**3. Clinical studies supporting the folklore use of alternative therapies**

Scientists advocate more clinical studies to be conducted to provide robust proof‐of‐concept of folklore wound healing property of the herbs mentioned in alternative therapies. Few of the clinical studies carried out are documented subsequently.

### **3.1. Ayurveda-based clinical studies**

### *3.1.1. Katupila study*

excessive deposition of collagen and also promoted collagen maturity, thus obstructing the formation of scar. The mechanism of the effect of ANBP on collagen expression is different in the early and late stages of wound healing, which is favourable for wound closure and scar contraction. Using proteomics approach, the authors suggested that ANBP promoted wound healing and condensed scarring by bidirectional regulation of

**4.** Chinese medicine book, Compendium of Materia Medica proclaims *Lucilia sericata* known as *'WuGuChong'* in Chinese for treating superficial purulent diseases like carbuncle. Zhang *et al.* reported that fatty acid extracts of *Lucilia sericata* can promote murine cutaneous wound healing by virtue of its remarkable angiogenic activity. Wound excision model in rats followed by Vascular Endothelial Growth factor (VEGF) expression analysis by western blotting, RT‐PCR and immunohistochemistry strongly suggested the mechanism

**5.** Chak *et al*. [76] demonstrated the effect of another Chinese medicine *Shiunko* consisting of sesame oil, *Lithospermi radix*, (*LR; Lithospermum erythrorhizon Sieb*. *et Zucc*.), *A*. *sinensis*, lard, and beeswax. The authors reported that *Shiunko*‐treated fibroblasts induced range of biochemical events engaged in the wound healing process, including cell proliferation and anti‐apoptosis, anti‐oxidant activity, secretion of collagen, and cell mobility. It was also noted that Stathmin, a differentiation marker was greatly induced by *Shiunko*, which is a sign of good healing process. Proteomics suggested peroxiredoxin and glutathione S‐ transferase were involved in antioxidantion offered by *Shiunko*. Also, superoxide dismu‐ tase was enhanced after *Shiunko* treatment which again contributed to its wound healing property. TGF‐β was upregulated on *Shiunko* treatment which happens to be upstream

regulator of collagen expression and an indispensable factor for wound healing. **6.** *Terminalia chebula* is mentioned in other systems of medicine like Ayurveda for its wound healing ability. Likewise, it was proven by Li *et al*. [77] that tannin extracts from immature *Terminalia chebula* fruits helps in cutaneous wound healing in rats. The immunohisto‐ chemical, transcriptional and translational levels of VEGF analysed in the study helped the authors conclude that the wound healing property was by the virtue of anti‐angiogenic effects. Also, the proliferation of bacteria like *Staphylococcus aureaus* and *Klebsiella pneumonia* were inhibited by the extract thus conferring the much needed antibacterial effect beneficial for faster wound healing. Thus the study concluded that tannin extracts from immature fruits of *Terminalia chebula Fructus* (*Retz*.) stimulated cutaneous wound healing

Ozone therapy dates back to the year 1914 when it was used during World War I for the treatment of gas gangrene. Ozone has multiple therapeutic effects in wound healing due to the property of releasing nascent oxygen, which has been shown to have bactericidal capabil‐ ities and to stimulate antioxidant enzymes. There are few randomized clinical trials to verify the use of ozone therapy in the early stages of wound healing. To verify the same, Zhang *et al*. [78] recently carried out a study assessing the use of ozone therapy in the early stages of

the Transforming Growth Factor β (TGF‐ β)‐/Smad‐dependent pathway.

involved in wound healing property of the herb [75].

472 Wound Healing - New insights into Ancient Challenges

in rats.

**2.5. Ozone therapy**

A case study of diabetic wound of a 55‐year‐old female patient wherein *Katupila* paste [(*Securinega leucopyrus*) (*Willd*.)] was applied daily and after a month the wound was reported to have healed completely leaving a minimal scar. The healing properties of *Katupila* were attributed to its antimicrobial, antiseptic, and wormicidal qualities. Also it was shown to possess abundant quantities of flavonoids and tannins which offer the antioxidant effects [13].

### *3.1.2. Manjishthadi Gritha*

A clinical study employing *Manjishthadi Gritha* was carried out by Baria *et al*. The *Gritha* was prepared using seven herbs namely, *Manjishtha* (*R*. *cordifolia Linn*.), *Daruharidra* (*B*. *aristata DC*.), *Mocharasa* (*Salmalia malabaricum*), *Dhatakipushpa* (*Woodfordia fruticosa* (*Linn*.) *Kurz*.), *madhuka* (*Madhuca indica J*. *F*. *Gmel*), *Lodhra* (*Symplocos racemosa Roxb*.) *and Rasanjana* (*Extractum berberis*). The *Gritha* was applied topically on wounds mostly from anorectal cases twice a day for 21 days. The observation period of 1 month recorded the results of the study. Out of 45 patients, 24 were treated with the *Gritha* and 21 with povidone iodine ointment. The *Gritha*treated patients showed better wound healing, no left‐over scar, no excess pigmentation, and absence of adverse effects. The authors reported *Manjishthadi Gritha* as an economical and effective wound healing combination [83].

### *3.1.3. Honey: A pilot study*

Vijaya *et al*. [84] reported a pilot study using honey for healing the cutaneous wounds of 10 randomly selected patients of both sexes. Honey collected locally was applied daily for 20 days and the size of the wound was measured on day 7, 15, 20, and after complete wound healing. The authors concluded that honey was remarkable in healing the wounds and can be very effectively used as first aid dressing material. A case study [85] was reported employing honey for the cure of a chronic infected wound on the right lower limb of a 70‐year‐old female. Every morning the wound was cleaned with neem bark decoction, and Dabur® honey was applied on the wound. Along with the local application, following drugs were administered orally every 12 hours: *Glycerrhiza glabra* (*Linn*.), *Asparagus racemosus* (*Willd*.), *Tribulus terrestris*, *Tinispora cordifolia* (*Willd*). At the end of fifth week, the authors reported a complete healing of the wound leaving a minimal scar. Sushruta Samhita has mentioned *honey* (*madhu*) as a wound healer centuries ago. The above case study practically proved the effectiveness of honey. It is hyperosmolar so confers antibacterial effect. It has high viscosity so acts as physical barrier. Presence of enzyme catalase in honey gives it antioxidant properties. The four drugs given orally possess antioxidant, adaptogenic, and immunomodulatory activities. Clinical studies employing honey with bigger population although would yield more authentic conclusions.

### **3.2. Unani medicine-based study**

### *3.2.1. Dragon's blood cream*

Namjoyan *et al*. [86] reported a clinical study using Dragon's blood cream, a deep red resin obtained from four different sources, *Croton spp*., *Dracaena spp*., *Daemonorops spp*., and *Pterocarpus spp*. 60 patients referred to remove their skin tags were included in this randomized clinical trial to receive either Dragon's blood cream or placebo cream. Wound measurement and process of healing was checked on 3rd, 5th, 7th, 10th, 14th, and 20th day of the trial. The patients receiving Dragon's blood cream showed significant wound healing. The phenolic compounds present in Dragon's blood cream reportedly contribute to its effective wound healing property.

### **3.3. Clinical study on ozone therapy**

### *3.3.1. Adjuvant ozone therapy*

*3.1.2. Manjishthadi Gritha*

474 Wound Healing - New insights into Ancient Challenges

*3.1.3. Honey: A pilot study*

**3.2. Unani medicine-based study**

*3.2.1. Dragon's blood cream*

healing property.

effective wound healing combination [83].

A clinical study employing *Manjishthadi Gritha* was carried out by Baria *et al*. The *Gritha* was prepared using seven herbs namely, *Manjishtha* (*R*. *cordifolia Linn*.), *Daruharidra* (*B*. *aristata DC*.), *Mocharasa* (*Salmalia malabaricum*), *Dhatakipushpa* (*Woodfordia fruticosa* (*Linn*.) *Kurz*.), *madhuka* (*Madhuca indica J*. *F*. *Gmel*), *Lodhra* (*Symplocos racemosa Roxb*.) *and Rasanjana* (*Extractum berberis*). The *Gritha* was applied topically on wounds mostly from anorectal cases twice a day for 21 days. The observation period of 1 month recorded the results of the study. Out of 45 patients, 24 were treated with the *Gritha* and 21 with povidone iodine ointment. The *Gritha*treated patients showed better wound healing, no left‐over scar, no excess pigmentation, and absence of adverse effects. The authors reported *Manjishthadi Gritha* as an economical and

Vijaya *et al*. [84] reported a pilot study using honey for healing the cutaneous wounds of 10 randomly selected patients of both sexes. Honey collected locally was applied daily for 20 days and the size of the wound was measured on day 7, 15, 20, and after complete wound healing. The authors concluded that honey was remarkable in healing the wounds and can be very effectively used as first aid dressing material. A case study [85] was reported employing honey for the cure of a chronic infected wound on the right lower limb of a 70‐year‐old female. Every morning the wound was cleaned with neem bark decoction, and Dabur® honey was applied on the wound. Along with the local application, following drugs were administered orally every 12 hours: *Glycerrhiza glabra* (*Linn*.), *Asparagus racemosus* (*Willd*.), *Tribulus terrestris*, *Tinispora cordifolia* (*Willd*). At the end of fifth week, the authors reported a complete healing of the wound leaving a minimal scar. Sushruta Samhita has mentioned *honey* (*madhu*) as a wound healer centuries ago. The above case study practically proved the effectiveness of honey. It is hyperosmolar so confers antibacterial effect. It has high viscosity so acts as physical barrier. Presence of enzyme catalase in honey gives it antioxidant properties. The four drugs given orally possess antioxidant, adaptogenic, and immunomodulatory activities. Clinical studies employing honey with bigger population although would yield more authentic conclusions.

Namjoyan *et al*. [86] reported a clinical study using Dragon's blood cream, a deep red resin obtained from four different sources, *Croton spp*., *Dracaena spp*., *Daemonorops spp*., and *Pterocarpus spp*. 60 patients referred to remove their skin tags were included in this randomized clinical trial to receive either Dragon's blood cream or placebo cream. Wound measurement and process of healing was checked on 3rd, 5th, 7th, 10th, 14th, and 20th day of the trial. The patients receiving Dragon's blood cream showed significant wound healing. The phenolic compounds present in Dragon's blood cream reportedly contribute to its effective wound Shah *et al*. [87] presented a case study of a 59‐year‐old female patient with an extensively infected wound and exposed tibia to about 4 /5th of its extent. Topical ozone therapy twice a day and ozone hemotherapy once a day along with daily dressings and parenteral antibiotics showed significant improvement in 15 days in the patient. After a follow‐up of 20 months, the patient was able to walk with minimal disability. Ozone disintegrates into reactive oxygen species which further lead to increased growth factors contributing to faster wound healing. The study stated that oxidative injury is a possible side effect of ozone therapy but at thera‐ peutic doses oxygen radicals are removed by the blood antioxidants and thus side effects are rare and only observed in overdose or compromised anti‐oxidant system.
