DIAGNOSA, INTERVENSI, DAN LITERATUR JURNAL

GANGGUAN SISTEM INTEGUMEN

Dosen Pembimbing:

Dedi Irawandi,S.Kep.,Ns

Oleh:

1. Ayu Cahyaningtyas (141.0022)

2. Etty Khandhayoni (141.0042)
3. M Iqbal Rinaldhi (141.0066)
4. Nevinda Hervi F (141.0068)
5. Nuril Mufidah C (141.0074)
6. Putri Wardah Nafisah (141.0078)
7. Ridho Fajar Aprilianto (141.0082)
8. Riza Agustin (141.0086)
9. Selviana Dwi S (141.0092)
10. Yuniar Indah Prastiwi (141.0110)

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH

2016
Diagnosa Medis : Candidiasis

Diagnosa Keperawatan : Hipertermi b.d proses inflamasi

Intervensi Keperawatan :

No. Masalah Keperawatan Tujuan dan Kriteria Hasil Intervensi Rasional

1. Hipertermi b.d proses Setelah dilakukan asuhan 1. Observasi suhu tubuh setiap 1. Mengetahui
inflamasi keperawatan selama 2 x 24 4 jam sekali perkembangan dari status
jam, diharapkan hipertermi kesehatan pasien
2. Berikan kompres hangat di
2. Di ketiak dan lipatan paha
teratasi dengan kriteria hasil :
sekitar lipatan misalnya
terdapat banyak
ketiak, lipatan paha
- Suhu tubuh normal pembuluh darah besar.
(36,5 -37,5)oC Hipertermi mengalami
- Akral hangat
vasodilatasi sehingga
- Mukosa bibir lembab
- Pasien tidak gelisah harus diberi kompres
hangat agar terjadi
memperluas vasodilatasi
dan menyebabkan suhu
3. Ciptakan suasana yang
panas tubuh lebih cepat
 nyaman (atur ventilasi) keluar
3. Suhu ruangan harus
diubah untuk
4. Anjurkan kepada pasien
mempertahankan suhu
dan keluarga untuk
mendekati normal
minum, sedikit tapi sering
4. Peningkatan suhu tubuh
mengakibatkan
penguapan tubuh
5. Anjurkan keluarga untuk
meningkat sehingga perlu
tidak memakaikan selimut
diimbangi dengan asupan
dan pakaian yang tebal
6. Kolaborasi : pemberian obat cairan yang banyak.
5. Pakaian tipis membantu
anti mikroba, antipiretik
mengurangi penguapan
pemberian cairan parenteral
tubuh
6. Digunakan untuk
mengurangi demam
dengan aksi sentralnya
pada hipotalamus,
meskipun demam
mungkin dapat berguna
dalam membatasi
pertumbuhan organisme
dan meningkatkan
autodestruksi dari sel-sel
yang terinfeksi.
Diagnosa medis :tinea kapitis:

Masalah Keperawatan: Gangguan citra tubuh b.d perubahan penampilan.

Intervensi

No Diagnosa Tujuan dan kriteria Intervensi Rasional

hasil
1. Gangguan Setelah dilakukan 1. Kaji perubahan pada klien. 1. Menentukan tindakan keperawatan
citra tubuh asuhan keperawatan selanjutnya.
b.d selam 3x24 jam, 2. Dorong pasien melakukan perawatan
2. Meningkatkan rasa kemandirian
perubahan gangguan citra tubuh diri.
dan kontrol klien.
3. Berikan kesempatan kepada pasien
penampilan diharapkan teratasi 3. Mengungkapkan keluhannya dan
untuk menyatakan perasaan tentang
dengan kriteria hasil : memperbaiki kesalah pahaman.
citra tubuhnya dan hospitalisasi.
- Klien sudah
4. Berikan keyakinan pada diri klien.
tidak merasa 5. Dorong interaksi dengan keluarga.
malu.
- Lesi tidak lagi
kasar.
- Lesi tidak lagi
bersisik. 6. Kolaborasi
dengan dokter pemberian
4. Meningkatkan kepercayaan diri
griseofulvin. klien.

5. Mempertahankan komunikasi
dengan mendukung secara terus-
menerus pada klien.
6. Menghilangkan keefektifan
mikroorganisme yang ada pada
rambut.

TINEA KORPORIS
Masalah Keperawatan tinea korporis :

1. Gangguan Integritas kulit berhubungan dengan adanya lesi

Intervensi :

n Diagnosa Tujuan Dan KH Intervensi Rasional

o
1 Gangguan Setelah dilakukan 1. Observasi klien 1. Untuk menentikan tindakan yang
integritas kulit asuhan keperawatan akan dilakukan
2. Untuk mengetahui keparahan
b.d adanya lesi diharapkan tidak ada
lesi dengan kriteria 3. Untuk mengurangi alergi pada kulit
2. Catat perubahan pada kulit 4. Untuk mencegah petumbuhan
hasil : keluhan gatal
jamur
berkurang 3. Hindari makanan yang tinggi
Integritas jaringan kulit protein
memmbaik
4. Kolaborasi pemberian antibiotik

MASALAH KEPERAWATAN PADA TINEA CRURIS

 1. Nyeri akut berhubungan dengan perubahan kenyamanan.
2. Kerusakan integritas kulit berhubungan dengan kerusakan permukaan kulit.
3. Gangguan citra tubuh berhubungan dengan perubahan struktur kulit.

INTERVENSI PADA TINEA CRURIS

No Diagnosa Tujuan & Kriteria Intervensi Rasional

. Keperawatan Hasil
1. Nyeri akut Setelah dilakukan - Catat lokasi, lamanya intensitas (skala - Mengetahui lokasi nyeri dan berat
berhubungan asuhan keperawatan 0-10) dan penyebaran. Perhatikan ringannya nyeri.
- Perawatan kulit dengan baik akan
dengan selama 3x24 jam tanda non-verbal, contoh peningkatan
membuat px nyaman sehingga
perubahan diharapkan nyeri TD dan nadi, gelisah, merintih,
mempercepat penyembuhan dan
kenyamanan pasien berkurang/ menggelepar.
mengurangi resiko infeksi
(gatal) hilang, dengan - Lakukan perawatan kulit dengan tepat - Pengetahuan pasien terhadap nyeri
krirteria hasil : dan baik dapat membuat pasien lebih patuh
- Nyeri hilang atau - Ajarkan teknik relaksasi dan distraksi pada pengobatan.
teradaptasi - Membantu mengurangi nyeri,
- Skala nyeri - Kolaborasi pemberian analgetik
Analgesik memblok stimulus rasa
minimal 1-4 dari (mempridin)
nyeri
skala (1-10)
- Pasien tampak
rileks
2. Gangguan Setelah dilakukan - Kaji kondisi luka klien (area, warna, - Mengetahui kondisi luka secara
integritas asuhan keperawatan bau, kelembaban, turgor). umum
kulit selama 3x24 jam - Menganjurkan pasien untuk
berhubungan diharapkan pasien menghindari atau mengkonsumsi
- Mengurangi timbulnya rasa gatal
dengan dapat mengalami makanan yang tinggi protein
- Beri pasien pengetahuan tentang factor yang berlebihan
kerusakan penyembuhan, dengan
factor yang bisa mengakibatkan lesi
permukaan kriteria hasil :
atau penyakit bisa bertambah parah - Meminimalkan adanya komplikasi
kulit - Pasien - Kolaborasi dengan dokter untuk
menunjukkan pemberian obat antibiotik
penyembuhan
jaringan progresif
- Berkurangnya
- Mencegah untuk pertumbuhan
gangguan jaringan
jamur pada daerah luka
epidermis, lesi,
eritema, dan
pruritis
3. Gangguan Setelah dilakukan - Pantau dan tanyakan mengenai - Membuat pasien dan percaya diri
citra tubuh asuhan keperawatan masalah, penanganan, perkembangan, - nformasi dapat membuat pasien
berhubungan selama 3x24 jam prognosis kesehatan. lebih lebih tahu tentang
- Berikan informasi yang dapat permasalahannya
dengan diharapkan menerima
dipercaya dan perkuat informasi yang - Orang terdekat mempunyai pengaruh
perubahan perubahan citra
telah diberikan. lebih dominan ntuk membantu
struktur kulit tubuhnya dengan
- Anjurkan orang terdekat untuk pasien menerima keaadaannya
kriteria hasil:
memberikan support system terhadap sekarang ketika sudah di masyarakat.
- Pasien
perubahan fisik dan emosional. - Untuk membuat pasien bisa
menerima
- Mengungkapkan perasaannya menerima keaadaannya sekarang
penampilan
membuat pasien merasa lebih nyaman
yang sekarang
setelahnya
- Pasien tidak
malu bertemu
dengan kerabat
atau orang lain
- Pasien bisa
beraktivitas
seperti biasa
tanpa rasa
malu atau
 minder

Diagnosa Medis : Tinea Pedis

Diagnosa Keperawatan : Gangguan pola tidur berhubungan dengan pruritus (rasa gatal)

Intervensi Keperawatan :
No. Masalah Keperawatan Tujuan dan Kriteria Hasil Intervensi Rasional
Gangguan pola tidur
1. Setelah dilakukan 1. Kaji tingkat tidur 1. Untuk mengetahui
berhubungan dengan
asuhan keperawatan pasien kualitas tidur pasien
pruritus (rasa gatal)
2. Anjurkan pasien untuk 2. Untuk mencegah efek
diharapkan kebutuhan
menghindari minuman samping dari kafein
tidur pasien terpenuhi
yang mengandung
dengan kriteria hasil : 3. Memberikan efek
kafein menjelang tidur
yang menguntungkan
malam hari
untuk tidur jika
3. Anjurkan pasien untuk
dilakukan di sore hari
melakukan gerak
4. Meberikan obat
badan secara teratur
diharapkan pasien
4. Kolaborasi dengan
dapat tidur
dokter pemberian obat
anti histtamin
 DAFTAR PUSTAKA
Adhi Djuanda, prof. Dr.1999. Ilmu Penyakit kulit & Kelamin. Jakarta.
Doenges, Marylinn E. 1999. Rencana Asuhan Keperawatan. Edisi III. Jakarta. EGC
Nanda International.2009. Diagnosis Keperawatan Nanda 2009-2011. Jakarta : EGC
Taylor, C. M., & Ralph, S. S. (2013). Diagnosis Keperawatan Dengan Rencana Asuhan. Jakarta:
EGC.
 REVIEW

Herbal Therapy in Dermatology

Monica K. Bedi, MD; Philip D. Shenefelt, MD

H
erbal therapy is becoming increasingly popular among patients and physicians. Many
herbal preparations are marketed to the public for various ailments including those of
the skin. Herbal therapies have been used successfully in treating dermatologic
disorders for thousands of years in Europe and Asia. In Germany, a regulatory com-
mission oversees herbal preparations and recommended uses. In Asia, herbal treatments that have
been used for centuries are now being studied scientifically. Currently, the United States does not
regulate herbal products, as they are considered dietary supplements. Therefore, there is no stan-
dardization of active ingredients, purity, or concentration. There are also no regulations govern- ing
which herbs can be marketed for various ailments. This has made learning about and using these
treatments challenging. Information compiled in a practical fashion may enable more pa- tients to
benefit from these treatments currently used worldwide. We reviewed the herbal medi- cations that
show scientific evidence of clinical efficacy, as well as the more common herbs shown to be useful
in the treatment of dermatologic disorders. The safety of each herb has been addressed to better
enable the physician to know which herbal therapies they may want to begin to use in practice.
Common drug interactions and side effects of herbal medicines that may be seen in the dermatologic
setting were also studied. Arch Dermatol. 2002;138:232-242
Herbal medicine dates back thousands of From the Division of Dermatology and
years. It originated in India and China and Cutaneous Surgery, University of South
it is still widely used in Asia. In India, Florida, Tampa.
Ayur- vedic medicine dates back to 3000
BC. Ayur- vedic medicine combines
physiological and holistic principles. It is
based on the con- cept that the human
body is composed of S energy elements
that also make up the uni- verse: earth,
water, fire, air, and space. In- teraction of
these elements gives rise to the
3 doshas (forces), 7 dhatus (tissues), and 3
malas (waste products). All diseases are
at- tributed to an imbalance between the 3
doshas. Diagnosis is made by an elaborate
system of examination of the physical
find- ings, the pulse, and the urine, as well
as an
8-fold detailed examination to evaluate
both the physical and mental aspects of
the con- dition. Treatment is then
individually tai- lored to the findings.l
 Chinese medicine dates back about on the physical examina- tion of the
4000 years and is aimed at treating the whole person. It is based on the tongue, iris, and pulse of the in- dividual
complementary forces yin and yang. In healthy individu- als, the yin and to determine the cause of the imbalance
yang are in balance, and ill- ness occurs when there is inequality be- and then to determine the ap- propriate
tween the forces. The Chinese evaluate the individual treatment. Treatment is usually
a mixture of herbs, massage, and
See also pages 207 and 251 acupuncture.2
In Western medicine, herbal therapy
exchange between the environment and the body, such as food, drink, and began as folk medicine. In the United
air into the body and waste leaving the body. Special at- tention is placed States, it began in the colonial days, when
homemade botanicals were provided by the women in the from white oak tree or the English walnut tree. These
home.3 Native American use of botanical treatments also preparations should be strained before use and can be
greatly influenced the use of herbal therapy in the United used 2 or 3 times per day. Commercially available
States. In the 19th century, these traditions were preparations are not recommended, as the tannins are lost
expanded and used by a group of physicians known as in the distillation process.11
the Eclectics. As herbal medicine has developed in the
United States, it has also been influenced by European
and Chinese practices.4
Herbal therapy has recently become increasingly
popular among patients seeking alternative treatment
options. The number of visits to alternative medicine
practitioners in the United States is growing rapidly. In
1997, the number of visits was estimated to be 629 mil-
lion, which exceeded the number of visits to all primary
care physicians.5 Approximately $27 billion was spent
out of pocket for these alternative therapies in 1997, and
$3.24 billion of this was spent on herbal therapy.6
It is estimated that about 50% of the population uses
some form of alternative medicine, and many patients do
not share this information with their physicians. In a
previous survey, those most likely to use unconven-
tional treatment modalities were nonblack, college edu-
cated, and between the ages of 25 and 49 years and had
an annual income greater than $35000.7 Most patients
seeking the alternatives do so because conventional
therapy has failed or they feel there are fewer side
effects, as the products are natural. This recent increase
in alternative medicine has led to more research and
education on the subject to enable physicians to better
inform and care for their patients.
In the United States, herbal remedies are sold as
dietary supplements, and standards of potency and effi-
cacy are not currently required. In Germany, a regula-
tory authority known as Commission E has performed an
extensive review of common botanicals. The com-
mission has evaluated the quality of evidence, clinical
efficacy, and uses of 300 herbal preparations.8,9 This
evaluation has led to standardization of herbal treat-
ments. Several herbal therapies for dermatologic
conditions have stood the test of time for their efficacy
and some show significant scientific evidence of use-
fulness. In this day of advanced communication be-
tween physicians worldwide, it is important that we share
information on herbal therapy, effects, and in- teractions,
so that we may offer alternatives to our patients.

ACNE

Tannins

Tannins have been used topically to treat acne because of

their natural astringent properties. Witch hazel
(Hamamelis virginiana) bark extract is commonly used
by making a decoction from 5 to 10 g of herb in 1 cup
(0.24 L) of water. Witch hazel is considered very safe to
use topically.10 Other similar astringents can be made
 Fruit Acids
Fruit acids, such as citric, gluconic, gluconolactone, gly-
colic, malic, and tartaric acids, have been used topically
and have shown promise in treating acne because of their
exfoliative properties. In one study, gluconolactone was
as effective in clearing inflamed and noninflamed acne
lesions as 5% benzoyl peroxide and more effective than
placebo.12 Irritation is the main adverse effect, espe-
cially in higher concentrations.
Tea Tree Oil
Tea tree oil may also play a role in topical acne treat-
ment. It is an essential oil extracted from the leaves of
Melaleuca alternifolia, a small tree indigenous to Austra-
lia. It contains approximately 100 compounds, mainly
plant terpenes and their corresponding alcohols.13 In
1990, a study of 124 patients compared 5% tea tree oil in
a water- based gel with 5% benzoyl peroxide. Although
the tea tree oil did not work as quickly as benzoyl
peroxide, it did show statistical improvement in the
number of acne lesions at the end of 3 months. Also,
there was a signifi- cantly lower incidence of adverse
effects such as dry- ness, irritation, itching, and burning
with the tea tree oil (44%) than with benzoyl peroxide
(79%).10(p629) There are occasional reports of allergic
contact dermatitis and of poisoning if taken internally.14-18
However, the degrada- tion products of monoterpenes in
the tea tree oil actu- ally appear to be the sensitizing
agents.19 Therefore, topi- cal treatment is considered very
safe.
ring associated with radiation dermatitis.21 It has also
been shown to accelerate healing of chronic leg ulcers,
surgi- cally induced wounds, and frostbite. The
mechanism of ac- tion has been studied by in vivo animal
studies. Aloe vera decreases thromboxane A2,
thromboxane B2, and prosta- glandin 2 , which cause
vasoconstriction and platelet ag- gregation. This is
thought to increase dermal perfusion, re- ducing the risk
of tissue loss from ischemia.21 In vitro studies have
shown a carboxypeptidase that inactivates bradyki- nin
(potent pain-inducing agent at sites of acute inflam-
mation), thereby possibly decreasing pain at the treat-
ment site.22 Salicylic acid has been shown to be present in
aloe vera; it acts as an analgesic and anti-inflammatory
by inhibiting prostaglandin production.23 Magnesium
lactate is also present in aloe vera. It is thought to act as
an anti- pruritic by inhibiting histidine decarboxylase,
which con- trols the conversion of histidine to histamine
in mast cells.21
Relief of inflammation is also thought to be due to the
im- munomodulatory properties of the gel
polysaccharides, es- pecially the acetylated mannans.24
Aloe vera has also shown bactericidal and antifungal
activity in vitro. The main ad- verse effect of topical aloe
vera gel is allergic contact der- matitis. There have also
been reports of delayed healing af- ter laparotomy or
cesarean section. Taken orally, aloe vera is considered
very safe when used properly.25(p7)
Honey
Honey has been used topically for centuries to accelerate
wound healing. It has been reported to be helpful in treat-
ing burns, decubitus ulcers, and infected wounds.26 In
Vitex
Vitex (Vitex agnus-castus) taken orally has been shown to
be effective in treating premenstrual acne. The whole-
fruit extract is thought to act on follicle-stimulating
hormone and luteinizing hormone levels in the pituitary
to increase progesterone levels and reduce estrogen
levels. The Ger-
manCommissionEmonographsrecommend40mg/d.The
main adverse effects reported are gastrointestinal tract
up- set and rash. It should not be taken by pregnant or
nursing women.20(p176)
TheGermanCommissionEhasalsoapproved topical
bittersweet nightshade (Solanum dulcamara) and orally
administered brewer's yeast (Saccharomyces cerevi- siae)
for the treatment of acne because of their antimicro-
bialeffects.20(p88,118) InChina,topicalduckweed(Lemmami-
nor) is used to treat acne.20(p258)
WOUNDS AND BURNS
Aloe Vera
Aloe vera leaves produce 2 substances, a gel and a juice
or latex. The gel is obtained from the inner part of the
leaf and has been used topically for centuries for the
treat- ment of wounds and burns. The juice or latex refers
to a bitter yellow fluid extracted from the specialized
areas of the inner leaf skin and is generally sold as a
powder that has very potent laxative effects.10(p31)
Several case reports and animal studies have
demon- strated that aloe vera reduces burning, itching,
and scar-
vitro it has been shown to have antibacterial and
antifungal ac- tivity to organisms commonly infecting
surgical wounds.27
In 1998, a small study was performed of 9 infants with
large, open, culture-positive postoperative wound
infections in which standard treatment (>14 days of
appropriate intra- venous antibiotics and cleansing with
chlorhexidine) failed. These wounds were then treated
with 5 to 10 mL of fresh unprocessed honey twice a day.
By day 5, there was marked clinical improvement, and
by day 21, the wounds were all closed, clean, and
sterile.28 In another randomized con- trolled trial, honey-
impregnated gauze was compared with a polyurethane
film (OpSite; Smith & Nephew, North Hum- berside,
England) for partial-thickness burns. The honey- treated
wounds healed statistically earlier (mean, 10.8 days vs
15.3 days) and with equal complications such as infec-
tion, overgranulation, and contracture compared with the
polyurethane film-treated wounds.29 The wound-healing
properties of honey are thought to result from the debrid-
ing properties of the enzyme catalase, absorption of
edema because of honey's hygroscopic properties, its
ability to pro- mote granulation and reepithelialization
from the wound edges, and its antimicrobial properties.30
Although there have been reports of contact dermatitis to
honey, there have been no reports of significant adverse
effects.30
Marigold
Calendula officionalis, more commonly known as mari-
gold, has been used topically since ancient times and is
currently approved by the German commission as an an-
tiseptic and to heal wounds.9(p119) Contemporary herb-
pears very safe, but care should be used when it is taken
orally.25(p58) In China, herpes zoster is commonly treated
alists continue to recommend a topical preparation for the
treatment of wounds, ulcers, burns, boils, rashes, chapped
hands, herpes zoster, and varicose veins. Gargles are also
popular for mouth and throat inflammation.10(p129) It is
widely accepted as a topical treatment for diaper derma-
titis or other mild skin inflammation.31 This is treated
with an application several times a day of an ointment or
cream made by mixing 2 to5g of the flower heads with
100 g of ointment. A gargle or lotion can also be used,
which is made by mixing 1 to 2 tsp (5-10 mL) of tincture
with
0.25 to 0.5 L of water.10(p130) The main adverse effect is
allergic contact dermatitis. No serious adverse effects
have been reported, and it is considered safe to use both
topically and orally.25(p22)
The anti-inflammatory effects of marigold are
thought to be due to the triterpenoids. In animal studies
Calendula appears to stimulate granulation and increase
glycoproteins and collagen at wound sites.31 It also
shows in vitro antimicrobial and immune-modulating
properties.10(p130)
Tannins
There are also many herbs containing tannins that act as
astringents, thereby helping to dry oozing and bleed- ing
wounds. Some of the more commonly reported tannin-
containing herbs that may be helpful for the topical
treatment of wounds include English walnut leaf,
goldenrod, Labrador tea, lavender, mullein, oak bark,
rhatany, Chinese rhubarb, St John's wort, and yel- low
dock.10(p709)
HERPES
SIMPLEX Balm
Balm (Melissa officinalis) is a lemon-scented member of
the mint family. The leaves can be steam distilled to pro-
duce an essential oil. Topical uses include treating her-
pes simplex and minor wounds. In a randomized double-
blind trial of 116 patients with herpes lesions, 96% had
complete clearing of lesions at day 8 after using 1% balm
extract cream 5 times a day.32 In another trial, balm ex-
tract was placed on lesions within 72 hours of onset of
symptoms. The size of the lesions and healing time were
statistically better in the group treated with balm.31 A tan-
nin and polyphenols appear to be responsible for its an-
tiviral effect.10(p58) Balm appears very safe to use both
topi- cally and orally.10(p58),25(p75) Other herbal preparations
have also shown test tube activity against herpes sim-
plex, but clinical studies have not yet been performed.
These include Echinacea, sweet marjoram, peppermint,
and propolis.10(p702)
Licorice and Hibiscus
Herpes zoster and postherpetic neuralgia have been
treated with a topical licorice (Glycyrrhiza glabra,
Glycyrrhiza uralensis) gel preparation.33(p155-156)
Glycyrrhizen, one of the active components of licorice,
has been shown to in- hibit replication of varicella
zoster.34 However, there have been no clinical studies to
support this. Topical use ap-
topically with hibiscus (Hibiscus sabdariffa).20(p394) This
has been shown to be very safe topically and orally.25(p61)

BACTERIAL AND FUNGAL
INFECTIONS Tea Tree Oil
Tea tree oil (see the "Acne" section for a description) has
been widely used topically for the treatment of bacterial
and fungal infections. Tea tree oil has shown in vitro
activity against a wide variety of microorganisms, in-
cluding Propionibacterium acnes, Staphylococcus
aureus, Escherichia coli, Candida albicans,
Trichophyton mentag- rophytes, and Trichophyton
rubrum.35,36 In a randomized double-blind trial of 104
patients, 10% tea tree oil cream was compared with 1%
tolnaftate cream and placebo cream. Symptomatic relief
was comparable in the tea tree oil and the tolnaftate
groups; however, there was signifi- cantly greater
mycologic cure in the tolnaftate group (85%) than the tea
tree oil group (30%). Cure rates between the tea tree oil
and placebo groups were not statistically dif- ferent.37
Another randomized double-blind study of 117 patients
compared a solution of 100% tea tree oil with
1% clotrimazole solution in the treatment of onychomy-
cosis. After 6 months of treatment, the 2 groups showed
comparable results on the basis of mycologic cure (11%
for clotrimazole and 18% for tea tree oil) and clinical as-
sessment and subjective rating of appearance and symp-
toms (61% for clotrimazole and 60% for tea tree oil).38
Therefore, tea tree oil may have a role in at least symp-
tomatic treatment of tinea pedis and onychomycosis and
other superficial wounds. However, it should not be used
for burns because of its cytolytic effect on epithelial cells
and fibroblasts.39
Garlic
Garlic (Allium sativum) contains ajoene, which has been
shown to have antifungal activity. In a study of 34 pa-
tients treated with 0.4% ajoene cream topically once a
day for tinea pedis, 79% noted clearing within 7 days and
the remainder had clearing within 14 days. At a 3-month
follow-up, all participants remained free of fungus.40
There are reports of contact dermatitis with frequent
topical ex- posure.20(p328) Oral administration should be
avoided while breastfeeding.25(p6) There are also reports
of prolonged bleeding when garlic is taken orally.20(p328)
SCABIES
Certain other common dermatologic infections have been
treated for centuries with herbal preparations. Anise
(Pimpinella anisum) seeds are a source of an essential oil
that has displayed antibacterial and insecticidal activity in
vitro and has been used topically to treat scabies and
head lice. It should not be used in pregnancy.25(p86) Neem
(Azadirachta indica) is indigenous to India, and every
part of the plant has been used medicinally. In a report of
more than 800 villagers in India, a paste of neem and tur-
meric applied topically appeared to treat chronic ulcers
and scabies.10(p452) It appears safe in adults, but it can be
poisonous to children.10(p453) Numerous other herbs have
been used for centuries in India and China to treat sca-
bies.20
CONDYLOMA AND VERRUCA
VULGARIS
There are also herbal preparations for the topical treat-
ment of condyloma and verruca vulgaris. Podophyllin,
used to treat condyloma acuminata, comes from the root
of the American mayapple (Podophyllum peltatum).20(p510)
It should not be used during pregnancy.25(p89) The German
commis- sion has approved bittersweet nightshade (S
dulcamara) and oat straw (Avena sativa) for the
treatment of common warts.20(p88,552) Calotropis
(Calotropis procera) is used in In- dia and greater
celandine (Chelidonium majus) is used in China for the
treatment of warts.20(p142,170) Bittersweet night- shade and
celandine should also be avoided in pregnancy and while
breastfeeding.20(p88,170)
DERMATITIS AND
PSORIASIS Chinese Herbal
Medicine
Traditional Chinese herbal medicine (CHM) for the treat-
ment of atopic dermatitis and psoriasis has recently re-
ceived much attention. In traditional Chinese medicine,
the body is treated as a whole and the aim of therapy is to
restore harmony to the functions of the body.41 This
requires a mixture of various herbs individually formu-
lated for the patient,42 making randomized controlled tri-
als difficult to undertake. Recently, 2 randomized
placebo- controlled crossover trials were performed in
England to study the effects of orally administered CHM
in the treat- ment of atopic dermatitis in which traditional
Western therapy had failed.42-44 The investigators were
aided by a Chinese physician who was able to create a
standard- ized mixture of 10 herbs useful in treating
atopic der- matitis characterized by erythema,
lichenification, and plaques of dermatitis in the absence
of active exudation or clinical infection. The 10 herbs
used were Potentilla chinensis, Tribulus terrestris,
Rehmannia glutinosa, Lo- phatherum gracile, Clematis
armandii, Ledebouriella sa- seloides, Dictamnus
dasycarpus, Paeonia lactiflora, Schi- zonepeta tenuifolia,
and G glabra.43 These herbs were placed in sachets and
boiled to make a decoction that was orally administered
daily as a tea. The placebo arm consisted of a decoction
made from several herbs with similar smells and tastes
that have no known efficacy in the treatment of atopic
dermatitis. The first study focused on 37 chil- dren and
showed a median decrease in erythema score of 51.0% in
the treatment group compared with only a
6.1% improvement in the placebo group. The percent-
age surface involvement also decreased by 63.1% and
6.2% for the treatment and placebo groups, respectively.
In this initial study, no serious adverse effects were
found. These
37 children were offered continued treatment with the
CHM and then followed up for 1 year.45 Eighteen chil-
dren completed the year of treatment and showed 90%
reduction in eczema activity scores. The children who
withdrew from the study did so because of lack of fur-
ther response to treatment, unpalatability of the tea, or
difficulty in preparation of the treatment. By the end of 1
year, 7 patients were able to discontinue therapy without
relapse. Asymptomatic elevation of aspartate aminotrans-
ferase level was noted in 2 patients, which returned to nor-
mal with discontinuing treatment. No other serious se-
quelae were observed. In the other study, the design was
similar; however, the investigators studied 31 adult pa-
tients with atopic dermatitis.42 Again, the decrease in ery-
thema and surface damage was statistically superior in the
treatment group compared with the placebo group. There
was also subjective improvement in itching and sleep.
These patients were also followed up for a year, with
continued improvement and no serious adverse effects,
whereas the patients who discontinued treatment noted a
decline in their condition.45 Although the sample sizes
were limited dur- ing the course of the study, initial results
were promising for patients in whom standard therapy
failed. The main limi- tation appeared to be the taste and
the preparation of the decoction. It should be emphasized,
however, that, al- though no serious adverse effects were
noted in this study, careful monitoring of complete blood
cell count and liver function is recommended, as reports of
liver failure and even death have been reported when
baseline laboratory values were not followed up.46-48
It is known that specific herbs used in these studies
have anti-inflammatory, antibacterial, antifungal, anti-
histaminic, immunosuppressant, and corticosteroidlike
effects. A few ingredients also are smooth muscle relax-
ants and inhibit platelet activating factor. Several stud-
ies have tried to elucidate the mechanism of action of this
group of 10 herbs (Zemophyte; Phytotech Limited, God-
manchester, England) in treating atopic dermatitis. It is
known that patients with atopic dermatitis have el- evated
levels of the low-affinity IgE receptor CD23 ex- pressed
on circulating monocytes. In studies of interleu- kin (IL)
4-induced CD23 expression on monocytes, there
appeared to be a reduction of the CD23 expression when
the cells were exposed to the aqueous herb extracts.2,49
Another study examined immunologic markers for T
cells, macrophages, Langerhans cells, and low-affinity
and high- affinity IgE receptors in biopsy specimens of
lesional skin treated with Zemophyte compared with
biopsy speci- mens of nonlesional skin.50 The
investigators found clini- cal improvement similar to that
seen in the studies de- scribed above and also found that
the improvement was associated with statistically
significant reduction in CD23 antigen-presenting cells.
In a survey of patients with psoriasis at a large uni-
versity dermatology practice, 51% of patients used 1 or
more alternative therapeutic modalities.51 This is
compatible with previous Norwegian surveys of patients
with psoriasis.52
Herbal therapy is one of the most frequently chosen alter-
native therapies. Psoriasis has been treated for centuries
with herbal preparations, both topical and oral. There are
many herbal preparations composed of furocoumarins,
which act as psoralens when combined with UV-A. One
common CHM, known as Radix Angelicae dahuricae,
contains the furocoumarins imperatorin, isoimpertorin,
and alloim- peratorin. In a study involving 300 patients
with psoria- sis, this CHM, taken orally, was combined
with UV-A therapy and compared with standard
treatment of psoralen- UV-A with methoxsalen. The
efficacy of the 2 treatments
was equivalent; however, there were fewer adverse
effects such as nausea and dizziness in the group treated
with the CHM and UV-A.46 There are also topical
preparations made from herbs that have shown systemic
efficacy against pso- riasis, but are too toxic when given
systemically.53 One ex- ample is the topical CHM
composed of the plant Campto- theca acuminata decne.
An open trial including 92 patients with psoriasis found
that this CHM was statistically more effective than 1%
hydrocortisone. However, allergic con- tact dermatitis
was seen in 9% to 15% of the patients in the CHM group.
Several other studies have compared various Chinese
herbal preparations with ethyliminum, which is a popular
"Western remedy" in China, although it is no longer used
as standard therapy for psoriasis in Western medicine.
Therefore, although results were promising, there is no
applicability, since ethyliminum is no longer used or
comparable with other current therapy. More double-
blind placebo-controlled trials are needed to compare
these herbal preparations with current standard Western
treat- ment. However, this is difficult, because the
mixture of herbs prescribed varies individually
depending on the subtype of psoriasis ("blood-heat" type,
"blood deficiency dry- ness" type, and "blood stasis"
type), which is determined in traditional Chinese
medicine by many findings, includ- ing the lesions of
psoriasis, the pulse, and the condition of the tongue.46
Aloe Vera
As previously described, aloe vera has been used for cen-
turies for wound healing and has recently been shown to
be a potential treatment for psoriasis. In a double- blind
placebo-controlled study, 60 patients with slight to
moderate plaque psoriasis were treated topically with
either 0.5% hydrophilic aloe cream or placebo. The aloe-
treated group showed statistically significant improve-
ment (83.3%) compared with placebo (6.6%). There were
no adverse effects in the treatment group.54
Capsaicin
The main ingredient in cayenne pepper, Capiscum fru-
tescens or capsaicin, has also been studied for the treat-
ment of psoriasis. Two trials have shown that 0.025%
cream used topically is effective in treating psoriasis. The
first study showed significant decrease in scaling and
erythema during a 6-week period in 44 patients with
moderate and severe psoriasis.55 The second was a
double- blind study of 197 patients with psoriasis treated
with the cream 4 times daily for 6 weeks. It showed a
signifi- cant decrease in scaling, thickness, erythema,
and pruritus.56 The main adverse effect reported was a
short- lived burning sensation at the application site.
Capsa- icin is contraindicated on injured skin or near the
eyes, and Commission E suggests it not be used for more
than 2 consecutive days, with a 14-day lapse between
applications.25(p23)
OTHER HERBS FOR TOPICAL
USE
In Europe, especially Germany, there is much attention to
the use of topical herbal preparations as corticosteroid-
sparing agents for the treatment of skin inflammation,
including dermatitis and psoriasis. Several herbs are cur-
rently approved by Commission E for topical treatment
of skin inflammation. These include the following bo-
tanicals: Arnica (Arnica montana), German chamomile
(Matricaria recutita), bittersweet nightshade (S dulca-
mara), and brewer's yeast (S cerevisia) are thought to
have anti-inflammatory and antibacterial effects.
Heartseases (Viola tricolor), English plantain (Plantago
lanceolata), fenugreek (Trigonella foenum-gaecum), and
flax (Linum usitatissimum) contain mucilages, which act
as emol- lients and soothe. Agrimony (Agrimonia
eupatoria), jam- bolan bark (Syzygium cumini), oak
(Quercus rubar), wal- nut (]uglans regia), and St
John's wort (Hypericum montana) contain tannins and
act as astringents. Oat straw (A sativa) is also approved
for its soothing and antipu- ritic qualities.8,9,10,20
Arniea
Arnica comes from the dried flowers of A montana or
other arnica species. Although oral administration can
cause severe health hazards in even small amounts, the
external preparations appear to be very safe and effective.
Arnica has been used for centuries as an anti-
inflammatory aid to rub into sore muscles and joints,
bruises, insect bites, boils, inflamed gums, acne
eruptions, and hemor- rhoids. It is also an ingredient
found in many seborrheic dermatitis and psoriasis
preparations. When used as a compress, 1 tbsp (15 mL)
of tincture is mixed with 0.5
L of water; if used as an infusion, 2 g of dried arnica is
mixed with 100 mL of water. The cream or ointment
preparations should contain a maximum of 15% arnica
oil or 20% to 25% tincture.9(p85),10(p45)
It has been known since the 1980s that the active
ingredients of arnica are the sesquiterpene lactones such
as helanalin, 11u,13-dihydrohelenalin, chamissonolid,
and their ester derivatives. It appears that these compo-
nents act to reduce inflammation by inhibiting the tran-
scription factor nuclear factor-KB. Nuclear factor-KB
controls the transcription of many genes, including
cytokines such as IL-1, IL-2, IL-6, IL-8, and tumor ne-
crosis factor u, as well as adhesion molecules intercel-
lular adhesion molecule 1, vascular cellular adhesion
molecule 1, and endothelial leukocyte adhesion mol-
ecule 1. It also inhibits many genes responsible for an-
tigen presentation and for cyclo-oxygenase II.57
Although most individuals tolerate the external
preparations well, there have been many reports of con-
tact dermatitis. There are also several reports of irrita-
tion when arnica is used at stronger concentrations or for
longer periods than are recommended. It is not recom-
mended to use it on open wounds or broken skin.25(p14)
Also, it is important to buy arnica from a reputable
source, as it is a protected species in some countries and
other plants have been surreptitiously used.
German Chamomile
German chamomile (M recutita), a member of the daisy
family, has been used for centuries, internally and ex-
ternally, for almost all ailments, most notably gastroin-
for the treatment of dermatitis include witch hazel, oak
bark, English walnut leaf, agrimony, jambolan bark, La-
brador tea, goldenrod, lady's mantle, lavender, mullein,
rhatany, Chinese rhubarb, yellow dock, and St John's
testinal tract symptoms, oral or skin inflammation, and
dermatitis. A tea is made by using 2 to 3 tsp (10-15 mL)
of dried flowers per cup of water and is taken internally
or used as a compress. Other topical preparations with
cream or ointment bases have also been used and stud-
ied in Germany.9(p324) Studies have shown that topical
chamomile is comparable with 0.25% hydrocortisone and
showed improvement in a sodium lauryl sulfate-
induced contact dermatitis.31 One small double-blind trial
found that chamomile significantly decreased the sur-
face area of wounds, and, in animal studies, healing time
was reduced with chamomile. It has also shown in vitro
antimicrobial activities.10(p157) The main adverse effect re-
ported is allergic contact dermatitis, and it is considered
safe to use topically and orally.25(p74)
The anti-inflammatory, wound-healing, and anti-
microbial effects of German chamomile are attributed to
a blue essential oil that contains sesquiterpene alcohol, u-
bisabolol, chamazulene, and flavinoids. These com-
ponents have shown anti-inflammatory and antispas-
modic properties in animal studies. This is partially at-
tributed to the inhibition of cyclo-oxygenase and
lipoxygenase in vitro. The flavinoids also act by inhib-
iting histamine release from antigen-stimulated human
basophilic polymorphonuclear leukocytes.31 Bisabolol has
also been shown to promote granulation tissue in wound
healing.10(p157)
Mueilage-Containing Herbs
Several herbs contain a substance called mucilage, which
is useful topically to soothe and act as an emollient on
skin. Mucilage quickly swells into a gooey mass when it
comes in contact with water, thereby aiding in dry or
mildly inflamed skin. The material will also dry and can
be used as an herbal bandage for minor wounds. The
herbs most notable for their mucilage content are flax,
fenu- greek, English plantain, heartseases, marshmallow,
mul- lein, and slippery elm.10,20
Oats
Oats have been used topically for several hundred years
for their soothing and antipruritic properties when placed
in baths, and they are approved for this use by the Ger-
man commission.9(p97),20(p552) Colloidal oatmeal turns to a
gooey mass when mixed with liquid, thereby coating the
skin and sealing in moisture. This soothing and mois-
turizing property is attributed to the gluten content in the
plant. This can be useful in atopic dermatitis as well as
idiopathic pruritus of the elderly.
Tannins
As previously mentioned, several herbs contain tan- nins,
which act as astringents. Tannins used topically are
thought to be beneficial in treating dermatitis by coagu-
lating surface proteins of cells, thereby reducing perme-
ability and secretion. The precipitated proteins also form
a protective layer on the skin.31 They may also have an-
timicrobial properties. Several herbs are known to con-
tain tannins. Some of the more commonly used agents
wort. Although there is limited research on the use of
these agents, one study showed that a witch hazel extract
in a phosphatidyl choline base was less effective in
reducing erythema from UV radiation and cellophane
tape strip- ping in 24 healthy patients than 1%
hydrocortisone.58 In another clinical trial, one group with
atopic dermatitis (n=36) and another group with contact
dermatitis (n=80) compared witch hazel extract with
control. In the atopic group, the witch hazel was slightly
superior in reducing inflammation and itching. There are
also anecdotal re- ports of witch hazel's usefulness in
treating atopic der- matitis.31
Pansy Flower
Pansy flower infusion is recommended by German health
authorities for the topical treatment of seborrheic der-
matitis, especially in infants. The infusion is made by
mix- ing 1 to 2 tsp of flowers per cup of water and is
used as a wet dressing. Salicylic acid in concentrations of
about
0.3% appears to be the active ingredient. It also contains
saponins and mucilage, which have softening and sooth-
ing action. No adverse effects have been reported with its
topical use.10(p480)
Jewelweed
Jewelweed (Impatiens biflora) is reputed to be useful in
topically treating poison ivy contact dermatitis. How-
ever, research results are conflicting. In a 1958 study,
treat- ment with jewelweed was comparable with
standard treat- ment for poison ivy contact dermatitis; in
108 of 115 patients, symptoms cleared within 2 to 3
days.59 How- ever, in a 1980 study, not only did
jewelweed extract fail to reduce symptoms of poison ivy
dermatitis, but symp- toms became worse, and in a recent
study there was no prophylactic effect of jewelweed in
poison ivy dermati- tis.60,61 Jewelweed has been
mentioned to be most help- ful if applied to the area the
poison ivy touched as soon after contact as possible;
however, this was not ad- dressed in the studies. There
have been no reports of topi- cal jewelweed causing
adverse effects.10(p365)
CHRONIC VENOUS
INSUFFICIENCY
Chronic venous insufficiency (CVI) is a common con-
dition affecting at least 10% to 15% of men and 20% to
25% of women.62 It is a source of great cost and morbid-
ity. Compliance with current treatments such as com-
pression stockings is poor, which has led to the search for
alternative therapies.
Horse Chestnut
Horse chestnut seed extract (HCSE) is one of the most
stud- ied herbal alternatives. Horse chestnut (Aesculus
hippocas- tanum) contains the plant compounds known
as terpenes, and the active component appears to be
aescin.10(p343) The
cular disorders than for CVI.10(p293),65 Care should be used
when ginkgo is taken orally, as there have been reports of
subarachnoid and intracerebral hemorrhage, as well as
increased bleeding time.20(p344)
mechanism of action appears to be related to inhibiting
leukocyte activation, an important physiological com-
ponent of CVI. It is also thought to prevent vascular leak-
age by inhibiting elastase and hyaluronase, which are in-
volved in proteoglycan degradation at the capillary
endothelium.63 There have been many double-blind ran-
domized trials of oral HCSE for patients with CVI. It has
been shown that HCSE decreases lower-leg volume as
well as calf and ankle circumference. There were also de-
creased symptoms such as fatigue, tenderness, and pru-
ritus. Another study showed relative equality of using
HCSE compared with grade II compression stockings for
treatment of CVI.64 Most of these studies achieved sta-
tistically significant results for treatment of CVI with
doses of HCSE containing 100 to 150 mg of aescin per
day, most commonly taken as 50 mg twice a day.
Adverse effects reported were minimal and included
gastrointestinal tract symptoms, dizziness, headache, and
pruritus. The rates of reported adverse effects were from
0.9% to 3.0% and in several studies were not statistically
different from rates of adverse effects with placebo.
Although there are no long-term studies of oral HCSE in
treating CVI and its sequelae, these results seem
promising and offer patients a safe alternative to
compression stockings. In Europe, HCSE has also been
used in the form of a topi- cal gel, lotion, or ointment to
reduce inflammation and discomfort associated with
varicose veins, phlebitis, and hemorrhoids.10(p344)
The seeds of the horse chestnut tree are poisonous
and must be specially prepared by a reputable manufac-
turer, such as those seeds currently on the American
market, to remove all toxins. Once the toxins have been
removed, it is considered relatively safe taken orally.
There has been one case report of drug-induced
lupus attributed to Venocuran (Knoll AG,
Ludwigshafen, Germany), a drug for venous
insufficiency containing HCSE.10(p344-345) There have been
reports of contact der- matitis when used topically.9(p269)
Grapeseed
In France there is also research on the use of herbs in
CVI. Several double-blind trials have studied the effects
of grapeseed extract on CVI. Grapeseed extract contains
oligomeric proanthocyanidins, which are bioflavinoids
shown to be beneficial in strengthening capillaries. The
dosage in the studies varied from 50 mg orally once a
day to 100 mg 3 times per day. No serious adverse effects
have been reported.20(p363-364)
Ginkgo
Ginkgo (Ginkgo biloba) has been used orally in China
for centuries and more recently in Europe and the United
States for numerous conditions, including heart dis- ease,
asthma, vertigo, tinnitus, impotence, cerebral and
vascular insufficiency, peripheral vascular disorders, de-
mentia, and other conditions. Much research indicates
that ginkgo promotes vasodilation, thereby improving
many of the conditions above. Most of this research on
ginkgo relates to cerebral insufficiency and claudica-
tion, suggesting that it may be more useful for these vas-
Witch Hazel
Witch hazel (H virginiana) contains considerable
amounts of tannin, making it a useful astringent. It has
been used topically to soothe inflammation of the skin
and mu- cous membranes in such disorders as varicose
veins and hemorrhoids. Animal research suggests that the
witch ha- zel extract has local styptic and
vasoconstrictive effects. The alcohol fluid extract has
also been shown to cause venous constriction in rabbits;
thus, it is often used orally for CVI in Europe. Although
it appears safe when taken orally, efficacy of such
treatment has not been well stud- ied in humans.8(pp670-
672),25(p59)
Butcher's Broom and Sweet Clover
In addition to horse chestnut, the German commission
has approved orally administered butcher's broom (Rus-
cus acuteatus) and sweet clover (Melilotus officinalisis)
for relief of symptoms associated with venous
insufficiency such as pain, heaviness, pruritus, and
swelling. In ani- mal studies, butcher's broom has been
shown to in- crease venous tone and also has diuretic
properties. Sweet clover has been shown to increase
venous reflux.20(p132) However, reflux is probably a
misnomer, as the term is generally used to describe a
backward flow, and in the case of venous return it would
indicate undesired pool- ing. A better description of the
effect of sweet clover would be to say that it increases
venous return. Both butcher's broom and sweet clover
appear to be safe when used as recommended.20(p132),25(p100)
ALOPECIA
Essential Oils
Few randomized trials have studied herbal remedies for
alopecia. Recently, a randomized controlled double-
blind study of 86 patients with alopecia areata was per-
formed.66 A mixture of essential oils including thyme,
rose- mary, lavender, and cedarwood in carrier oils;
grapeseed; and jojoba (a liquid wax) was massaged into
the scalp daily. The control group massaged only the
carrier oils into the scalp. Success was evaluated on the
basis of se- quential photographs, by both a 6-point scale
and a com- puterized analysis of areas of alopecia.
Overall, the treat- ment group had statistically significant
improvement over the control group (44% vs 15%). This
improvement com- pares with the success of standard
treatment practices used conventionally. There were no
adverse effects.
Chinese Herbal Medicine
Another study evaluated the topical use of a Chinese
herbal formula, Dabao (Engelbert : Vialle, Venlo, the
Netherlands), for the treatment of androgenic alope- cia.67
In this study, 396 patients participated in the double-
skin tumors.73 A recent survey of older patients com-
pared tea consumption and history of squamous cell car-
cinoma. There was a lower risk of squamous cell carci-
noma in patients who consumed hot black tea than in
blind placebo trial, which lasted 6 months. The compo-
nents of Dabao include 50% ethanol, 42% water, and 8%
Chinese herbal extracts, including saffron flowers, mul-
berry leaves, stemona root, fruits of the pepper plant,
sesame leaves, the skin of the Szechuan pepper fruit, gin-
ger root, Chinese angelica root, bark of the pseudolarix,
and fruit of the hawthorn. The components of the pla-
cebo included 50% ethanol, 48% water, and 2% odor and
coloring agents consisting of cherry laurel water, cinna-
mon water, licorice syrup, sugar syrup, and a solution of
burned sugar. In both groups there was an increase in
nonvellus hairs. Although the Dabao group was statisti-
cally superior to the placebo group in number of non-
vellus hairs, the cosmetic improvement in both groups
was minimal. Therefore, although there were no re-
ported adverse effects, improvement is unlikely.
SKIN
CANCER Tea
There has been much research on the use of teas in the
prevention and treatment of skin cancer. Tea is manu-
factured from the leaf and bud of Camellia sinensis. The
majority of tea consumed worldwide is in the form of
black tea. However, in Asia, green tea is most commonly
con- sumed, and oolong tea is popular in China. Teas
con- tain polyphenolic compounds, which have
antioxidant properties. The oxidative states of these
compounds vary between the different tea formulations.
Green tea is pro- duced from the fresh leaves, and
preparation is aimed at avoiding oxidation and
polymerization of the polyphe- nols. Production of black
tea involves a controlled fer- mentation process. Green
tea has been shown in several mouse models to have anti-
inflammatory and antitu- morigenic properties. This is
thought to be due to the polyphenolic constituent (-)-
epigallocatechin-3- gallate. Numerous studies of green
tea and skin cancer were recently reviewed.68 It was
found that topical ap- plication or oral consumption of
green tea protects against inflammation, chemical
carcinogenesis, and photocar- cinogenesis. Green tea has
been shown to block many mediators in the inflammatory
process important in the early steps of skin tumor
promotion. It also appears that there is inhibition of
biochemical markers of chemical carcinogenesis,
inhibition of UV-induced oxidative stress, and prevention
of UV-induced immunosuppression.68
There is also evidence that green tea protects against pso-
ralen-UV-A-induced photochemical damage to the skin.69
Therefore, many cosmetics and skin care products re-
cently have been supplemented with green tea. How-
ever, more research in humans is needed to understand
the true benefits.
There is also evidence that black tea may play a role
in the prevention of skin tumors. It appears that the the-
aflavins are the active components in chemopreven-
tion.70 Several studies have provided evidence that topi-
cal application of constituents in black tea can decrease
UV-B-induced erythema, inhibit tumor initiation, and act
as an antitumor promoter.71,72 Oral administration of black
tea also appears to inhibit tumor proliferation and pro-
motes tumor apoptosis in nonmalignant and malignant
nonconsumers.74 Studies comparing the effectiveness of
black and green teas in protecting against UV-induced
skin tumors are conflicting as to which is more benefi-
cial.75-78 However, it does appear that caffeinated teas are
more protective than decaffeinated teas and that caf-
feine alone has some inhibitory effects on UV-B-
induced carcinogenesis.76-78
Rosemary
There are also a few reports of other herbs playing a role
in the prevention of skin tumors in mice. Rosemary (Ros-
marinus officinalis) extract has been reputed to have an-
tioxidant activity. Recently, a methanol extract of the
leaves was evaluated for its effects on skin tumors in
mice. It was found that topically applied rosemary
inhibited in- duction and promotion of skin tumors in
mice treated with known chemical carcinogens. Although
the exact mechanism of action is still under study, it
appears that several components of the extract are
important in this process. This finding suggests that it
was not the anti- oxidant properties alone that were
beneficial in the pre- vention of skin tumors.79 Rosemary
should not be used in pregnancy.25(p99)
Propolis
Propolis is a resinous material produced by honeybees
from the buds and bark of certain plants and trees. It has
been used for centuries for antimicrobial, anti-
inflammatory, analgesic, and antitumor effects. These
properties are thought to be due to the flavinoid and re-
lated phenolic acids that are components of propolis. Re-
cently, a tumoricidal component, clerodane diterpe- noid,
was isolated. This compound was studied for its topical
effects on skin tumorigenesis in mice. Clero- dane
diterpenoid appeared to reduce the incidence of
chemically induced dysplastic papillomas by inhibiting
the synthesis of DNA in a de novo pathway and by sup-
pressing the growth of tumors by decreasing DNA syn-
thesis in a salvage pathway.80
Red Ginseng
Red ginseng is a classic traditional Chinese medicine
thought to enhance immune function of the body. In a
recent study, red ginseng extracts used topically ap-
peared to inhibit chemically induced skin tumors in mice.
This is thought to be due to immune-modulating prop-
erties of the red ginseng.8l
Silymarin
Silymarin is a flavinoid isolated from milk thistle (Sily-
bum marianum) and is approved by the German com-
mission for liver disease because of its antioxidant prop-
erties. Recently, a study was performed to assess whether
this antioxidative effect would protect against tumor pro-
dermatologic setting are discussed. The immune-
modulating effects of Echinacea, Astragalus, licorice, al-
motion. Topically applied silymarin appeared to pos- sess
high protective effects against chemically induced skin
tumor promotion in mice. This may involve inhi- bition
of promoter-induced edema, hyperplasia, and pro-
liferation as well as the oxidant state.82 These results are
promising, yet more research involving human models is
needed. Silymarin appears to be safe to use topically and
orally when used appropriately.25(pl07)
ADVERSE EFFECTS OF HERBAL THERAPY
Many patients have the misconception that, because
herbs are "natural," there are no adverse effects.
Physicians of- ten do not question patients about herbal
supplements, and patients are often reluctant to divulge
the use of these agents for fear of criticism from their
physician. It is im- portant that dermatologists become
aware of the most common, as well as the more serious,
effects. This will aid in better education of patients, as
well as better di- agnosis of possible fatal sequelae.
Herbal therapies vary greatly in their therapeutic in-
dexes. For example, some are consumed as foods and
have high therapeutic indexes, and others are highly
biologi- cally active and must be used very carefully.
Safety of the herbs mentioned in this article were
addressed in each section, and further discussion of
interactions of herbal therapies that may be encountered
in the dermatologic setting follows.
Many cutaneous reactions to herbal preparations
have been reported. The most common cutaneous ad-
verse effect of herbal preparations is allergic contact der-
matitis. However, more serious cutaneous reactions have
been reported. Two patients developed erythroderma af-
ter using topical herbal treatments for psoriasis and
atopic dermatitis, and l patient developed Stevens-
Johnson syn- drome after taking "Golden Health Blood
Purifying Tab- lets," which contained multiple herbs,
including red clo- ver, burdock, queen's delight, poke
root, prickly ash, sassafras bark, and Passiflora.83 There
have been reports of bullous and nodular lichen planus
induced by inges- tion of native African medicines.84 A
young woman has also been described with leukemia-
related Sweet syn- drome elicited by pathergy to topical
arnica cream.85
Serious systemic adverse effects have been re-
ported with the use of CHM for the treatment of derma-
tologic disorders. The most common are hepatotoxic ef-
fects. Although most patients recover without serious
consequences as long as the medication is stopped, there
have been reports of patients with acute liver failure and
death. There are also reports of renal failure and agranu-
locytosis.46-48 One patient has been described with adult
respiratory distress syndrome after administration of a
CHM, Kamisyoyo-san, for seborrheic dermatitis.86 An-
other patient was described with reversible dilated car-
diomyopathy after treatment for her atopic dermatitis
with a Chinese herbal tea.87 There are also several reports
of Chinese and Indian herbal medicines containing heavy
metals, such as lead, arsenic, and mercury. Prescription
medications have also been found in over-the-counter
herbal formulations from other countries.
There are many possible drug interactions with
herbs and prescription medications. The most important
in the
falfa sprouts, vitamin E, and zinc may decrease the effi-
cacy of corticosteroids and immunosuppressants.88 There
are herbs that have been shown to cause hepatitis and
therefore should not be used in combination with such
medications as methotrexate. These include many of the
ingredients in the CHM preparations, as well as Echina-
cea, chaparral, germander, ragwort, and life root.87,89
Herbs containing gamolenic acid, such as evening
primrose oil, which has been used for dermatitis,
psoriasis, and xero- sis, lower the seizure threshold, and
therefore dosages of anticonvulsants may need to be
increased.87
In addition to the adverse effects discussed already,
patients should be counseled on the lack of regulation for
herbal medicines. There are no quality-control measures
currently in place in the United States to ensure the pu-
rity, concentration, or safety of herbal supplements. Al-
though herb manufacturers are restricted from making ef-
ficacy statements, there are no regulations on claims for
which symptoms these herbs can alleviate. In the United
States, there are also no regulations on which herbs can
be restricted in formulations.90
CONCLUSIONS
The use of alternative medical therapy including herbs is
increasing dramatically in the United States. Many of
these herbal therapies have been used for centuries and
show good anecdotal results. A few randomized con-
trolled trials have also shown promising results in the use
of herbal therapies for the treatment of dermato- logic
disorders. Other countries, such as Germany, are now
requiring standardization of herbal preparations and
making specific recommendations as to the use and ef-
ficacy of herbs in the treatment of disease. However,
much more research is needed. For now, it is important to
know what common herbal alternatives exist and which
po- tential adverse effects can occur so as to counsel pa-
tients more effectively.
Accepted for publication ]uly 6,
2001.
Corresponding author and reprints: Philip D.
Shenefelt, MD, Division of Dermatology and Cutaneous
Surgery, Box
79, Department of Internal Medicine, College of
Medicine, University of South Florida, 12901 Bruce B.
Downs Blvd, Tampa, FL 33612 (e-mail:
pshenefe@hsc.usf.edu).
REFERENCES
1. Routh HB, Bhowmik KR. Traditional Indian medicine in dermatology.
Clin Der- matol. 1999;17:41-47.
2. Latchman Y, Whittle B, Rustin M, Atherton DJ, Brostoff J. The efficacy
of tradi- tional Chinese herbal therapy in atopic eczema. Int Arch
Allergy Immunol. 1994;
104:222-226.
3. Winslow LC, Kroll DJ. Herbs as medicine. Arch Intern Med.
1998;158:2192-
2199.
4. Winston D, Dattner A. The American system of medicine. Clin
Dermatol. 1999;
17:53-56.
5. Neldner KH. Complementary and alternative medicine. Dermatol Clin.
2000;18:
189-193.
6. Klepser TB, Klepser ME. Unsafe and potentially safe herbal therapies.
Am J Health
Syst Pharm. 1999;56:125-138.
7. Eisenburg DM, Kessler RC, Foster C, et al. Unconventional medicine
in the United
States: prevalence, costs and pattern uses. N Engl J Med.
1993;328:246-
252.
8. Blumenthal M, Gruenwald J, Hall T, Rister RS, eds. The Complete
German Com- mission E Monographs: Therapeutic Guide to Herbal
Medicine. Boston, Mass: Integrative Medicine Communications; 1998 .
9. Bisset NG, Wichtl M, eds. Herbal Drugs and Phytopharmaceuticals.
2nd ed. Boca
Raton, Fla: CRC Press; 2001.
10. Peirce A, Fargis P, Scordato E, eds. The American Pharmaceutical
Association
Practical Guide to Natural Medicines. New York, NY: Stonesong Press
Inc; 1999.
11. Buchness MR. Alternative medicine and dermatology. Semin Cutan
Med Surg.
1998;17:284-290.
12. Hunt MJ, Barnston RS. A comparative study of gluconolactone versus
benzoyl peroxide in the treatment of acne. Australas J Dermatol.
1992;33:131-134.
13. Swords G, Hunter GLK. Composition of Australian tea tree oil. J Agric
Food Chem.
1978;26:734-737.
14. de Groot AC, Weyland JW. Contact allergy to tea tree oil. Contact
Dermatitis. 1993;
28:309.
15. Selvaag E, Eriksen B, Thure P. Contact allergy due to tea tree oil and
cross- sensitization to colophony. Contact Dermatitis. 1994;31:124-
125.
16. Knight TE, Hansen BM. Melaleuca oil (tea tree oil) dermatitis. J Am
Acad Der- matol. 1994;30:423-427.
17. Elliot C. Tea tree oil poisoning. Med J Aust. 1993;159:830-831.
18. Moss A. Tea tree oil poisoning [letter]. Med J Aust. 1994;160:236.
19. Hausen BM, Reichling J, Harkenthal M. Degradation products of
monoterpenes are sensitizing agents in tea tree oil. Am J Contact
Dermatitis. 1999;10(2):68-77.
20. Fleming T, ed. PDR for Herbal Medicines. 2nd ed. Montvale, NJ:
Medical Eco- nomics Co; 2000.
21. Klein AD, Penneys NS. Aloe vera. J Am Acad Dermatol. 1988;18:714-
720.
22. Fujita K, Shosike I. Bradykinase activity of aloe extract. Biochem
Pharmacol. 1976;
25:205.
23. Robinson MC, Heggers JP, Hagstrom WJ. Myth, magic, witchcraft, or
fact? aloe vera revisited. J Burn Care Rehab. 1982;3:157-162.
24. Reynolds T, Dweck AC. Aloe vera leaf gel: a review update. J
Ethnopharmacol.
1999;68:3-37.
25. McGuffin M, Hobbs C, Upton R, Goldberg A, eds. Botanical Safety
Handbook.
Boca Raton, Fla: CRC Press; 1997.
26. Greenwood D. Honey for superficial wounds and ulcers. Lancet.
1993;341:90-
91.
27. Efam SE, Udoh KT. The antimicrobial spectrum of honey and its
clinical signifi- cance. Infection. 1992;29:527-529.
28. Vardi A, Barzilay Z, Linder N, Cohen HA, Paret G, Barzilai A. Local
application of honey for the treatment of neonatal postoperative wound
infections. Acta Pae- diatr. 1998;87:429-432.
29. Subrahmanyam M. Honey impregnated gauze versus polyurethane
film (Op- Site) in the treatment of burns: a prospective randomised
study. Br J Plastic Surg. 1993;46:322-323.
30. Efem SE. Clinical observations on the wound healing properties of
honey. Br
J Surg. 1988;75:679-681.
31. Brown DJ, Dattner AM. Phytotherapeutic approaches to common
dermatologi- cal conditions. Arch Dermatol. 1998;1:15-17.
32. Wobling RH, Leonhardt K. Local therapy of herpes simplex with dried
extract of
Melissa officinalis. Phytomedicine. 1994;1:25-31.
33. Lininger SW, ed. The Natural Pharmacy. 2nd ed. Montvale, NJ:
Medical Eco- nomics Co; 2000.
34. Baba M, Shigeta S. Antiviral activity of glycyrrhizen against varicella
zoster virus in vitro. Antiviral Res. 1987;7:99-107.
35. Williams LR, Home VN, Zang X. The composition and bactericidal
activity of oil of Melaleuca alternifolia. Int J Aromather. 1988;1(3):15-
17.
36. Beylier MF. Bacteriostatic activity of some Australian essential oils.
Perfum Fla- vor. 1979;4(2):23-25.
37. Tong MM, Altman PM, Barnetson R. Tea tree oil in the treatment of
tinea pedis.
Australas J Dermatol. 1992;33:145-149.
38. Buck DS, Nidorf DM, Addini JG. Comparison of two topical 393-395.
preparations for the treatment of onychomycosis: Melaleuca 41. Atherton DJ, Sheehan MP, Rustin MHA, Whittle B, Guy G. Treatment
alternifolia (tea tree) oil and clotrima- zole. J Fam Pract. 1994;38:601- of atopic eczema with traditional Chinese medicinal plants. Pediatric
605. Dermatol. 1992;9:
39. Faoagali J, George N, Leditschke JF. Does tea tree oil have a place in 373-375.
the topical treatment of burns? Burns. 1997;23:349-351. 42. Sheehan MP, Rustin MHA, Atherton DJ, et al. Efficacy of traditional
40. Ledezma E, DeSousa L, Jorquera A. Efficacy of ajoene, an Chinese herbal therapy in adult atopic dermatitis. Lancet.
organosulphur de- rived from garlic, in the short-term therapy of tinea 1992;340:13-17.
pedis. Mycoses. 1996;39:
 43. Sheehan MP, Atherton DJ. A controlled trial of traditional Chinese medicinal plants in widespread non-exudative atopic
eczema. Br J Dermatol. 1992;126:179-184.
44. Armstrong NC, Ernst E. The treatment of eczema with Chinese herbs: a system- atic review of randomized clinical trials. Br
J Clin Pharmacol. 1999;48:262-264.
45. Sheehan MP, Atherton DJ. One-year follow up of children treated with Chinese medicinal herbs for atopic eczema. Br J
Dermatol. 1994;130:488-483.
46. Koo J, Arain S. Traditional Chinese medicine for the treatment of dermatologic disorders. Arch Dermatol. 1998;134:1388-
1393.
47. Graham-Brown R. Toxicity of Chinese herbal remedies [letter]. Lancet. 1992;
340:673.
48. Mostefa-Kara N, Pauels A, Pines E, Biour M, Levy VG. Fatal hepatitis after herba l tea. Lancet. 1992;340:674.
49. Latchman Y, Banerjee P, Poulter LW, Rustin M, Brustoff J. Association of im- munological changes with clinical efficacy in
atopic eczema patients treated with traditional Chinese herbal therapy (Zemaphyte ). Int Arch Allergy Immunol. 1996;
109:243-249.
50. Xu XJ, Banerjee P, Rustin MHA, Poulter LW. Modulation by Chinese herbal therapy of immune mechanisms in the skin of
patients with atopic eczema. Br J Derma- tol. 1997;136:54-59.
51. Fleischer AB, Feldman SR, Rapp SR, Reboussun DM, Exum ML, Clark AR. Al- ternative therapies commonly used within a
population of patients with psoria- sis. Cutis. 1996;58:216-220.
52. Jensen P. Use of alternative medicine by patients with atopic dermatitis and pso- riasis. Acta Derm Venereol. 1990;70:421-
424.
53. Ng SK. Topical traditional Chinese medicine. Arch Dermatol. 1998;134:1395-
1396.
54. Syed TA, Ahmad SA, Holt AH, Ahmad SA, Ahmad SH, Afzal M. Management of psoriais with aloe vera extract in a
hydrophilic cream: a placebo-controlled, double- blind study. Trop Med Int Health. 1996;1:505-509.
55. Bernstein JE, Parish LC, Rapaport M, et al. Effects of topically applied capsaicin on moderate and severe psoriasis vulgaris.
J Am Acad Dermatol. 1986;14:504-
507.
56. Ellis CN, Berberian B, Sulica VI, et al. A double-blind evaluation of topical cap- saicin in pruritic psoriasis. J Am Acad
Dermatol. 1993;29:438-442.
57. Lyss G, Schmidt TJ, Merfort I, Pahl HL. Helenalin, an anti-inflammatory sesqui- terpene lactone from arnica, selectively
inhibits transcription factor NF-KB. Biol Chem. 1997;378:951-961.
58. Korting HC, Schafer-Korting M, Hart H, Laux P, Schmid M. Anti-inflammatory activity of hamamelis distillate applied topically
to the skin. Br J Clin Pharmacol.
1993;44:315-318.
59. Lipton RA. Comparison of jewelweed and steroid in the treatment of poison ivy contact dermatitis. Ann Allergy.
1958;16:526-567.
60. Guin JD, Reynolds R. Jewelweed treatment of poison ivy dermatitis. Contact Der- matitis. 1980;6:287-288.
61. Long D, Ballentine NH, Marks JG Jr. Treatment of poison ivy/oak allergic con- tact dermatitis with an extract of jewelweed.
Am J Contact Dermatol. 1997;8:
150-153.
62. Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81:167-173.
63. Pittler MH, Ernst E. Horse-chestnut seed extract for chronic venous insuffi- ciency. Arch Dermatol. 1998;143:1356-1360.
64. Diehm C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic
venous insufficiency. Lancet. 1996;347:
292-294.
65. Hadley SK, Petry JJ. Medicinal herbs: a primer for primary care. Hosp Pract. 1999;
34(6):105-123.
66. Hey IC, Jamieson M, Ormerod AD. Randomized trial of aromatherapy. Arch Der- matol. 1998;134:1349-1352.
67. Kessels AGH, Cardynaals RLLM, Borger RLL, et al. The effectiveness of the hair restorer "Dabao" in males with alopecia
androgenetica: a clinical experiment. J Clin Epidemiol. 1991;44:439-447.
68. Katiyar SK, Ahmad N, Mukhtar H. Green tea and skin. Arch Dermatol. 2000;136:
989-994.
69. Zhao JF, Zhang YJ, Jin XH, et al. Green tea protects against psoralen plus ultra- violet A-induced photochemical damage
to skin. J Invest Dermatol. 1999;113:
1070-1075.
70. Nomura M, Ma WY, Huang C, et al. Inhibition of ultraviolet B-induced AP-1 ac- tivation by theaflavins from black tea. Mol
Carcinog. 2000;28:148-155.
71. Zhao J, Jin X, Yaping E, et al. Photoprotective effect of black tea extracts against
UVB-induced phototoxicity in skin. Photochem Photobiol. 1999;70:637-644.
72. Javed S, Mehrotra NK, Shukla Y. Chemopreventive effects of black tea polyphe- nols in mouse skin model of
carcinogenesis. Biomed Environ Sci. 1998;11:307-
313.
73. Lu YP, Lou YR, Xie JG, Yen P, Huang MT, Conney AH. Inhibitory effect of black tea on the growth of established skin
tumors in mice: effects on tumor size, apop- tosis, mitosis, and bromodeoxyuridine incorporation into DNA. Carcinogenesis.
1997;18:2163-2169.
74. Hakim IA, Harris RB, Weisgerber UM. Tea intake and squamous cell carcinoma of the skin: influences of type of tea
beverages. Cancer Epidemiol Biomarkers Prev. 2000;9:727-731.
75. Record IR, Dreosti IE. Protection by black tea and green tea against UVB and
UVA + B induced skin cancer in hairless mice. Mutat Res. 1998;422:191-199.
76. Huang MT, Xie JG, Wang ZY, et al. Effects of tea, decaffeinated tea, and caffeine on UVB light-induced complete
carcinogenesis in SKH-1 mice: demonstration of caffeine as a biologically important constituent of tea. Cancer Res.
1997;57:
2623-2629.
77. Lou YR, Lu YP, Xie JG, Huang MT, Conney AH. Effects of oral administration of tea, decaffeinated tea, and caffeine on the
formation and growth of tumors in the high-risk SKH-1 mice previously treated with ultraviolet B light. Nutr Cancer. 1999;
33:146-153.
78. Wang ZY, Huang MT, Lou YR, Xie JG, Reuhl KR, Newmark HL. Inhibitory effects of black tea, green tea, decaffeinated
black tea, and decaffeinated green tea on ultraviolet B light-induced skin carcinogenesis in 7,12-dimethybez[a]anthracene-
initiated SKH-1 mice. Cancer Res. 1994;54:3428-3435.
79. Huang MT, Ho CT, Wang ZY, et al. Inhibition of skin tumorigenesis by rosemary and its constituents carnosol and ursolic
acid. Cancer Res. 1994;54:701-708.
80. Mitamura T, Matsuno T, Sakamoto S, Maemura M, Kudo H, Satoe S. Effects of a new clerodane diterpenoid isolated from
propolis on chemically induced skin tumors in mice. Anticancer Res. 1996;16:2669-2672.
81. Xiaoguang C, Hongyan L, Xiaohong L, Zhaodi F, Yan L, Lithua T. Cancer che- mopreventive and therapeutic activities of
red ginseng. J Ethnopharmacol. 1998;
60:71-78.
82. Lahiri-Chatterjee M, Katiyar SK, Mohan RR, Agarwal R. A flavinoid antioxidant , silymarin, affords exceptionally high
protection against tumor promotion in the SENCAR mouse skin tumorigenesis model. Cancer Res. 1999;59:622-632.
83. Monk B. Severe cutaneous reactions to alternative remedies. BMJ. 1986;293:
665-666.
84. Soyinka F. Atypical lichen planus induced by native medicine. Br J Dermatol. 1973;
88:341-345.
85. Delmonte S, Brusati C, Parodi A, Rebora A. Leukemia-related Sweet's syndrome elicited by pathergy to arnica.
Dermatology. 1998;197:195-197.
86. Shota Y, Wilson JG, Matsumoto H, et al. Adult respiratory distress syndrome induced by a Chinese medicine, kamisyoyo-
san. Intern Med. 1961;65:494-496.
87. Ferguson JE, Chalmers RJG, Rowlands DJ. Reversible dilated cardiomyopathy following treatment of atopic eczema with
Chinese herbal medicine. Br J Der- matol. 1997;136:592-593.
88. Miller LG. Herbal medicinals. Arch Intern Med. 1998;158:2200-2208.
89. Borins M. The dangers of using herbs: what your patients need to know. Post- grad Med. 1998;104:91-100.
90. Shaw D. Risks or remedies? safety aspects of herbal remedies in the UK. J R Soc Med. 1998;91:294-296.