Clinical Cases

Management of Diabetic Foot with Classical Homeopathy Case Reports

Dr. G.C. Dayananda and Aaditi Lakshmana share a case of diabetic foot treated through classical homeopathy. The patient was a man of 64 with a history of type 2 diabetes mellitus, senile dementia, hypertension and ischemic heart disease.

Keywords:

Diabetes mellitus, amputation, diabetic foot, homeopathy

Background:

Diabetes mellitus is a metabolic disorder characterized by an overall deficiency of insulin (type-1) or defective insulin function (type-2), which causes hyperglycemia.1 Chronic hyperglycemia may result in vascular complications such as diabetic nephropathy, retinopathy and neuropathies.

 1Diabetic foot ulcer is the most significant complication of diabetes. Foot ulcers occur in 1 to 4% of the diabetic population, 3% of them end in lower limb amputation.2  Patients with type-2 diabetes had a higher prevalence of ulceration at 6.4%, compared to patients with type-1 diabetes mellitus at 5.5%.2

The etiology is multifactorial and the prognosis is good when detected early. Common sites of ulcer formation involve great toe and the plantar surface. There are 3 types of diabetic foot ulcers namely, neuropathic, neuro-ischemic and the ischemic type. The Wagner-Meggitt classification of diabetic foot assesses the ulcer based on the depth of ulceration by using six grades (table 1).3

This classification helps in understanding the complications and planning the required treatment strategies. Pathogenesis of diabetic foot involves the interaction of several pathological factors such as peripheral neuropathy, abnormal foot anatomy, peripheral arterial disease and poor wound healing.4

This phenomenon can be explained by motor, sensory and autonomic neuropathy. Neuropathy interferes with the normal tissue protective mechanism and allows the patient to sustain the foot trauma, without the knowledge of the injury. Disordered proprioception causes abnormal weight bearing which leads to subsequent callus formation and ulceration.5

Peripheral arterial disease and poor wound healing impede the resolution of minor breaks and fissures in the skin, allowing them to be enlarged and infected. Wound healing involves a cascade of events, disruption of which results in poor healing and leads to diabetic foot ulcer.6

Conventional management includes blood sugar control, wound debridement, advanced dressing and removal of callus to prevent infection. Revascularization surgery and hyperbaric oxygen therapy are considered as an essential component of management to prevent recurrence.7

Recent advances in the treatment of diabetic foot include the use of becaplermin gel and use of Living Skin Equivalent (LSE) which stimulates angiogenesis, wound contraction, remodeling and healing.8However, despite such advances, the drain on economy from these ulcers is great.9

Previous case reports of homeopathy in gangrene and diabetic foot have provided evidence for positive outcomes with homeopathy.[10,11] Here, we present two more cases of diabetic foot ulcer which were obstinate to the conventional management, treated satisfactorily with homeopathy. The approach not only helped the ulcers but also the quality of life and the co morbidities.

Case presentation:

Case 1:

A 64-year-old Indian man, with a history of type 2 diabetes mellitus, senile dementia, hypertension and ischemic heart disease, presented to the homeopath with left sided hemi paresis and a non-healing, painless ulcer over the left lateral malleolus since 6 months.

Patient had a stroke attack two months back and was brought to the hospital in a semi-conscious state. During consultation, patient was stuporous, he complained of extreme weakness of both extremities since two months. Patient was on tablet of metformin HCl 500mg twice a day.

His ailments started after a mental shock that he experienced from a loss in business. He used to pass involuntary urine and stools since a few days. The initial symptoms available for prescription were:

  1. Deep stupor (++), no response to pinch
  2. Increased sleepiness (+++)
  3. Ailments from fright (+++)
  4. Skin-ulcers painless (++)
  5. Bladder-urination-involuntary (++)
  6. Rectum-involuntary stool-fright after (++)

Past history: patient has a history of type 2 diabetes mellitus since 25 years, senile dementia since, hypertension since and ischemic heart disease since.

Local examination: it was found to be Wagner’s grade-2 type of diabetic ulcer (a deep ulcer involving the ligament, muscle and tendons)

Diagnosis: Type 2 diabetes mellitus with foot ulcer (ICD 10 – E11. 621)12

Homeopathic intervention: The indicated remedies in this case were Papaver somniferum and Arsenicum album, prescribed in sequence over a span of 5 months. The remedies were selected based on the principles of individualization of classical homeopathy.

Papaver somniferum is indicated when causations from fright lead to disturbances of the nervous system such as drowsy stupor, sleepiness, painlessness and general sluggishness.13

Arsenicum album is a polychrest remedy suggested for tremendous anxiety about health. Symptoms aggravate during mid-day or midnight (1-2 am/pm) and are ameliorated by warm applications.13 The case details and follow up of the case are presented in table 2. Photographic evidences of the case before and after treatment are shown in figure 1.

Case 2:

A 72-year-old Indian man, with a history of type II diabetes mellitus and hypertension presented to us on 21st January 2017 with complaints of non-healing ulcer over the plantar surface of the right big toe. His complaints started as a crack in the skin of the toe and progressed to a wound which never healed.

At the time of consultation, patient was on allopathic treatment with insulin (16-0-18 units), vildagliptin and metformin with glibenclamide 5mg tablets twice a day. The initial symptoms considered for prescription are as follows:

  1. Extremities-ulcers-lower limbs-deep (+++)
  2. Extremities-ulcers-lower limbs-fetid (offensive as decay) +++
  3. Generalities-cold-air-aggravation (++)
  4. Extremities-ulcers-painless (+)

Past history: patient has a history of type 2 diabetes since over 25 years, and hypertension since.

Local examination: Callus surrounding the wound was noted. It was found to be Wagner grade-2 type of diabetic ulcer (deep ulcer involving the ligament, muscle and tendons).

Diagnosis: Type 2 diabetes mellitus with foot ulcer (ICD 10 – E11. 621)12

Homoeopathic intervention: After a careful study, the homeopathic remedies instituted for this case were Psorinum and Secale cornutum given in sequence over a span of 7 months, showing a steady improvement. Calendula mother tincture and echinacea ointment were used as external application for the purpose of dressing to promote wound healing.

Psorinum is a remedy with extreme sensitiveness to cold, wants warm clothing even in summer. Discharges having a filthy smell are also a keynote of the remedy.13

Secale cornutum primarily acts on the circulation and is indicated in gangrene of distal extremities. Warmth, both generally and locally, aggravates the symptoms and the patient desires to be fanned vigorously on the affected part.13The case details along with the follow-ups are given in Table 3. Photographic evidence of the case before and after treatment are shown in figure 2.

Discussion:

Diabetic foot ulcer accounts for more frequent admissions in hospitals than any other complications of diabetes.1Integrative medicine emphasizes how physical, emotional and mental planes interact intimately to keep the organism in a state of homeostasis.[14,15]

In cases of diabetic foot, the experience of a homeopath is that when the defense mechanism is empowered, the wound starts to heal. Signs such as warmth, appearance of healthy granulation tissue, fresh bleeding and appearance of pain may be noticed as signs of improvement.

This is presumably because the immune system gains the strength required for establishment of collateral circulation.[10,11] Furthermore, the possibility of an organism to develop acute inflammatory or infectious diseases during the chronic disease treatment provides a wealth of information about the immune status of an individual.[16,17]

Appearance of an acute (especially accompanied with high fever) helps the organism to overcome the chronic disease and is considered as a good response to treatment in homeopathy.16 Acute conditions must be carefully handled with expertise, especially given the danger of sepsis in cases such as reported here.18

In the first case, the patient had co-morbidities, yet selection of the right simillimum could save the limb from further deterioration. The remedy instituted during first prescription was Papaver somniferum.

During the fourth month of treatment, the patient developed cystitis with high fever, for which a new remedy-Arsenicum album was prescribed according to the new circumstances. After the resolution of cystitis, the previously indicated remedy-Papaver somniferum was repeated and the wound healed drastically leaving the skin intact.

In the second case, though the causation is not so clear, a clear picture of the remedy portrayed an efficient immune status and thus indicated a very good prognosis. The general and local symptoms were well-marked and hence the case improved steadily.

During the third month of treatment, patient developed a fever of 102oF –for which a new remedy-Secale cornutum was prescribed. Correct treatment of the fever not only improved the acute condition but also helped the organism to overcome the diabetic ulcer. 16

The Modified Naranjo Criteria for Homeopathy (MONARCH) causality assessment provided a score of 9 each in both cases, suggesting a significant causal relationship between homeopathic treatment and the outcome (table 4).19Hence, classical homeopathy must be investigated in light of such cases.

Conclusion:

While these case reports indicate fruitful outcomes from individualized classical homeopathy in diabetic foot ulcer, further scientific studies are required in a hospital setting to demonstrate the real extent to which this therapy may be useful.

References:

  1. Graves LE, Donaghue KC. Vascular Complication in Adolescents With Diabetes Mellitus. Front Endocrinol (Lausanne). 2020;11:370. doi:10.3389/fendo.2020.00370
  2. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis†. Ann Med. 2017;49(2):106-116. doi:10.1080/07853890.2016.1231932
  3. Aziz Nather, Wo Yu Jun TN and SLLJ. Scientia Ricerca Open Access | Scientific Publications | International Journals. 2017. Accessed January 19, 2021. https://scientiaricerca.com/srortr/SRORTR-01-000018.php
  4. Diabetic Foot Ulcer – StatPearls – NCBI Bookshelf. Accessed January 16, 2021. https://www.ncbi.nlm.nih.gov/books/NBK537328/
  5. Volmer-Thole M, Lobmann R. Neuropathy and diabetic foot syndrome. Int J Mol Sci. 2016;17(6). doi:10.3390/ijms17060917
  6. Blakytny R, Jude E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med. 2006;23(6):594-608. doi:10.1111/j.1464-5491.2006.01773.x
  7. Edmonds M, Foster A, Caravaggi C, et al. The future of diabetic foot care: modern management and recent advances. Pract Diabetes Int. 2000;17(4):S1-S8. doi:10.1002/1528-252x(200006)17:4<::aid-pdi90>3.0.co;2-9
  8. Shafi S. World Journal of Pharmaceutical Sciences. Accessed January 19, 2021. https://www.wjpsonline.org/view_issue.php?title=Recent-Advances-in-the-Treatment-of-Diabetic-foot
  9. Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs. Ann Vasc Surg. 2016;33:149-158. doi:10.1016/j.avsg.2015.11.025
  10. Vithoulkas G, Mahesh S, Mallappa M. Gangrene: Five case studies of gangrene, preventing amputation through Homoeopathic therapy. Indian J Res Homoeopath. 2015;9(2):114. doi:10.4103/0974-7168.159544
  11. seema mahesh, george vithoulkas mahesh mallappa. Gangrene – Healing Through Classical Homeopathy – Seema Mahesh. hpathy.com. Accessed January 19, 2021. https://hpathy.com/clinical-cases/gangrene-healing-through-classical-homeopathy/
  12. Dugan J, Shubrook J. International classification of diseases, 10th revision, coding for diabetes. Clin Diabetes. 2017;35(4):232-238. doi:10.2337/cd16-0052
  13. Boericke W. Pocket Manual of Homeopathic Materia Medica and Repertory. B.Jain publishers; 2002.
  14. Hanhemann S. Organon of Medicine. B.Jain publishers; 1994.
  15. Kent JT. Kent’S Lectures on Homoeopathic Philosophy. B.Jain publishers; 2002. https://www.naturopathicmedicineinstitute.org/wp-content/uploads/2016/09/Lectures-on-Homeopathic-Philosophy.pdf
  16. Vithoulkas G. Levels of Health.; 2017.
  17. Vithoulkas G and Tiller.w. The Science of Homeopathy. 7th Edition.; 2014.
  18. Mahesh S, Shah V, Mallappa M, Vithoulkas G. Psoriasis cases of same diagnosis but different phenotypes—Management through individualized homeopathic therapy. Clin Case Reports. 2019;7(8):1499-1507. doi:10.1002/ccr3.2197
  19. Lamba CD, Gupta VK, Van Haselen R, et al. Evaluation of the Modified Naranjo Criteria for Assessing Causal Attribution of Clinical Outcome to Homeopathic Intervention as Presented in Case Reports. Homeopathy. 2020;109(4):191-197. doi:10.1055/s-0040-1701251

Table 1: Wagner-Meggitt classification of diabetic foot

Grade: Description:
0 Intact skin
1 Superficial ulcers
2 Deep ulcers involving tendon,muscle,ligament
3 Deep ulcer with bone involvement
4 Partial foot gangrene
5 Whole foot gangrene

Table 2: observations and follow up with prescriptions: case 1

Date Detailed symptoms/observations Vitals/local examination findings: Homeopathic prescription: Conventional treatment
18th May 2017 The symptoms available for prescription were:

1.     Weakness of upper limbs and lower limbs (+)

2.     Painless foot ulcers (+)

3.     Loss of sensation in both lower limbs (+)

4.     Deep stupor (++), no response to pinch

5.     Increased sleepiness (+++)

6.     Ailments from fright (+++)

7.     Skin-ulcers painless (++)

8.     Bladder-urination-involuntary (++)

9.     Rectum-involuntary stool-fright after (++)

B.P – 100/80 mmHg

Pulse – 108 beats/min

SpO2 – 96%

GRBS – 141mg/dl

Local examination: Wagner grade-2 type of diabetic ulcer

Papaver somniferum 30CH –

thrice a day for 5days.

Echinacea and Calendula mother tincture (external use for dressing, changed every 3 days)

tablet metformin HCl 500mg twice a day
23rd May 2017 Wound is stable.

Weakness of lower limbs is better.

 

B.P – 130/90mmHg

Pulse – 102 beats/min

Spo2 – 97%

GRBS – 183mg/dl

Papaver somniferum 30CH –

thrice a day – the same medicine was continued till the next follow up.

tablet metformin HCl 500mg twice a day
12th June 2017 Patient is able to move by himself.

No episodes of involuntary stools and urine.

Healthy granulation tissue is seen surrounding the wound.

B.P – 130/80mmHg

Pulse -102beats/min

Spo2– 96%

GRBS – 170 mg/dl

Papaver somniferum 30CH –

thrice a day for 1 month

 

tablet metformin HCl 500mg twice a day

1st July 2017 Patient is stable. He is able to stand up and walk with support.

Sleep is refreshing

 

 

F.B.S –  244 mg/dl

P.P.B.S – 327mg/dl

B.P – 170/100 mmHg

Pulse- 92 beats/min

Spo2– 96%

Local examination: Wagner grade-1 type of diabetic ulcer

Papaver somniferum 30CH –

thrice a day for 1 month

 

tablet metformin HCl 500mg twice a day
7th August 2017 Fever with chills since early morning. Diagnosed as cystitis. Patient was hospitalized for his acute condition.

Urine analysis reports revealed turbid urine with deposits and plenty of pus cells.

The symptoms available for prescription were as follows:

1.     Nausea and vomiting with loss of appetite (+)

2.     Mouth tastes bitter for water (++)

3.     Generalities-cold-aggravation (++)

4.     Fever-with chills-midnight-12 to 1 AM (++)

B.P – 170/100 mmHg

Pulse – 118 beats/min

Temp – 1020F

Spo2– 97%

GRBS – 230 mg/dl

 

 

 

Arsenicum album 200CH -Twice a day for 3days

 

 

tablet metformin HCl 500mg twice a day

10th August 2017 Urine is clear.

Patient is stable. No fresh complaints.

Appetite improved.

Wound is healing

Temp – 97.20F

B.P – 120/80mmHg

Pulse- 92beats/min

FBS – 130mg/dl,

PPBS – 180mg/dl

Spo2– 97%

Arsenicum album

200 CH – twice a day for 3days

 

tablet metformin HCl 500mg twice a day
1st September 2017 Advised to discharge. At the time of discharge, patient was able to sit   and carry out his daily routine activities by himself.

Wound has healed

B.P – 120/80 mmHg

Pulse – 92beats/min.

GRBS – 120mg/dl

Local examination: Wagner grade-0 type of diabetic ulcer

Papaver somniferum 30CH – thrice a day for 15 days.

 

tablet metformin HCl 500mg twice a day

Table 3: observations and follow up with prescriptions: case 2

Date Clinical symptoms /observations Vitals/ local examinations/parameters: Homoeopathic prescription: Conventional treatment:
21st January 2017 The symptoms available for prescription were:

1.     Painless ulcer of right leg-great toe (+)

2.     Offensive discharge of the wound (+++)

3.     Extreme sensitiveness to cold (+++)

4.     Extremities-ulcer deep (+++)

FBS – 131mg/dl

PPBS – 300mg/dl

Weight- 75kg

B.P – 150/80 mmHg

blood urea – 40.7mg/dl,

serum creatinine – 1.6mg/dl

Local examination:  Wagner grade-2 type of diabetic ulcer

Psorinum30CH –

5 times for 4days.

Echinacea and Calendula mother tincture (External dressing, changed every 3 days)

Insulin dosage –

(18-0-16) units.

 

Vildagliptin (1-0-1)

Metformin with glibenclamide 5mg tablets twice a day.

25th January 2017 The offensive odor from the ulcer reduced by 50-70%.

Granulation tissue formed.

Now patient complains of pain in ulcer edges, with watery discharges.

B.P – 140/90mmHg

Weightt – 73.5Kg

Psorinum30CH

-5times for 8 days

Insulin dosage

(18-0-16) units.

Vildagliptin (1-0-1)

Metformin with glibenclamide 5mg tablets twice a day

2nd February 2017 Lower limb arterial venous Doppler study: It revealed significant arterial hemodynamic abnormality.

Wound is healing.

Patient was consuming alcohol daily, advised to stop

RBS – 170mg/dl

B.P – 140/90 mmHg

serum creatinine – 1.7mg/dl

Blood Urea – 42.2mg/dl

Psorinum 30CH

-5 times a day for 1 month

Insulin dosage reduced

(16-0-12 units)

Vildagliptin (1-0-1)

metformin with glibenclamide 5mg tablets twice a day

25th March 2017 Swelling over lower limb reduced. Granulation tissue started forming with fresh bleeding.

Patient had fever with chills since yesterday. The symptoms available for prescription were:

1.     Skin-ulcers-painless (++).

2.     Skin-ulcers-discharge-offensive (++).

3.     Fever –chills –with shaking (++)

Temp – 1020F

Pulse – 114 beats/min

GRBS – 124mg/dl

Weight – 71kg

B.P – 110/70 mmHg

serum creatinine – 1.9mg/dl

blood urea – 38.9mg/dl

 

Secale cornutum 30CH-

thrice a day for 4days

 

Insulin dosage –

(16-0-12) units.

 

Vildagliptin (1/2-0-1/2)

Metformin with glibenclamide 5mg tablets (1/2 – 0 – 1/2)

29th March 2017 Now patient is not so sensitive to cold.

Wound is healing.

No new complaints.

 

 

Serum creatinine – 1.8mg/dl

blood urea – 37.9mg/dl

Local examination:  Wagner grade-1 type of diabetic ulcer

Secale cornutum 30CH-

thrice a day for 4days

 

 

Insulin dosage

(16-0-12) units.

Vildagliptin (1/2-0-1/2)

Metformin with glibenclamide 5mg tablets (1/2 – 0 – 1/2)

2nd April 2017  Wound healed- no fresh wounds, no offensive discharges

 

B.P – 110/70mmHg

Wt- 73kg

GRBS -110mg/dl.

Serum creatinine – 2.0mg/dl

blood urea – 40.0mg/dl

Secale cornutum 30CH-

thrice a day for 2 months

 

Insulin dosage reduced (12-0-8 units)

Vildagliptin (1/2-0-1/2)

metformin with glibenclamide 5mg tablets (1/2 – 0 – 1/2)

17th June 2017 Patient feels better by 90%, numbness felt in both the limbs

 

serum creatinine: 1.6mg/dl

B.P – 140/90mmHg

FBS –   126mg/dl

blood urea – 31.7mg/dl

Local examination:  Wagner grade-0 type of diabetic ulcer

Secale cornutum 30CH-

thrice a day for 1 month

 

Insulin dosage reduced (12-0-8 units)

Vildagliptin (1/2-0-1/2)

metformin with glibenclamide 5mg tablets (1/2 – 0 – 1/2)

17th July 2017 No fresh complaints.

Wound has healed

FBS – 130mg/dl

PPBS – 297mg/dl

serum creatinine – 1.7mg/dl,

blood urea – 29.1mg/dl

 

Secale cornutum 30CH-

thrice a day for 1 month

 

Insulin dosage reduced (12-0-8 units)

Vildagliptin (1/2-0-1/2)

Metformin with glibenclamide 5mg tablets (1/2 – 0 – 1/2)

Table 4: Modified Naranjo Criteria for Homeopathy (MONARCH) – for causality assessment of both cases

Criteria Y N Not sure/NA Score in  case 1  Score in case 2
1. Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed? 2 -1 0 2  2
2. Did the clinical improvement occur within a plausible time frame relative to the drug intake? 1 -2 0 1  1
3. Was there an initial aggravation of symptoms? 1 0 0 0  0
4. Did the effect encompass more than the main symptom or condition, i.e., were other symptoms ultimately improved or changed? 1 0 0 1  1
5. Did overall well-being improve? 1 0 0 1  1
6 (A) Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease? 1 0 0 0  0
6 (B) Direction of cure: did at least two of the following aspects apply to the order of improvement of symptoms:- from organs of more importance to those of less importance, from deeper to more superficial aspects of the individual, from the top downwards 1 0 0 1  1
7. Did “old symptoms” (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement? 1 0 0 0  0
8. Are there alternate causes (other than the medicine) that with a high probability could have caused the improvement? (consider known course of disease, other forms of treatment, and other clinically relevant interventions) -3 1 0 1 1
9. Was the health improvement confirmed by any objective evidence? (Photos in these cases) 2 0 0 2  2
10. Did repeat dosing, if conducted, create similar clinical improvement? 1 0 0 0  0
Total 9 9

Figure 1: Case 1 photos


Figure 2: Case 2 photos

About the author

G.C. Dayananda

G.C. Dayananda

Dr. C.G. Dayananda holds a homeopathic medical degree from the Government Homeopathic Medical College and Hospital, Bangalore, India; a Diploma from the International Academy of Classical Homeopathy, Athens and PGDIP in Yoga and Naturopathy. He worked at the Centre for Classical Homeopathy, Bangalore with Dr Mahesh M, where he got exposure in treating challenging and difficult cases through the Classical Homeopathic approach. He has served as the Regional Medical Officer in Bhagawan Buddha Homeopathic Medical College and Hospital, Bangalore; Regional Medical Officer in Anuradha Homeopathic Medical College and Hospital, Bangalore; Senior validator in Suvarna Arogya Suraksha Trust in the Ministry of Health and family welfare and he is a physician at Health Cube Classical Homeopathy Clinic, Bangalore.

About the author

Aaditi Lakshmana

Aaditi Lakshmana - Government Homeopathic Medical College and Hospital, Bengaluru, India

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