Hai-Xia Zhang, Qi Li, Fu-Ling Tian, Si-Tong Wang, Bin Ye, Fan-Wu Wu

Traditional Chinese Medicine College of North China University of Science and Technology,Tangshan 063210, Hebei Province, China

Keywords:Diabetic foot Internal treatment of traditional Chinese Medicine External treatment of traditional Chinese Medicine Comprehensive therapy of traditional Chinese Medicine Research progress

ABSTRACT Diabetic foot is one of the chronic complications of diabetes, which is serious and expensive to treat. As an effective method for treating diabetic foot, Chinese medicine plays an important role in improving the clinical symptoms and reducing the suffering of diabetic foot patients. The methods of traditional Chinese medicine to treat diabetic foot include internal treatment method, external treatment method and comprehensive therapy. This article reviews the research results of traditional Chinese medicine treatment of diabetic foot in order to provide reference for the treatment of diabetic foot.?Corresponding author: Wu Fan-Wu, professor, Ph.D.

Diabetic foot is the foot infection, ulcer and/or deep tissue destruction caused by the distal nerve abnormality and vascular disease of different degrees in diabetic patients [1]. In recent years, the prevalence of diabetic foot has increased in China. The incidence rate of diabetic foot is 8.1% in patients over 50 years old. Severe diabetic foot can cause disability and death. It is estimated that there is one amputation in every 20 seconds in the world[2]. The amputation rate and the annual mortality rate of diabetic foot ulcer are 22% and 11%, respectively [3], research shows that the treatment of diabetic foot costs a lot, accounting for about 1 / 3 of the total cost of diabetes treatment, which is a major problem causing heavy economic burden on families and society [4]. How to improve the symptoms of diabetic foot patients and reduce the pain of diabetic foot patients is the focus of current research. Traditional Chinese medicine (TCM) has attracted wide attention because of its combination of prevention and treatment, significant curative effect and small side effects. In order to explore the role of traditional Chinese medicine in the treatment of diabetic foot, this paper reviews the relevant literature in recent years.

1.Internal treatment of traditional Chinese Medicine

Syndrome differentiation and stage treatment are common methods of internal treatment of diabetic foot, both of which can play an obvious role in the treatment of diabetic foot.

1.1 Syndrome differentiation and treatment

According to the different foot manifestations and accompanying symptoms of diabetic foot patients[5], diabetic foot is divided into five syndrome types and listed the recommended prescription. Four Miao Yong'an Decoction and Yin Zhilian decoction are recommended for syndrome of dampness, heat, dampness and rotten flesh; Gubu decoction is recommended for syndrome of heat, toxin, yin and blood stasis; Shengmai Decoction and Xuefu Zhuyu decoction are recommended for syndrome of deficiency of Qi and blood and blood stasis; Liuwei Dihuang pill is recommended for syndrome of deficiency of liver and kidney yin and blood stasis; Jinkui Shenqi Pill is recommended for syndrome of deficiency of spleen and kidney yang and syndrome of phlegm and blood stasis. According to the guidelines issued by the surgery branch of the Chinese society of traditional Chinese medicine [6], diabetic foot can be divided into four types: Simiao Yong'an decoction or Xi's Qingxiao Decoction for the syndrome of dampness heat and toxin excess; Taohong Siwu Decoction or Xuefu Zhuyu Decoction for the syndrome of blood stasis; Gubu Decoction for the syndrome of heat, toxin and Yin injury; ginseng Yangrong decoction or Buyang Huanwu decoction or Bazhen decoction for the syndrome of deficiency of Qi and blood. Liu Cong et al. [7] used the self-made formula to treat 47 cases of diabetic foot with stomach heat, lung heat, and kidney yin deficiency. The effective rate was 95.74%. Chen Lu [8] used Huoxue Tongluo formula to treat 40 diabetic foot patients with deficiency of both qi and Yin on the basis of routine treatment. The fasting blood glucose, vascular endothelial growth factor and interleukin-6 levels were significantly reduced, and the clinical effect was significant.

1.2 Treatment by stages

With the development of the disease, diabetic foot patients often have different clinical manifestations in different periods, and the treatment by stages can often achieve satisfactory results. Professor Wang Bingnan divided diabetic foot into early, middle and late stages according to the relationship between the rise and fall of pathogenic factors and the prosperity and deficiency of Qi and blood. He treated it by three stages of "Xiao, Tuo and bu". In the early stage, it can warm the meridians, activate the blood and remove stasis, in the middle stage, it can nourish Qi and blood, and in the later stage, it can nourish Qi and blood, warm the spleen and kidney. The clinical effect is significant [9]. Yu Hongjun et al. [10] divided 39 patients with diabetic foot into early, middle and late stage. On the basis of basic Western medicine treatment, TCM was used to treat them by stages and syndrome differentiation, and the corresponding Chinese herbal compound was given orally to improve the microcirculation of the patients. The total effective rate was 82.05%. According to the course of diabetic foot, Professor Lv Yanwei classified the early stage of diabetic foot as the type of dampness, heat and toxin excess, used tangzu No.1 to clear away heat and dampness, detoxify and detumescence; classified the middle and later stage of diabetic foot as the type of deficiency of both qi and blood, used tangzu No.2 to Nourish Qi and blood, and warmed the meridians [11]. According to Yue Rensong, the basic pathogenesis of diabetic foot is the damage caused by sugar poison, dampness and heat stagnation, and blood rot and flesh failure. On this basis, diabetic foot can be divided into three stages of treatment. The early stage focuses on clearing away heat, removing dampness and toxin, the middle stage is also promoting blood circulation and removing stasis, and the later stage focuses on strengthening the body [12].

2.External treatment of traditional Chinese Medicine

As far as the external treatment of traditional Chinese medicine is concerned, there has been a theory of "surgical method, the most important external treatment" as early as the theory of medical origin. The traditional Chinese medicine external treatment for diabetic foot includes fumigation, foot bath, sticking, acupuncture, massage, etc.

2.1 Fumigation therapy

Fumigating and washing therapy can improve the blood supply of lower limbs of diabetic foot patients and promote wound healing, with the advantages of small side effects and simple operation

[13]. Zhou Yiye et al. [14] treated 30 patients with diabetic foot of grade 0 by fumigating and washing Qi Dan Wai Xi Fang, which was cut from Danggui Sini Decoction and Wu Zhuyu Shengjiang decoction. It was found that Qi Dan Wai Xi Fang could effectively improve the clinical symptom score, ankle brachial index and nerve conduction velocity of patients with diabetic foot of grade 0. Li Chang [15] selected 30 cases of diabetic foot with dampness and heat stagnation of spleen and blood stasis type. On the basis of routine treatment and fumigating and washing with Huashi Tongluo Decoction, the symptoms and TCM syndrome scores of the patients were significantly improved. Zhang Bei [16] et al. Divided 40 patients with diabetic foot of cold coagulation and blood stasis type into two groups. The control group was given symptomatic treatment, and the treatment group was given symptomatic treatment plus warming jingtongluoxuxi formula. Results the levels of advanced glycation end products, tumor necrosis factor α, interleukin-6 and vascular endothelial growth factor in the two groups were lower than before treatment, and the treatment group was better than the control group.

2.2 Foot bath therapy

Meta analysis shows that foot bath with Chinese medicine has a certain clinical effect in the treatment of early diabetic foot [17]. Li Li [18] divided 60 patients with early diabetic foot into the treatment group and the control group, 30 cases in each group. The effective rate of the treatment group was 93.33% in the treatment group and 70.00% in the control group, when the treatment group used traditional Chinese medicine foot bath at the same time of routine nursing intervention. Yang Suxiu [19] selected 33 patients with diabetic foot of grade 0 (yang deficiency and pulse obstruction type), and treated them with Tangtong foot bath formula which has the effects of warming the meridians and dispersing cold, supplementing qi and activating blood circulation, combined with intravenous thiocaproic acid, the total effective rate was 100%. It was found that the treatment method can effectively inhibit the progression of diabetic foot, reduce or avoid the toxic and side effects of Western medicine, and prevent diabetic foot ulcer.

2.3 Application therapy

Traditional Chinese medicine with the functions of promoting blood circulation and removing blood stasis, clearing heat and detoxification, detumescence and pain relief is often used in application therapy [20]. Fan Tingting et al. [21] applied Sanhuang Siwu powder on the basis of conventional western medicine to treat diabetic foot of grade 0. The results showed that Sanhuang Siwu can not only improve the clinical symptoms of diabetic foot of grade 0, but also improve the total effective rate and the level of growth factor of patients. Zhang Xiaohui et al. [22] selected 30 inpatients and outpatients with diabetic foot (grade I-IV). On the basis of routine treatment of diabetes and Mecobalamin capsule treatment, they added Huang's butter gauze for external application, and found that Huang's butter gauze can improve the TCM symptom score of diabetic foot patients. Yang Xiaoxia [23] divided 50 patients with diabetic foot ulcer of dampness heat stasis type into treatment group and control group, 25 cases in each group. At the same time of routine treatment, the treatment group was applied with traditional Chinese medicine ulcer oil, while the control group was applied with western medicine ethacridine lactate. The total effective rate of the treatment group was 86.96%, higher than that of the control group.

2.4 Acupuncture therapy

Acupuncture can clear the meridians, reconcile yin and yang, and clinically select points for treatment according to the symptoms of patients with diabetic foot, and often can achieve satisfactory results. Li Haiyan et al. [24] selected 53 patients with Wagner grade 0 diabetic foot. Based on conventional treatment, they selected Zusanli, Sanyinjiao, Qihai, Honglong and Yinlingquan, Taixi, Guanyuan, Hangzhong, and Yanglingquan. 5%。 The main point of the group, acupuncture treatment of 1-2 acupoints of the affected feet, the patient's neurological function improved significantly, the total effective rate of treatment was 92.5%. Zheng Mingyue et al. [25] selected 31 patients with latent syndrome of diabetic foot gangrene, and performed warm acupuncture on Zusanli, Yanglingquan, Fenglong, Feiyang, Chengshan, Hegu, etc. during basic treatment, and found that the patient's TNF-α, Hs-CRP levels are reduced, the micro-inflammatory status is improved, and the risk of limb ulceration is reduced. Huzi Chen [26] performed acupuncture treatment on 215 diabetic foot patients, with Pishu, Jishu, Yishu as main points, and Feishu, Weishu and Ganshu as matching points, and according to the different lesions of the patient Acupuncture points were increased with symptoms, and 92 cases were basically cured, 67 cases were markedly effective, 55 cases were improved, and 1 case was ineffective.

2.5 Massage

The auxiliary treatment of massage can dredge the meridians, regulate the balance of Qi, blood, yin and Yang and the function of viscera, so as to play a role in the treatment of diabetic foot [27]. Sun Liyan et al [28] treated 30 diabetic foot patients with phlegm dampness constitution and yin deficiency constitution with different foot acupoint massage methods by distinguishing constitution. The main acupoints were Yongquan, Taixi and Sanyinjiao of both feet. Phlegm dampness constitution was combined with double foot stomach reflex area, foot spleen reflex area, yin deficiency constitution with double foot kidney reflex area and foot sea area. The effect was significant. It was considered that this method could make clear Significantly improve the foot condition of patients, prevent early diabetic foot. Huang Qiang et al. [29] treated 30 cases of diabetic foot of blood stasis type with Tongluo acupoint massage (Zusanli, Yanglingquan, yinlingquan, etc.) on the basis of routine treatment and nursing of type 2 diabetes, the wound healing rate was 93.33%, and the total effective rate was 90%. Sun Shize [30] selected 36 patients with diabetic foot complicated by hemodialysis, 18 in the conventional group and 18 in the treatment group respectively. In the treatment group, foot massage was used at the same time of regular hemodialysis in the conventional group. Results the total effective rate of the conventional group was 71.43%, and the total effective rate of the treatment group was 94.44%.

3. Comprehensive treatment of traditional Chinese Medicine

In order to play a more comprehensive role in the treatment of diabetic foot, Chinese medicine often uses a variety of treatment methods. Wang Lingli et al. [31] included 112 diabetic foot ulcer patients, divided into the control group and the observation group, 56 cases in each group. The control group was washed with Compound Cortex Phellodendri solution, the observation group was washed with Compound Cortex Phellodendri solution plus Buyang Huanwu Decoction for syndrome differentiation and internal administration. Results the total effective rate of the observation group was higher than that of the control group. Bu Hanmei et al.

[32] used basic treatment of diabetes combined with comprehensive external treatment of traditional Chinese medicine and Huazhuo Jiedu Decoction to treat 30 patients with diabetic foot. The wound healing rate and total effective rate of the patients were 82.55% and 93.33% respectively. Yang Yaowu et al. [33] selected 64 patients with diabetic foot of qi deficiency and blood stasis type, and took Xiaoju decoction combined with Huoxue Tongluo Decoction for fumigation and washing at the same time of routine treatment. After treatment, the nerve conduction speed of patients increased, ankle brachial index increased, the effective rate of treatment was 93.75%, and there was no adverse reaction.

4. Conclusion

Diabetic foot has become a serious threat to the physical and mental health of diabetic patients. Traditional Chinese medicine adopts the internal treatment of syndrome differentiation and treatment by stages, the external treatment of fumigation, foot bath, sticking, acupuncture, massage and so on, as well as the comprehensive treatment shared by many methods, which greatly improves the curative effect of diabetic foot patients, reduces the amputation rate and mortality, delays the progress of the disease, and fully embodies the unique advantages of traditional Chinese medicine in the treatment of diabetic foot 。 However, at present, there are relatively few researches on the pharmacology and mechanism of action of traditional Chinese medicine in the treatment of diabetic foot. Aiming at the above problems, in the future research process, we should further explore its pharmacology and internal mechanism of action, in order to create a broader development space for the treatment of diabetic foot by traditional Chinese medicine and provide more ideas for the prevention and treatment of diabetic foot.