Topical Herbal Applications in Ayurveda for Healing Diabetic Ulcers

Shelley D. Meier
California College of Ayurveda

Introduction

Diabetes mellitus is a health concern affecting millions of people worldwide. Among one of the more serious complications associated with diabetes is the development of diabetic foot ulcers, which can lead to infection, hospitalization, and amputation to the lower limb if left untreated. Contributing to this risk is impaired circulation, neuropathy, and delayed wound healing, which attributes to the chronic nature of these wounds. With the increasing rise of prevalence in America, there is a growing interest in complementary approaches to improve patient outcomes.

Ayurveda, the classical medical system of India, has a long history of treating all types of wounds through both internal and external therapies. Classical texts such as the Caraka Samhita and the Ashtanga Hrdayam describe numerous medicinal plants used to cleanse wounds, reduce inflammation, prevent infection, and promote tissue regeneration.

Some classical herbs used in Ayurveda have been tested through Western medical practice to research their healing properties. Three specific herbs will be discussed in this paper. They are called neem (Azadirachta indica), turmeric (Curcuma longa), and guduchi (Tinospora cordifolia). These herbs are valued for their wound-healing properties and continue to be used in traditional practices. This paper examines the Ayurvedic understanding of diabetes, how to treat diabetic ulcers both traditionally and according to Western medicine, and how these three herbs may support healing when applied topically or taken internally.

Western Pathology

As of 2023, 12% of Americans have diabetes, with approximately 1.5 million people receiving a new diagnosis every year. There are currently 115 million American adults with pre-diabetes that can be managed with diet and lifestyle. ¹ For the purpose of this paper, only Types I and II will be discussed.

Type I diabetes mellitus, or insulin-dependent diabetes mellitus (IDDM), affects both children and adults. IDDM is thought to be an autoimmune disorder where the beta cells of the pancreas, located in the Islet of Langerhans does not produce insulin. ² Type I diabetics are at higher risk for hyperglycemia and ketoacidosis. Injections are required to administer insulin. If insulin becomes too low, it is called insulin shock and can be fatal. When blood sugars become unstable, some individuals must be hospitalized to receive intravenous insulin to become stabilized. Ongoing care requires daily insulin injections to keep blood sugars under control.

Type II diabetes is a condition of insulin resistance. Type II diabetes is also called non-insulin dependent diabetes mellitus (NIDDM). Insulin levels are close to normal, but the cells become resistance to insulin. ³ NIDDM affects both children and adults who are obese and can be controlled with diet and lifestyle. Living a sedentary lifestyle, intake of processed foods, and overconsumption contribute to this disease. Some people need ongoing Western medical support with oral or injectable medications.

Both Type I and II diabetes mellitus affect numerous organs and body systems systemically, with complications related to microvascular blockages ⁴ in the eyes, kidneys, and nerves. The issues directly related to diabetic foot ulcers result from a combination of vascular, metabolic, and neurological complications associated with diabetes mellitus. Circulatory disorders can decrease blood flow to the extremities, causing ischemic ulcers in the feet. High blood sugars decrease the effectiveness of the immune system. Dysfunction within the nervous system may cause both motor and sensation loss in the feet, which diminishes the protective sensation.

Vascular Complications

Peripheral arterial disease decreases blood flow to the lower extremities, limiting both oxygen and nutrient delivery to repair tissues. Ongoing lack of blood flow keeps wounds in a prolonged inflammatory phase of wound healing. The arteries harden, become stiff, and have no rebound effect when the heart pumps blood to the body. Smoking cigarettes or intake of any nicotine products can cause a detrimental effect to wound healing and significantly decreases blood flow, especially to the lower extremities, due to its vasoconstrictive effects. ⁵

Metabolic Complications

The wound healing process is also impaired in people with diabetes. Elevated blood sugars contribute to chronic inflammation, oxidative stress, and dysfunction of immune cells. Delayed activity of fibroblasts, collagen syntheses, angiogenesis, and epithelialization results in wounds that remain in a prolonged inflammatory stage. This chronicity of wounds increases risk of infection and delayed healing rates.⁶ Chronic hyperglycemia damages both blood vessels and nerves throughout the body. When fasting blood glucose exceeds 170-180 mg/dL, high blood glucose decreases white blood cell activity, specifically neutrophils which help our immune system to fight off infection.

Neurological Complications

Peripheral neuropathy damages sensory nerves, which reduce the protective sensation in the feet, which can increase the likelihood of injury, pressure points from ill-fitting footwear, and stepping on foreign objects. Motor neuropathy alters foot mechanics, which increases pressure to bony landmarks on the feet, causing tissue disruption. Foot complications due to neuropathy is one of the main issues of poor patient outcomes. Due to no longer having the protective sensation in the soles of the feet, there is a lack of awareness of injuries to this area that may go undetected. Lack of knowledge of how to care for feet that a person can’t feel and socioeconomic status play a significant role in patient outcomes.⁷

Ayurvedic Classification and Pathology

In Ayurveda, diabetes is categorized under the umbrella of prameha or polyuria. Prameha means excessive urination. ⁸ In the classical texts, there are twenty types of prameha. Ten types related to kapha are curable because the dosa and dhatus involved have similar attributes. Some of the signs and symptoms of kaphaja meha are: resembling sugar-cane juice, sweet taste, white in color, dense, containing sand-like substance, cold touch, slimy, and passing out slowly.⁹ There are six types of pitta, which are palliable due to the incompatibility of therapies for treatment. Characteristics of pittaja meha are colored yellow like turmeric, reddish, or having blood in it. ¹⁰ Four types are attributed to vata and are incurable due to affecting deeper dhatus. Common characteristics of vataja meha are urine mixed with bone marrow, ojas, muscle fat, or lymph with a grayish color. ¹¹ Regardless of the responsible dosa, “All types of prameha, if not treated in time, lead to Madhu Meha and become incurable.”¹²

Vata Aggravation

IDDM or Type I diabetes is categorized under vata vitiation and is referred to as Madhu Meha in Ayurveda. Madhu Meha is considered one of the most severe forms and is frequently associated with chronicity, tissue depletion, weakness, dryness, and systemic dysfunction. Some people are born with IDDM, which could be a genetic or karmic tendency. The signs and symptoms of IDDM are increased thirst, increased urination, and hunger.¹³ IDDM is caused by a vata vitiating lifestyle. Vata accumulates and aggravates in the purishavaha srotas, overflows into the rasa and rakta dhatus, and relocates into the ambuvaha srotas. Specific to diabetic ulcers, the vyana and samana vayu in the majja dhatu and majjavaha srotas create sensory dysfunction, which in Western terms is called neuropathy. In Western medicine, IDDM is treated with insulin injections. Nourishing Ayurvedic therapies like a vata-pacifying diet that does not increase blood sugar levels, applying tonic oil therapies, and decreasing stress are vital.¹⁴

Kapha and Channel Obstruction

NIDDM or type II diabetes is called Iksu Meha in Ayurveda and is caused by being overweight, which affects kapha dosha. Traditionally, diabetes was seen as a disease of excess as stated in the Astanga Hrdayam, “Food, drinks and activities which produce increase of medas (fat), mutra (urine), and kapha are generally the chief causes such as; foods which are sweet, sour, salt, not animals of marshy regions, sugarcane juice, molasses and milk, (habit of) always sitting at a place and sleeping without adopting its proper procedure.”¹⁵ The Astanga Hrdayam also states, “Poor digestion, anorexia, vomiting, sleepiness, cough and nasal catarrh are secondary diseases of diabetes arising from kapha.”¹⁶ The signs and symptoms are similar to Madhu Meda or IDDM of thirst, hunger, and excessive urination. Kapha accumulates and becomes aggravated in the annavaha srotas. Kapha then overflows in the rasa and rakta dosha and relocates in the ambuvaha dosa.¹⁷ Weight gain happens when kapha relocates in the medas dhatu and medovaha srotas as well as the mamsa dhatu and mamsavaha srotas. Intake of a kapha-pacifying diet and lifestyle will help to address this disease. Strong patients should undergo a purifying panchakarma. Iksu Meha can be controlled via diet and lifestyle, which includes exercise and weight loss.

Western and Traditional Herbal Classifications

Neem

Western & Traditional Herbal Classification

Neem is called Azadirachta indica from the Meliaceae family. It is a tree that can grow up to 60 feet in height. Not only does this tree provide shade, but it has been known to be called the village pharmacy due to its many health benefits from the leaves, stem, root, fruit, seed, and flowers. The most common parts used are the bark and leaves. It has a bitter rasa or taste with a cooling virya or energy. The vipaka or post-digestive effect is pungent and purifying. The guna or quality of neem is light and dry. ¹⁸ The dosic qualities of neem decrease pitta and kapha but increase vata due to its rasa, virya, and vipaka.

Traditionally called nimba, margosa, and nim, it is commonly found in India and grows wild throughout Asia.¹⁹ The active ingredients of nimbidin, nimbin, and nimbidol are the constituents in the tree that have an anti-inflammatory, antibacterial, antifungal, and antiviral properties. ²⁰ Neem has been used in Ayurveda to treat internal worms and parasites in the digestive tract as an anthelmintic. It treats inflammation in the intestines related to pitta and kapha as well as reducing high fevers associated with malaria.²¹ When taken internally, neem helps to purify the blood and remove toxins to cleanse the rasa and rakta dosas. The branches of the tree are used to treat dental cavities and gum inflammation, and can be used as a toothbrush.²² Neem also treats numerous skin diseases. As an antiseptic, the extract from the leaves and bark have antimicrobial properties with low toxicity levels.²³ Neem is helpful in decreasing pitta-type skin reactions and infections, ringworm, scabies, and fungal infections. The bitter and dry qualities help to address lung issues.²⁴

Metabolically, the leaves help to decrease blood sugars, which is imperative in the treatment of diabetes. When taken internally, the pancreas is stimulated to secrete insulin and supports the immune system, which can aid in diabetes management.²⁵ In a study done on the anti-diabetic activity, the onset of action took thirty minutes to four hours.²⁶ Neem is also used as an insecticide to spray on plants in the garden without toxic side effects.

Turmeric

Western & Traditional Herbal Classifications

Turmeric is known as Curcuma longa in Western medicine and belongs to the Zingiberaceae family. Traditionally named haridra or haldi, it was frequently administered with honey and ghee. ²⁷ The main parts used of this plant is the root or rhizome. It has a bitter, astringent, and pungent rasa or taste. The virya or energy is heating, although it does not seem to aggravate pitta unless taken in high doses. The vipaka or post-digestive effect is pungent and purifying. The guna or quality is dry and light. It alleviates kapha due to its hotter nature and relieves pitta with the bitter taste. It can increase vata in excess due to the light and dry qualities. ²⁸

As a native of India and South Asia, turmeric is a member of the ginger family. It grows well in warm and moist areas up to five feet tall. ²⁹ It is a perennial herb with tuberous roots that can grow up to two feet long. The lily-like leaves and central flower spine with funnel-shaped yellow flowers grow best in tropical climates.³⁰ It is yellow in color, which has dubbed the name Indian saffron. Turmeric contains a compound named curcumin, which aids in its anti-inflammatory effects comparable to cortisone but in itself is not a steroid.³¹

Taken both internally and externally, this herb helps to decrease blood sugar, cholesterol, and lipid levels. This medicine has been traditionally used in numerous ways. It has been used for digestion disorders, cleansing the liver, diabetes, and decreases inflammation. ³² It is great for digestion by stimulating bile and helping to digest fats. The anti-inflammatory effect of curcumin helps treat arthritis and bruises.³³ Turmeric reduces pathogenic bacteria and destroys ama in the intestines. A common culinary herb, the bitter and pungent qualities nourish the rasa dhatu and cleanses the blood. ³⁴ As a blood purifier, it cleanses the rakta dhatu and liver. Turmeric prevents and dissolves gallstones and is known for treating hepatitis. ³⁵ The anti-inflammatory effects have positive outcomes for the joints. Vagbhata quoted it as “the best for prameha. Presently it is considered as an important antidiabetic and antioxidant drug.”³⁶ Turmeric is a natural antibiotic and can be applied topically as a paste to treat diabetic ulcers. ³⁷

Guduchi

Western & Traditional Herbal Classifications

Guduchi is named Tinospora cordifolia in Western medicine and is from the moonseed family Menispermaceae. Traditionally, it has been named guduchi, amrit, and ambrosia. It is a creeping viney plant often found on neem trees through the forests of southern Asia and India. This climbing plant has succulent, corky, and grooved stems with slender branches with pendulous fleshy roots. ³⁸ Leaves are heart-shaped and dark green, about two to four inches long, with pale flowers, and fruits are orange-red in color, approximately the size of large peas.

It is said the guduchi growing on the neem trees is the best due to similar qualities they both have. Termed plant which protects from diseases, guduchi is described as divine nectar.³⁹ The myth of this plant is recorded in ancient teachings as “During the fearful war between Rama & Ravana, several monkey warriors were killed by enemy forces. At the end, Lord Indra sprinkled elixir (Amrta) on their dead bodies and provided rebirth to the monkeys. During the process, wherever the elixir drops have fallen on the ground, Guduchi plants originated.”⁴⁰

Guduchi has a bitter, astringent and pungent rasa or taste. It has a heating virya or energy with a sweet vipaka or post-digestive effect. The guna or quality is light and unctuous. Parts used are the stem, leaves, and root. The balance of the bitter taste, heating virya, and sweet vipaka make this a tridosic plant which balances each of the dosas. It has a prabhava or special affinity to decrease ama. ⁴¹ Since it helps to decrease ama or toxins in the body, it helps to clear body channels and assists the delivery of other herbs when added into a formula.⁴² When taken with certain foods, this herb works well for each dosa. Eating with ghee will reduce vata, taken with sugar will alleviate pitta, and ingested with honey it reduces kapha. This herb helps to rejuvenate the body after recovering from fever or an infectious disease. It is a good tonic for the immune system and helps with immune function. ⁴³

As a bitter tonic, this herb helps to cleanse the rasa and rakta dosa and is good for treating both liver disorders and digestion issues. Where this herb shines is in its affinity for skin diseases and treatment of diabetes. This herb has a broad-spectrum antimicrobial action and is a source of berberine.⁴⁴ Berberine is useful in decreasing weight, cholesterol, and blood sugars, which have a decreasing effect on the medas dhatu. It has been called Madhunashini or sugar destroyer.⁴⁵

Phases of Wound Healing

Normal wound healing progresses through four overlapping phases. These phases are hemostasis, inflammation, proliferation, and remodeling. Immediately following injury, small blood vessels constrict, and clotting mechanisms activate to stop bleeding. This phase is called hemostasis, and platelets release growth factors to aid in the initial repair. The other three phases can be seen as interdependent of one another due to the factors that go into the healing process.

Once bleeding is controlled, the inflammatory phase begins. Immune cells migrate to the wound site to remove pathogens, damaged tissue, and debris. Neutrophils and macrophages are the first white blood cells on the scene. Enzymes are released during this phase to begin the growth of new blood vessels and formation of collagen, called vascular endothelial growth factor (VEGF). While inflammation is necessary, excessive or prolonged inflammation can delay healing, particularly in diabetic ulcers. ⁴⁶

The next phase is the proliferation phase with fibroblasts producing type III collagen and new blood vessels that form through angiogenesis. This creates the scaffolding within the wound base. As the granulation tissue develops, it fills the wound and begins to contract and knit back together by myofibroblasts. Re-epithelialization begins as new skin cells cover the wound surface.

The last phase of wound healing is the remodeling or maturation phase. Type I collagen replaces type III collagen to increase tensile strength of the tissue. At best, a wound will only be 80% of its original strength due to the presence of scar tissue. It is in this phase that epithelialization occurs and the wound heals.⁴⁷

In diabetic wounds, persistent inflammation, impaired formation of new blood vessels, dysfunctional fibroblasts, and abnormal collagen deposition delays progress. Hard-to-heal wounds may have reduced VEGF activity, delayed keratinocyte migration, and decreased collagen synthesis, which delays healing and increases risk of infection.⁴⁸

Herbal Characteristics That Favor Different Stages of Healing

Inflammation Phase

Helping the regulation of inflammation so that it does not turn into a chronic issue can be difficult in a person suffering from diabetes. Turmeric, guduchi, and neem all have attributes that help this phase of wound healing. In a study done on mice, it was found that curcumin, which is the primary active constituent in turmeric, has been shown to transform inflammatory pathways, support the deposit of collagen in the wound base, and reduce oxidative stress.⁴⁹ In a separate study on rats, zinc oxide and turmeric extract were combined and placed as a topical dressing. It was found that turmeric helped to increase the number of macrophages earlier than normal. ⁵⁰ By limiting excessive inflammation, turmeric may help diabetic wounds progress into later stages of healing.

Guduchi similarly demonstrates anti-inflammatory and immunomodulatory activity. Ayurvedic practitioners have traditionally used guduchi to reduce tissue irritation while supporting the body’s natural healing responses. Together, turmeric and guduchi may help address the chronic inflammatory environment present in diabetic ulcers.

Proliferation Phase

Each herb has their own constituent to aid this phase of the healing process. Turmeric and gaduchi are valuable during the proliferative phase of wound healing. Turmeric has been associated with increasing fibroblast activity, the formation of granulation tissue, and collagen deposition during wound healing. ⁵¹ Turmeric also helps to stimulate the formation of healthy blood vessels. The active ingredient curcumin increases the differentiation of fibroblasts to myofibroblasts. ⁵² All these effects contribute to the formation of healthy granulation tissue.

Neem contains vitamins, amino acids, and minerals to help the proliferation phase. ⁵³ The presence of these fatty acids in neem helps to create a moist wound healing environment. ⁵⁴ In a study utilizing neem and honey on radiation dermatitis neem “directly affects the proliferation stage and helps to maintain the granulation integrity of the wound.”⁵⁵ Neem leaves have been shown to have the same effect as povidone iodine to increase wound healing rates in rats. ⁵⁶

Guduchi’s antioxidant and tissue-supportive properties may further encourage cellular regeneration and wound closure. As a Rasayana herb, guduchi is traditionally believed to strengthen tissue vitality and promote recovery from chronic disease.

Remodeling Phase

Neem is beneficial during the remodeling stage due to the compound nimidin which helps collagen and new capillaries form in the wound base. ⁵⁷ Its antimicrobial and antioxidant properties help maintain a healthy wound environment while tissue maturation occurs. Traditional use suggests neem supports the purification of wounds and the development of healthy skin integrity. Traditionally it is used for cleansing wounds topically. It is a good disinfectant agent and anti-inflammatory.⁵⁸ By reducing microbial burden and oxidative stress, neem may contribute to improved tissue organization and scar formation. In a study on diabetic foot ulcers, doctors found that irrigating wounds using extracts of neem had a significant reduction in wound area compared to using only normal saline.⁵⁹ Saline is a Western evidence-based cleanser on diabetic ulcers.

Compare and contrast current Western evidence based topical dressings to aid in diabetic ulcers with Ayurvedic herbs.

There are many evidence based topical dressings used in Western medicine today. The application of topical collagen is derived from numerous sources ranging from the rumen of sheep from New Zealand to the submucosal lining of pig intestines. Honey, which has been used since the times of ancient Egypt has an autolytic effect on the wound base to aid the white blood cells of the body.

Western preparation of the wound base

After the establishment of goals, in Western healthcare there are a few objectives that need to be met. Adequate blood flow to the area, removal of infection, appropriate wound base preparation, and the establishment of a moist wound environment.

Ensuring there is blood flow can be done with a simple bedside assessment called an Ankle Brachial Index. Blood pressure cuffs are applied to the ankle and upper arm. The blood pressure is taken to the upper arm after patient sits quietly for fifteen minutes, then lies down on their back, and a blood pressure cuff is applied at the ankle to find the systolic pressure. The systolic pressure of the ankle is divided by the systolic pressure of the brachial or arm, and a number is given. A reading above 0.8 is considered normal. Anything below 0.5 is considered arterial insufficiency, and the patient must be seen by a vascular surgeon.

Infection control is important for the health of the wound base and to progress through the phases of wound healing. Infection prolongs the inflammation phase and can interfere with healing. In Western medicine, oral antibiotics and topical antimicrobial dressings are used to eradicate infection.⁶⁰

Debridement of a diabetic ulcer is needed to remove the hyperkeratotic ring surrounding the wound base. This buildup of callus creates increased pressure around the wound and prevents granulation tissue formation to rise to the skin surface for epithelialization of the wound base to occur. Removal of topical debris and biofilm from the wound base is next and then the wound is cleansed. Currently, hypochlorous acid is a common wound cleanser as well as normal saline. After the wound is cleansed then topical dressings are applied to support tissue health and create a moist environment. Topical collagens as mentioned above, foams, and other dressings are used to maintain a moist environment are applied.

Moist wounds heal two to three times faster than wounds allowed to dry out. Wounds kept at body surface temperature promote neutrophils to proliferate as well as allow the immune response of white blood cells to protect from pathogens.⁶¹ Wound bases need to be maintained to ensure the wound does not get too dry or too wet with heavy exudate.

Evidence-based topical dressings used in Western medicine

The gold standard for diabetic ulcers is aggressive offloading. Due to motor and sensory neuropathy, individuals with diabetic ulcers have minimal to no feeling in their feet. Structural changes to the bones can create deformities which increases pressure to that area of the foot. This can alter the way a person walks and stands. Once an ulcer occurs on the foot this can be difficult to heal unless the pressure is relieved from that area and redistributed away.62 Total contact casts, boots, shoes, inserts and padding are a few treatments.

Topical dressings depend on the type of offloading device. If it’s a cast the dressings must be able to contain drainage for up to a week, otherwise a different modality should be used. There are topical dressings ranging from animal collagen, silver impregnated collagen and foams, antimicrobial foams and impregnated gauze. Some ulcers need negative pressure wound therapy to increase granulation tissue formation. Hyperbaric oxygen therapy is used to increase circulation to the area. Even the choroid lining of donated human placentas are used topically to add growth factors to the wound base. ⁶³

Traditional treatment of skin complications

Diabetic foot ulcers can be understood through the concept of prameha pitaka which are painful skin complications. There are ten specific types based on shape, depth, and symptoms due to the depletion of healthy tissues and disturbance of vata which can impair nourishment to the extremities. Kapha related stagnation and accumulation of metabolic waste products contribute to delayed healing and susceptibility to infection. 64 In the Astanga Samgraha it states “the body is weak due to loss of medas (fat), kleda (body fluids), and the dosas vitiating all tissues of the body.” ⁶⁵

The ten types of skin complications occur in the lower parts of the body. The first five called saravika, kacchapika, jalini, vinata, and alaji are difficult to tolerate due to their origin of greatly increased kapha and fat. ⁶⁶ Saravika is blue black in color, elevated edges, exudate and pain, depressed in the center, and resembles a saucer in shape and size. Kacchapika has deep and severe continuous or intermittent pain that extends over a large area and resembles a tortoise shell.⁶⁷ Jalini occupies a large area with severe pain, immovable and exudates a fatty material with minute openings and network of muscles and veins. ⁶⁸ Vinata is a large skin eruption on the torso with deep pain and exudate. Alaji burns with elevated skin that spreads like boils.⁶⁹

The remainder of the skin complications are easier to treat and are primarily pitta type versus kapha. These are called masurika, sarsapika, putrini, vidarika, and vidhradhi. ⁷⁰ Masurika looks like a lentil in size and shape. Sarsapika is the size and shape of a mustard seed with severe pain and ulcers that resemble a mustard seed. Putrini is a big eruption surrounded by smaller ones. And finally vidarika is round and hard like a vidari tuber.⁷¹

In the Astanga Samgraha the specific treatment of diabetic ulcers is outlined as stated “Oil for healing of wounds (of diabetes) should be prepared from drugs of eladigana, the thick decoction of drugs of aragvadhadi gana should be used for massaging, decoction of drugs of asanadigana for bathing, and that of vatsakadigana for drinking and cooking food. ⁷²

According to Marc Halpern diabetic ulcers should be treated with a wash prepared from cool vulnerary herbs and kept aseptic. Herbs such as comfrey and heal-all are particularly effective. ⁷³ Washing ulcers with manjistha was also effective and patients who are strong should undergo purgation therapy to reduce pitta in the skin.⁷⁴

Topical Ayurvedic herbal therapies offer potential advantages in diabetic wound management. Many people do not have insurance or can’t afford medical bills associated with open wounds.

Conclusion

Diabetes is a growing health concern not only in America but worldwide. Ensuring people receive treatment that is patient-centered and evidence-based is a focus of Western medicine. Diabetic foot ulcers are a common complication of diabetes. These can be secondary to poorly controlled blood sugars, impaired circulation, and neuropathy in the feet. In classical Ayurveda, diabetes is classified under the umbrella of prameha which is polyuria in Western medicine. It can fall under; either a vata disturbance which closely aligns with IDDM or Type I diabetes, a kapha dosa disturbance with closely aligns with NIDDM or Type II diabetes. Three herbs used in traditional Ayurvedic medicine have been researched in Western medicine to test their effects on healing both internally and externally. These herbs are neem, turmeric, and guduchi. They each have positive effects on different phases of wound healing that have been proven effective both in Western medicine and classical Ayurveda.

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Notes

1. American Diabetes Association, “Diabetes Research, Education & Advocacy,” ADA.
2. Dr. Marc Halpern, Clinical Ayurvedic Medicine, 8th ed., Vol. 1 (Nevada City, CA: California College of Ayurveda, 2020), pp. 3-38, 3-41–3-42, 3-45–3-46.
3. R.K. Sharma and Bhagwan Dash, trans., Caraka Samhita, Vol. III (Varanasi: Chowkhamba Krishna Academy, 2024), Chapter 6, verses 7–12, pp. 299–300, 303.
4. K.R. Srikantha Murthy, trans., Vagbhata’s Astanga Hrdayam, Vol. II (Varanasi: Chowkhamba Krishnadas Academy, 2024), Chapter 10, verses 1b–34b, pp. 92, 96–98.
5. Sebastian Pole, Ayurvedic Medicine: The Principles of Traditional Practice (London: Singing Dragon, 2013), pp. 189–190, 233–234, 282.
6. Dr. J.L.N. Sastry and Dr. Tanuja M. Nesari, A Text Book of Dravyaguna Vijnana, Vol. II (Varanasi: Chaukhambha Orientalia, 2022), pp. 101, 114–115, 212, 214.
7. Naveen Chundran, Ike Husen, and Irra Rubianti, “Effect of Neem Leaves Extract (Azadirachta Indica) on Wound Healing,” Althea Medical Journal 2 (2015), pp. 199, 202, doi:10.15850/amj.v2n2.535.
8. Michael Tierra, The Way of Herbs (New York: Pocket Books Health, 1998), pp. 166, 200.
9. Karta Khalsa and Michael Tierra, The Way of Ayurvedic Herbs (Twin Lakes, WI: Lotus Press, 2008), pp. 45, 140, 163, 191, 195.
10. Rosemary Gladstar, Medicinal Herbs: A Beginner’s Guide (North Adams, MA: Storey Publishing, 2012), pp. 94, 99.
11. Michael Castelman, The Healing Herbs: The Ultimate Guide to the Curative Power of Nature’s Medicine (Emmaus, PA: Bantam Books, 1991), p. 518.
12. A. Shedoeva, D. Leavesley, Z. Upton, and C. Fan, “Wound Healing and the Use of Medicinal Plants,” Evidence-Based Complementary and Alternative Medicine 2019 (2019): 2684108, p. 7, doi:10.1155/2019/2684108.
13. David Frawley and Vasant Lad, The Yoga of Herbs: An Ayurvedic Guide to Herbal Medicine (Twin Lakes, WI: Lotus Press, 2001), pp. 180, 242–243.
14. L. McNichol, C. Ratliff, and S. Yates, eds., Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management, 2nd ed. (Philadelphia: Wolters Kluwer, 2021), pp. 41–42, 138, 144, 561, 569.
15. Y. Yen, C. Pu, C. Liu, et al., “Curcumin Accelerates Cutaneous Wound Healing via Multiple Biological Actions: The Involvement of TNF-α, MMP-9, α-SMA, and Collagen,” International Wound Journal 15, no. 4 (2018): 605–617, p. 612, doi:10.1111/iwj.12904.
16. A. Meizarini, A. Aryati, D. Rianti, W. Riawan, and A. Puteri, “Effectivity of Zinc Oxide–Turmeric Extract Dressing in Stimulating the Reepithelization Phase of Wound Healing,” Veterinary World 13, no. 10 (2020): 2221–2225, p. 2222, doi:10.14202/vetworld.2020.2221-2225.
17. S. Sahu, Y. Ramawat, N. Kumawat, R. Sahu, V. Kumar, and M. Nath, “Holistic Care Approach for the Effective Management of Severe Radiation Dermatitis Using Neem (Azadirachta Indica) and Honey after Head-and-Neck Radiotherapy,” Indian Journal of Palliative Care 26, no. 4 (2020): 540–543, pp. 541–542, doi:10.4103/IJPC.IJPC_32_20.
18. M. Jayalakshmi, P. Thenmozhi, and R. Vijayaraghavan, “Plant Leaves Extract Irrigation on Wound Healing in Diabetic Foot Ulcers,” Evidence-Based Complementary and Alternative Medicine 2021 (2021): 9924725, p. 6, doi:10.1155/2021/9924725.
19. K.R. Srikantha Murthy, trans., Astanga Samgraha of Vagbhata, Vol. II (Varanasi: Chaukhambha Orientalia, 2023), Chapter 10, verses 11–14, pp. 208–209; Chapter 14, verse 21, p. 436.

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Abstracts

Journal: Evidence-Based Complimentary and Alternative Medicine 2019 Sep 22:2019:2684108

Title: Wound healing and the use of medicinal plants

Author: Shedoeva, A., Leavesley, D., Upton, Z., Fan, C.

Abstract

Cutaneous wound healing is the process by which skin repairs itself. It is generally accepted that cutaneous wound healing can be divided into 4 phases: haemostasis, inflammation, proliferation and remodeling. In humans, keratinocytes re-form a functional epidermis (reepithelialization) as rapidly as possible, closing the wound and reestablishing tissue homeostasis. Dermal fibroblasts migrate into the wound bed and proliferate, creating “granulation tissue” rich in extracellular matrix proteins and supporting the growth of new blood vessels. Ultimately, this is remodeled over an extended period, returning the injured tissue to a state similar to that before injury. Dysregulation in any phase of the wound healing cascade delays healing and may result in various skin pathologies, including nonhealing, or chronic ulceration. Indigenous and traditional medicines make extensive use of natural products and derivatives of natural products and provide more than half of all medicines consumed today throughout the world. Recognising the important role traditional medicine continues to play, we have undertaken an extensive survey of literature reporting the use of medical plants and plant-based products for cutaneous wounds. We describe the active ingredients, bioactivities, clinical uses, formulations, methods of preparation, and clinical value of 36 medical plant species. Several species stand out, including Centella asiatica, Curcuma longa, and Paeonia suffructicosa, which are popular wound healing products used by several cultures and ethnic groups. The popularity and evidence of continued use clearly indicates that there are still lessons to be learned from traditional practices. Hidden in the myriad of natural products and derivatives from natural products are undescribed reagents, unexplored combinations, and adjunct compounds that could have a place in the contemporary therapeutic inventory.

PMID: 31662773

Journal: International Wound Journal 2018 Aug;15(4):605-617

Title: Curcumin accelerates cutaneous wound healing via multiple biological actions: The involvement of TNF-a, MMP-9, a-SMA, and collagen

Author: Yen, Y., Pu, C.,, Liu, C., Chen, Y., Chen, Y., Liang, C., Hsieh, J., Huang, H., Chen, Y.

Abstract

Curcumin, a constituent of the turmeric plant, has antitumor, anti-inflammatory, and antioxidative effects, but its effects on wound healing are unclear. We created back wounds in 72 mice and treated them with or without topical curcumin (0.2 mg/mL) in Pluronic F127 gel (20%) daily for 3, 5, 7, 9, and 12 days. Healing in wounds was evaluated from gross appearance, microscopically by haematoxylin and eosin staining, by immunohistochemistry for tumor necrosis factor alpha and alpha smooth muscle actin, and by polymerase chain reaction amplification of mRNA expression levels. Treatment caused fast wound closure with well-formed granulation tissue dominated collagen deposition and regenerating epithelium. Curcumin increased the levels of tumor necrosis factor alpha mRNA and protein in the early phase of healing, which then decreased significantly. However, these levels remained high in controls. Levels of collagen were significantly higher in the curcumin-tested wounds. Immunohistochemical staining for alpha smooth muscle levels in tumor necrosis factor alpha-treated fibroblasts via nuclear factor kappa B signaling. Thus, topical curcumin accelerated wound healing in mice by regulating the levels of various cytokines. Keywords: curcumin, inflammation, MMP-9, TNF-a, wound healing

PMID: 29659146

Journal: Veterinary World 2020 Oct. 13 (10):2221-2225

Title: Effectivity of zinc oxide-turmeric extract dressing in stimulating the reepithelization phase of wound healing

Author: Meizarini A., Aryati, A., Rianti D., Riawan W., Puteri, A.

Abstract

Background and Aim: Reepitheliazlization can be described as the resurfacing of a wound with new epithelium in the process of healing, with the overlapping step from keratinocyte migration and proliferation to the tissue contraction. Zinc oxide-turmeric extract dressing has been proven to have anti-inflammatory properties, but its effectivity in the reepithelialization process is still unknown. This study aimed to determine the effect of a wound dressing consisting of zinc oxide and turmeric extract on wound reepithelialization by assessing the expression of cytokeratin 14 (CK14), epidermal growth factor receptor (EGFR), and epithelial cadherin (E-cadherin). Materials and Methods: a total of 40 Wistar rats were randomized into four control and four treatment groups (n=5 per group). On day 1, a square-shaped full thickness skin excision measuring 6×6 mm in size was created in the dorsal thoracic area of the rats, and the wounds were either dressed with a combination of zinc oxide and turmeric extract in the treatment groups or left undressed in the control groups. Then, the rats were sequentially sacrificed on days 3, 5, 7, and 14 to obtain subepithelial excision samples, which were subsequently subjected to immunohistochemistry analysis for the expression of CK14, EGFR, and E-cadherin to ascertain wound reepithelization. The data were tabulated and analyzed using a one-way analysis of variance and least significant different test. Results: The highest expression levels of CK14, EGFR, and E-cadherin were observed on days 7 and 14 in the treatment and control groups, respectively. While the expression levels of these markers on day 7 were found to be significantly higher in the treatment than the control groups, no significant difference in the expression levels on day 14 was detected between the control and treatment groups (p<0.05). Conclusion: A wound dressing consisting of zinc oxide and turmeric extract can help accelerate reepithelization in the wound healing process. Keywords: cytokeratin 14, epithelial cadherin, epidermal growth factor receptor, turmeric extract, wound dressing.

PMID: 33281360

Journal: Indian Journal of Palliative Care 2020 Oct-Dec:26(4):540-543

Title: Holistic care approach for the effective management of severe radiation dermatitis using neem (Azadirachta indica) and honey after head-and-neck radiotherapy

Author: Sahu S., Ramawat Y., Kumawat N., Sahu, R., Kumar, V., Nath M.

Abstract

Head and neck cancer is the eighth common type among all cancer types around the world. Its treatment comprises surgery, radiation therapy, chemotherapy and/or a combination of restoration therapy and social support. Conventional fraction size ranges from 1.8 to 3 Grays (Gy) per fraction over 4-6 weeks. The accumulative dose of radiation for the primary treatment of head and neck cancer treatment is 60 to 70 Gy, depending on the irradiation of the tumor. Ionizing radiotherapy is used along with concurrent chemotherapy which is the standard treatment in locally advanced head and neck cancers. Radiation treatment is commonly delivered in the form of high energy photons through an external beam. This results in ionization of electrons that cause direct strand breaks of cellular DNA and the release of free radicals, resulting in cellular damage to both normal and tumor cells. Radiation disrupts the normal process of wound healing at various stages. Keywords: Holistic care, honey, neem, palliative care, radiation dermis.

PMID: 33623321

Journal: Evidence-Based Complementary and Alternative Medicine 2021 May 11;2021:9924725

Title: Plant leaves extract irrigation on wound healing in diabetic foot ulcers

Abstract

Purpose: We aimed to evaluate and compare the efficacy of neem leaves extract with normal saline irrigation practice in wound dressing on healing outcome and clinic-physiological parameters among individuals with diabetic foot ulcer (DFU). Methods: A quasiexperimental with repeated measures design was used on two study groups. One group received neem leaf extract wound irrigation and another group received normal saline wound irrigation. Study participants were randomly assigned to each group of 100 DFU individuals. Demographic and clinical data sheets were used to collect baseline information. Random blood sugar and HbA1C measurement was performed on the initial day of visit for all participants. We used the PUSH tool for wound assessment (wound surface area, exudate amount, and tissue type), and clinical physiological parameters (temperature, pulse rate, respiration, blood pressure, wound pain, wound infection, and local warmth) assessment was performed at baseline and then at the end of each week till four weeks were completed. Participants attended a foot clinic every 3rd or 4th day for wound care. Results: Reduction of wound healing score (PUSH score) and other wound variables improved significantly in the neem leaves extract group (p<0.001). There were no significant changes in the clinic-physiological parameters. Conclusion: Neem leaves extract irrigation for foot ulcers is considered to be very safe as it did not cause any complication systematically during the study. Neem leaf extract solution can be used as an alternative solution for normal saline. Managing DFU requires continuous foot care and early risk identification of ulcer.

PMID: 34055026

Journal: Althea Medical Journal. 2015;2(1): 199-203

Title: Effect of neem leaves extract (Azadirachta Indica) on wound healing

Author: Chundran, N., Husen, I., Rubianti, I.

Abstract

Background: Neem leaves (Azadirachta Indica) have active ingredients such as nimbidin and sodium nimbidate which possess/possessing anti-inflammatory, antibacterial, and antiviral properties that help in healing process and also contain an excellent nutrition which plays/playing a vital role in formation of collagen and formation of new capillaries. The aim of this experimental study is to evaluate healing activity of neem leaves. Methods: The experiment was conducted in Pharmacology La of Universitas Padjadjaran on October 2012. Twenty seven rats were grouped randomly into 3 groups and 1.5cm of excision wound was created. Negative control group was treated with a topical application of saline solution (sodium chloride 0.9%), treatment group with a topical application of neem leaves extract and positive control group had been treated with a topical application of povidone-iodine for 15 days. Healing was assessed by the longest diameter of the raw surface of wound on days 0, 5, 10, and 15. The data were then analyzed using Mann-Whitney U test. Results: There was a significant reduction in the longest diameter of wound in group of neem leaves extract, compared with group sodium chloride 0.9%, and there was no significant difference in the longest diameter of wound between neem leaves, extract and povidone iodine. Conclusions: Neem leaves extract has the same wound healing rate compared to povidone iodine. A further study in human should be conducted in the future. Keywords: neem, povidone iodine, wound healing

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