420 J Contemp Med Sci | Vol. 8, No. 6, November-December 2022: 420–423 Case Report The Effectiveness of Topical Arnebia euchroma Oil in the Treatment of Pressure Ulcer: A Case Report Sakineh Erabi1,2,3, Ali Ghobadi1,4, Hoorieh Mohammadi Kenari1,2* 1Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran. 2Department of Traditional Medicine, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran. 3Student Research Committee, Iran University of Medical Sciences, Tehran, Iran. 4Department of Traditional Pharmacy, School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran. *Correspondence to: Hoorieh Mohammadi Kenari (E-mail: hooriehmohhamadikenari@yahoo.com) (Submitted: 10 September 2022 – Revised version received: 25 September 2022 – Accepted: 19 October 2022 – Published online: 26 December 2022) Abstract: Decreased tissue blood flow causes pressure ulcers due to prolonged pressure on the area, which becomes problematic for immobile individuals. The medical community has often been involved in curing such a problem in individuals with disabilities and immobility. To alleviate this problem, therefore, plenty of investigations are always seeking novel methods. Furthermore, herbal plants are increasingly used owing to the accepted status of plant-derived drugs in recent years. Our female case aged 52 years that was referred to the wound clinic complaining sensory and motor weakness of the upper extremity and sudden paralysis of the lower extremity as of 1 year ago, which was diagnosed as myelitis. She complained of two wounds on both sides of the right and left buttocks with a size of 9 × 5 and another 6 × 4.5 cm from 3 months ago, and a wound with a size of 5 × 4.5 in the sacral area (sacrum) from 20 days prior to the admission. There was tissue necrosis without muscle engagement, osteomyelitis, or tunneling; besides, nasty odors and sludge were absent accounted for in class 3 in the group of wounds. She received starting therapy using Arnebia euchroma oil. As of the 2nd week onward, she was treated very successfully, and the complete wound healing occurred in 8 weeks. The use of A. euchroma for wound healing and reducing infection and inflammation can greatly contribute to the cure of pressure ulcers and can be properly suggested in healing these ulcers. Keywords: Pressure ulcer, wound healing, Arnebia euchroma, bed sore, traditional persian medicine ISSN 2413-0516 Introduction In a pressure ulcer, the skin or the underneath tissue is locally injured from unmitigated pressure on the soft tissue of the body,1 or pressure along the cleft between a boney protuber- ance and an exterior surface for a prolonged period.2,3 There is an increased number of patients with pressure ulcers in spite of the improvements in the quality of delivering healthcare on the globe such that pressure ulcers have become mainly prob- lematic in acute and prolonged care centers.4,5 This problem is reported to be prevalent in over 1.3 million adult people glob- ally.6 Sore results from tissue blood flow impairment and pro- gressively necrotic areas of the body cells and necrotic cells that destroy their underneath layers.7 Bedsores are mostly observed in sacrum and heels, with types 1 and 2 being the prevalent levels of austereness.8,9 As defined by the National Pressure Ulcer Advisory Panel (NPUAP),10 it is a persistently pressured area typically on a boney protuberance leading to ischemia, cell death, and necrotic tissue (Table 1).11 As an index, the quality of patient care services is indicated by WHO using the occurrence and frequency of bedsores. It is highly important to use efficacious preventing actions and their ther- apies. The therapy is based on assessing sore austereness, reduction of pressure, friction, and shear stresses, wound care improvement, necrotic residue removal, bacterial infection management, and correction of nutrition-related shortages. Intervention approaches consist of special alterations in bed- sores in combination with training approaches. The 2019 CPG defines bedsore as “the locally injured skin and/or the underneath tissue, resulting from pressure or pres- sure combined with shear. While PUs/PIs typically happen over a boney protuberance, they can result from a medical apparatus or different objects”.12 Bedsore may be represented as healthy skin or as an open sore with possible pain. The tissue is damaged due to the intensely and/or lengthily exposed soft tissues to persistent mechanical loading, i.e., malforma- tions in compression, tension, or shear or a combined condi- tion of these loading styles. Persistent loading (defined as quasi-static loading as well, i.e., a nearly/almost static loading state) denotes loads exerted constantly for prolonged periods, including minutes to hours or even days. The soft tissues are differently tolerant to persistent malformations by the tissue type; microclimate, perfusion, age, health status (either chronic or acute), and systemic comorbidities and localized (topical) conditions of the soft tissues may also influence per- sistent malformations, and the persistent mechanical loading affects the mentioned factors.13 Bedsore therapy is strongly predicted by the use of humid coatings and supporting sufficiently through nutrition.14,15 Currently, society and the medical workforce are interested in plant-derived drugs and remedies and conventionally con- ducted traditional medicine, which are justifiable cost-effec- tively in addition to their lengthy history, safe use, accessibility, and ease of utilization.16,17 Additionally, traditional herbal spe- cies are today commonly used for sore remedies, and more than 80% of the global population is reliant on traditional medicine for various skin ailments.18,19 Herbal plants are the main resource of natural products with different actions regarding their structures, biologic activities, and modes of action.20-22 Plant materials contain various constituents, in par- ticular polyphenols, flavonoids, phenolic acids, and the like, which play a role in suppressing free radicals and in the anti- oxidant activities of herbal plants.17,23 Arnebia euchroma (Royle) I.M. Johnst is a traditional herbal species that is reputable in the traditional medicine of Iran,24 termed a red plant or Heveh choaeh. Arnebia belongs to mailto:hooriehmohhamadikenari@yahoo.com 421J Contemp Med Sci | Vol. 8, No. 6, November-December 2022: 420–423 S. Erabi et al. Case Report The Effectiveness of Topical Arnebia euchroma Oil in the Treatment of Pressure Ulcer: A Case Report Table 1. Degrees of bedsore defined by NPUAP14,40 Degree 1 Erythema without pressure whitening Intact skin with redness with no pressure whitening (non-blanchable) in a localized area, typically on a boney protuberance. The area can possibly have pain and may be hard, soft, and warmer, or colder than adjacent tissues. Degree 2 Relative thickness Losing partially the thickness of the dermis appearing as a surface lesion with a red, pink, scaly bed. It appears as a blushing or dry surface lesion with no scaling or bruising. This categorization is not useable in describing skin tears, band burns, dermatitis accompanied by incontinence, maceration, or excoriation. Degree 3 Losing all skin thickness Fat may be present beneath the skin, but not under the bone, tendon, or muscle. Scaling may be present but the depth of the tissue loss is unknown. This lesion can comprise atrophy and perforation. Degree 4 Losing all tissue thickness Losing complete thickness of tissue by appearing bone, tendon, or muscle. It is typically accompanied by degeneration and perforation. Grade 4 sores can extend to muscle or supportive structures (the fascia, tendon, or joint capsule) possibly leading to osteomyelitis or osteitis. Fig. 1 Sacral ulcer at the start of treatment. the Boraginaceae family and contains a variety of species growing in Asian and North African regions. It appears as an herb-like plant covered with pointy silver hairs. H. choaeh is a dark red and unscented herbal species growing in south- eastern Iran. The herb’s root is the useable part. The roots of herbal plants, such as Echium, Lithospermum, Onosma, Alkanna, and Arnebia are replete in naphthoquinone, Shi- konin, alkanin, and Isohexenylnaphthazarin derivatives with various remedial activities, including anti-inflammatory, anti- microbial, and anticancer properties.25-27 The reliable books of Iranian medicine, e.g. Makhzan Al-Adavieh and Qarabadin, introduce “H. choaeh” as one of the main remedies to heal wounds. It is also utilized in the formulation of some topical wound-remedial drugs that assist the skin recovery and regenerate the tissue, cure skin inflam- mation, and old refractory lesions.28-32 In recent years, the activities of this herbal species have been investigated in plenty of research. H. choaeh has shown anti-inflammatory impacts on the remedy of surgical wounds, burns, and bedsores.33-36 In addition to its wound remedy activity, this herbal species has been demonstrated to possess anti-inflammatory, antibacterial, anti-tumor, anti-diabetic, anti-viral, antioxidant, and anti-thrombotic activities.37-39 Case Report Our case was a female aged 52 years who complained of sen- sory and motor weakness of the upper extremity and abrupt palsy of the lower extremity since a year ago; she was diag- nosed with myelitis and complained of three lesions, two of which were on both sides of the right and left buttocks involving the muscle with no osteomyelitis, tunneling, nasty smell, and slush since 3 months prior to the admission. For a month prior to referral, she was under antibiotic therapy, progressive bandages, and ozone therapy for these two wounds in the hospital. Despite the debridement and cleaning of the lesions, indications of curing were absent. These two lesions were measured at 9 by 5 and another one 6 by 4.5 cm, which accounted for grade 3 in the class of lesions. Besides, 20 days prior to the visit, a newly emerged lesion measuring 5 by 4.5 occurred in the sacral region, with tissue necrosis with no muscle engagement, osteomyelitis, or tun- neling, having nasty odors and slush, which accounted for grade 3 in the class of lesions. The wound was not debrided in this case (Figure 1). All the lesions were scored 13 by PUSH criteria scoring. Although the surgery was necessary, it was not possible to operable the patient due to her overall situation; thus, she was introduced to our wound clinic (Orchid) for topical therapies. A. euchroma oil was the starting remedy for her. She underwent a oil-containing bandage two times daily that covered the lesion surface by 3 mm each time. Enhancements in serous secretion, granula- tion tissue, odor, and lesion size shrinking were initially monitored every day and then every week. Serous was dis- charged slightly in the whole lesions on the 1st day. Within the 1st week, the discharge rose in the lesions but with no nasty odor. Following 10 days of beginning the therapy, the nature of the tissue changed in the pressure ulcers with a pinkish color change and generating healthy granulation tissue, which caused the wound contraction. By the 3rd week, the length and width of the lesions did not change signifi- cantly, however, the 10th day of the therapy onward was associated with the filled cavity depth and reduced lesion depth, appearing nearly healed. The sacral lesion was photo- graphed after 6 weeks of therapy, indicating the considerable and acceptable remedy of the lesions (Figure 2), which were scored 11, 9, and 9 in PUSH scoring. Similarly, the lesions 422 J Contemp Med Sci | Vol. 8, No. 6, November-December 2022: 420–423 The Effectiveness of Topical Arnebia euchroma Oil in the Treatment of Pressure Ulcer: A Case Report Case Report S. Erabi et al. healed completely (disappearance of the secretions, filling of the cavity, and fully closed lesions) after the 8th week. Preparation of H. choaeh drug Qarabadin is a worthful pharmacological book of tradi- tional medicine in Iran, which was employed to prepare H. choaeh oil.41 The preparation process was started with heating olive oil (to the degree without burning the oil with no rising odor of burns by preventing fumes). This was fol- lowed by adding the ground root of H. choaeh in a volume of a quarter of its weight and then boiling for dying the oil. Next, some wax was added for oil filtration and concentration. Discussion This case demonstrated that H. choaeh can be used with high contribution to healing bedsores. The H. choaeh root uti- lized here contains a variety of compounds such as alkanin and chiconin.3 As mentioned by the specialists of traditional medicine, H. choaeh has a hot and dry nature, and its roots possess various activities including the application in wound-drying liniments and for treating some skin ail- ments. The anti-inflammatory impact of H. choaeh roots was assigned to its two natural products, alkannin and shikonin, by Kourounakis et al. (2002). As claimed by Sidhu et al., the therapy with H. choaeh is beneficial as it significantly reduces the ulcer surface area, increases cell multiplication, and amplifies collagen biosynthesis. Additionally, Senel and Papageorgious proposed the antioxidant property and the function of oxygen free radicals, alkaline, and chiconin as novel alternates for wound remedy via anti-inflammatory, antimicrobial, and antioxidant activities.35-38 Assimopoulou et al. ascribed the anti-inflammatory impacts of H. choaeh roots to hydroxynaphthoquinones being present in its root extracts. Ahmadian et al. also report that chiconin (beta alkanin) is a naphthoquinone pigment obtained from plant roots with antimicrobial effects.42,43 Damiaunakos et al. pre- sented evidence of potent chiconin and alkaline drugs having substantial biologic functions, such as wound remedy and antimicrobial, anti-inflammatory, antioxidant, anti- cancer, and anti-thrombotic effects.44 Akkol et al. docu- mented that therapy by H. choaeh lowered the lesion area and enhanced cell multiplication, migration, vascular for- mation, and re-epithelialization of lesions.45 In a study on the properties of A. euchroma and Malva sylvestris, Pir- balouti et al. found that H. choaeh significantly influenced wound remedy acceleration.46 The same authors examined the influence of H. choaeh root extract on diabetic sores in rats. They reported that the sore level showed a significant reduction in the test animals with a shorter epithelial time than the control rats as the sore was contracted more swiftly.47 Nasiri et al. assessed the impact of H. choaeh on burns and observed a 10% better mean wound remedy in the H. choaeh group than silver sulfadiazine after 10 days of burns. The H. choaeh group also showed a greater percentage of shrinking wounds.32 In their research on rats, Ashkani et al. found that the extract of H. choaeh more significantly affected epithelialization, fibroblast proliferation, and col- lagen synthesis, as well as more anti-inflammatory impacts than the control group.48 Sedaghat et al. investigated the impact of H. choaeh on the remedy of sores in rats. They observed the anti-inflammatory impacts of A. euchroma that helped wound remedy by mitigating the degree and acute- ness of inflammation.36 The literature indicates the anti-inflammatory and wound remedy impacts of H. choaeh. According to the present case study, the use of this herb alongside appropriate nursing care resulted in significantly improved wound healing. Plant sources are worthwhile for investigations on developing novel medicines. Accordingly, the renewing impact of H. choaeh was examined in this research, indi- cating that the oil prepared from this herb possesses anti- bacterial, anti-inflammatory, and immunomodulatory properties involved in decontamination. It helps in the cre- ation of an intact granulation tissue for wounds, and its antioxidant properties eliminate free radicals from the environment, preventing their creation. Such activities of the drug control the wound remedy procedure and the view of remedial signs. The H. choaeh oil has a mediatory role between the sore surface and the coverage substance to attach them together that hinders drying the wound and improves the appropriate remedy of wounds by the acceler- ation of epithelialization and collagen synthesis. Regarding this, it seems that the major mode of action of anti-inflam- matory impacts of this herbal species is the antioxidant impact of alkaloids present in its roots. To confirm this, it is recommended to implement a clinical trial with this drug. Acknowledgments This research was carried out as a case when the disease was observed with this high bedsore that fortuitously led to a good consequence for the patient. Herewith, the authors express their appreciation to the esteemed patient and her family. Conflict of Interest None.  Fig. 2 Sacral ulcer at week seven of the treatment. 423J Contemp Med Sci | Vol. 8, No. 6, November-December 2022: 420–423 S. Erabi et al. Case Report The Effectiveness of Topical Arnebia euchroma Oil in the Treatment of Pressure Ulcer: A Case Report References 1. Akhkand SS, Seidi J, Ebadi A, Gheshlagh RG. Prevalence of pressure ulcer in Iran’s intensive care units: A systematic review and a meta-analysis. Nursing Practice Today 2020; 7: 21-9. 2. 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