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Malva Sylvestris in the treatment of hand eczema

Authors:
Behrooz Barikbin at Shahid Beheshti University of Medical Sciences
Behrooz Barikbin
Afsaneh Maarefat
Afsaneh Maarefat
Afsaneh Maarefat
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Rayhaneh Rahgoshai at Shahid Beheshti University of Medical Sciences
Rayhaneh Rahgoshai
Hamideh Moravvej at Shahid Beheshti University of Medical Sciences
Hamideh Moravvej
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Abstract

Background: Hand eczema is one of the most common dermatologic diseases requiring treatment but common therapeutics such as corticosteroids and anti-histamines have numerous side effects. So, use of herbal agents, which generally have no major side effects, may be useful especially if their efficacy is established. Malva Sylvestris (MS) is a tropical plant in Iran with cooling characteristics. Hence, in this study, its efficacy in of the treatment of hand eczema was evaluated. Methods: In this randomized clinical trial, 50 patients with hand eczema who were visited at Shohada-e Tajrish and Loghman hospitals, Tehran, Iran, between 2006 and 2008, were recruited and divided into two groups. In the first group, MS 4% ointment was applied twice a day and in the other group, placebo ointment was usd. The efficacy and side effects were evaluated three and six weeks after beginning of the treatment. Results: Mean age of the patients was 37.3 years and 35.6 years in MS and placebo groups, respectively (P > 0.05). There were no therapeutic adverse effects in the groups. There was a statistically significant difference in all measured scores between two groups in the first and second follow-up sessions (P < 0.0001). Conclusion: Malva Sylvestris seems to be a safe and effective therapeutic modality for the treatment of hand eczema and can be used as an optimal substitute for corticosteroids and anti-histamines.
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131
Original article
Iranian Journal of Dermatology, Vol 13, No 4, Winter 2010
Malva Sylvestris in the treatment of hand eczema
Background: Hand eczema is one of the most common dermatologic
diseases requiring treatment but common therapeutics such as
corticosteroids and anti-histamines have numerous side effects.
So, use of herbal agents, which generally have no major side
effects, may be useful especially if their efficacy is established.
Malva Sylvestris (MS) is a tropical plant in Iran with cooling
characteristics. Hence, in this study, its efficacy in of the treatment
of hand eczema was evaluated.
Methods: In this randomized clinical trial, 50 patients with hand
eczema who were visited at Shohada-e Tajrish and Loghman
hospitals, Tehran, Iran, between 2006 and 2008, were recruited
and divided into two groups. In the first group, MS 4% ointment
was applied twice a day and in the other group, placebo ointment
was usd. The efficacy and side effects were evaluated three and
six weeks after beginning of the treatment.
Results: Mean age of the patients was 37.3 years and 35.6 years
in MS and placebo groups, respectively (P > 0.05). There were no
therapeutic adverse effects in the groups. There was a statistically
significant difference in all measured scores between two groups
in the first and second follow-up sessions (P < 0.0001).
Conclusion: Malva Sylvestris seems to be a safe and effective
therapeutic modality for the treatment of hand eczema and can
be used as an optimal substitute for corticosteroids and anti-
histamines.
Keywords: Malva Sylvestris, herbal drugs, dermatitis, eczema, treatment
Behrooz Barikbin, MD
Afsaneh Maarefat, MD
Rayhaneh Rahgoshai, MD
Hamideh Moravvej, MD
Nahid Mohtasham, MD
Maryam Yousefi, MD
Skin Research Center, Shahid
Beheshti University of Medical
Sciences, Tehran,Iran
Corresponding Author:
Maryam Yousefi, MD
Skin Research Center, Shahid
Beheshti University of Medical
Sciences, Tehran,Iran
E-mail: myousefi_md@yahoo.com
INTRODUCTION
Hand eczema is one of the most common
dermatological diseases requiring treatment
1,2
but the treatment usually fails due to the
relapsing feature of hand eczema
3
. On the
other hand, use of conventional drugs such as
corticosteroids and anti-histamines for a long
time is not without adverse effects
4-6
. Hence,
using some natural drugs, especially herbal
ones, would be beneficial. Also, there has been
a resurgence in public’s demand for herbal
remedies in recent years
7
. Three categories of
herbs used for people with hand eczema: anti-
inflammatories and herbs that affect the immune
system (immunomodulators), astringents (herbs
that bind to fluids and exudates so they are only
helpful when weeping eczema is present), and
herbs that affect the liver (also called alterative,
are poorly researched). Herbal drugs are usually
without considerable side effects and if their
efficacy is established, they can be of use for
the treatment of atopic dermatitis and hand
eczema
8
.
Among available herbal derivatives, the
efficacy of some such as Phenol, Chamomile,
Calendula, Chickweed, Menthol and Aloe Vera has
been established, especially due to their cooling
characteristics and few side effects
8
. However,
the efficacy of other herbal agents with cooling
Iran J Dermatol 2010; 13: 131-4
Received:June 27, 2010
Accepted: September 16, 2010
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Iranian Journal of Dermatology
©
2010 Iranian Society of Dermatology
properties may also be evaluated in clinical settings
among volunteer subjects. One of these plants
is Malva Sylvestris (MS). This plant is a tropical
species which grows in some regions of the Middle
East, especially Iran. It is also one of the most
important medicinal species in southern Italy. MS
is important in topical remedies for the treatment
of heat- and diaper- rash, bruise and some other
common diseases in Italy
9,10
. It is documented that
phytoalexin, malvone A (2-methyl-3-methoxy-5,6-
dihydroxy-1,4-naphthoquinone) is also induced
in MS
11
. MS leaves and flowers contain high
amounts of mucilage which is made up of complex
carbohydrates and gives MS most of its soothing
activity, though flavonoids and anthocyanidins
may also contribute. In herbal medicine, MS is
classified as a demulcent—a soothing agent that
counters irritation and mild inflammation
12,13
.
Although this plant is used as a drug in traditional
medicine, there is no academically performed
clinical trial about it and therefore, this study was
conducted to compare the efficacy of this agent
with placebo.
PATIENTS AND METHODS
In this randomized clinical trial, 123 patients
with hand eczema who were visited at Shohada-
e-Tajrish and Loghman-e-Hakim hospitals,
Tehran, Iran, from 2007 to 2008, were recruited.
Among them, 50 patients with hand eczema were
included based on clinical symptoms, physical
examination, and personal and family history. Two
dermatologists examined all patients to exclude
other differential diagnoses, such as hand psoriasis,
and confirmed the clinical diagnosis of hand eczema.
Pregnant women, patients with allergic reactions/
anaphylaxis to MS, and history of corticosteroid or
anti-histamine consumption in the last six weeks
or use of topical steroid in the last three weeks
were excluded.
After receiving explanation regarding the study
protocol, all participants signed informed consent
forms (according to Helsinki Declaration). We
then divided the patients into two groups using
a table of random numbers. Group A received MS
4% ointment in a tube without a label and group
B received placebo in a similar tube which only
contained eucerin. Both groups were given with
similar instructions to use the ointments twice
daily. Only one finger tip unit was used for each
affected 2-3% of the body surface which was equal
to one hand (four FTUs for both hands every day).
All patients were followed up for six weeks after
treatment.
Both groups were similar regarding demographic
features (P>0.05). The therapeutic results for
erythema, edema, excoriation, lichenification,
dryness, oozing, and itching (according to
calculated scores) were compared between the two
groups three and six weeks after beginning of the
treatment. The severity of erythema, excoriation
and lichenification was evaluated according to
the eczema area severity index (EASI) scoring
(Table 1)
14
. Edema, dryness, itching, and oozing
were also scored similar to the EASI severity
section.
Statistical analysis
Data were analyzed using SPSS (version 13.0)
software [Statistical Procedures for Social Sciences;
Chicago, Illinois, USA]. Independent-sample T,
Chi square, and Fisher Exact tests were used for
comparison. P values less than 0.05 were considered
significant.
RESULTS
Thirty-eight patients were female and 12 were
male. Both groups were sex-matched (18 and
20 female patients in MS and placebo groups,
respectively). Mean age of the patients was
37.3 and 35.6 years in MS and placebo groups,
respectively (P > 0.05). No therapeutic adverse
effects were seen in the two groups. Table 2
shows the outcomes at baseline and after three
and six weeks. There was a statistically significant
difference between two groups for all measured
scores at the first and second follow-up sessions
(P < 0.0001).
Severity
erythema, infiltration/population,
lichenification, and excoriation
Score
None 1
Mild 2
Moderate 3
Severe 4
Table 1. Eczema Area and Severity Index (EASI) scoring system
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Malva Sylvestris in the treatment of hand eczema
133
Iranian Journal of Dermatology, Vol 13, No 4, Winter 2010
DISCUSSION
Hand eczema is a common dermatologic disease
worldwide
1,2
. The relapsing characteristic of the
disease is the main issue of concern in patients
4
.
In this study, 50 patients were evaluated. Our
results showed that MS had a good efficacy without
side effects in the treatment of hand eczema in
comparison with placebo.
MS is a tropical plant which grows in Southern
Europe and Asia. Its leaves, flowers, and shoots
are used for therapeutic reasons. It has been
historically used as a medicine, internally as a
demulcent using its seed extract or boiled young
leaves, and externally as an emollient
15,16
. There
are few reports regarding its efficacy in the
treatment of dermatologic disorders, especially
hand eczema and it has proved to be a safe and
effective therapeutic modality
9,15,16
.
Cortic o s t e roids a nd a n t i-histami n e s , a s
conventional therapeutics, are generally used with
caution due to their side effects while herbal agents
are generally well-tolerated.
Previous studies have documented the efficacy
of MS in the treatment of some other diseases,
especially febrile ones
16,17
. Also, this agent has been
used as a softener in some conditions
16
. Although
MS is classified as a demulcent, our study proved
its efficacy in successful treatment of hand eczema
for the first time. Hence, the importance of our
study lies in introducing a new herbal modality for
treating hand eczema. Another interesting finding
was that this medicine caused no side effects, even
allergic reactions. Also, all patients were willing
to attend the follow-up sessions.
In conclusion, our study showed that MS, as a
safe and effective therapeutic modality, can be used
as an optimal substitute for corticosteroids and
anti-histamines for the treatment of hand eczema.
Finally, it is suggested that further studies with
longer follow-up periods be conducted to confirm
our findings.
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MS Placebo
Baseline 3
rd
week 6
th
week Baseline 3
rd
week 6
th
week
Mean erythema score 1.5 1.1 0.6 1.4 1.3 1.2
Mean edema score 0.8 0.5 0.3 0.8 0.8 0.7
Mean excoriation score 1.5 1 0.6 1.6 1.5 1.5
Mean lichenification score 1.6 1.2 0.7 1.7 1.8 1.7
Mean dryness score 2 1.4 0.9 2.1 2 1.9
Mean itching score 0.2 0.1 0.1 0.3 0.4 0.4
Mean oozing score 1.7 1.2 0.8 1.7 1.6 1.5
*There was a statistically significant difference between two groups in all features (P < 0.0001)
Table 2. Severity scores at baseline and after three and six weeks in the two groups*
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  • Jun 2017
1. Introduction Over one billion people, mostly in developing countries, use medicinal plants for the whole life or some part of it or at least prefer them to the synthetic drugs. According to a study of World Bank, trade in medicinal plants will have a share of over 5$ trillion in global trade in 2050. Growing population during last century and the demand for harvesting medicinal plants from natural areas, particularly those which commonly used, endangered these species with the risk of extinction. Common Mallow (Malva sylvestris L.) is a medicinal plant commonly used as a natural remedy and other industries e.g. cosmetic industry. On the other hand, negative impacts of synthetic agricultural inputs on human health, the need for producing healthy commodities, replacing chemical agricultural inputs with some environmental friendly ones, and paying attention to new concepts like sustainability, lead agroecologists to introduce ecologically alternatives to farmers, in order to be replaced with chemical fertilizers. Using Plant growth Promoting Rhizobacteria (PGPR) and fungi symbiotic with many vascular plants, is one of these alternatives. Mechanistic crop growth analysis including radiation absorption and use efficiency was compiled in agricultural researches from 1950, farther than classical analysis. Thus, the goal of this experiment is to evaluate radiation absorption and use efficiency of Common Mallow under the effect of different sources of biological, chemical and organic fertilizers and intercropping with Fenugreek (Trigonellafoenum-graecum). Materials and Methods The experiment was conducted as a split plot design based on RCBD with three replications at the research farm of Ferdowsi University of Mashhad during the growing season of 2013. The main plot factor had two levels: 1-application of cattle manure and 2-no application of cattle manure, and the sub plot factor had seven levels as: 1- Nitroxin®, 2-Sulphur solubilizing bacteria (SSB) 3-Phosphate solubilizing bacteria (PSB), 4- Nitroxin + SSB + PSB, 5- Chemical fertilizer, 6-Row intercropping with Fenugreek, and 7- Control. Inoculation of seeds with boifertilizers done in standard situation recommended by their producers and the CFU of all biofertilizers were more than 108 . On 25 of March, 25 ton.ha-1 of cattle manure distributed by hand in needed plots. The sowing operation was done on March 30.The total area of a plot was 12 square meters and the distance between and on the rows were 50 and 20 cm, respectively. Leaf area index, dry matter and the radiation above, and transmitted through, the canopy measured each 14 days (with a Linear Septometer, SunScan, Delta T Co., UK). Then the total radiation absorption for each plot was calculated by the relevant equations. Finally, radiation use efficiency is estimated with measuring the slope of the regression line between cumulative absorbed radiation and dry matter of the plant. Results and Discussion The results showed that application of cattle manure increased LAI, particularly in the early stages of Common Mallow growth, and the highest level of LAI was on the treatment of “Nitroxin + SSB + PSB + Cattle manure” and “Chemical fertilizer + cattle manure” with 2.49 and 2.37, respectively. This is while, in the absence of cattle manure, chemical fertilizer had more effect on increasing LAI compared to the biofretilizers. Application of cattle manure also reduced the light extinction coefficient (K) of the plant, while “Nitroxin + SSB + PSB + Cattle manure” treatment had the least K value (K=0.47, R2=0.98). ANOVA results showed all experimental treatments had a significant effect (P≤ 0.001) on the cumulative absorbed radiation of Mallow during the growing season. The most accumulated absorbed radiation occurred under Nitroxin + SSB + PSB treatment (by mean of 986.6 MJ.m-2 ), while application and no-application of cattle manure had no significaneffect on radiation absorption. The total calculated mean of RUE was 1.26 g.MJ-1 . Nitroxin inoculation resulted in the least RUE (1.09 g.MJ-1) and Nitroxin + SSB + PSB inoculation plus cattle manure application had the highest RUE (1.5 g.MJ-1). Conclusions Generally, according to the goals of the experiment which were comparing some ecological inputs with chemical fertilizer from the point of mechanistic crop growth analysis factors such as radiation absorption and RUE, it seems that mixture of the three biological fertilizers of Nitroxin + SSB + PSB plus application of cattle manure can compete with chemical nitrogen fertilizer in such factors.
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Ethnopharmacological notes about ancient uses of medicinal plants in Tr??s-os-Montes (northern of Portugal)
Article
Full-text available
  • Jun 2009
In order to preserve the ancestral knowledge, an ethnopharmacological study has been carried out in two councils belonging to Trás-os-Montes region a small area located in the northern of Portugal. In that area, medicinal plants, most of the species wild, are still in use among farmers, shepherds and other people who live far from villages and built-up areas. Among the 46 people that were interviewed (mean age of 66 years old), 88 species belonging to 42 families of vascular plants were identified for treatment of various human ailments. An ethnopharmacological report is made consisting of species names, vernacular names, popular uses of the plants and their pharmacological properties. The most dominant family is Lamiaceae (18%) and the most frequently part of the plant used for the treatment of diseases are leaves (37.9%). The largest number of taxa is used to treat gastrointestinal disorders (73.9%).
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Herbal Drugs and Phytopharmaceuticals
Article
  • Sep 2004
  • Focus Alternative Compl Ther
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Leaves, flowers, immature fruits and leafy flowered stems of Malva sylvestris: A comparative study of the nutraceutical potential and composition
Article
  • Mar 2010
Malva sylvestris is widely used in Mediterranean and European traditional medicine and ethnoveterinary for the treatment of external and internal inflammation, as well as injuries. Moreover, its use is not only limited to therapeutic purposes; but also the species is locally regarded as a food wild herb. Considering that antioxidants and free radical scavengers can exert also an anti-inflammatory effect, the extracts of different parts of the medicinal/edible plant M. sylvestris (leaves, flowers, immature fruits and leafy flowered stems) were compared for their nutraceutical potential (antioxidant properties) and chemical composition. Particularly, mallow leaves revealed very strong antioxidant properties including radical-scavenging activity (EC(50)=0.43 mg/mL), reducing power (0.07 mg/mL) and lipid peroxidation inhibition in lipossomes (0.04 mg/mL) and brain cells homogenates (0.09 mg/mL). This part of the plant is also the richest in nutraceuticals such as powerful antioxidants (phenols, flavonoids, carotenoids, and tocopherols), unsaturated fatty acids (e.g. alpha-linolenic acid), and minerals measured in ash content.
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Folk pharmaceutical knowledge in the territory of the Dolomiti Lucane, inland southern Italy
Article
  • Jan 2004
  • J ETHNOPHARMACOL
An ethnopharmacognostic survey on the traditional pharmaceutical knowledge (TPhK) of old and newly introduced natural remedies used for healing humans in a small mountainous area in Central Lucania, inland southern Italy, was carried out using classical ethnographical and ethnobiological methods. Approximately 110 remedies of plant origin (belonging to 103 botanical taxa), 30 of animal origin and 20 mineral or industrial (non-pharmaceutical) products were recorded. Among these remedies, the common use of the aerial parts of Hypericum hircinum and the leaves of Morus alba against cough, and the uncommon uses of Salvia argentea leaves as a haemostatic, of Erigeron acer roots to relieve toothaches and arthritic pains, and Elaphe quatuorlineata snake fat for rheumatism are reported for first time in Italy. Moreover, diverse medicinal plants used for uncommon medical purposes and a few biological ingredients used in food preparations with the aim to improve human health were identified. Pharmacological and toxicological considerations relating to possible applications of the recorded traditional knowledge in modern evidence-based medicine are discussed as well. The data that we present here could suggest new inputs for further phytochemical and pharmacological studies among Mediterranean folk pharmacopoeias, and also for sustaining environmentally integrated projects focused on of the maintenance of TPhK via breeding or controlled gathering activities of local medicinal species.
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New and existing therapeutic options for hand eczema
Article
  • Apr 2009
  • Skin Ther Newslett
Hand eczema affects up to 10% of the population and encompasses a diverse range of morphological presentations and underlying pathophysiological processes. This article will review the new and existing treatments that are available for this common dermatologic problem.
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Chronic hand eczema: Epidemiology and therapeutic evidence
Article
  • Oct 2008
  • HAUTARZT
Hand eczema (HE) is one of the most frequent skin diseases, although it is not a homogenous entity. The degree of severity can range from mild manifestations to severe chronic cases which are refractory to therapy and tend to disable patients. Chronic HE is a high social and economic impact and often leads to a loss in quality of life. Although there are many options, the therapy of chronic HE is difficult and often unsuccessful. Randomized controlled clinical trials demonstrating the efficacy of therapeutic options, including established ones, are lacking.
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Meding B, Swanbeck GPrevalence of hand eczema in an industrial city. Br J Dermatol 116:627-634
Article
  • Jun 1987
The occurrence of hand eczema in an industrial city was studied. Questionnaires were sent to 20000 individuals aged 20–65 years, randomly selected from the population register of the city. After two reminders, a response rate of 83% was obtained. Analysis of the drop-outs did not indicate that the presence of hand eczema was an important selection factor for response to the questionnaire. Those subjects considering themselves to have had hand eczema within the previous 12 months were invited to a dermatological examination to verify the diagnosis and for further investigation. Seventy-one per cent accepted the invitation. Analysis of drop-outs showed that willingness to attend the dermatological examination was to some extent dependent on the severity of the hand eczema. It was found that almost 11% considered themselves to have had hand eczema at some time during the previous 12-month period; approximately two thirds were women. Five point four per cent had had hand eczema at a particular point in time (prevalence) and 2% had had continuous problems with hand eczema during the previous year.
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Herbal Remedies: Issues in Licensing and Economic Evaluation
Article
  • Nov 1999
In recent years, the use of alternative therapies has become widespread. In particular, there has been a resurgence in the public's demand for herbal remedies, despite a lack of high-quality evidence to support the use of many of them. Given the increasing pressures to control healthcare spending in most countries, it is not surprising that attention is being focused on the cost effectiveness of herbal remedies. We address the question of whether there is sufficient information to enable the assessment of the cost effectiveness of herbal remedies. In so doing, we discuss the current state of play with several of the more high-profile alternative herbal remedies [Chinese medicinal herbs for atopic eczema, evening primrose oil, ginkgo biloba, hypericum (St John's wort)] and some which have made the transition from being alternative to being orthodox remedies. We use historical context to discuss, on the one hand, the increasing commodification of herbal remedies and on the other, the trend towards greater regulatory control and licensing of alternative herbal remedies. We argue that unless great care is exercised, these changes are not necessarily in the best interests of patients. In order to identify cost-effective care, we need reliable information about the costs as well as the efficacy and safety of the treatments being assessed. For most alternative therapies, such data are not available. We believe that studies to gather such data are long overdue. Whilst we argue strongly in favour of control of some herbal remedies, we urge caution with the trend towards licensing of all herbal remedies. We argue that the licensing of those herbal remedies with equivocal benefits and few risks, as evidenced by a long history of safe use, increases barriers to entry and increases societal healthcare costs.
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The Eczema Area and Severity Index (EASI): assessment of reliability in atopic dermatitis. EASI Evaluator Group
Article
  • Feb 2001
To test the reliability of the eczema area and severity index (EASI) scoring system by assessing inter- and intra-observer consistency. Training of evaluators, application, and assessment over 2 consecutive days. An academic center. Twenty adults and children with atopic dermatitis (AD); cohort 1 (10 patients > or = 8 years) and cohort 2 (10 patients < 8 years). None. The EASI was used by 15 dermatologist evaluators to assess atopic dermatitis in cohort 1 and cohort 2 on 2 consecutive days. Inter- and intraobserver reliability were analyzed. Overall intra-evaluator reliability of the EASI was in the fair-to-good range. Inter-evaluator reliability analyses indicated that the evaluators assessed the patients consistently across both study days. This study demonstrated that the EASI can be learned quickly and utilized reliably in the assessment of severity and extent of AD. There was consistency among the evaluators between consecutive days of evaluation. These results support the use of the EASI in clinical trials of therapeutic agents for AD.
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Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The Odense Adolescence Cohort Study on Atopic Diseases and Dermatitis
Article
  • Mar 2001
Atopic diseases are common in children and adolescents. However, epidemiological knowledge is sparse for hand eczema and allergic contact dermatitis in this age group. Furthermore, no population-based studies have evaluated the prevalence of atopic diseases and hand and contact dermatitis in the same group of adolescents. To assess prevalence measures of atopic dermatitis (AD), asthma, allergic rhinitis and hand and contact dermatitis in adolescents in Odense municipality, Denmark. The study was carried out as a cross-sectional study among 1501 eighth grade school children (age 12-16 years) and included questionnaire, interview, clinical examination and patch testing. The lifetime prevalence of AD was 21.3% (girls 25.7% vs. boys 17.0%, P < 0.001) using predefined questionnaire criteria. The 1-year period prevalence of AD was 6.7% and the point prevalence 3.6% (Hanifin and Rajka criteria). In the interview the lifetime prevalence of inhalant allergy was estimated as 17.7% (6.9% allergic asthma, 15.7% allergic rhinitis). The lifetime prevalence of hand eczema based on the questionnaire was 9.2%, the 1-year period prevalence was 7.3% and the point prevalence 3.2%, with a significant predominance in girls. A significant association was found both between AD and inhalant allergy, and between AD and hand eczema using lifetime prevalence measures. The point prevalence of contact allergy was 15.2% (girls 19.4% vs. boys 10.3%, P < 0.001), and present or past allergic contact dermatitis was found in 7.2% (girls 11.3% vs. boys 2.5%). Contact allergy was most common to nickel (8.6%) and fragrance mix (1.8%). High prevalence figures were found for atopic diseases, hand eczema and allergic contact dermatitis, and the diseases were closely associated. A considerable number of adolescents still suffers from AD, and a considerable sex difference was noted for hand eczema and allergic contact dermatitis. Nickel allergy and perfume allergy were the major contact allergies. In the future this cohort of eighth grade school children will be followed up with regard to the course and development of atopic diseases, hand eczema and contact dermatitis.
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