Decubitus ulcer and homoeopathic therapeutics: a review

Dr Monisha.M

Abstract
Decubitus ulcers, commonly known as bedsores or pressure ulcers, are localized injuries to the skin and underlying tissues caused by prolonged pressure, friction, or shear forces. They primarily affect individuals with limited mobility, such as bedridden patients or those in wheelchairs. Bedsores most often arise on the skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. This article explores the pathophysiology, risk factors, stages of ulcer development, and common sites affected. Preventive strategies, including regular repositioning, proper nutrition are discussed. Additionally, treatment approach in Homeopathy with indications are highlighted. Homeopathic medicines are very useful in such type of ulcers. Early detection and comprehensive management play crucial roles in reducing morbidity and improving patient outcomes.

KEYWORDS: Decubitus ulcer, Bed sores, Pressure sores, Homoeopathy

INTRODUCTION
Pressure injuries, also termed bedsores, decubitus ulcers, or pressure ulcers, are localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences. These ulcers are present 70% of the time at the sacrum, ischial tuberosity, and greater trochanter. However, they can also occur in the occiput, scapula, elbow, heel, lateral malleolus, shoulder, and ear.

EPIDEMIOLOGY
The prevalence of high-grade decubitus ulcers (grades 3 and 4) is as high as 3%, and may reach 4% among elderly persons receiving nursing care in institutions. Globally, the number of prevalent cases of decubitus ulcers in 2019 is 0.85 (95% UI 0.78 to 0.94) million.

The prevalence of pressure injuries appears to have a bimodal age distribution. A small peak occurs during the third decade of life. Two thirds of pressure injuries occur in patients older than 70 years.

Most younger individuals suffering from pressure injuries are males. In the older population, most patients with pressure injuries are women.

SITES OF DECUBITUS ULCER (ANATOMY)

The hip and buttock regions account for up to 70% of all pressure injuries, with ischial tuberosity, trochanteric (greater trochanter), and sacral locations being most common.

The lower extremities account for an additional 15-25% of all pressure injuries, with malleolar (lateral malleolus), heel, patellar, ischial, calcaneal tuberosity and pretibial locations being most common.

The nose, chin, forehead, occiput, chest, back, and elbow are among the more common of the infrequent sites for pressure injuries.

No surface of the body can be considered immune to the effects of pressure. Pressure injuries can involve different levels of tissue. Muscle has been proved to be most susceptible to pressure.

CAUSES:

1. Impaired mobility (neurologically impaired, heavily sedated, recovering from traumatic injury)
2. Contractures and spasticity
3. Inability to perceive the pain
4. Paralysis, insensibility and aging leads to atrophy of skin and thinning
5. Bacterial contamination, diabetes, sepsis delays ulcer healing
6. Malnutrition, hypoproteinemia, anaemia may also delay wound healing
7. Local tissue hypoxia
8. Peripheral vascular disease

PATHO- PHYSIOLOGY-

• Pressure injuries result from constant pressure sufficient to impair local blood flow to soft tissue for an extended period. This external pressure must be greater than the arterial capillary pressure (32 mm Hg) to impair inflow and greater than the venous capillary closing pressure (8-12 mm Hg) to impede the return of flow for an extended time.
• The inciting event is compression of the tissues against an external object such as a mattress, wheelchair pad, bed rail, or other surface.
• Of the various tissues at risk for death due to pressure, muscle tissue is damaged first, before skin and subcutaneous tissue
• Irreversible changes may occur during as little as 2 hours of uninterrupted pressure.
• A localized area of erythema develops at sites of bony prominences and progresses to a blister and then erosion which will develop into a deep necrotic ulcer, usually colonized by pseudomonas aeruginosa if pressure is not alleviated.

STAGES OF DECUBITUS ULCER –

Stage 1: The skin is intact with non-blanchable erythema.

Stage 2: There is partial-thickness skin loss involving the epidermis and dermis.

Stage 3: A full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it. Slough or eschar may be visible, and the lesion may be foul-smelling.

Stage 4: Full-thickness skin loss extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement.

EVALUATION OF DECUBITUS ULCER
There are 3 risk assessment scales: Waterlow, Norton, and Braden. The Braden scale is the most common and accepted in the current literature. It includes 5 sections worth 4 points and 1 section worth 3 points. Sum the points to provide a risk assessment score.

Braden Scale

• Sensory perception (1-4; completely limited, very limited, slightly limited, or no impairment)
• Mobility (1-4; completely immobile, very limited, slightly limited, or no limitations)
• Moisture (1-4; constantly moist, very moist, occasionally moist, rarely moist)
• Nutrition (1-4; very poor, probably inadequate, adequate, excellent)
• Activity (1-4; bedfast, chairfast, walks occasionally, walks frequently)
• Friction and Shear (1-3; problem, potential problem, no apparent problem)

Scores

• Mild Risk = 15 to 18
• Moderate Risk = 13 to 14
• High Risk = 10 to 12
• Very High Risk = 9 or below

PROGNOSIS OF DECUBITUS ULCER-

The prognosis for patients with pressure ulcers varies depending on the anatomic location, stage of injury, and treatment regimen.
Factors that affect prognosis include advancing age, the size and stage of PI, nutritional status and chronic co-morbidities.

PREVENTION OF DECUBITUS ULCER –

• Prevention is the key and first it involves identification of at- risk patients and regular repositioning
• Use of pressure relieving mattresses
• Correcting pre disposing factors such as anemia, poor nutrition,etc
• Regularly changing a person’s lying or sitting position is the best way to prevent pressure ulcers.
• Some people who are hardly able to move don’t get very hungry or thirsty. In order for them to stay in good physical condition, though, it’s important to make sure they get enough to eat and drink. Eating too little or a very unbalanced diet and hardly having anything to drink may weaken their skin even more.
• Dietary supplements that are high in calories and protein can be used to prevent malnutrition.
• It is essential to keep the skin clean. This is especially true for people who have incontinence (trouble controlling their bladder or bowels). Then it’s important to regularly change their diapers or incontinence pads.
• It is important to keep the skin from getting too dry, but also to prevent it from being exposed to constant moisture – either one increases the likelihood of damage to the skin.

MANAGEMENT AND TREATMENT
Before discussing different treatments for pressure ulcers, it is essential to emphasize that prevention intervention is the best treatment.

• Infection must be treated
• Necrotic tissue debrided
• Medicines to control pain
• Dressings encourage granulation although surgical interventions sometimes needed (flap surgery)

HOMOEOPATHIC MANAGEMENT OF DECUBITUS ULCER:
The list of homoeopathic remedies for Decubitus ulcer is as follows:

1. Fluoric acid: Typhus with decubitus. Ulcers – <warmth, >cold. Pain like streaks of lightening. Intractable decubitus (hard to control). Ulcers with red edges and vesicles. Copious discharge which is offensive acrid. Sweat promotes excoriation soreness of skin and decubitus. Burning pains confines to a small spot.
2. Baptisia: Decubitus in typhoid. In whatever position the patient lies, the parts feel sore and bruised. Bedsores with hot burning livid spots turning into ulcers and putrid smell. Decubitus ulcers especially on sacrum and hips.
3. Pyrogen: Rapid decubitus of septic origin. Bed feels hard. Parts lain on feel sore and bruised. Eschars of decubitus. When best selected remedy fails to improve. >must move constantly.
4. Lachesis: Decubitus ulcer with intense pain. Dark bluish – purple appearance of ulcer. Black edges, ulcers red and inflamed. Rapid decubitus. Increased weakness with decubitus ulcer in typhoid.
5. Paeonia officinalis: Ulceration of seat from decubitus in a bed ridden patient. Ulcers below coccyx. Sacral sores. Vitality of skin is destroyed by pressure. Decubitus ulcers of coccyx. Bedsores easily ulcerate.
6. Anti – crud: neurological sensation impaired that she may develop bedsores at several locations due to contact with faecal matter without seeming to feel them. Strange absence of pain in bed-sores.
7. Argentum nitricum: Erysipelatous bedsores. On left shoulder, sacrum, both hips. Decubitus ulcer – covered with dry bloody incrustations in centre. On sacrum- ulcers black hard.
8. Hepar sulphuris: Decubitus ulcer on right hip joint. Lies immovable on right side with knees drawn up-to chest
9. Muriatic acid: Bedsores from inability to turn. Indolent pale looking painless ulcers. Extends very rapidly.
10. Plumbum met: Difficulty he experiences in moving obliges him to keep lying in same position, which gives rise to bedsores especially on sacrum and thighs. Acute decubitus ulcer. Sensitive to open air. Burning ulcers – small wounds easily inflame and suppurate.
11. Arnica: soreness of parts on which one lies. Decubitus ulcer especially on hip and sacrum. Bed feels too hard to lie. Ulcers – black, blue border with crops of pimples and boils around.
12. Chloralum hydratum: Decubitus in dropsy, scarlatina, erysipelas. Large,greenish decubitus ulcer at base of spine.
13. Zincum met: Decubitus ulcer with typhoid and typhus. Ulcer especially on sacrum and trochanter
14. Carbo-veg: Decubitus threatens to break out. In typhus, bedsores from decomposition of blood.
15. Arsenicum album: Septic changes in blood. Decubitus with typhus. Burning lancinating pains. >heat, <cold. Ulcers with gangrenous scurfs with dark red borders.
16. Vinca minor: Burning pains and ulcers from decubitus. Especially on left natis.
17. Rajania subsamarata : gangrenous patches from decubitus position causing bedsores. Skin rough. <moving, > discharge, cold. Profuse perspiration with bedsores.
18. Carbolic acid: Rapid decubitus ulcer especially in diabetic and gangrene. Rapid decubitus ulcers
19. Sulphur: Ulcers turn to gangrenous bedsores. Decubitus ulcer with gnawing pains.
20. Sulphuric acid: Acrid blood discharge in decubitus ulcer. >warmth, <heat, cold.

Other remedies for decubitus ulcer: Calendula Q, Echinacea Q, Zingiber, Hippozaeninum, Hydrastis can, Calotropis, Senna, Nux moschata, China, Crotalus-hor, Acid phos, Camphor, Alstonia, Ammonium carb, Secale-cor, Platina, salicylic acid, Calcarea carb, Valeriana

RUBRICS THAT CORRELATE TO DECUBITUS ULCER –

Synthesis Repertory

• Skin – decubitus
• Skin – decubitus – gangrenous
• Skin – decubitus – sensitive
• Skin – decubitus – bend of joints
• Skin – decubitus – folds in
• General – wounds – decubitus
• Fever – typhoid fever – accompanied by – decubitus
• Extremities – bedsores
• Skin – bedsores

References:

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Dr. Monisha.M
PG Scholar, Department of homeopathic Materia medica
Under Guidance of: Dr. Renuka.S.Patil Professor and HOD
Government Homoeopathic Medical College and Hospital. Benguluru – 560079
Email : Monijanumahe555@gmail.com