Hirudo Therapy and Science
Case Report: Positive outcome of medical leeches (hirudotherapy) for venous congestion
P.Brzezinski1, C. Solovan2, AChiriac3 ,LFoia4
1. Head of Department of Dermatology, 6th Military Support Unit, Ustka, Poland
2. Head of Department of Dermatology, University of Medicine V Babes, Timisoara, Romania
3. Head of Department of Dermato-Physiology, Apollonia University Iasi, Strada Muzicii nr 2, Iasi-700399, Romania
4. Head of Department of Dermatology, Grigore T. Popa University of Medicine and Pharmacy, Strada Universitãtii 16, Iasi, Romania
Corresponding author: Piotr Brzezinski, Emailfirstname.lastname@example.org
A 65 year Caucasian woman was seen for numerous, oval- to-round, well-de ned 1.5 to 3.5 cm erythematous plaque- lesions, with central umbilication (central black eschar), intensely itching, distributed on both inferior limbs, (Figures 1,2,3). She admitted a history of leech therapy (3 sessions daily) 5 days prior to consultation, for chronic venous insuf ciency under the supervision of a general practitioner. The patient had no pain or any other symptom, no fever, malaise. There were no palpable lymph nodes. Moreover, no history of trauma or insect bites could be recorded. She has been treated for several years for chronic super cial venous insuf ciency with compression therapy (stockings) and micronized diosmin orally. She had no past or present trophic ulcers, just slight bilateral edema. A routine blood test was within normal limits. Echo Doppler evaluation con rmed chronic venous disease (CVD) class II and excluded venous thrombosis. Based on clinical examination, in the presence of normal investigations, we were in the position of deciding if it was a common evolution of hirudotherapy or an allergic contact dermatitis caused by the leech bite. The patient was treated with oral cefuroxime 1g daily and antihistamines for 7 days, associated to topical steroids cream class II for 2 weeks, resulting in almost complete recovery. The patient was subsequently lost to follow-up.
Figure 2: Round-oval erythematous plaques centered by small ulceration covered by black and adherent eschar on the inner surface of the right thigh
Figure 3: Close view of the lesion
Figure 4: Hirudo medicinalis
The medicinal use of leeches goes far away back in the history. Galen (130-201 AD) used the technique to remove blood and provide health to patients2 but, the rst use of leeches for medical purposes appears on the wall of an Egyptian tomb (1567-1308 BC)1. During centuries it became a popular remedy for many medical problems, but declined after the mid-nineteenth century due to the development of new medicine. In 2004, this treatment procedure received the approval of the Food and Drug Administration (FDA) in the USA2.
Leeches belong to the Phylum Annelids; they live in water (lakes, streams, seas, pools) or land in tropical areas. European leech Hirudo medicinalis is used in medicine and gave the name of hirudotherapy to the medical procedure, (Figure 4).When it is applied to skin Hirudo medicinalis sucks blood directly through the external mammalian skin. At the moment of biting, saliva of the Hirudo medicinalis releases into the skin substances that induce local anesthesia and vasodilatation (with enhanced blood ow); brinase
Figure 1: Multiple lesions on the left leg
Malawi Medical Journal; 27(1): 38-39 March 2015
and anticoagulant (hirudin) to prevent clotting3. Depending on the size of the leech,a large quantity of blood can be ingested.Side effects, accidents, medical problems have been described during or after using this method. Psychological impact can be signi cant and might push cessation of the procedure, with or without anxiolytic medication.Continued and uncontrolled leech use can induce bleeding and anaemia. Allergic local reactions and anaphylaxis have been reported, induced by substances contained in saliva of leeches4. Local infections with Aeromonas spp are by far the mostdangerous complications, ranging from super cial to deep infections (cellulitis, subcutaneous abscess)5 and even septicemia8. High Resistance to rst-generation Cephalosporin, Penicillin, Tetracycline, Augmentin widely used in daily practice, have been reported recently with the recommendation of prescribing uoroquinolones6. Moreover, the multiple uses of the same leeches from one patient to another induces high risk of hepatitis and HIV transmission. The leech therapy can be used effectively for the management of various disorders. Rasi et all described 64-year-old Iranian man who presented with numerous asymptomatic multilobular oval-to-round cystic lesions3. The patient used leech therapy with positive effect. Zaidi descibes using leech therapy in a 60-year-old woman suffering from diabetic foot (she was facing the prospect of imminent amputation)7. Wound dressing was done with unripe papaya as it has a very good role in clearing necrotising area and hirudotherapy was also used in poorly healing wounds. The pain score decreased to 0-10mm on a 100mm visual analogue scale within 20days and no further pain relieving medication was required. Over a time interval of nearly 3.5months, necrotic areas disappeared and the wound was completely healed. Authors from India described a patient with nevus of Ota where leech was applied upon the lesion for ve times spanned in a period of 2 months8. A substantial reduction in color of the nevus was reported following the completion of the therapy. An interesting case was presented by TarazJamshidi et al9. The authors presented a case of leech therapy after near total amputation of the ngers. A 25-year-old patient was admitted following a sawing injury with crashed bundles of the third, fourth and fth ngers. Microvascular surgery was not performed because of crush injury. The patient was treated using leech therapy. The result was satisfactory. The third and fourth ngers were salvaged.
Besides being rare for practical dermatological activity, leech therapy raises a few questions:
-Are skin lesions “normal” reactions to leech therapy or must they be regarded and treated as an allergic contact dermatitis with the recommendation of discontinuing the therapy?
-Could the lesions be the expresssion of a consumption coagulopathy induced by substances from saliva of leeches?
-Is hirudotherapy of any help in providing relief in patients with chronic super cial venous insuf ciency class I, II in the absence of complications?
-How can be proved the value of the method by objective paraclinical investigations?
The leech therapy has unique features; the leech sucks venous blood and aids ulcer healing, and can therefore be used as an effective adjunct in the management of complicated varicose veins and venous congestion. Iranian authors showed that (in animal models) the process of
Medical leeches 39
wound healing was signi cantly faster in the group treated with leech therapy (p < 0.05) than in the group treated with the topical phenytoin10. It may be used for the restoration of normal heath through its prophylactic and palliative action. However, there is the need to develop standard procedures and scienti c parameters so that the ef cacy of leech therapy can be proved in a rational manner.
1. Whitaker IS, Rao J, Izadi D, Butler PE. Hirudomedicinalis: ancient origins of leeches, and trends in the use of medicinal leeches throughout history. Br J Oral Maxillofac Surg 2004; 42(2):133–137.
2. Mumcuoglu KY, Huberman L, Cohen R, Temper V, Adler A, Galun R, et al. Elimination of symbiotic Aeromonas spp. from the intestinal tract of the medicinal leech, Hirudo medicinalis, using cipro oxacin feeding. Clin Microbiol Infect 2010; 16(6):563-567.
3. Rasi A, Faghihi A, Jalali MA, Zamanian A, Ghaffarpour G. Leech therapy for epidermoid cysts and review of the literature. Adv Biomed Res 2014; 31(3):112.
4. Wells MD, Manktelow RT, Boyd JB, Bowen V. The medical leech: an old treatment revisited. Microsurgery 1993; 14(3):183-186.
5. Evans J, Lunnis PJ, Gaunt PN, Hanley DJ. A case of septicaemia due to Aeromonas hydrophila.Br J Plast Surg 1990; 43(3):371-372.
6. Bauters TG, Buyle FM, Verschraegen G, Vermis K, Vogelaers D, Claeys G, et al. Infection risk related to the use of medicinal leeches. Pharm World Sci 2007; 29:122-125.
7. Zaidi SA. Unani treatment and leech therapy saved the diabetic foot of a patient from amputation. Int Wound J. 2014 May 8. doi: 10.1111/ iwj.12285.
8. Rastogi S, Chaudhari P Pigment reduction in nevus of Ota following leech therapy. J Ayurveda Integr Med. 2014;5(2):125-128.
9. TarazJamshidi M, Bagheri F, Mirkazemi M, Amelfarzad S, Ashraf H, Azami M, et al. Leech therapy in nearly total amputation of ngers without vascular repair: a case report. Iran Red Crescent Med J. 2014;16(5):e6897.
10. Darestani KD, Mirghazanfari SM, Moghaddam KG, Hejazi S. Leech therapy for linear incisional skin-wound healing in rats. J Acupunct Meridian Stud. 2014;7(4):194-201.
Leech therapy, like cupping therapy, has been known for centuries. It was only forgotten for a long time and is now being “rediscovered”. It is now widely used in the treatment of bruises, poorly healing wounds, inflammation of the joints and for rheumatism.
Today, scientific studies were able to prove the effectiveness of leeches (Prof. Dobos, Clinic for Naturopathy and Integrative Medicine, Essen).
Why should offer these methods to our patients?
What happens with leech therapy:
The patient lies down comfortably in a quiet and slightly darkened room. (Leeches don't like stress and bright light!). Then the leeches are placed on the parts of the body where they bite. This process is painless. The process of biting can take anywhere from minutes to an hour. The skin should not be washed for 2 days beforehand, or rubbed with perfume or creams. The leeches remain on the patient until they are completely soaked and then fall off themselves. This can take up to 3 hours, after which the wounds can bleed easily for up to 2 days.
Prof. Dobos and his colleagues were able to show that a single treatment is sufficient. In rare cases, treatment was repeated after 6 weeks to ensure persistent pain reduction.
Leech therapy to combat and alleviate local pain syndromes
Leech therapy is one of the oldest healing methods in alternative medicine. Their widespread use worldwide is based on their beneficial influence on combating and alleviating local pain syndromes. Several studies on this topic have repeatedly confirmed the effectiveness of this traditional therapy.
Leech treatment as an extension procedure
Leech therapy particularly successful for osteoarthritis (private)
According to its mechanism of action, this therapy belongs to the group of extension procedures. This means that harmful substances and slags are excreted in the blood. The result is a relief of the whole body. In contrast to cupping and the well-known bloodletting, leech therapy has a special feature. It is the saliva secretion of the leeches that has an additional positive effect.
The saliva of the leeches brings the active ingredients with them. Over 20 different substances were found in the saliva of the leeches, the best studied active ingredients are Edlin and Hirtin. Edlin has a beneficial effect on the healing process in inflammation by blocking certain enzymes in their activity. In addition, Edlin has an analgesic effect, which is very pleasant for the affected patients during leech therapy.
Shepherdess is a substance that acts on the thrombin factor, so that the flow properties of the blood improve. It is very positive that trombons can be dissolved in this way and the formation of new thromboses can be prevented. This significantly reduces the risk of getting an embolism. By accelerating the flow of the lymph, shepherdess contributes to a quick detoxification of the organism. A very important aspect is the influence of shepherdess on the formation and activity of new white blood cells. Since these blood components play a crucial role in the defense against pathogens, shepherdess also strengthens the immune system. Finally, its antispasmodic effect on the vessels is another positive characteristic.
Studies prove the effectiveness of leech therapy
Studies have now shown that treatment with leeches is sometimes superior to conventional therapy. A study carried out by the Karl and Veronica Carstens Foundation in 2004 shows that the use of leeches in 80% of those suffering from arthrosis provides better pain relief than the application of an analgesic ointment. The “Randomized Controlled Study on the Effectiveness of Leech Therapy for Symptomatic Irritation Osteoarthritis” carried out by the University of Duisburg-Essen in 2009 also points to the superiority of this alternative healing method over conventional drug therapy.
The extensive fields of application of leech therapy
The spectrum of effects of leech treatment shows what these little animals can do. It is primarily inflammatory processes and diseases based on circulatory disorders that can be treated effectively with leeches. The main areas of application for leech treatment are:
- Diseases of the veins (varicose veins, thromboses, hemorrhoids)
- Diseases of the cardiovascular system
- Diseases of the joints (gout, arthrosis, arthritis)
- bruises and bruises
- Lymphatic and liver congestion
- Different clinical pictures of migraines
Who should do without leech treatment
In principle, leech therapy is almost free of side effects. Nevertheless, there are certain factors and patient groups for which treatment is not appropriate in this procedure:
- Taking anticoagulant and blood-thinning preparations (Marcumar, acetylsalicylic acid and the like)
- Known allergy to the active ingredient shepherdess
- tendency to excessive scarring
- Already existing weakening of the immune system
- women in pregnancy
The little animals are so sensitive
In order for the leeches to do their job properly, the patient must take some precautions. Although it is hardly suspected, these animals have a strong sense of smell in addition to a sense of temperature. For this reason, the areas of the skin intended for leech therapy may only be washed with pure water a few days beforehand. The use of creams, sprays, etc. is taboo before treatment.
To ensure a comfortable temperature for the leeches, the areas to be treated are covered with warm compresses beforehand. As primitive as these animals appear, they also react to stimuli such as bright light, shocks and noise. During treatment, the therapist makes sure that these influences are excluded. Only if the leeches are comfortable are the prerequisites for successful leech therapy.
Procedure of leech therapy
According to the clinical picture, the therapist selects those parts of the body on which the leeches are placed. The number of animals used (usually two to six) depends on the findings. Some areas are basically left out:
- Skin areas with inflammatory processes
- Veins and varicose veins
- Open wounds
- regions with poor blood circulation (low impact factor)
The leeches are applied to the affected skin with tweezers. In order to prevent the animals from migrating, the therapist holds them upside down in their "work area" with an inverted glass. The actual process begins with the tiny teeth penetrating the skin. During the suction that now takes place, the saliva secretion and its active substances are simultaneously released into the bloodstream. Penetration into the skin is painless and comparable to the bite of a mosquito.
Depending on your "appetite", 10-20 milliliters of blood are taken from a leech. If his hunger is satisfied, he falls off all by himself. As a rule, leech therapy lasts between half an hour and an hour and a half. If, in exceptional cases, it is absolutely necessary to interrupt the treatment, the leech must be carefully removed. This is done with an alcohol-soaked swab.
To avoid the transmission of infections, bacteria, etc., the leeches are always grown under controlled conditions and of course only used once.
After therapy - desired effects and aftercare
After leech therapy, it is completely normal for the bite to start bleeding. This so-called bleeding is a necessary and desired effect. In addition to a decongestant effect, the wound is cleaned and germs removed. The treated skin areas are then covered loosely with a sterile bandage. The next day it will be changed. After about 12 hours, but at the latest after 24 hours, the bleeding is complete. The bite site heals completely after one to three weeks. Only in rare cases does a tiny, barely visible scar remain.
Although the amount of blood consumed by the leeches is very small, there may be a harmless temporary drop in blood pressure. For people suffering from high blood pressure, this is a desirable side effect.