Case Study.cdr


 

 

 

    ISSN : 2693 6356 

2018 | Vol 1 | Issue 4 

 

Necrotizing fasciitis: a case study of the use of the 

Ayurvedic treatments ksharakarma (caustic 

cauterization) and jalukavacharana 

(hirudotherapy). 

Rajesh V Giri * 

* Professor and Head, Department of Post Graduate Studies in Shalyatantra, Muniyal 
Institute of Ayurveda Medical Science, Manipal, chanai 

 
 

Abstract 
An invasive infection of the skin and soft tissues, including the deep fascia, necrotizing fascitis, with relative 
sparing of the muscle. The treatment plan often includes removing the diseased tissue or maybe amputating 
the limb. The purpose of this study is to compare the efficacy of Ksharakarma (caustic cautery) and 
Jalukavacharana (hirudotherapy) in the treatment of necrotizing fascitis to that of surgical intervention. 
Substances and Techniques: Kshara was used on a case of an infected wound at the tip of the right index nger 
until enough debridement of slough occurred, and then Jalukavacharana was used to speed up tissue 
perfusion to the wound site and hasten the healing process. After 15 days, the necrotized region had been 
totally debrided (in two Ksharakarma sessions) and healed (in three Jalukavacharana sessions), preventing the 
need for surgical amputation of the terminal phalanx. The necrotizing fascitis wound was successfully 
managed by Ksharakarma and Jalukavacharana, preventing the need for amputation. 
 
Keywords: Necrotizing fasciitis, gangrene, hirutotherapy, jalukavacharana, ksharakarma, and caustic cauterization 

 

 

Introduction 

since ages, management of injuries has been a 

challenge to the surgeons of medical  

Tissue injury in the form of wounds caused by 

vehicular accidents, warfare, animal attacks or 

ulcers caused due to various diseases, have 

always posed  challenges to the 

practitioners of medicine. Ayurveda, especially, 

the branch of Shalyatantra (surgery). The 

various management methods explained by 

Sushrutha in  

validity even in this century. 

Traumatic wounds as a consequence to animal 
attacks and warfare (Abhighataja vrana) and ulcers 
due to various pathologies (Nija vrana) were 
observed and recorded in a detailed manner by 
Ayurveda. The management of which posed a 
great challenge to the surgeons of Ayurveda in 

ancient period. Giving due importance, wound 
management has been described under the branch 
of Shalyatantra [1]. 

 

 
A great in-depth description is available in 
Sushrutha Samhita (Text book by Sushrutha) 

regarding traumatic 

wounds, ulcers, their causes, examination 
methods and clinical features, signs of a clean 
wound, signs of a healing wound, signs of a 
healed wound, signs of infected wound, signs of 
chronic infected wounds and gangrenous wounds 
[2].Sushrutha Samhita describes 60 therapeutic 
methods [3] for the management of a wound/ulcer, 
right from the stage of abscess till the cosmetic 
repair of the formed scar (after healing). 
The present case study has been undertaken as a 
preliminary effort to re-validate the therapeutic 
modules explained by Acharya Sushrutha in the 
management of an Ulcer (Necrotising 



 

 

fasciitis).Caustic cautery or Ksharakarma is one of 
the important methods mentioned for the early 
non-surgical debridement of slough from the 
wound site. Ksharakarma is considered as a 
superior treatment module as it not only has a 
unique effect of managing all the vitiated three 
Dosha, but also has the ability to perform various 
surgical procedures like Chedana (excision), 
Bhedana (incision) etc without the actual 
necessity of any surgical instruments. The 
caustics extracted from the plant – Apamarga 
(Achyranthes aspera) and various other Ayurvedic 
ingredients have a potent antibacterial property 
against Escherichia coli, Enterococcus faecalis, 
Staphylococcus aureus and Pseudomonas species [4]. 

Thus caustic cautery has a potent antibiotic 
property and also debrides the dead, necrotising 
slough from the wound non-surgically. Its role in 
the form of Ksharasutra (medicated seton) has 
already been proved to be highly effective in the 
management of 

 in ano[5]. 

Hirudotherapy (Jalukavacharana or 
therapeutic application of leeches) has been 
mentioned as one of the non-surgical methods of 
removal of  located Gratitha 
(coagulated or blocked vessels) Rakta and thus 

 the 
area. Hirudotherapy by its anti-coagulant salivary 
secretions promotes micro-circulation of fresh 
blood into the tissues and removes venous 
obstructions, thus reducing venous congestion [6]. 
Case                                                                       
Study In the present study, a girl, aged 14 years, 
presented at the Shalyatantra OPD of the Hospital, 
with an infected wound at the tip of right index 

 with distal portions gangrenous  
1). There was foul smelling discharge and pain 
in the nail bed – since 20 days with the local tissue 
around the nail bed was fast turning dark  2) 
and the nail was turning brittle. around the nail bed 
of the 

 
Fig 1:Non-healing wound Fig 2: Darkened 
tissue with gangrenous portions  

 

 

 

 

 

 

 

 

On taking a detailed history, about 20 days back, 
she complained of pain in the tip of right index 

 with an associated mild swelling and 
fever. A local physician, diagnosing it as an 
abscess, conducted Incision and Drainage, and 
advised analgesics and antibiotics. But within a 
day, the swelling increased and blackish 
discoloration appeared. On visiting another 
surgeon, the case was diagnosed as a case of 
Necrotising fascitis. I & D was again done, and 
thick creamy pus was drained and abscess cavity 
was found to reach bone. After thorough 
debridement and toileting, abscess cavity was 
packed with betadine and was advised IV 
antibiotics, 12 hourly. Pus culture showed 
presence of heavy Staphylococcus aureus 
growth. Radiography clearly ruled out 
any osteomyelitis of the distal phalanx of the index 

 
 

On referral to a Plastic and Reconstructive, Hand 
and Burns Surgeon, she was advised amputation 
of distal 
advised 
from the neighboring  To avoid 
amputation and loss of most useful part of the 

 more importantly to 
 she approached 

for an alternative to amputation. After educating 
the patient regarding the treatment modalities 
available, and taking consent from her mother, 
she was put on caustic cautery and 
hirudotherapy measures. 

Treatment History: 

washed with distillate of Cow's urine and then, 
Apamarga Teekshna Kshara was applied and left in 
situ for about 1 minute. The area was then 
washed with lemon juice (to neutralize Kshara) 
and a Pichu dipped in Jathyadi Taila was placed 
on the site. Ksharakarma does Ksharana and 
Kshanana karma i.e. debrides and removes slough 
or the devitalized tissue from the site. Hence care 
was taken to do Ksharakarma only till slough 
was present in the site. Two sittings of 
Ksharakarma were done on alternate days, 
followed by three sittings of Jalukavacharana on 
alternate days. 

 

After cleaning the area with warm water, one 
fresh leech was applied to the site for 15 minutes 



 

 

 During the procedure, the leech was 
covered with a thin piece of cotton soaked in 
water to keep the leech moist. After the passage 
of 15 minutes, leech was removed by sprinkling 

turmeric powder on its anterior sucker. The site 
was then covered with a Pichu dipped in Jathyadi 
taila and bandaged tightly. 

 
 

Fig 3: Hirudotherapy on the non-healing 

wound 

 

Oral medications 
1. Tab. Munibyeotic 2 TID after food 

Table. 5: Grading of granulation tissue in the 

wound 
 

 

Granulation tissue Grade 
Healthy granulation tissue in the complete 0 wound 
Unhealthy granulation in 25% of the wound 1 
area 
Unhealthy granulation in 25-50% of the 2 

wound area 
Unhealthy granulation in more than 50% of 3 

the wound area 

Assessment of results 

2. Mahamanjishtadi Kashaya 30 ml BD with 
equal water, before food was advised 

Duration of the study 
Duration of study was for 15 days, during which 
on alternate days, she underwent two sittings of 
Ksharakarma , followed by three sittings of 
Jalukavacharana.Assessment of the results was 
made based on the above mentioned criteria and 

 Follow up 1 as F1, Follow up 
2 as F2 and so on, on alternate days. 

Results: 
During the treatment it was observed that from the 
3rd follow up the pain started reducing and by the 
end ofw up the pain had becoly 

Assessment criteria 

a.Subjective criteria–Pain (table 1) 

Table 1: Grading of pain 
 

 

Pain Grade 
No pain 0 
Tolerable localized pain 1 
Pain requires analgesics 2 

Pain even during rest, disturbing the sleep 3 

 

b.Objective criteria–Size of the wound (table 2), 
odor (table 3), discharge (table 4), granulation 
tissue (table 5) 

Table.2: Grading of the size of the wound 
 

 

Size of the wound Grade 
Completely healed wound 0 
Up to 0.5cm 1 
0.6 – 1 cm 2 

1.1 – 1.5cms 3 

Table. 3: Grading of odor of the wound 

Odor Grade 
No odor 0 

Foul odor 1 

Table. 4: Grading of discharge from the wound 

Discharge

 Grad

e 
No discharge, dry dressing 0 

Scanty discharge, little wet dressing 1 
Moderate discharge, requires daily dressing 2 
Profuse discharge, requires dressing twice a 3 

day 
 

relieved, indicating that the therapy had a good 
healing property (table 6). The caustic cautery 
and hirudotherapy, reduced infection, pus and 
slough and along with distillate of cow's urine 
prevented re- infection of the wound and thus 
helped in the early relief in pain. 

 

Till the 3rd follow up , though there 
were other changes, the wound size continued to 
be the same, and later there was good reduction 
and by the end of the 7th follow up the wound 
had completely reduced in size. After the 
slough, infected material had been debrided by 
caustic cautery, cow's urine, hirudotherapy and 
Jathyadi Taila, reduced venous congestion, 
improved micro-circulation and thus 
oxygenation might have supported early wound 
healing (table 6). 

 

The odor from the wound reduced by the 4th 

follow up. Caustic cautery along with distillate 
of cow's urine, helped to control infection. 
Controlled infection along with improved 
oxygenation to the tissue (through 
hirudotherapy) might have helped in early 
reduction in the odor from the wound (table 6). 

 



 

 

The most interesting  was till the 4th follow 
up the discharge was constantly on the higher 
side, with improvement in other parameters. 
This indicates towards the debriding action of 
the caustics used in the therapy. Caustics used 
could debride the slough from the wound 
without the necessity of any surgical intervention. 

Fig 4: 3rd    follow-up Fig 5: 4th follow-up 

  
 

Fig 6: 5th  follow-up Fig 7: 6rd  follow-up 

 

  

 

There was a gradual decrease in the quantity of 
unhealthy granulation tissue in each follow up 
to 

 be completely removed by the seventh 
follow up  5-11). This reduction in 
unhealthy 
debriding action of 
improved blood supply to the area. This reasserts 
the role of hirudotherapy and Jathyadi Taila in 
healing the wound (table 6). 

 
Table 6: Grade wise representation of therapeutic 

effect on assessment parametersFigure 
8: 7th follow-up Figure 9: 7th follow-up 

  
 

Figure 10: 1 month after Figure 11: 1 month 
after the 8th follow up the 8th follow up 

  

Discussion 

The Gomutra Arka (Distillate of Cow's urine) has 
good antimicrobial property[7]. Hence it was used 
for washing the wound site. Various studies 
have also already proved that the Kshara of 
Achyranthes aspera has antibacterial property 
against Escherichia coli, Enterococcus faecalis, 
Staphylococcus aureus and Pseudomonas species [4]. 
The Kshara debrided the gangrenous slough and 
along with Gomutra Arka provided a clean 
environment for the wound to heal. 
Jalukavacharana by stimulating micro-circulation 
and 

Assessment 

reducing venous congestion improved oxygen 
and nutrients perfusion to the healing tissues 
thus promoting the clean wound to heal [6]. 
Jathyadi Taila, the topical application also 
supported the faster wound healing [ 8] . Jati 
mainly contains tannins. Tannins have the 
capacity to combine with tissue protein and 
precipitate them. They act as mild antiseptics 
and check small hemorrhages; forms 
protective covering on the surface of wound, 
which helps in the process of wound healing 
[9]. Tab. Munibyeotic with its ingredients 
Triphala, Pippali, Shuddha Guggulu, Swarna 



 

 

Makshika Bhasma, Mukta shukti Bhasma, Shuddha 
Gairika, Kapardika Bhasma, Gandhaka Rasayana, 
Nimba Twak, Haridra – possesses 
immunomodulatory, antioxidant, anti-

 and anti-  microbial  
properties,  s t imulatesphagocytosis, 
increases the level of antibody-forming cells 
and also specially sensitizes T lymphocytes. 

 
Conclusion 
The procedures have revealed encouraging 
results in the management of infected, gangrenous 
wounds. Their therapeutic application needs to 
be reassessed in a larger sample of cases and in 
gangrene of various etiologies viz, gangrene 
secondary to diabetic ulcer, gangrene secondary 
to arterial diseases in order to observe if the limb 
can be saved from amputation, thus providing a 
superior relief to the patient medically as well as 
psychologically. 
 
 

References 
1. S u s h r u t a , S u s h r u t a s a m h i t a , 

Vedotpatthiadhyaya, Sutra Sthana, 
Chapter 1, Verse 9, edited by Ambikadatta 
Shastry, 12th ed. Varanasi; Chaukambha 
Sanskrit Sansthan; 2001, p. 3 

2. S u s h r u t a , S u s h r u t a s a m h i t a , 
Vranasravavijnaniyamadhyaya, Sutra 
Sthana, Chapter 22, Verse 7, edited by 
Ambikadatta Shastry, 12th ed. Varanasi; 
Chaukambha Sanskrit Sansthan; 2001, p. 95 

3. S u s h r u t a , S u s h r u t a s a m h i t a , 
Dvivraniyachikitsitamadhyaya, 
Chikitsa Sthana, Chapter 1, Verse 8, 
edited by Ambikadatta Shastry, 12th ed. 
Varanasi; Chaukambha Sanskrit Sansthan; 
2001, p. 4 

4. Rajneesh V Giri, Standardization and 
Evaluation of Guggulu based Kshara Sutra 
in 
Thesis, IMS, Banaras Hindu University, 
2003. 

5.  
sutra (medicated seton) therapy in the 
management of -in-ano, World 
Journal of Colorectal Surgery 2010; 2(2) 
(Art.6:01-10) 

6. Conforti M L, Connor N P, Heisey D M, 
Hartig G K , E v a l u a t i o n o f p e r f o r 
m a n c e characteristics of the medicinal 
leech for the treatment of venous 
congestion, Plast Reconstr Surg 
2002:109:228-235 

7. Anami Ahuja, Pushpander Kumar et al, 
Antimicrobial activities of Cow Urine 
against various Bacterial strains, 
International Journal of Recent Advances 
in Pharmaceutical Research April 2012; 
2(2): 84-87 

8. Dhande Priti P, Raj Simpy et al, Burn 
wound healing potential of Jatyadi 
Formulations in rats, Research Journal of 
Pharmaceutical, Biological and Chemical 
Sciences, Oct-Dec 2012; 3(4): 747