Effect of a twin-herb formula for the Treatment of Chronic Non-healing Ulcers: a Clinical Study

Forty-four patients (27 males and 17 females) with Chronic Non-healing Ulcers that had been refractory to conventional treatment were enrolled in a single arm preand post-treatment clinical trial. A twin-herb formula was provided for the treatment for the 6-month study period. All conventional treatment of wound care remained unchanged. Their ulcers were assessed every month. The ulcer sizes greatest length and width was measured at baseline. The target ulcer was assessed at baseline and then every month for 6 months or healed. The mean age of patients was 66.6 (38.0-93.0) years. The mean surface area of ulcers was 28.0±77.1 cm2 and 14.8±55.0 cm2 at baseline and six months of study respectively. Differences in ulcer area between the initial and fi nal visit were signifi cant (p<0.001). The mean healing time was 149 days (median 167 days). Our results showed that the two-herb recipe (NF3) could reduce the wound size about 50% during 6 months period. 36.7% ulcers were healed. No adverse side effects were founded in our patients during study period. The twin-herb formula showed promising results in initiating the healing process in chronic nonhealing ulcers. It was found to be well tolerated and safe to use. However, further clinical trials should be performed involving a control group to verify these data. Research Article Effect of a twin-herb formula for the Treatment of Chronic Non-healing Ulcers: a Clinical Study Ping-Chung LEUNG1,5*, Tommy NaiMing LUK2, Heidi CORCORAN3, Chun -Hay KO1,5, Leung-Kim HUNG4, LungFung TSE4, Hi-shan CHENG4, Winnie W.M. LO1,5, Ellie S.Y. PANG1,5 and King-Fai CHENG1,5 1Institute of Chinese Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong 2Dermatology Research Centre, Faculty of Medicine & Therapeutics, CUHK, Hong Kong 3Podiatrist Prince of Wales Hospital, Australia 4Department of Orthopaedics & Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong 5State Key Laboratory of Phytochemistry and Plant Resources in West China, Chinese University of Hong Kong, Hong Kong, China Dates: Received: 01 February, 2017; Accepted: 09 March, 2017; Published: 10 March, 2017 *Corresponding author: Ping-Chung Leung, Professor, DsocS (Hon), D.Sc, M.S, Director, Centre for Clinical Trials on Chinese Medicine, 5/F, The CUHK Hong Kong Jockey Club School of Public Health Building, Prince of Wales Hospital, Shatin, NT, Hong Kong, Tel: (852) 2252 8868; Fax: (852) 2632 5441; Email:


Introduction
When a chronic ulcer fails to heal, the longer it exists, the more diffi culty would be expected. It gives much diffi culty to both patients and service providers all over the world. Causes of the failure to heal include deformities in the foot, loss of sensation and bacterial infections. Known situations of nonhealing ulcers of long durations thus occurred among elderly patients suffering from diabetes and venous stasis. Such patients usually have received surgery including skin grafting yet failed to achieve healing.
We have previously reported on the favorable results of chronic ulcer treatment using a herbal formula of Chinese Medicine among patients suffering from type 2 diabetes and persistent foot ulcers [1,2]. With limited surgical interventions such as limited toe amputations and ulcer debridement, we managed to avoid major amputation in 80% of patients originally scheduled for such intervention unless the ulcer healed.
Basing on the good experience, we have worked out in the laboratory the biological activities of the herbs on the promotion of tissue healing. The herbs mainly worked on the control of infl ammation and promotion of granulation formation through stimulation of fi broblast proliferation [3,4].
We therefore planned to offer treatment to a small group of patients who suffered from chronic ulcers for average three years using the same herbal formula. These patients and their attending clinicians lost confi dence in surgery or medications and accepted a pessimistic view that the ulcers would never heal. They would therefore accept alternative treatment using herbal extracts.
The aim of this open non-comparative single centre clinical study was to assess the effi cacy and safety of a twin-herb formula in the treatment of chronic non-healing ulcers.

Method
This clinical trial was designed as a prospective, non- purpose of the study is to assess the progress of ulcer healing among the patients who failed all attempted active treatment in the past years. Duration of ulcer before recruitment in the study and the number of days taken for healing of the wound was recorded.
To assess the infl ammatory state of the patients with chronic ulcers, the serum expression of TNF- and CRP were taken before the start of herbal treatment and at the end of the 6 months' treatment. The TNF- data were taken as secondary outcome. During the treatment period, patients received the standard wound care at out-patient clinics. Standard wound care included wound cleansing with saline or water and gentle removal of sloughy or necrotic tissue. Concomitant medications and their indications were also recorded.

Protocol of herbal formula
The study medication consisted of two herbs, viz. Radix Rehmanniae and Radix Astragali. The herbs, in the assigned proportions were boiled together in water in the standard way to produce a broth which was hydrolyzed into standard granules (5 gm per sachet) ready to be made into a drink for consumption. The target wound's greatest length and width were measured at baseline. The target wound was photographed at baseline and then every month. The target wound was assessed at each visit for local infection and wound condition (improving, stable, or deteriorating). The wound size was calculated by multiplying the length and width. (The greatest length x the greatest width, measured in centimeters).

Follow-up evaluations
Aspects of the patients' existing treatment, such as method of cleansing, dressing-change frequency and type of bandaging/ hosiery used, were left unchanged. The only intervention was the application of the twin-herbal formula.
The effi cacy of the twin-herb formula was evaluated using the following parameters every four weeks: 1. The number and percentage of patients/ulcers healed by the end of the 6-month study period.

Healing rates
Cytokines such as TNF-, HBA1C and CRP were tested preand post-treatment.
The patients were fully informed regarding the composition of the herbal formula and its role in treating ulcers. All the study participants gave written informed consent. The study was approved by the Clinical Research Ethics Committee (CRE-2011.024-T).

Statistical analysis
Evaluation of the effi cacy and safety endpoints was descriptive in nature. Healing was assessed by the number and percentage of patients healed by the end of the study. Reduction in wound size was evaluated by percentage change in wound area from baseline and calculated for each assessment (the difference between baseline and post-baseline assessment value divided by the baseline value and the result converted to a percentage).
Data were presented a means ±standard deviations (SD). Effi cacy data was performed by using Paired t-test or Mann-Whitney Test to compare the changes between pre-and posttreatment.
The wounds healing time was estimated using the Kaplan-Meier method of survival analysis. This was repeated under the following scenarios: 1. Using all of types of wounds of the patients in the study with standard censoring of observations. 2. Using type of wounds with standard censoring of observations.
3. Cox's proportional hazards survival analysis with regression covariates was run on all of the wounds to test whether any of the following factors affected wound-healing time: type of wound, size of wound, and duration of wound.

Results
The demographic data, etiologies of ulcers, ulcer area, and duration of ulcer existence and location of the ulcers were shown in (Tables 1-3 Table 1).
Wound size changes duration study period: Table 4 shows the changes in mean surface area of ulcers from visit 1 (28.0±77.1cm 2 ) to visit 7 (14.8±55.3 cm 2 ). From the visit 4, the mean area of ulcer was signifi cantly reduced (p=0.001) (Figure   1). (Table 4) also shows the numbers of healed ulcers during study (6 months).
The number of ulcer was reduced from 65 at the start of study to 29 at the end of study. At 5 months (visit 6), 56.9% of the ulcers were healed. The proportion healed at 6 months (visit 7) was 55.4%. Table 5 summarises the results of wound size for the 44 patients when segregated into different ulcer duration groups.
The wound size reduction in the group wound duration over 53 weeks was fewer that the duration less than 52 weeks.
On completion of the 6 months' treatment, thirty-six ulcers healed completely. The overall healing rate was 55.4% (36/65). During the course of treatment the average total wound area decreased steadily (Table 4).
When the patients stratifi ed by duration of ulcer before enrollment in the study, we can fi nd that patients with duration of ulcer less than 12 weeks had a signifi cant reduction in ulcer area after 6-month treatment (reduced 87.7%, p<0.001), duration of ulcer 13-52 weeks reduced 59.0% and the duration over 53 weeks only reduced 29.0% (Table 6).
In patients with ulcer duration less than 12 weeks, 71% of ulcers healed within 3 months.

Wound healing time:
The overall time taken for healing of the wound was 148.8 days. The shorter the duration of ulcer before enrollment in the study, the shorter the healing time of the wound was taken (Table 7, Figures 1,2).
The overall healing rate was 24.6%. In the group of wound duration less than 12 weeks two patients (28.6%) were complete healed; duration 13-52 weeks 42.9% healed; duration over 53 weeks only 6.7% healed ( Table 8). Table 9 demonstrated a signifi cant relationships to healing time of duration of wounds (p=0.009). Other covariates (wound type, wound size) did not demonstrate any signifi cant relationships to healing time of all wounds (wound type p=0.862; wound size p=0.682).    Time to healing/partial healing of different duration of Wounds was shown in Figure 2. There were signifi cant differences in healing time among the three ulcer duration groups (p=0.009). That means the duration of ulcer before enrollment in the study could infl uence the healing time.

Analysis of Covariate Effects on Healing Time:
The longer the duration of ulcer, the longer the healing time ( Figure 2).
Case study: 48 year old male patient with a non-healing ulcer: The patient (subject no. DII 17) was a male, aged 48 years old and suffered from diabetic ulcer, which existing already for 43 weeks (301 days), not responding to classic treatment. After 6-month treatment, the ulcer was completely healed ( Figure   3).
Infl ammatory cytokine changes: There were no signifi cant changes in TNF-, CRP (C-reactive protein) and HBA1C between pre-and post-treatment (Table 10).
There were 9 patients reported Adverse Events (AEs) such as wound infection, anaemia, congestive heart failure, hypoglycemia, low back pain, hot and red ulcer, chest pain and psychiatric syndrome. However, after assessment, the AEs were unlikely associated with the study herbal formula.

Discussion
Chronic ulcers arising from pathologies of neuropathy and repeated infection fail to heal when the predisposing causes hinder the control of infl ammation, block granulation formation and promote infection.
The main objective of the present study was to evaluate the effi cacy and safety of a two-herb recipe, as an adjuvant therapy in chronic non-healing ulcers. Our small non-randomized and non-comparative clinical observational trial can give information about the effi cacy and tolerance of the treatment with the two-herb recipe.
The results showed that two-herb recipe could reduce the wound size about 50% during 24 weeks period without any signifi cant adverse effect in the studied patient population.

The herbal formulation used in this study contains Radix
Rehmanniae and Radix Astragali. Radix Rehmanniae has been shown to greatly facilitate fi broblast proliferation in our laboratory and also in some other studies [3][4][5]. Astragalus is well known for its immunomodulating effects. The herbal formula works as a supplement to control infl ammation and improve wound healing.
For those cases recruited under our present cohort study that yet failed to heal completely at the end of the six months of assigned treatment, the herbal drink was discontinued but topical application of the herbal powder (Radix Rehmanniae) was used so as to acquire more information about the outcome of topical use. Results will be discussed in a separate report.
In order to promote tissue healing, attempts have been given       show that this herbal preparation could reduce the wound size without any signifi cant adverse effects.
In conclusion, the two-herb recipe could reduce the wound size signifi cantly in a mean period of 6 months without any adverse side effects. The two-herb recipe may be effective in treating chronic ulcers along with current standard care.
However, it must be stressed that good wound care practices including debridement, infection control and offl oading play an important role in healing a chronic non-healing ulcer.