Eric Yarnell, N.D., R.H. (AHG)
and Kathy Abascal, B.S., J.D., R.H. (AHG)
Natural treatments for acne vulgaris, a common con-
dition in industrialized societies, have much to offer
although clinical studies are lacking. Several studies
have shown that low stomach acid is a common finding in
patients who have acne. This suggests that the traditional use
of bitter herbs, which act by stimulating digestive function,
including acid secretion, may be useful and important for
correcting acne vulgaris. Herbs with antimicrobial, inflam-
mation-modulating, anticomedogenic, and, in certain cases,
hormone-balancing actions are also useful for treating acne.
(See Table 1.)
Acne vulgaris remains a common condition in industrialized
societies, with many mainstream treatment options available. All
these treatments carry risks, and none is completely satisfactory.
Natural alternatives are gaining greater research support and
have much to offer clinically.
Antibiotic resistance in Propionibacterium acnes and Staphylococ-
cus epidermidis has been rising steadily since the 1980s. In one
analysis covering 10 years in the United Kingdom, carrying resis-
tant bacteria were noted in more than 50 percent of patients who
had acne and who were treated with antibiotics, with most
patients carrying multiple different resistant strains on different
parts of their bodies.1Similar trends have been reported in many
other industrialized nations.2
Despite some efforts by drug manufacturers to inform con-
sumers, the incidence of women exposed to oral tretinoin, a
known teratogen, during pregnancy has been increasing, possi-
bly the result of direct-to-consumer drug advertising.3These and
other concerns, including cost, underscore the need for safer,
effective, more-inexpensive approaches, including those offered
by herbal medicine.
This article focuses primarily on herbal treatments for acne.
Few botanical medicines have been evaluated systematically in
clinical trials, and there is virtually no research on the common
approach of natural-medicine practitioners for acne—recom-
mending multiple lifestyle changes along with multiple natural
products. Nonetheless, biologic plausibility has been demonstrat-
ed for many therapies in isolation.4
Diet, Digestion, Acne, and Herbs
Mainstream dermatology has long maintained that “diet is not
related to acne,” based on outdated, low-quality, and rather
sparse research. Mounting modern research supports that diet
can, in fact, affect acne in multiple ways.5If nothing else, it is
quite clear that people living in “Stone Age societies” have no
acne, compared with rates as high as 95 percent in adolescents in
industrialized societies.6Although diet is not the only difference
between these traditional and industrial societies, it is likely to be
a major factor.
Changing diet and lifestyle are, therefore, still considered to be
critical to any natural approach to acne. Herbal medicine can
potentially help make dietary changes more effective. It is a tenet
of natural medicine that poor digestion may exacerbate poor
dietary intake and contribute to acne.
Several studies have shown that low stomach acid is a com-
mon finding in patients who have acne.7,8 This suggests that the
traditional use of bitter herbs, which act by stimulating digestive
function including acid secretion, may be useful and important
for correcting acne vulgaris. (See box entitled Case Study: Diges-
tive Herbs for Acne.) Some common bitter herbs used include
Taraxacum officinale (dandelion) leaf and root, Achillea millefolium
(yarrow) flowering top, Artemisia absinthium (wormwood) leaf,
Gentiana lutea (gentian) root, and Mahonia aquifolium (Oregon
The concept in natural medicine that liver function is also criti-
cal to avoiding diet-induced acne is more theoretical. The idea is
that, if the liver and its detoxification and excretory functions are
not functioning optimally, the body will attempt to compensate
by eliminating toxic compounds through other routes in the
body, including the skin. It is possible that the liver herbs com-
monly used, such as Arctium lappa (burdock) root, actually work
because of their bitter digestive stimulant actions. Sufficient clini-
cal research has not been done on this line of reasoning to allow a
reasoned analysis of the approach.
Various bacteria play a role in the pathogenesis of acne with P.
acnes and S. epidermidis being studied most often. Both of these
microbes, and others potentially related to acne pathogenesis, are
present on normal skin, and none has been shown definitively to
cause acne.9Once either excess sebum production or inflamma-
tory changes begin, these microbes can and often do overgrow
and worsen inflammation.
Given these facts, antimicrobial herbs are likely to have a role to
play in acne treatment. The best supported natural treatment in
this regard is steam-distilled volatile oil of Melaleuca alternifolia (tea
tree) leaf. A single-blinded trial was conducted comparing a 5 per-
cent gel of tea tree oil with 5 percent benzoyl peroxide lotion in 124
patients with mild-to-moderate acne.10 The two treatments were
304 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2006
Table 1. Herbs and Formulas Used to Treat Acne Vulgaris
Latin binomials Common names
Achillea millefolium flowering top Yarrow
Aloe barbadensis gel Aloe vera
Arctium lappa root Burdock
Artemisia absinthium leaf Wormwood
Azardirachta indica leaf Neem
Berberis vulgaris root Barberry
Chamaelirium luteum root False unicorn
Coptis chinensis root Goldthread
Commiphora mukul resin Guggul
Embelia ribes fruit Vidanga
Curcuma longa rhizome Turmeric
Emblica officinalis fruit Amalaki
Eucalyptus globulus leafaEucalyptus
Eucalyptus maculata leafaEucalyptus
Eucalyptus viminalis leafaEucalyptus
Gentiana lutea root Gentian
Hemidesmus indicus root Indian sarsparilla
Holarrhena antidysenterica stem bark Kutaj
Hydrastis canadensis root Goldenseal
Mahonia aquifolium root Oregon grape
Medicago sativa flowering top Alfalfa
Melaleuca alternifolia leaf Tea tree
Mitchella repens leaf Partridge berry
Ocimum basilicum leaf Basil
Piper longum fruit Long pepper
Scutellaria baicalensis root Asian skullcap, scute
Serenoa repens fruit Saw palmetto
Taraxacum officinale leaf and root Dandelion
Terminalia chebula fruit Chebulic myrobalan
Terminalia arjuna stem bark Arjun
Verbena spp. flowering top Vervain
Vitex agnus-castus fruit Chaste tree, vitex
Xanthorrhiza simplicissima root Yellowroot
Zingiber officinale rhizome Ginger
Withania somnifera root Ashwagandha
Angelica and Sophora Root Pills b
Compound Oldenlandis Mixture b
Sunder Vati 180 mg of Holarrhena antidysenterica
(kutaj) stem bark
30 mg of Emblica officinalis (amalaki) fruit
30 mg of Embelia ribes (vidanga) fruit
10 mg of Zingiber officinale (ginger) rhizome
aShowed potential in vitro; bFull information not provided in studies of this compound.
ultimately equally effective for clearing comedones, although the
tea tree oil took longer to show efficacy. Tea tree oil caused signifi-
cantly less skin irritation than benzoyl peroxide in this trial.
In vitro, microemulsified and liposomally dispersed formulations
of tea tree oil at pH 6.5 have shown optimal follicular penetration
and antimicrobial activity, although it is unclear whether these prod-
ucts are clinically more effective than direct application of the oil.11,12
We have found that 25–50 percent tea tree oil diluted in jojoba
(Simmodsia chinensis) oil applied twice daily is highly tolerable
and effective for most patients, though occasionally the strong
scent of the tea tree oil is unacceptable for daytime application. In
such instances, a 5 percent dilution is usually acceptable scent-
wise for application in the morning, and the stronger application
can be used in the evening or at bedtime.
Because excessive organic matter can interfere with the activity
of tea tree oil (and because mild cleansing seems to be helpful
empirically),13 it is recommended that patients cleanse their skin
gently with soap or other cleansers that do not contain any active
pharmaceutical ingredients prior to applying the tea tree oil. Jojo-
ba oil is used because it is noncomedogenic and has demonstrat-
ed its own inflammation-modulating effects in animal studies.14
Another clinical trial apparently showed that steam-distilled
volatile oil of Ocimum basilicum (basil) leaf was effective for patients
with acne, but full details of the study could not be obtained.15
Basil oil is both antimicrobial and inflammation-modulating.16
In vitro, a methanol-dichloromethane extract of the leaves of
Eucalyptus globulus,E. maculata, and E. viminalis (various species of
eucalyptus) all showed potent anti–P. acnes activity.17 This activity
was strongly associated with flavonoids and chalcones (flavonoid
precursors) in E. maculata, which is surprising as these compounds
are not normally antimicrobial. Eucalyptus steam-distilled volatile
oils have been used successfully and safely for treating skin infec-
tions such as scabies in pilot clinical trials.18 Thus, the potential for
eucalyptus volatile oil to help acne patients is good.
Oregon grape crude root extracts and its alkaloids berberine
and jatrorrhizine all showed minimum inhibitory concentrations
(MIC) of 5–50 mcg/mL against P. acnes in vitro.19 Oregon grape
is often used as an antimicrobial clinically and has at least two
other properties that make it particularly compelling for patients
with acne—the herb is a bitter digestive stimulant and an inflam-
Ultimately, it is clear that an antimicrobial approach does not
cure most cases of acne, and that the organisms involved are
almost certainly responding to other pathologic processes. This
broader approach using herbs is completely logical.
Inflammation plays a major role in the pathogenesis of acne.
As microcomedones form, a lymphocytic infiltrate occurs and
triggers inflammation.20 This tends to trigger follicular ker-
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2006 305
Taraxacum officinale (dandelion).
Arctium lappa (burdock).
Extract of the leaves of Eucalyptus globulus,E. maculata, and E. viminalis
(various species of eucalyptus) all showed potent anti–P. acnes activity.
atinocytes further to produce more keratin, as well as stimulating
increased sebum production and reducing linoleic acid content in
the sebum generated by the sebaceous glands. Most Westernized
people have experienced the inflammatory nature of acne vul-
garis, given the various red, swollen, tender lesions associated
with it, particularly papules, pustules, nodules, and cysts.
Herbs that relieve inflammation could therefore also be useful
for limiting or resolving acne. Berberine-containing herbs,
besides their antimicrobial action already discussed, have been
shown to be inflammation-modulating.21 Besides Oregon grape,
Berberis vulgaris (ba r berry), Coptis chinensis (goldthread),
Hydrastis canadensis (goldenseal), and Xanthorrhiza simplicissima
(yellowroot) all contain berberine and similar alkaloids. Oregon
grape has been shown repeatedly to be helpful in clinical trials
for patients with psoriasis, another inflammatory skin condi-
tion.22 Acne clinical trials are still lacking but sorely needed.
Scutellaria baicalensis (Asian skullcap, scute) root extracts are
well-established inflammation modulators from traditional Asian
medicine.23 Attention has focused on scute’s flavonoids, wogo-
nin and baicalein in particular, as potent inflammation-modula-
tors.24,25 The potential for internal and topical administration of
this herb to help patients with acne is great, although clinical tri-
als are unfortunately lacking.
Magnolia spp. (magnolia) stem bark is used quite frequently in
traditional Asian medicine. Its diphenylpropanid constituents
honokiol and magnolol have low MICs against P. acnes in vitro.26
The compounds also reduced inflammatory reactions to the
microbe in this study, and were nonirritating when applied to
the skin of healthy human volunteers. The inflammation-modu-
lating effects of magnolol and honokiol have been shown to be
related to their ability to suppress the critical inflammatory medi-
ator NF-kappaB.27 Clinical trials are needed on this promising
herb and its constituents.
Preliminary evidence looks promising, but much work remains
to be done to prove the value of inflammation-modulating herbs
for acne. Many inflammation-modulating herbs or herbal com-
pounds have additional actions, including the antimicrobial
effects discussed above. These herbs and compounds often also
appear to affect comedone formation.
A comedone arises when a hair follicle is blocked by excess ker-
atin and sebum. If the lipids and/or sebum involved are exposed
to air, they oxidize, turning black (forming the infamous “black-
head”). If the follicle is completely closed and an anaerobic envi-
ronment forms, the material is cream-colored (thus forming a
“whitehead”). Several natural keratolytics, such as glycolic acid or
salicylic acid, are well-established as treatments for comedones.
However, these keratolytics tend to be painful when applied and
can cause bizarre whitening patterns on the skin. These substances
also do not resolve the underlying causes of the comedones.
In contrast, several natural products have been shown to inhib-
it abnormal lipogenesis—directly and significantly—in hamster
sebaceous glands.28 Berberine and wogonin were the most active
in this study. In a separate study, a crude extract of goldthread
root (which contains berberine alkaloids) at a concentration of
just 0.01 percent also had a strongly antilipogenic effect in seba-
While no further work has been done to clarify the clinical rele-
vance of these findings, they indicate yet another way in which
the herbs containing these compounds may operate in acne.
Thus, one cannot focus too closely on any single action for most
herbs that could be beneficial for acne, as research continually
shows they have multiple ways of affecting the disease.
In a double-blinded clinical trial, tetracycline 500 mg twice
daily or an extract of Commiphora mukul (guggul) providing 25
mg guggulsterone twice daily were compared in 20 patients with
nodulocystic acne.30 After 3 months, all subjects had similar
reductions in the number of inflammatory lesions (approximate-
ly 65 percent). Three (3) months after discontinuation of therapy,
4 patients who were previously on tetracycline and 2 who were
on guggul relapsed. The researchers suggested that patients with
306 ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2006
Digestive Herbs for Acne
A 23-year-old male patient with mild-to-moderate papulopustular
acne on the face, back, and chest that had not responded to systemic
erythromycin treatment sought naturopathic care. He also
complained of having claylike stools. He was a vegan (and had been
for 7 years) except for occasional dairy-product intake and was in a
stressful educational program. He used no medication but was taking
a multivitamin and vitamin C. Blood tests revealed that he had low-
grade macrocytic anemia. Stool fecal-fat analysis indicated elevated
fecal-fat levels. Celiac disease was excluded by a negative serum
antiendomysial antibody test.
The initial treatment for this patient included:
• Increasing omega-3 fatty acid-rich foods in his diet, particularly
(Linum usitatissimum) flax oil
• An elimination/challenge diet (which revealed that he had various
negative reactions to dairy products, avocados, and chocolate)
• One intramuscular (IM) vitamin B12 shot weekly for 6 weeks.a
After 3 months on this protocol, the patient had a moderate
reduction in number of acne lesions and his anemia was resolved, but
his stools had not improved much. Therefore, a bitter tincture
formula containing 50 percent Gentiana lutea (gentian) root, 30
percent Taraxacum officinale (dandelion) leaf, and 20 percent Mahonia
aquifolium (Oregon grape) root was prescribed at a dose of 2
droppers-full before meals. The patient also decided to start eating
fish and began taking 6 g of fish oil per day.
Three (3) months of this program led to a near-total resolution of
all lesions as well as normalization of his stools. The bitters were
discontinued after 1 more month, and the acne remained almost
After 1 year that was associated with a severe time of stress,
some of his acne lesions recurred, but these were reduced when his
stress passed. Reinstituting bitters, occasional use of topical tea tree
(Melaleuca alternifolia)oil in jojoba (Simmodsia chinensis) oil, and stress
reduction were sufficient to control these episodes. After 4 years of
this treatment, the patient would often go for months with no
lesions, and acute outbreaks would consist of no more than 4–5
lesions on his back and face.
aVitamin B12 has been reported to exacerbate acne in some cases, but this patient was
vitamin B12–deficient and, clearly, the vitamin was indicated (and it did not exacerbate his
acne). This is an instance that illustrates the value of individualized medicine.
more oily skin reacted best to the guggul, raising the possibility
that this agent works by addressing comedogenesis. Guggul also
may have antimicrobial and inflammation-modulating activities.
Multiherbal Approaches from Traditional
In traditional Asian herbal medicines, the standard approach is
to combine multiple herbs into a formula suited to an individual
patient. While this approach is also used by many herbal practi-
tioners in the western world, it is difficult for mainstream health
care providers to understand. When one is schooled in a system
of medicine that focuses on single molecular entities to treat dis-
ease in broad groups of people, and also having been taught that
combining multiple agents is potentially dangerous, polyphar-
macy makes the use of polyherbal formulas seem quite foreign.
Nevertheless, ample experience and published clinical trial data
support that this approach can be quite effective.
In a double-blinded trial, four different herbal and mineral
combinations were compared with a charcoal placebo in Indian
patients with acne vulgaris. Only one of the formulas, Sunder
Vati, showed a significant improvement in inflammatory and
noninflammatory lesions compared with baseline or placebo.31
Sunder Vati contains Holarrhena antidysenterica (kutaj) stem bark
180 mg, Emblica officinalis (amalaki) fruit 30 mg, Embelia ribes
(vidanga) fruit 30 mg, and Zingiber officinale (ginger) rhizome 10
mg for a total of 250 mg, administered at a dose of 500 mg, three
times per day.
A similar double-blinded trial compared various combinations
of internal and external herbal formulas. A combination of Aloe
barbadensis (aloe vera), Azardirachta indica (neem), Curcuma longa
(turmeric), Hemidesmus indicus (Indian sarsparilla), Terminalia
chebula (chebulic myrobalan), Terminalia arjuna (arjun), Withania
somnifera (ashwagandha) and Piper longum (long pepper) was
given orally combined with either a gel or cream of the same for-
mula but without long pepper (which is used orally to increase
absorption of other herbs).32
One group took herbs orally and applied a placebo topically
and one group took an oral placebo and an active topical treat-
ment. All groups who used the herbal preparation had improve-
ment compared with no improvement in the placebo group. The
active cream preparation combined with oral herbs was judged
to be the most effective.32 These inflammation- and immune-
modulating herbs definitely should be investigated further for
helping patients who have acne.
One preparation, known as Compound Oldenlandis Mixture
(COM) in Chinese medicine was compared with Angelica and
Sophora Root Pills (ASRP) in 120 patients with acne.33 COM led
ALTERNATIVE & COMPLEMENTARY THERAPIES—DECEMBER 2006 307
Tell Your Patients
Proposed Acne Vulgaris Protocol
Increase omega-3 fatty acid, fruit, and vegetable intakes.
Eliminate or greatly reduce trans-fatty acid and simple
carbohydrate intake. Reduce or eliminate animal product ingestion,
and use only organic animal products if any are taken to avoid
exogenous hormones. Avoid iodized salt and swimming in
Use bitter herbs before meals for any suspected or documented
problems with malabsorption, hypochlorhydria, or other digestive
Cleanse the skin with non-medicated soap gently on a daily basis.
Apply 5–50 percent tea tree (Melaleuca alternifolia)oil diluted in
jojoba (Simmodsia chinensis) oil topically one to two times per day as
needed. Apply after skin cleansing.
Use natural skin moisturizers as needed for dry skin.
As needed, use inflammation-modulating (IM), antimicrobial (AM),
and anticomedogenic (AC) herbs internally and topically. A typical
formula would be:
•Mahonia aquifolium (Oregon grape) fresh root tincture, 20–30
percent (IM, AM, AC, bitter)
•Scutellaria baicalensis (scute) decocted dried root tincture, 20–30
percent (IM, AC)
•Achillea millefolium (yarrow) fresh flowering top tincture, 10–20
percent (IM, AM, bitter)
•Curcuma longa (turmeric) fresh root tincture, 10–20 percent (IM)
•Commiphora mukul (guggul) resin tincture, 5–10 percent (AC, IM)
•Glycyrrhiza glabra (licorice) dried root fluid extract, 5–10 percent
(IM, AM, flavor enhancer)
•Oplopanax horridum (devil’s club) fresh root bark glycerite, 5–10
percent (if stress is a problem)
•Vitex agnus-castus (chaste tree) mature fruit tincture, 10–20
percent (for hormone balancing)
•Serenoa repens (saw palmetto) mature fruit tincture, 10–20 percent
(if androgens are a factor).
The dose is 1 tsp, three times per day, in water, sipped before
Terminalia chebula (chebulic myrobalan). Drawing © 2006 by Kathy
Abascal, B.S., J.D., R.H. (AHG).
to a cure rate of 73 percent compared with 47 percent for the
ASRP. While the full details of what was in these formulas are
not available, and although arguably a known active treatment
was not used as a control, this study still provides some evidence
that multiple herbs working in synergy can be quite effective for
patients who have acne.
In a similar trial, a topical formula known as xiao cuo fang (full
details of the contents of this formula were not available) was
combined with 0.1 percent adapalene (a synthetic retinoid) gel
and compared with topical 0.03 percent retinoic acid cream in 133
patients with acne.34 The adapalene and herbal combination was
significantly more effective at reducing the number of acne lesions
compared with retinoic acid. Adverse effects caused by the herbal
formula were minimal. More-rigorous follow-up research is nec-
essary, but this trial again shows the potential benefit of poly-
herbal formulas applied topically in patients with acne vulgaris.
Very often, acne flareups are related to the impending onset of
menses. This particular type of acne highlights the fact that acne
is often affected by hormone balance in the body. Much work has
focused on the potential negative impact of androgens on acne;
estrogen and progesterone can definitely also be involved.35
Two herbs are commonly used for addressing hormonal issues
that arise in acne. The first is Vitex agnus-castus (chaste tree, vitex)
fruit. This plant acts in the pituitary gland to balance secretion of
lutetinizing and follicle-stimulating hormones, thus regulating
estrogen and progesterone levels.36
Preliminary German research confirms that chaste tree can
help moderate hormonal acne.37 Chaste tree should be taken
throughout the menstrual cycle for optimal effects. Vitex is often
used together with vitamin B6, which has also proven to be quite
helpful for resolving hormonal acne, although one comparative
trial found that vitex was superior to vitamin B6for helping
patients with symptoms of premenstrual syndrome.38
When androgens are a problem in acne vulgaris, Serenoa repens
(saw palmetto) fruit is the first herb most clinicians use. If polycys-
tic ovarian syndrome or documented high serum androgens are
present, saw palmetto should be considered to help offset the neg-
ative effects of excessive androgens. Saw palmetto does this by
moderately inhibiting 5-_reductase (which activates testosterone
to the much more potent dihydrotestosterone form) and by antag-
onizing the androgen receptor.39 No clinical trials were located on
the efficacy of saw palmetto in acne. The only other well-docu-
mented antiandrogenic herb is Glycyrrhiza glabra (licorice),
although it also has not been studied for acne in clinical trials.40,41
Other hormone-balancing herbs may have a role in acne vul-
garis, including but not limited to, Medicago sativa (alfalfa),
Chamaelirium luteum (false unicorn root), Verbena spp. (vervain),
and Mitchella repens (partridge berry). This is yet another fruitful
area for more study.
Much disparate and introductory research exists on the
effects of herbs on multiple aspects of acne. A comprehensive
appr oach com bining m ult iple her bs as well as lifesty le and
dietary changes has helped people with acne in preliminary
The continued resistance of mainstream dermatology to the
possibility of this approach does not optimally serve patients
who might be significantly helped by natural therapies. There are
sufficient pilot data to warrant larger trials on various herbal
medicines in isolation and combined with each other and other
natural therapies. The data are also sufficient to support a recom-
mendation for use of these herbs in clinical practice. This is par-
ticularly true, given how safe they are. Overall, herbal medicine
has much to offer to improve our ability to deal with the complex
issues acne presents. ■
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In an open clinical trial, 90 of 98 patients had significant
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While this trial did not incorporate herbal medicine, it is still
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• Vitamin A, water soluble form, 50,000 international units (IU), bid,
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Eric Yarnell, N.D., R.H. (AHG), is president of the Botanical Medicine
Academy, a specialty board for using medicinal herbs, and is an adjunct
faculty member at Bastyr University, Kenmore, Washington. Kathy
Abascal, B.S., J.D., R.H. (AHG), is executive director of the Botanical
Medicine Academy, Vashon, Washington.
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