Marham-i-Raal: a natural multifaceted formulation for enhanced wound healing

INTRODUCTION

Wound is any discontinuity in the skin's structure. It has been described as “normal anatomical structure and functional disturbance”. Edwin Smith Papyrus first mentioned wounds in 1700 BC.¹ Depending upon the exposure to external environment wounds have been classified as the following: open wounds: when the skin layer is broken, exposing the underlying tissue known as open wounds, which included incised, lacerated, puncture, penetrating and crushed wounds.² Closed wounds, when there is no visible break in the skin but there is injury to the underlying tissue such as contusion and hematoma.² As per the duration of healing, they have been classified as acute wounds: those that repair on their own and proceed according to systematic healing process, resulting in the restoration of both function and anatomical structure. Chronic wounds, those that cannot heal normally and cannot be properly organized manner.¹ Classification on the basis of depth of the wound - superficial wounds: these are indicated by an injury that affects only the uppermost layer of skin.² Partially thickness wounds: passing through the epidermis and into the dermis while the dermis is still at least partially intact that create new epidermis. Full thickness wounds: might reveal bone, muscle, tendon, or fatty tissue as it totally penetrates the skin to the underlying structures.¹

In Unani system of Medicine, Wound is described as ‘Tafarruq al-Ittiṣāl (loss of continuity) of skin or flesh called ‘Jarāḥat’.^3-8 If Jarāḥat is with peep/sadeed (suppuration) it is called Qarḥa (ulcer).^3,4,6-8 In Unani medicine, wounds are classified based on clinical characteristics, including the presence or absence of sepsis, the type of inflammation, the occurrence of maggots, the presence of burns, and the overall severity.⁹ There are numerous reasons like waram (inflammation), Fasād-i-Mizāj (altered temperament), Qilla al-Dam (anemia), Dam Ghayr Ṭabī‘ī (abnormal sanguine), mail (filth), Ufūnat (sepsis), used improper medicines, and the presence of bone fragments in the wound that delay to heal wounds.^10,11

Source of the study

This review is based on an extensive analysis of both classical Unani literature and contemporary scientific studies. Classical texts, such as Tibb-i-Akbar, Qarabadeen Majeedi, and Khazain-ul-Advia, were thoroughly examined to understand the traditional formulations and therapeutic principles of Marham-i-Raal. To integrate modern perspectives, electronic databases including PubMed, Google Scholar, and ResearchGate were searched for relevant scientific articles using keywords such as "chronic wounds", "chronic ulcers", "Marham-i-Raal", and "wound healing". Inclusion criteria focused on studies reporting antimicrobial, anti-inflammatory, and wound-healing properties of the formulation and its individual components. Additionally, recent clinical trials, quality control assessments, and experimental studies involving Marham-i-Raal were reviewed to evaluate its efficacy and safety. The synthesis of traditional and modern insights highlights the potential of this Herbo-Animal formulation in chronic wound management.

MECHANISM OF WOUND HEALING

The term "healing" refers to the replacement of damaged tissue with healthy tissue.¹² Wound healing is a complex physiological process comprising three overlapping phases: inflammation, proliferation, and remodeling.^13,14 Inflammation begins with the damage to blood vessels and the activation of the homeostatic cascade.¹³ This cascade forms a physical barrier at the wound site through coagulation, leading to the deposition of fibrin and thrombin, which halts bleeding typically within a few hours.⁹ Inflammatory mediators, such as histamine, granulocytes, and platelets, are released, increasing capillary permeability. Prostaglandins and kinins attract white blood cells and fibroblasts to the site. During the initial 48 hours, polymorphonuclear (PMN) leukocytes dominate, clearing dead and necrotic tissue.¹⁵ Proliferation begins with the formation of granulation tissue.¹⁶ Monocytes, which act as specialized scavengers, proliferate as PMN leukocytes decrease. By days 5 to 6, fibroblasts appear, producing protocollagen, which is then converted into collagen by protocollagen hydroxylase.¹⁵ Epithelialization starts from the wound margins, and wound contraction generally begins around days 10 to 12, with the cutaneous surface becoming keratinized. However, the timing can vary based on the patient's overall health and wound severity.¹³ Remodeling starts around 2-3 weeks after injury, as the collagen and extracellular matrix are refined. This phase involves the smoothing of collagen, with type I collagen fibrils becoming more cross-linked and stronger, leading to the formation of a scar known as cicatrisation.¹⁶ Effective wound care is costly and complex. Proper management involves an initial assessment of the patient's condition and wound. Essential steps include cleaning the wound to remove microorganisms, dead tissue, and foreign bodies, often using a bacitracin solution. Debridement, the removal of non-viable tissue, is crucial for promoting healing.² Wound bed preparation and appropriate dressings are also important.¹

The wound healing can be accelerated by approximating the wound margins, applying desiccants, and consuming gelatin-rich foods. Key principles for wound treatment include: achieving hemostasis; encouraging healing through proper diet and medication; preventing infection and decay. Priority should be given to hemostasis.⁷ For chronic wounds, such as ulcers, maintaining dryness is essential. Astringents may suffice for clean ulcers, while caustics or cautery may be necessary for more severe cases. Medications that promote granulation tissue growth should be used along with suitable diet,⁷ and tissue debridement is often recommended.^10,11

Contemporary medical practices and Unani medicine often intersect in their approaches to wound management. Marham-i-Raal, a notable compound formulation of the Unani medicine has shown significant efficacy in treating persistent ulcers.^17-21 This formulation supports wound healing by encouraging the development of new, healthy tissue while removing necrotic material. Additionally, it facilitates prolonged epithelialization, which helps in wound contraction and overall repair.¹⁸

MARHAM-I-RAAL AND ITS WOUND HEALING PROPERTIES

Marham-i-Raal aids at pathophysiological level. It has wonderful Dāfi’-i-‘Ufūnat (antiseptic), Indimāl-i-Jarāḥat (wound healing) and, Inbāt-i-Laḥm (formation of flesh) properties. It removes the devitalised tissue.^22,23 It is useful in all types of wounds (acute and chronic).^20,24-26 It is indicated for Qurūḥ-i-Ātshak (syphilitic ulcer), Nawāṣīr (fistula), Qurūḥ-i-Anf (nasal ulcer) and Qarḥa ‘Asir al-Indimāl (non-healing ulcer).^22-24,26-28

DPPH: 2,2-diphenyl-1-picrylhydrazyl, ABTS: 2,2'-azino-bis (3-ethylbenzothiazoline-6-sulphonic acid)

Method of preparation

First grind the Raal (Vateria indica linn) and Kath (Acacia catechu) finely and sieve it through the 100 NO. mesh. Then crush (Kharal) the Kafoor (Cinnamomum camphora) with some powder safely. Add the ghee (clarified butter) and mom (Beeswax) in a pan put it on fire and keep it. When the mom melts take it down from the fire and mix the medicated powdered in lukewarm mixture of ghee and mom. Mix it well and store in a jar.²⁰

Method of administration

Marham-i-Raal is a topical ointment used exclusively for external application. First, cleanse the wound with a neem leaf decoction, then apply the ointment.^20,24-26

DISCUSSION

In Unani Medicine, Marham-i-Raal has been widely used as an effective remedy for chronic ulcers and wounds due to its comprehensive therapeutic properties. The formulation incorporates ingredients with unique attributes that synergistically aid in wound healing and microbial infection management. Vateria indica serves as a natural cleansing agent, effectively removing pus and wound exudates, while its anti-parasitic and rubefacient properties make it particularly beneficial for chronic wound care. The presence of monoterpenes, such as bergenin, contributes significantly to its antibacterial activity by inhibiting the growth of several bacterial strains. Camphor, known for its stimulant, antibacterial, and rubefacient qualities, improves local blood circulation through venous dilation, promoting tissue regeneration. Additionally, it provides analgesic and demulcent effects, with its linalool content proving particularly effective against Staphylococcus aureus and Candida albicans. Acacia catechu offers antipruritic benefits and is especially effective for syphilitic ulcers and burns. Its haemostatic properties help control bleeding when applied topically, while its strong astringent and anti-parasitic actions enhance wound healing. Furthermore, compounds such as kaempferol and quercetin within Acacia catechu exhibit potent antibacterial, anti-inflammatory, and anticancer effects. Beeswax enhances the penetration of active ingredients into tissues, amplifying the efficacy of the formulation, while ghee provides antifungal and anti-ulcer benefits. The presence of various saturated and unsaturated fatty acids in ghee supports essential metabolic processes involved in wound healing. Collectively, these ingredients contribute to the multifaceted action of Marham-i-Raal, offering antimicrobial protection, accelerating tissue regeneration, and addressing long-standing wounds, ulcers, and skin conditions, thereby solidifying its role as an indispensable preparation in Unani medicine.

CONCLUSION

Marham-i-Raal is a highly effective formulation of wound-healing. Its efficacy can be attributed to the diverse properties of its ingredients, which include antimicrobial, antiseptic, antifungal, antiviral, antioxidant, anti-inflammatory, analgesic, anesthetic, antiparasitic, anti-ulcerogenic, vasodilator, de-sloughing, and wound-healing effects. Scientific studies have shown that these properties collectively enhance its ability to treat acute and chronic wounds. Given the promising results from ingredient studies, it is imperative to conduct extensive scientific research and clinical trials to further validate and expand on Marham-i-Raal's effectiveness in treating chronic cutaneous wounds. Such studies will help in understanding its full potential and optimizing its use in modern wound management practices.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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