Keywords: varicose ulcer, venous ulcer, homoeopathy.
Venous ulcers are late manifestations of chronic venous insufficiency that develop in a postphlebitic limb as a result of varicose veins or deep vein thrombosis. Venous ulcers account for approximately 70% to 80% of leg ulcers, with a global incidence of 1.33%.1
It is more frequent in the elderly and females who are obese and have a hereditary tendency to develop venous disorders.2Venous ulcers also called varicose ulcers, are characterized by full thickness skin loss which fails to heal spontaneously and is propagated by continuing venous hypertension.
Venous ulcers commonly develop around the medial mallelous due to the presence of large perforators around the handbreadth area of the ankle. This area is called gaiter’s area.3 The exact pathophysiology of ulcer development has not been established.
At present, ambulatory venous hypertension is the only accepted underlying cause of venous ulceration.4 Venous hypertension of lower limbs occurs as a result of valve incompetence or blockage of saphenous veins and the perforator veins.5
Increased blood pressure in the veins causes protein extravasations and fibrin cuff formation, which impedes the diffusion of oxygen and releases free radicals, thus, triggering an abnormal fibroblast activity.6 Chronic inflammatory response and incompetent blood flow favours thrombus formation and leads to dermatitis, lipodermatosclerosis and fibrosis destroying the capillary bed.2
These cascades of events impair the healing process and result in ulceration. A prolonged inflammatory phase allows the growth of granulation tissue and it attempts to heal itself by scarring, however, coexisting factors inhibit the healing process.5 Effective treatment of venous ulcer depends on addressing the underlying cause and diagnosis is therefore essential. CEAP classification system helps us to understand the severity of varicose veins (table 1).7
Table 1: CEAP classification system
|C (clinical)||E (etiological)||A (anatomical)||P (pathophysiological)|
|C0 – no visible or palpable signs of venous disease||Ec-congenital||As- superficial veins||Pr-reflux|
|C1- telangiectases or reticular veins||Ep-primary||Ap-perforator veins||Po-obstruction|
|C2- varicose veins||Es-secondary||Ad-deep veins||Pr,o –reflux and obstruction|
|C3- edema||En-no venous cause is identifiable||An- no venous location was identifiable.||Pn- no venous pathophysiology identifiable|
|C4a- pigmentation or eczema|
|C4b- lipodermatosclerosis or atrophie blanche|
|C5- healed venous ulcer|
|C6- active venous ulcer|
A venous Doppler and duplex scan is very important to assess the status of the veins. ESR, CRP, blood glucose levels, discharge from ulcer for culture and sensitivity also facilitate the evaluation of the severity. 8X-ray of foot is taken in order to rule out periostitis which prevents ulcer from healing.
The keystone of conventional management is to decrease the hypertension, reduce edema, increase the venous drainage and promote ulcer healing. Primary management includes use of compression. 4-Layer Bandaging system (4LB) is considered safe and effective.4
When 4 LB system fails to impact, superficial venous ablation or surgery comes to the rescue. Pentoxyfylline is the only drug that has shown promising results by increasing the microvascular perfusion, although the exact mechanism is not fully understood.8
Almost all the venous ulcers heal but the risk of recurrence is great. Many cases require a surgical intervention hence an alternative is always welcome. There are earlier studies that suggest positive evidence for use of homeopathy in cases of slow healing ulcers.9,10 Here we present to you a case of varicose ulcer managed with classical homeopathy.
A 38 year old Indian man with a history of varicose veins for 5 to 6 years, presented with complaints of ulceration on lateral aspect of the left leg ankle since 2 months. Despite allopathic treatment, the ulcer was unresponsive. The patient was dressing the ulcer every alternate day but could not provide any details of the allopathic treatment given.
X-ray of foot did not show any signs of periostitis. The first consultation took place on 20/08/2016. Investigations of the case before homeopathic consultations are mentioned in table 2.
Table 2: Investigations before the homeopathic treatment:
|Date||Impression of venous Doppler scan|
|12/07/2010||5mm sized incompetent perforator noted on later aspect of right knee
Sluggish flow noted. Signs of impending thrombosis.
Deep vein system appears normal.
|11/10/2013||There is no deep vein thrombosis
Incompetent perforators noted:
Below right knee joint(0.4cms)
Above left medial malleolus(0.5cms)
The initial symptoms considered for prescription are as follows:
- Mind-silent grief (3)
- Mind-lack of confidence (2)
- Mind-sluggishness, difficulty to think, comprehend (2)
- Mind –restless, nervousness, pains from (2)
- Generalities-cold agg (2)
- Desires-chicken (1)
- Desires-fish (1)
- Extremities-lower limbs-legs-varicose veins (3)
- Extremities-leg-ulcer-painful (3)
- Extremities-lower limbs – ulcer-burning (3)
Past history – patient had a history of
- Jaundice – 10-12 years ago, treated with allopathic medication
- Malaria- 6-7 years ago.
- No high fevers noted after malaria
Father – age – 74 yrs., convulsions, on allopathic treatment
Mother – died due to heart attack at age of 45
1 younger brother – attempted suicide at age of 35
1 younger sister – Tuberculosis
Grandparents – No info available
Mental and emotional state:
At the time of consultation, patient was reluctant to give any information. His wife gave the history. Since childhood, patient was tormented by his father to do household chores and was treated like a servant which lowered his confidence.
Patient could not pursue his education after 8th grade due to which he was working as a security guard though his father was a government official. He had to stand for long hours during his duty. Patient suffered silently and never disclosed this matter to anyone. He could not express his anger to anyone. His mother was his only support and she died when patient was 25 years old.
- Sleep – disturbed due to pain. Sleep position on back.
- Thermally – towards chilly
- Desires – chicken (1), fish (1)
- Aversion – sweet (1)
- Thirst – thirstless (1)
- Dreams – does not remember
- Stool – satisfactory.
Diagnosis: varicose ulcer (ICD 10: I83. 209)11
Case analysis and prescription:
Figure 1: reportorial result on Vithoulkas Compass as on 20/08/2016
After a thorough case taking, Anthracinum 30 CH – twice a day for 3 days
followed by Anthracinum 200CH – twice a day for 2 days.
The prescription was based on essence and keynotes of the case. Professor Vithoulkas describes Anthracinum as a remedy which has blackness both on the emotional and physical level. Abscess forms due to silent suffering and patient feels as if ‘everything inside him is kept inside a big black boil’ and he cannot express himself.12 Extreme burning and black ulcers are also a keynote of the remedy.13 Photographic evidence of the case is shown in figure 2.The case details and follow up of the case is provided in table 3.
Table 3: follow up of the case
|19/10/2016||Ulcer almost healed.
Itching around ulcer is better.
Black discoloration around ulcer has reduced.
|24/04/2017||A small ulcer developed on ankle with burning 2+, not as strong as first time
Stool urge wakes him up in morning
Burning stool after 1+
|–||Sulphur 200CH one dose|
New small ulcer formed
Dullness, slow in answering 3+
Thick nails 2-3 +
Itching lower limbs 2-3+
|–||Graphites 200 CH one dose|
Ulcer was getting worse with intense burning pains
|–||Anthracinum 200 CH – twice a day for 3 days|
|06/12/2017||Previous ulcer healed within a month but again a small new ulcer started to form on right ankle.
On careful enquiry, it was discovered that patient was using camphor which could have antidoted and caused the relapse of the case frequently.
Advised to refrain the use of camphor.
|As on 27/09/2017, venous Doppler impression suggested
No sapheno-femoral or femoro-popliteal incompetence.
Bilateral incompetent perforators noted.
These incompetent perforators show reflux in erect posture.
Right- mid calf-5mm incompetent perforator.
Left- 4cm above left medial mallelous.
|Anthracinum 200 CH – twice a day for 3 days
|28/06/2018||A new ulcer formed which was very small compared to previous ulcers.
Patient is now able to handle emotional stress in a better way.
Timidity is better.
|–||Anthracinum 200 CH – twice a day for 3 days
|19/07/2019||After June 2018, there was no new ulcer formation.
Swelling of ankle was less compared to before.
Black discoloration of foot.
Patient is more confident now and can express his feelings.
Figure 2: photos –before and after treatment
Chronic venous insufficiency precipitates dermatological and vascular complications that culminate to form venous leg ulcers.4Venous leg ulcers represent a costly medical burden on the health care system with a greater risk of recurrence.14
While conventional medicine focuses on strategies such as compression and ablation, classical homeopathy promotes the concept of health as a whole and reinforces the fact that cure can be achieved by being in tune with oneself on mental, emotional and physical levels.15
Individualized classical homeopathy aims at diagnosing the etiologic factors under homeopathic principles, that is, genetic, epigenetic and infectious antecedents of the disease development and examines the patients’ signs and symptoms for diagnostic, therapeutic and prognostic interpretation.15,16
These signs and symptoms represent the balance achieved by the immune system in order to prevent complete collapse from the stress and guides the homeopath towards the correct remedy.16,17The above case example provides evidence for dealing with mental and emotional stress as a part of the pathology.
Long follow up periods were taken to establish consistency and evaluate the risk of recurrence. The case progress was recorded on venous doppler scans and photographs. This case also exemplifies the consideration of antidotal influence while evaluating the effect of remedy and the relapse during treatment.16
The mainstay of homeopathic treatment was to address the cause of the disease and stimulate the immune system to achieve balance on its own.16 The therapy not only impacted the slow healing ulcer but also enhanced the overall quality of life. The Modified Naranjo Criteria for Homeopathy (MONARCH) causality assessment provided a score of 9, suggesting a significant causal relationship between homeopathic treatment and the outcome (table 4).18
Table 4: Modified Naranjo Criteria for Homeopathy (MONARCH) – for causality assessment of both cases
|Criteria||Y||N||Not sure/NA||Score in case|
|1. Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed?||2||-1||0||2|
|2. Did the clinical improvement occur within a plausible time frame relative to the drug intake?||1||-2||0||1|
|3. Was there an initial aggravation of symptoms?||1||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|
|5. Did overall well-being improve?||1||0||0||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|
|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|
|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|
|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|
|9. Was the health improvement confirmed by any objective evidence? (Photos and Doppler scans in this case)||2||0||0||2|
|10. Did repeat dosing, if conducted, create similar clinical improvement?||1||0||0||0|
Previous case studies show beneficial outcomes for treatment of slow healing ulcers with classical homeopathy.9,10 In view of these case reports, homeopathy must be examined to establish the exact therapeutic outcomes.
This case report illustrates a favorable outcome for use of classical homeopathy in cases of venous ulcers. However, further research under hospital setting is required to prove the efficacy of this novel therapy and its relevance to this disease condition.
- Probst S, Weller CD, Bobbink P, et al. Prevalence and incidence of venous leg ulcers—a protocol for a systematic review. Syst Rev 2021 101. 2021;10(1):1-4. doi:10.1186/S13643-021-01697-3
- B S, T G. Chronic venous insufficiency – a review of pathophysiology, diagnosis, and treatment. J Dtsch Dermatol Ges. 2017;15(5):538-556. doi:10.1111/DDG.13242
- Robles-Tenorio A, Lev-Tov H, Ocampo-Candiani J. Venous Leg Ulcer. Phlebol Vein Surg Ultrason Diagnosis Manag Venous Dis. Published online April 15, 2021:341-353. Accessed August 22, 2021. https://www.ncbi.nlm.nih.gov/books/NBK567802/
- Robles-Tenorio A, Lev-Tov H, Ocampo-Candiani J. Venous Leg Ulcer. Phlebol Vein Surg Ultrason Diagnosis Manag Venous Dis. Published online April 15, 2021:341-353. Accessed August 23, 2021. https://www.ncbi.nlm.nih.gov/books/NBK567802/
- Ren S-Y, Liu Y-S, Zhu G-J, et al. Strategies and challenges in the treatment of chronic venous leg ulcers. http://www.wjgnet.com/. 2020;8(21):5070-5085. doi:10.12998/WJCC.V8.I21.5070
- Vasudevan B. Venous leg ulcers: Pathophysiology and Classification. Indian Dermatol Online J. 2014;5(3):366. doi:10.4103/2229-5178.137819
- F L, M P, M M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc surgery Venous Lymphat Disord. 2020;8(3):342-352. doi:10.1016/J.JVSV.2019.12.075
- Orhurhu V, Chu R, Xie K, et al. Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review. Cardiol Ther. 2021;10(1):111-140. Accessed August 22, 2021. http://www.ncbi.nlm.nih.gov/pubmed/33704678
- 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
- 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/
- 2021 ICD-10-CM Diagnosis Code I83.209: Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation. Accessed August 23, 2021. https://www.icd10data.com/ICD10CM/Codes/I00-I99/I80-I89/I83-/I83.209
- george vithoulkas. The Essence of Materia Medica. B.Jain publishers; 1998.
- Boericke W. Pocket Manual of Homeopathic Materia Medica and Repertory. B.Jain publishers; 2002.
- L B, Q C, R T, X L, D B, R P. Measuring costs and quality of life for venous leg ulcers. Int Wound J. 2019;16(1):112-121. doi:10.1111/IWJ.13000
- Hanhemann S. Organon of Medicine. B.Jain publishers; 1994.
- Vithoulkas G and Tiller.w. The Science of Homeopathy. 7th Edition.; 2014.
- Vithoulkas G. Levels of Health.; 2017.
- 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
very good, informative, nice way of analysis and evaluated case.
Excellent case Dr. Varsha
Thanks for the detailed case and the methodology of arriving at the remedy.
Keep sharing more!