments using the DUSS, LUMT, and the Wagner Ulcer Classification System (WUCS).²⁵.

Laboratory Markers such as ESR and CRP levels can be valuable for prognostic evaluation in managing ulcerative or inflammatory conditions²⁶. In the study of burns, higher CRP levels were associated with acute inflammation and difficulties in wound healing. Kingsley and colleagues investigated whether CRP levels could serve as a marker for wound infection²⁷. After treatment, both ESR and CRP levels showed significant reductions; ESR decreased from 29 mm/hr to 12 mm/hr, and CRP decreased from 19 mg/L to 7 mg/L. This indicates a notable reduction in inflammatory conditions.

The Siddha therapeutic regimens demonstrate promising wound healing activities, as well as anti-inflammatory, antimicrobial, and antioxidant properties. They also help regulate blood circulation in the affected area, reducing the risk of infections and promoting healing. According to this case report, all clinical features improved significantly by the third follow-up visit, and the patient completely recovered from a chronic non-healing ulcer. This case report indicates that Siddha intervention is highly effective in treating chronic non-healing ulcers.

CONCLUSION:

A variety of approaches are employed to treat chronic non-healing ulcers. This case study demonstrates that a patient with a chronic non-healing ulcer and other clinical features completely recovered after receiving Siddha medicine. The report highlights that Siddha medicine is not only effective but also affordable for the management of long- lasting non- healing ulcers. Furthermore, it suggests that Siddha interventions can significantly improve the quality of life for patients suffering from these ulcers. However, further studies with maximum number of samples are essential to fully determine the efficacy of Siddha management for chronic non-healing ulcers.

INFORMED CONSENT:

Written consent was obtained from the patient.

ACKNOWLEDGEMENTS:

Authors express sincere thanks to Dr. B. Akila, Research Officer (Siddha) and In-charge of the Siddha Clinical Research Unit at Safdarjung Hospital, Central Council for Research in Siddha, Ministry of AYUSH, New Delhi for the encouragement and support provided at every step throughout the preparation of this study.

CONFLICT OF INTEREST:

None.

REFERENCES:

1. Rogers LC, Frykberg RG, Armstrong DG, Boulton AJ, Edmonds M, Van GH, Hartemann A, Game F, Jeffcoate W, Jirkovska A, Jude E, Morbach S, Morrison WB, Pinzur M, Pitocco D, Sanders L, Wukich DK, Uccioli L. The Charcot foot in diabetes. Diabetes Care. 2011; 34(9): 2123-9. doi: 10.2337/dc11-0844. PMID: 21868781; PMCID: PMC3161273.

2. Keukenkamp R, Busch-Westbroek TE, Barn R, Woodburn J, Bus SA. Foot ulcer recurrence, plantar pressure and footwear adherence in people with diabetes and Charcot midfoot deformity: A cohort analysis. Diabet Med. 2021 Apr; 38(4): e14438. doi: 10.1111/dme.14438. Epub 2020 Nov 3. PMID: 33084095; PMCID: PMC8048542.

3. Salini D, Harish K, Minnie P, Sundaram KR, Arun B, Sandya CJ, Mangalanandan TS, Vivek L, Praveen VP. Prevalence of Charcot Arthropathy in Type 2 Diabetes Patients Aged over 50 Years with Severe Peripheral Neuropathy: A Retrospective Study in a Tertiary Care South Indian Hospital. Indian J Endocrinol Metab. 2018; 22(1): 107-111. doi: 10.4103/ijem.IJEM_257_17. PMID: 29535947; PMCID: PMC5838888.

4. Gratwohl V, Jentzsch T, Schöni M, Kaiser D, Berli MC, Böni T, Waibel FWA. Long-term follow-up of conservative treatment of Charcot feet. Arch Orthop Trauma Surg. 2022 Oct; 142(10): 2553-2566. doi: 10.1007/s00402-021-03881-5. Epub 2021 Apr 7. PMID: 33829302; PMCID: PMC9474498.

5. Who international standard terminologies on Siddha Medicine [Internet]. World Health Organization; [cited 2023 Jul 10]. Available from: https://www.who.int/publications/i/item/9789240064973.

6. Shah P, Inturi R, Anne D, Jadhav D, Viswambharan V, Khadilkar R, Dnyanmote A, Shahi S. Wagner's Classification as a Tool for Treating Diabetic Foot Ulcers: Our Observations at a Suburban Teaching Hospital. Cureus. 2022 Jan 22; 14(1): e21501. doi: 10.7759/cureus.21501. PMID: 35223277; PMCID: PMC8861474.

7. Samraj K, Kannan M, Sathiyarajeswaran P. A case report on the siddha management of diabetic foot ulcer (DFU): left plantar foot. Int. J. Res. Ayurveda Pharm. 2019; 10(2): 80-5.

8. Kuppuswamy muthaliyar K N, Siddha Vaidya Thirattu, 1st edition reprinting 2009, Department of Indian Medicine and Homeopathy, Chennai, Page no- 213.

9. Abid A, Hosseinzadeh S. Foot Ulcer. [Updated 2024 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557778/

10. Deepa R, Mahalakshmi V, Muthukumar NJ, Meenakumari R. A review on therapeutic effectiveness of Parangipattai choornam-A Siddha polyherbal formulation. World J Pharm Res. 2016;11(5):206-15.

11. Sudarsanam SR, Moonandi M. Potency of Kara sooda sathu parpam A herbo mineral siddha drug in the management of Kalladaippu noi (Urolithiasis) A drug review. Int J Res Ayurveda Pharm. 2014; 5(3): 372-9.

12. Samraj K, Kannan M, Sathiyarajeswaran P. A case report on the siddha management of diabetic foot ulcer (DFU): left plantar foot. Int. J. Res. Ayurveda Pharm. 2019; 10(2): 80-5.

13. Murugan V, Walter TM, Nihar SS, Kumar BS. Pharmacological evaluation of the Anti-inflammatory activity of Sangu Parpam (Conch)–A Siddha Medicine. Siddha Pap. 2008; 3(2): 1-0.

14. [Internet]. [cited 2023 Aug 9]. Available from: https://www.researchgate.net/publication/332961596_Sangu_parpam_Antioxidant

15. Madhavan R, Sathish R, Murugesan M. Standardization of Sangu parpam a herbo marine siddha drug. Int. J. Curr. Res. Chem. Pharm. Sci. 2016;3(6):77-84.

16. Meena R, Ramaswamy RS. Therapeutic potency of a Siddha formulation Kandhaga Rasayanam: a review. Int J Res Ayurveda Pharm. 2015;6(1):58-64.

17. M. Shrisaranya, M. Mohamed Mustafa. (2017). Antioxidant activity of siddha polyherbomineral drug Gandhaga Rasayanam. Int. J. Curr. Res. Chem. Pharm. Sci. 4(11): 12-16. DOI: http://dx.doi.org/10.22192/ijcrcps.2017.04.11.003

18. Shetty P, Kedukodi P, Kamath S et.al. Gandhaka rasayana: possible role as a modulator of fibroblast cell function in wound healing. Int J Health Sci Res. 2020; 10(6): 36-45.

19. Kumar MS, Kirubanandan S, Sripriya R, Sehgal PK. Triphala promotes healing of infected full-thickness dermal wound. J Surg Res. 2008 Jan;144(1):94-101. doi: 10.1016/j.jss.2007.02.049. Epub 2007 Jul 27. PMID: 17662304.

20. Arunadevi R, Susila R, Murugammal S, Divya S. Preparation and standardization of Mathan Tailam: A classical Siddha formulation for diabetic ulcerative wound healing. J Ayurveda Integr Med. 2020; 11(1): 10-15. doi: 10.1016/j.jaim.2017.08.011. Epub 2018 Mar 16. PMID: 29555256; PMCID: PMC7125365.

21. Samraj K et al. A case report on the siddha management of diabetic foot ulcer (DFU): left plantar foot. Int. J. Res. Ayurveda Pharm. 2019; 10(2): 80-85 http://dx.doi.org/10.7897/2277- 4343.100241

22. Selvaraju M., Periyannan M., Varudharajan V., Prakash S., Ravikumar K., Gopikrishnan D. (2022). Rejuvenating Effect of Mathan Thailam for a Wound Dehiscence following Caesarean Operation in a Kangayam Cow Affected with Uterine Torsion. Indian J Anim Res. 56(4): 502-504. doi: 10.18805/IJAR.B-4487.

23. Understanding Diabetic Foot Ulcer Classification Systems [Internet]. WoundSource. 2019. Available from: https://www.woundsource.com/blog/understanding-diabetic-foot-ulcer-classification-systems

24. Ghobadi A, Ahmadi Sarbarzeh P, Jalilian M, Abdi A, Manouchehri S. Evaluation of Factors Affecting the Severity of Diabetic Foot Ulcer in Patients with Diabetes Referred to a Diabetes Centre in Kermanshah. Diabetes Metab Syndr Obes. 2020 Mar 13; 13: 693-703. doi: 10.2147/DMSO.S242431. PMID: 32214832; PMCID: PMC7078779.

25. Woodbury MG, Houghton PE, Campbell KE, Keast DH. Development, validity, reliability, and responsiveness of a new leg ulcer measurement tool. Adv Skin Wound Care. 2004 May; 17(4 Pt 1): 187-96. doi: 10.1097/00129334-200405000-00018. PMID: 15360028.

26. Malachowski SJ, Latour E, Ortega-Loayza AG. Clinical and laboratory factors associated with wound healing in patients with pyoderma gangrenosum: a retrospective study. Wounds. 2022 Jun;34(6):178-184. doi: 10.25270/wnds/2022.0408. Epub 2022 Apr 15. PMID: 35767845.

27. Salvo P, Dini V, Kirchhain A, Janowska A, Oranges T, Chiricozzi A, Lomonaco T, Di Francesco F, Romanelli M. Sensors and Biosensors for C-Reactive Protein, Temperature and pH, and Their Applications for Monitoring Wound Healing: A Review. Sensors (Basel). 2017 Dec 19; 17(12): 2952. doi: 10.3390/s17122952. PMID: 29257113; PMCID: PMC5750823.

Received on 10.01.2024 Revised on 17.10.2024

Accepted on 27.03.2025 Published on 13.01.2026

Available online from January 17, 2026

Research J. Pharmacy and Technology. 2026;19(1):250-256.

DOI: 10.52711/0974-360X.2026.00035

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Subjective parameters	1^st visit- baseline of the treatment	2 weeks after the baseline treatment	4 weeks after the baseline treatment	6 weeks after the baseline treatment	8 weeks after the baseline treatment
Pain (VAS scale)	2	2	1	1	0
Hyperpigmentation	3	3	2	1	0
Itching	3	3	2	1	0
Pus Discharge	1	0	0	0	0
Swelling	2	2	1	0	0