Is oral administration of Chinese herbal medicine effective and safe as an adjunctive therapy for managing diabetic foot ulcers? A systematic review and meta-analysis

San Huang Xiao Yan recipe promoted wound healing in diabetic ulcer mice by inhibiting Th17 cell differentiation

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetic ulcer is a serious diabetes complication and a primary reason for amputations. For many years, the San Huang Xiao Yan (SHXY) recipe has served as a conventional remedy for these ulcers, effectively reducing inflammatory factors and exhibiting considerable therapeutic efficacy. However, the precise mechanism remains incompletely understood.

AIM OF THE STUDY

To explore the efficacy and mechanisms of SHXY and its active ingredients in treating diabetic ulcer.

MATERIALS AND METHODS

A diabetic ulcer mouse model was established using C57BL/6J mice on a high-fat diet, followed by streptozotocin injection and skin damage. We investigated the bioactive compounds, key targets, and pharmacological mechanisms of SHXY in addressing diabetic ulcers through network pharmacology, molecular docking, both in vitro and in vivo validation experiments.

RESULTS

One week after intragastric administration, SHXY can reduce inflammation and edema, increase collagen synthesis, and reduce the expression of RORγT and IL-17A without affecting Treg cells. In vitro, SHXY-containing serum inhibited the differentiation of Th17 cells but did not affect Treg and Th1 cells. Network pharmacology found that SHXY acts through inflammatory pathways, including TNF, IL-17, Th17 cell differentiation, HIF-1, and PI3K-Akt.

CONCLUSIONS

SHXY and its candidate enhance healing in diabetic ulcers by modulating CD4+ T cells, particularly by inhibiting Th17 cell differentiation.

Bioactive triterpenoid compounds of Poria cocos (Schw.) Wolf in the treatment of diabetic ulcers via regulating the PI3K-AKT signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetic ulcers represent a chronic condition characterized by prolonged hyperglycemia and delayed wound healing, accompanied by endocrine disorders, inflammatory responses, and microvascular damage in the epidermal tissue, demanding effective clinical treatment approaches. For thousands of years, ancient Chinese ethnopharmacological studies have documented the use of Poria cocos (Schw.) Wolf in treating diabetic ulcers. Recent research has substantiated the diverse pharmacological effects of Poria cocos (Schw.) Wolf, including its potential to alleviate hyperglycemia and exhibit anti-inflammatory, antioxidant, and immune regulatory properties, which could effectively mitigate diabetic ulcer symptoms. Furthermore, being a natural medicine, Poria cocos (Schw.) Wolf has demonstrated promising therapeutic effects and safety in the management of diabetic ulcers, holding significant clinical value. Despite its potential clinical efficacy and applications in diabetic ulcer treatment, the primary active components and underlying pharmacological mechanisms of Poria cocos (Schw.) Wolf remains unclear. Further investigations are imperative to establish a solid foundation for drug development in this domain.

AIM OF THE STUDY AND MATERIALS AND METHODS

In this study, we aimed to identify the active compounds and potential targets of Poria cocos (Schw.) Wolf using UHPLC-Q-TOF-MS and TCMSP databases. Additionally, we attempt to identify targets related to diabetic ulcers. Following enrichment analysis, a network of protein-protein interactions was constructed to identify hub genes based on the common elements between the two datasets. To gain insights into the binding activities of the hub genes and active ingredients, molecular docking analysis was employed. Furthermore, to further validate the therapeutic effect of Poria cocos (Schw.) Wolf, we exerted in vitro experiments using human umbilical vein vascular endothelial cells and human myeloid leukemia monocytes (THP-1). The active ingredient of Poria cocos (Schw.) Wolf was applied in these experiments. Our investigations included various assays, such as CCK-8, scratch test, immunofluorescence, western blotting, RT-PCR, and flow cytometry, to explore the potential of Poria cocos (Schw.) Wolf triterpenoid extract (PTE) in treating diabetic ulcers.

RESULTS

The findings here highlighted PTE as the primary active ingredient in Poria cocos (Schw.) Wolf. Utilizing network pharmacology, we identified 74 potential targets associated with diabetic ulcer treatment for Poria cocos (Schw.) Wolf, with five hub genes (JUN, MAPK1, STAT3, AKT1, and CTNNB1). Enrichment analysis revealed the involvement of multiple pathways in the therapeutic process, with the PI3K-AKT signaling pathway showing significant enrichment. Through molecular docking, we discovered that relevant targets within this pathway exhibited strong binding with the active components of Poria cocos (Schw.) Wolf. In vitro experiments unveiled that PTE (10 mg/L) facilitated the migration of human umbilical vein vascular endothelial cells (P < 0.05). PTE also increased the expression of CD31 and VEGF mRNA (P < 0.05) while activating the expressions of p-PI3K and p-AKT (P < 0.05). Moreover, PTE demonstrated its potential by reducing the expression of IL-1β, IL-6, TNF-α, and NF-κB mRNA in THP-1 (P < 0.05) and fostering M2 macrophage polarization. These results signify the potential therapeutic effects of PTE in treating diabetic ulcers, with its beneficial actions mediated through the PI3K-AKT signaling pathway.

CONCLUSIONS

PTE is the main active ingredient in Poria cocos (Schw.) Wolf that exerts therapeutic effects. Through PI3K-AKT signaling pathway activation and inflammatory response reduction, PTE promotes angiogenesis, thereby healing diabetic ulcers.

Healing of diabetic foot ulcer with topical and oral administrations of herbal products: A systematic review and meta-analysis of randomized controlled trials

This systematic review aimed to qualitatively synthesize recent randomized controlled trials (RCTs) regarding the effect of topical application and oral intake of herbal products on the healing of diabetic foot ulcer (DFU). Also, we sought to pool the obtained findings in a meta-analysis using a random-effects model, if RCTs were relatively comparable and homogenous. A comprehensive search was performed on five electronic data sources from their inception through 23 January 2024. The RCTs, without restriction on the country of origin, were included if they compared the effect of administering standard treatments and/or placebo (i.e. control condition) to applying standard treatments and/or herbal products in topical or oral routes (i.e. experimental condition). Out of 1166 retrieved records, 28 RCTs were included. Studies used different poly and single herbal formulations. Based on the meta-analysis, administration of standard care plus daily dressing of the ulcer site with olive oil for 28 days significantly increased the total ulcer healing score (3 RCTs; weighted mean difference [WMD] = 89.30; p < 0.001), raised frequency of complete ulcer healing (2 RCTs; risk ratio [RR] = 12.44; p = 0.039) and declined ulcer degree (3 RCTs; WMD = -22.28; p = 0.002). Also, daily use of the bitter melon leaf extract in oral form for 28 days significantly increased the total ulcer healing score (2 RCTs; WMD = 0.40; p = 0.001). Additionally, based on qualitative synthesis, the adjuvant use of herbal agents seems an intriguing choice to manage DFU. Nonetheless, considering the undesirable methodological quality of most studies and the high heterogeneity in administered herbal formulations, more robust trials are required to build a solid conclusion regarding the use of herbal products for healing DFU.

Advances in traditional Chinese medicine as adjuvant therapy for diabetic foot

Diabetes mellitus (DM) is a complex disease that often causes multiple systemic complications that have become a major international public health problem. Diabetic foot (DF) is one of the severe and frequent chronic complications of DM due to vascular lesions and neuropathy. DF ulcers (DFU) affect approximately 15% of people with DM and are the leading cause of death and disability. The prevalence and recurrence of DF are worrisome, and morbidity and mortality are also on the rise, which poses a substantial socioeconomic burden. Treating DF is difficult for clinicians and requires multidisciplinary cooperation, combining local and systemic therapy to reduce amputation and case-fatality rates. Traditional Chinese Medicine (TCM) has received extensive attention due to noticeable therapeutic effects and few adverse reactions. In recent years, research on DF treatment by TCM has been increasing, and further progress has been made. TCM includes oral medication, injectable preparations, and adjuvant therapy. This article reviews the relevant research on TCM-related adjuvant therapy for DF. We describe current progress in TCM in terms of external application, acupuncture, massage, acupoint injection, foot bath, fumigation, and moxibustion, as well as the mechanisms involved.

In silico analysis of Typha domingensis Pers. phytocompounds against wound healing biomarkers and ascertaining through in vitro cell migration assay

Typha domingensis Pers. is known for its medicinal properties. Although traditionally T. domingensis Pers. has been used for wound healing, yet scientific investigations reporting its ability to heal wounds are lacking. Phytochemical profiling of T. domingensis Pers. inflorescence crude extract was carried out by LC-MS analysis. Ten phytochemicals were selected for in silico analysis based on retention time, mass-to-charge ratio and resolution of mass spectrum. Molecular docking of all ten compounds was done against selected wound healing biomarkers viz., interleukin 6(IL-6), interleukin β (IL-β), insulin-like growth factor tyrosine kinase receptor (IGF-1R) and transformation growth factor β (TGF-β). Based on this, catechin, mesalazine and piperazine were subjected for in vitro cell migration assay (3T3 L1 mouse fibroblast cell line) to assess their wound healing potentials. Molecular docking revealed that mesalazine, catechin, and piperazine have potential ligands based on lowest docking energy (ranging from - 4.1587 to - 0.972), Glide E score (ranging from - 26.929 to - 57.882), Glide G score (ranging from - 4.16 to - 7.972) and numbers of hydrogen bonds compared to other compounds studied. The migration assay revealed that, compared to control (52.5%), T. domingensis Pers. inflorescence crude extract showed maximum wound healing potential (80%) followed by Catechin (66.8%) Mesalazine (58.3%) and Piperazine (51.2%). The combined in silico and in vitro approach opens new dimension for designing innovative therapeutics to manage different types of wounds.

Recent technological advances in the management of chronic wounds: A literature review

Background

Wound treatment comprises a substantial portion of the healthcare budgets in developed countries. Studies suggest that about 50% of patients admitted to hospitals have wounds, while 1%−2% of the general population in the developed world suffers from chronic wounds. Chronic wounds fail to repair themselves within the expected period of 30 days. Technologies have been developed to address challenges encountered during wound care with the aim of alleviating pain, promoting healing, or controlling wound infections.

Objective

The objective of this study was to explore the technological improvements that have been made in this field over time.

Methods

To gain insight into the future of wound management, a systematic review of literature on the subject was conducted in scientific databases (PubMed, Scopus, Web of Science, Medline, and Clinical Trials).

Results and Discussion

Results indicate that wound dressings have evolved from the traditional cotton gauze to composite materials embedded with appropriate ingredients such as metal‐based nanoparticles. Studies on biodegradable dressing materials are also underway to explore their applicability in dressing large and irregular wounds. On the other hand, conventional drugs and traditional formulations for the management of pain, inflammation, infections, and accelerating healing have been developed. However, more research needs to be carried out to address the issue of microbial resistance to drugs. Drugs for managing other ailments also need to be designed in such a way that they can augment wound healing. In addition, it has been demonstrated that a coordinated integration of conventional and traditional medicine can produce laudable results in chronic wound management.

Conclusion

Accordingly, collaborative efforts and ingenuity of all players in the field can accelerate technological advances in the wound care market to the benefit of the patients.

Wounds affect about 50% of patients admitted to hospitals.

Technologies have been developed including biodegradable dressing materials to address underlying challenges.

Technological advancement, rising incidences of chronic wounds, growing government support, and a rising elderly population will drive wound market growth.

A careful combination of recent research outputs can greatly change wound care technologies.

This review highlights the recent research advances and opportunities in the wound care field.

The future lies in biodegradable dressing materials, probably embedded with selected nanoparticles and which shall be combined in predetermined ratios.

Buxuhuayu decoction accelerates angiogenesis by activating the PI3K-Akt-eNOS signalling pathway in a streptozotocin-induced diabetic ulcer rat model

ETHNOPHARMACOLOGICAL RELEVANCE

Buxuhuayu decoction (BXHYD) has been frequently used to treat patients with diabetic ulcers (DUs), without notable adverse reactions. However, the related molecular mechanism remains unelucidated.

AIM OF THE STUDY

This study assessed the potential mechanism of BXHYD against DUs by using network pharmacology and animal experiments.

MATERIALS AND METHODS

First, high-performance liquid chromatography (HPLC) was used for quality control of BXHYD. Further, the hub compounds and targets were screened from the Active Compound-Targets (ACT) network and the protein and protein interaction (PPI) network. Enrichment analysis was performed using DAVID, and molecular docking technology was used to identify active compounds that may play a key role in pub targets. Finally, a DUs animal model was established and used to elucidate the effect of BXHYD on the PI3K/Akt/eNOS signalling pathway.

RESULTS

(1) Calycosin-7-glucoside, amygdalin, and tanshinone iiA were detected in the freeze-dried powder of BXHYD. (2) Twelve hub compounds and eight hub targets were screened using the ACT and PPI networks. Through molecular docking, it was found that the four hub targets (TP53, IL6, VEGFA, and AKT1) binds luteolin and quercetin more tightly. (3) BXHYD is most likely to promote angiogenesis and wound healing by activating the PI3K/Akt/eNOS signalling pathway.

CONCLUSIONS

This research revealed that BXHYD might activate the PI3K/Akt/eNOS signalling pathway to promote DUs healing. These findings support the clinical use of BXHYD and provide the foundation for its subsequent studies.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Micronutrients and Natural Compounds Status and Their Effects on Wound Healing in the Diabetic Foot Ulcer

The diabetic foot ulcer (DFU) is an invariably common complication of diabetes mellitus, it is also a significant cause of amputation as well as extended hospitalization. As most patients with DFU suffer from malnutrition, which has been related to improper metabolic micronutrients status, alterations can affect impaired wound healing process. Micronutrients and herbal remedies applications present a wide range of health advantages to patients with DFU. The purpose of this review is to provide current evidence on the potential effect of dietary supplementations such as vitamins A, C, D, E, magnesium, zinc, copper, iron, boron, and such naturally occurring compounds as Aloe vera, Naringin, and Radix Astragali (RA) and Radix Rehmanniae (RR) in the administration of lower extremity wounds, especially in DFU, and to present some insights for applications in the treatment of DFU patients in the future.

The Four-Herb Chinese Medicine Formula Tuo-Li-Xiao-Du-San Accelerates Cutaneous Wound Healing in Streptozotocin-Induced Diabetic Rats through Reducing Inflammation and Increasing Angiogenesis

Impaired wound healing in diabetic patients is a serious complication that often leads to amputation or even death with limited effective treatments. Tuo-Li-Xiao-Du-San (TLXDS), a traditional Chinese medicine formula for refractory wounds, has been prescribed for nearly 400 years in China and shows good efficacy in promoting healing. In this study, we explored the effect of TLXDS on healing of diabetic wounds and investigated underlying mechanisms. Four weeks after intravenous injection of streptozotocin, two full-thickness excisional wounds were created with a 10 mm diameter sterile biopsy punch on the back of rats. The ethanol extract of TLXDS was given once daily by oral gavage. Wound area, histological change, inflammation, angiogenesis, and collagen synthesis were evaluated. TLXDS treatment significantly accelerated healing of diabetic rats and improved the healing quality. These effects were associated with reduced neutrophil infiltration and macrophage accumulation, enhanced angiogenesis, and increased collagen deposition. This study shows that TLXDS improves diabetes-impaired wound healing.

Current and emerging therapies in the management of diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers are one of the major causes of mortality in diabetic patients. Very few drugs and therapies have regulatory approval for this indication and several agents from diverse pharmacological classes are currently in various phases of clinical trials for the management of diabetic foot ulcers.

SCOPE

The purpose of this review is to provide concise information of the drugs and therapies which are approved and present in clinical trials.

REVIEW METHODS

This review was carried out by systematic searches of relevant guidelines, patents, published articles, reviews and abstracts in PubMed/Medline, Web of Science, clinicaltrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar of all English language articles up to 1 March 2015. The following search terms were used: diabetes, diabetic foot, diabetic foot ulcer, diabetic wound, diabetic foot infections, wound management, randomized controlled trials, approved treatments, new treatments and clinical trials.

CONCLUSIONS

The various drugs and therapies for the management of diabetic foot ulcers comprise antibiotics, neuropathic drugs, wound dressings, skin substitutes, growth factors and inflammatory modulators. The majority of these therapies target the treatment of diabetic foot ulcers to address the altered biochemical composition of the diabetic wound. However, no single treatment can be definitively recommended for the treatment of diabetic foot ulcers.

The effect of topical olive oil on the healing of foot ulcer in patients with type 2 diabetes: a double-blind randomized clinical trial study in Iran

Background

Diabetic Foot Ulcer (DFU) is the most costly and devastating complication of diabetes mellitus which can lead to infection, gangrene, amputation, and even death if the necessary care is not provided. Nowadays, some herbal products have shown therapeutic effects on healing of DFU. So, this study aimed to assess the effects of topical olive oil on the healing of DFU.

Methods

This double-blind randomized clinical trial study was conducted in Diabetes Clinic of Ahvaz Golestan hospital, Iran, in 2014. Thirty-four patients with DFU of Wagner’s ulcer grade 1 or 2 were enrolled in this study. Patients who were randomly assigned to intervention group (n = 17) received topical olive oil in addition to routine cares, whereas patients in control group (n = 17) just received routine cares. Intervention was done once a day for 4 weeks in both groups, and in the end of each week; the ulcers were assessed and scored. Data was collected by demographic and clinical characteristics checklists as well as diabetic foot ulcer healing checklist, and was analyzed by SPSS version 19 software using descriptive (mean and standard deviation) and analytic (student’s sample t-test, chi-square and repeated-measures analysis of variance) statistics.

Results

At the end of 4^th week, there was a significant differences between two groups regarding to 3 parameters of ulcer including degree (P = 0.03), color (P = 0.04) and surrounding tissues (P < 0.001) as well as total status of ulcer (P = 0.001), while related to ulcer drainages no significant difference was seen between the two groups (P = 0.072). At the end of the follow up, olive oil significantly decreased ulcer area (P = 0.01) and depth (P = 0.02) compared with control group. Complete ulcer healing in the intervention group was significantly greater than control group (73.3% vs. 13.3%, P = 0.003) at the end of follow up. Also, there were no adverse effects to report during the study in intervention group.

Conclusions

Our results indicated that olive oil in combination with routine cares is more effective than routine cares alone, and is without any side effect. However, further studies are required in the future to confirm these results.

Trial registration

IRCT2014083014251N2.

Electronic supplementary material

The online version of this article (doi:10.1186/s40200-015-0167-9) contains supplementary material, which is available to authorized users.

Seeking effective interventions to treat complex wounds: an overview of systematic reviews

BACKGROUND

Numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. We aimed to identify effective interventions to treat complex wounds through an overview of systematic reviews.

METHODS

MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.

RESULTS

Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full-texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients) and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score ≥ 8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score ≥ 8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low quality systematic reviews.

CONCLUSIONS

Numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use our results to tailor effective treatment according to type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions. Please see related article: http://dx.doi.org/10.1186/s12916-015-0326-3.

Changes in Bacterial Profiles and Antibiotic Sensitivity Before and After Wound Bed Preparation for Diabetic Foot Ulcers

We aimed to investigate the characteristics of bacterial profiles and antibiotic sensitivity in diabetic foot ulcers before and after wound bed preparation. This study involved 423 diabetic patients with Wagner grades 1 to 4 foot ulcers. Secretion culture was performed before wound bed preparation. The observation endpoint was when the wound showed a tendency toward healing and a specialist determined that stopping antibiotic treatment would not affect wound healing. A second secretion culture was performed after the observation endpoint. We obtained results from both secretion cultures from 411 patients. The proportion of multi-drug-resistant (MDR) gram-positive bacteria was 22.0% and 47.8% before and after treatment, respectively; that for gram-negative bacteria was 3.5% and 19.2%, respectively (P < .05). Pretreatment antibiotic sensitivity of staphylococci and other gram-positive bacteria was 48.7% and 44.8%, respectively; the rates decreased significantly after treatment to 36.8% (P = .031) and 34.8% (P = .027), respectively. Pretreatment antibiotic sensitivity of common and nonfermenting rare gram-negative bacteria was 55.4% and 54.6%, respectively, which decreased substantially after treatment to 33.2% (P = .002) and 32.9% (P = .003), respectively. Wound healing was achieved in 92.7% of patients. Pretreatment and posttreatment C-reactive protein levels were 124.759 ± 71.58 mg/dL and 82.8 ± 53.61 mg/dL, respectively (P < .05). In conclusion, following wound bed preparation for diabetic foot ulcers, MDR bacteria numbers were increased and antibiotic sensitivity was decreased; inflammation was decreased. These findings warrant future studies for confirmation.

Adverse events in diabetic foot infections: a case control study comparing early versus delayed medical treatment after home remedies

Background

The aim of conventional medical therapy in diabetic foot infections is to control infection, thereby reducing amputation rates, infectious morbidity, and death. Any delay incurred during a trial of home remedies could allow an infection to progress unchecked, increasing the risk of these adverse outcomes. This study sought to determine the effects of delayed operative interventions and amputations in these patients.

Methods

A questionnaire study targeting all consecutive patients admitted with diabetic foot infection was carried out over 1 year. Two groups were defined, ie, a medical therapy group comprising patients who sought medical attention after detecting their infection and a home remedy group comprising those who voluntarily chose to delay medical therapy in favor of home remedies. The patients were followed throughout their hospital admissions. We recorded the duration of hospitalization and number of operative debridements and amputations performed.

Results

There were 695 patients with diabetic foot infections, comprising 382 in the medical therapy group and 313 in the home remedy group. Many were previously hospitalized for foot infections in the medical therapy (78%) and home remedy (74.8%) groups. The trial of home remedies lasted for a mean duration of 8.9 days. The home remedy group had a longer duration of hospitalization (16.3 versus 8.5 days; P<0.001), more operative debridements (99.7% versus 94.5%; P<0.001), and more debridements per patient (2.85 versus 2.45; P<0.001). Additionally, in the home remedy group, there was an estimated increase in expenditure of US $10,821.72 US per patient and a trend toward more major amputations (9.3% versus 5.2%; P=0.073).

Conclusion

There are negative outcomes when patients delay conventional medical therapy in favour of home remedies to treat diabetic foot infections. These treatments need not be mutually exclusive. We encourage persons with diabetes who wish to try home remedies to seek medical advice in addition as a part of holistic care.

Diabetic foot ulcer: an evidence-based treatment update

BACKGROUND

Diabetic foot ulcers (DFUs) are extremely debilitating and difficult to treat. Multidisciplinary management, patient education, glucose control, debridement, offloading, infection control, and adequate perfusion are the mainstays of standard care endorsed by most practice guidelines. Adjunctive therapies represent new treatment modalities endorsed in recent years, though many lack significant high-powered studies to support their use as standard of care.

OBJECTIVE

This update intends to identify recent, exclusively high level, evidence-based evaluations of DFU therapies. Furthermore, it suggests a direction for future research.

METHODS

PubMed, Embase, Ovid Technologies, CINAHL, Cochrane, and Web of Science databases were systematically searched for recent systematic reviews published after 2004, and randomized controlled trials published in 2012-2013 that evaluated treatment modalities for DFUs. These papers are reviewed and the quality of available evidence is discussed.

RESULTS

A total of 34 studies met inclusion criteria. Studied therapies include debridement, off-loading, negative pressure therapy, dressings, topical therapies, hyperbaric oxygen therapy, growth factors, bioengineered skin substitutes, electrophysical therapy, and alternative therapy. Good-quality evidence is lacking to justify the use of many of these therapies, with the exception of standard care (offloading, debridement) and possibly negative pressure wound therapy.

LIMITATIONS

There is an overall lack of high-level evidence in new adjunctive management of DFU. Comparison of different treatment modalities is difficult, since existing studies are not standardized.

CONCLUSIONS

Many therapeutic modalities are available to treat DFU. Quality high-level evidence exists for standard care such as off-loading. Evidence for adjunctive therapies such as negative pressure wound therapy, skin substitutes, and platelet-derived growth factor can help guide adjunctive care but limitations exist in terms of evidence quality.

Efficacy and safety of Suanzaoren decoction for primary insomnia: a systematic review of randomized controlled trials

BACKGROUND

Insomnia is a widespread human health problem, but there currently are the limitations of conventional therapies available. Suanzaoren decoction (SZRD) is a well known classic Chinese herbal prescription for insomnia and has been treating people's insomnia for more than thousand years. The objective of this study was to evaluate the efficacy and safety of SZRD for insomnia.

METHODS

A systematic literature search was performed for 6 databases up to July of 2012 to identify randomized control trials (RCTs) involving SZRD for insomniac patients. The methodological quality of RCTs was assessed independently using the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Twelve RCTs with total of 1376 adult participants were identified. The methodological quality of all included trials are no more than 3/8 score. Majority of the RCTs concluded that SZRD was more significantly effective than benzodiazepines for treating insomnia. Despite these positive outcomes, there were many methodological shortcomings in the studies reviewed, including insufficient information about randomization generation and absence of allocation concealment, lack of blinding and no placebo control, absence of intention-to-treat analysis and lack of follow-ups, selective publishing and reporting, and small number of sample sizes. A number of clinical heterogeneity such as diagnosis, intervention, control, and outcome measures were also reviewed. Only 3 trials reported adverse events, whereas the other 9 trials did not provide the safety information.

CONCLUSIONS

Despite the apparent reported positive findings, there is insufficient evidence to support efficacy of SZRD for insomnia due to the poor methodological quality and the small number of trials of the included studies. SZRD seems generally safe, but is insufficient evidence to make conclusions on the safety because fewer studies reported the adverse events. Further large sample-size and well-designed RCTs are needed.

Inflammatory state of type II diabetic patients with chronic ulcers in response to herbal treatment

BACKGROUND

Type II diabetic patients easily develop ulcers over their feet which heal with great difficulties and not infrequently, end up in amputations. In the quest for innovative means to avoid amputation, herbal medicine has been used in China to heal ulcers.

METHOD

A randomized placebo controlled clinical trial involving 80 patients was conducted to test whether a herbal formula taken orally could help to preserve the ulcerated leg. Other parameters measured included granulation maturation time, skin temperature and circulation, and tumor necrosis factor alpha (TNF-α).

RESULTS

showed a 85% limb rescue with the herbal treatment group showing superiority over placebo group. TNF-α decline was observed with gradual ulcer healing and the herbal supplement group showed a more impressive decline (p=0.037).

Characteristics and clinical managements of chronic skin ulcers based on traditional chinese medicine

Chronic skin ulcer (CSU), including diabetic ulcers, venous ulcers, radiation ulcers, and pressure ulcers, remains a great challenge in the clinic. CSU seriously affects the quality of life of patients and requires long-term dedicated care, causing immense socioeconomic costs. CSU can cause the loss of the integrity of large portions of the skin, even leading to morbidity and mortality. Chinese doctors have used traditional Chinese medicine (TCM) for the treatment of CSU for many years and have accumulated much experience in clinical practice by combining systemic regulation and tropical treatment of CSU. Here, we discuss the classification and pathogenic process of CSU and strategies of TCM for the intervention of CSU, according to the theories of TCM. Particularly, we describe the potential intervenient strategies of the “qing-hua-bu” protocol with dynamic and combinational TCM therapies for different syndromes of CSU.