Non-healing wounds are a significant problem for health care systems all over the world. In the industrialized world, almost 1-1½% of the population has a problem wound at any one time. Chronic wounds mostly affect people over the age of 60 years [1]. The incidence is 0.78% of the population and the prevalence ranges from 0.18 to 0.32%[ 2]. As the population ages, the number of chronic wounds is expected to rise [3]. Many medical conditions can cause non –healing ulcers. The condition range from vascular disease, diabetis to foreign bodies, autoimmune disease cancer and infection. Treating non-healing chronic wounds is a major challenge for health care professionals and affects the quality of life for millions of people all over the world [4]. Irsal-e-Alq (Leech therapy) is one of the oldest methods of wound healing, yet is relatively new or completely unused by many physicians. Irsale Alaq (Leech or Hirudo therapy) is a method of blood-letting which involves the withdrawal of blood in a considerable quantity from the body with the help of Leeches [5]. When leeches begin feeding, they inject salivary components like hirudin which inhibits blood coagulation by binding to thrombin, calin, Destabilase, Hirustasin, Bdellins, Hyaluronidase which have anti- inflammatory, anaesthetic, vasodialating effects. Results from clinical studies showed that the success rate of salvaging tissue with medicinal Irsal-e-Alq (Leech theraoy) is 70 to 80%. On June 28, 2004, the Food and Drug Administration (FDA) had for the first time cleared the commercial marketing of leeches for medicinal purpose U.S. Food and Drug Administration (FDA) [6]. According to the Unani doctrine, Irsal-e-Alq (Leech theraoy)works on the principles of Tanqiyae Mawad (Evacuation of morbid humours) and Imalae Mawad (Diversion of humours). The effectiveness of this therapy may also be attributed to the Mussakin(sedative) and Muhallil (anti-inflammatory) actions of saliva of leeches [5,7,8]. With this preview effectiveness of leech on a case of non healing ulcer was evaluated.

A case of non-healing ulcer in both legs who was advised amputation in hospital came to Skin OPD of A&U Tibbia College & Hospital Karol Bagh, New Delhi. Then the patient was referred to Ilaj Bit Tadbeer IPD for leech therapy. Diagnosis was made on the basis of history, physical examination. Case was interrogated about their chief complaints and duration of suffering. He had loss of sensation in both toes and was unable to walk. He had no history of hypertension, hyperlipidemia, diabetes mellitus, and myocardial infarction and no history of varicose vein in the family. After history general examination was done with special emphasis on pulse, (rate, rhythm, character and volume), B.P respiratory rate, respiratory distress, with anemia, edema, and lymphadenopathy, BMI etc. CT, BT, blood sugar fasting, and P.P, HBsAg, Elisa test for HIV and AIDS were carried out to rule out contraindications if any to leech therapy. Hb% assessment was done on every 15th day to check anemia, complete hierogram was done for safety purpose. Fresh unused, well cleaned leeches gathered 24 hours before starting a leeching session were collected in small sealable containers partly filled with water for used leeches. These containers were labeled with patient’s name. After debridement of necrosis tiseeue,skin of the target area was thoroughly cleaned with distilled water. After wearing surgical gloves, active and healthy leeches were selected and the head of the leech was put on the raw area, generally leeches used to attach instantaneously (Figures 1-6). Leeches usually stay attached for 30 minutes or till leeches sucked whichever was earlier. Patient was advised to avoid strenuous physical activity until the bleeding stop naturally. Primary dressing was consisting of a wide and thick sterile pad to absorb all the blood oozing from the wound. The layers of padding were loosely secured with a gauze bandage that is not so tight that it obstructs the blood flow. Area around leech bite was routinely observed for local infection. For efficacy assessment the Baseline observations were recorded on zero days thereafter at an interval of 15 days till 6 months. At every visit the patients were asked about the improvement and worsening in their symptoms and subjected to examination to assess clinical findings. The findings are summarized in the table below (Table 1). Intensity of leg pain / leg discomfort during walking was assessed on 4 point scale ranging from 0-3 (0 for no pain, 1 for mild pain ie, Irritating & uncomfortable, 2 for moderate i.e. Dreadful & Horrible and 3 for severe pain i.e. Unbearable or Agonizing). Pigmentation was assessed by color of pigmentation & area of pigmentation. Color of pigmentation was scored as 0 for none, 1 for Reddish to light brown, 2 for Light brown to dark brown, 3 for dark brown to blackish. Area of Ulcer was obtained by multiplying the greatest length of ulcer (head to toe) and greatest width of ulcer (side to side) i.e. length × width. Both dimensions were measured by centimeter ruler. Edema was measured by taking difference between the values of limb girth, before and after the treatment. Limb girth was measured at 3 points i.e. calf, ankle and foot. Intensity of pain in ulcer was assessed on 4 point scale ranging from 0-3 (0 for no pain, 1 for mild pain ie, Irritating & uncomfortable, 2 for moderate i.e. dreadful & horrible and 3 for severe pain i.e. unbearable or Agonizing). Greatest depth of ulcer was measured by using a probe/needle. Type of exudates was assessed on 4 point scale ranging from 0-3. 0 for none, 1 for Serous, 2 for Sanguineous and 3 for Purulent. Healing of ulcer was assessed by PUSH Tool 3.0. 9 Legal agreement for the use of PUSH SCORE was approved by BOD, 6/17/10, National Panel of Ulcer Advisory Panel (NPUAP). For this scale three parameters of wound were assessed ie. Size /area of the wound, exudates amount and tissue type or condition of ulcer bed. Step wise method of assessment ulcer by PUSH Tool, the pressure ulcer is assessed and scored on the three elements in the tool. In order to insure consistency in applying the tool to monitor wound healing, definitions for each element are supplied at the bottom of the tool.

Step 1: Using the definition for length x width, a centimeter ruler measurement is made of the greatest head to toe diameter. A second measurement is made of the greatest width (left to right). Multiple these two measurements to get square centimeters and then select the corresponding category for size on the scale and record the score.

Step 2: Estimate the amount of exudate after removal of the dressing and before applying any topical agents. Select the corresponding category for amount and record the score.

Step 3: Identify the type of tissue. Note: if there is ANY necrotic tissue, it is scored a 4. Or, if there is ANY slough, it is scored a 3, even though most of the wound is covered with granulation tissue.

Step 4: Sum the scores on the three elements of the tool to derive a total PUSH Score.

Step 5: Transfer the total score to the Pressure Ulcer Healing Graph. Changes in the score over time provide an indication of the changing status of the ulcer. If the score goes down, the wound is healing. If it gets larger, the wound is deteriorating. Appropriate scores were assigned to these parameters and the sum of the scores yields a total wound score. Score ranges from 0 (healed) to 17 (worst possible score). The PUSH score was determined at each wound assessment in order to monitor the changes in the direction and magnitude of the score over time indicates whether the wound is healing or not [9].

The main observations are tabulated below

*Intensity of leg pain / leg discomfort during walking was assessed on 4 point scale 0-3

• 0 for no pain,
• 1 for mild pain, Irritating & uncomfortable
• 2 for moderate i.e. Dreadful & Horrible
• 3 for severe pain i.e. Unbearable or Agonizing).

**Color of pigmentation was scored

• 0 for none,
• 1 for Reddish to light brown.
• 2 for Light brown to dark brown
• 3 For dark brown to blackish.

  Figure 1(a): Assessment of wound healing.

  

  Figure 1(b): Effect of leech therapy on wound healing according to PUSH SCORE.

  

  Figure 2(a): Case of non-healing ulcer on Day 0  in right lower extrimity.

  

  Figure 2(b): Case of non-healing ulcer on day 0  in right lower extrimity.

  Figure 2(c): case of non-healing ulcer right lower extrimity lateral side

  Figure 3(a): Application of leech (Irsal-eAlq) in case of non-healing ulcer.

  

   Figure 4(a): Progressive healing of the case of non healing ulcer.

  

   Figure 4(b): Progressive healing in the case of non healing ulcer.

  Figure 4(c): Progressive healing in case of non-healing ulcer.  Figure 4(d): Progressive healing in case of non-healing ulcer.Figure 4(e): Progressive healing in case of non-healing ulcer.Figure 5(a): Progressive healing in case of non-healing ulcer.Figure 6(a): Complete healing in case of non-healing ulcer Figure.

  Figure6(b): Complete healing in case of non-healing ulcer.

  As evident from the (Table 1), there was marked decrease in intensity of pain in leg during walking, the intensity of pain in ulcer was also reduced and there was marked improvement in color of skin and significant decrease in area and depth of ulcer was seen and it was found statically significant (ANNOVA P=0.0052). The effect of leech therapy on wound healing on PUSH SCORE was assessed and kuaka Wallis test (non parametric ANNOVA) to assess the effect and it was considered significant. (P value =0 .0379). Similarly one more study from India has proved the significant effect of leech therapy in the treatment of varicose ulcers [10]. Another study has established the safety and efficacy of leech therapy in the management of frostbite [11]. It is evident that Irsal-e-Alq (Leech therapy) can be effectively used in management of non-healing ulcers and its used should be advocated on large scale for the benefit of patients.

  Table 1: Assessment of efficacy of Irsal-eAlq (Leech therapy)in Non- Healing Ulcers.

  	Day 0	1st month				2nd month	3rd month	4th Month	5th Month	6th Month
  Intensity of Pain during walking	3	3				2	2	1	0	0
  Intensity of Pain in ulcer*	3	3				2	2	1	1	0
  Skin Color**	3	3				2	2	1	1	0
  Area Of Ulcer (LxB in cm2)	10	10				8	7	6	2	0
  Tissue Type	4	4				3	3	2	1	0
  Type of Exudate	3	3				2	2	1	1	0

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