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Saw palmetto extract: A dermatologist's perspective



Saw palmetto extract is believed to have antiandrogenic properties and has been used widely for the treatment of androgenic alopecia. It is claimed to have much less side effects as compared to finasteride. Along with its use for androgenic alopecia, it has also been tried for other conditions associated with increased androgen levels in dermatology. This article will review a dermatologist's perspective of this traditional herb.
© 2017 Indian Journal of Drugs in Dermatology | Published by Wolters Kluwer - Medknow 11
Review Article
Saw palmetto or serenoa repens (SR) is a small palm tree
native to eastern regions of the United States. Its extract is
believed to be a highly effective antiandrogen as it contains
phytoesterols and fatty acids as its major ingredient.[1] SR is
used in several forms of traditional herbal medicine. American
Indians used the fruit for food and to treat a variety of urinary
and reproductive system problems. The Mayans drank it as a
tonic, and the Seminoles used the berries as an expectorant
and antiseptic. Crude SR extract was used by the European
and American medical practitioners for at least 200 years
for various conditions, including asthenia, recovery from
major illness and urogenital problems. SR is currently being
commercially marketed for the treatment of benign prostatic
hyperplasia.[2] Of late SR has gained popularity as a magical
remedy for androgenetic alopecia (AGA).[3] Being a naturally
occurring 5 alpha reductase inhibitor, it has also been used for
other dermatologic indications. This article will review the
dermatologic perspective of SR.
mechanism oF action
Like finasteride, SR is believed to block the enzyme 5
alpha reductase. Whether SR inhibits 5 alpha reductase 1
or both the isoenzymes of 5 alpha reductase is not clear.
This action thereby blocks the conversion of testosterone to
dihydrotestosterone (DHT).[4] This is its primary mode of
action for most dermatologic conditions. Other mechanisms of
therapeutic benet by SR will be elaborated under the specic
conditions of its usage in dermatology.
dermatologic indications oF serenoa repens
There is no Food and Drug Administration (FDA) approved
indications of SR in dermatology. All are off-label indications.
Androgenetic alopecia
SR has proved to be effective in the management of
AGA. Apart from the primary mechanism of action of
5 alpha-reductase blockade,[4] SR is thought to decrease the
uptake of DHT by the hair follicles[3] and decrease its binding
to androgenic receptors. Another possible effect of SR in
AGA seen with its liposterolic extract is suppression of
lipopolysaccharide-activated gene expression of chemokines,
including CCL 17, CXCL 6, and LT B 4 associated inammatory
and apoptotic pathways.[5] Hence, its anti-inflammatory
properties are of value in AGA. With SR growth of hair is
prevalently seen over the frontal and temporal regions of the
The safety and efcacy of SR in treating hirsuitism have not
been sufciently investigated. Studies show that it inhibits
5 alpha reductase and as a result prevents the conversion
of testosterone to DHT.[7] Further SR strongly inhibits
3 ketosteroid reductase-mediated conversion of DHT to
5-alpha androstane-3 alpha and 17 beta-diol which may
Saw Palmetto Extract: ADermatologist’s Perspective
Varshini Reddy, Aditya Kumar Bubna, Mahalakshmi Veeraraghavan, Sudha Rangarajan
Department of Dermatology, Sri Ramachandra University, Chennai, Tamil Nadu, India
Saw palmetto extract is believed to have antiandrogenic properties and has been used widely for the treatment of androgenic alopecia. It is
claimed to have much less side effects as compared to nasteride. Along with its use for androgenic alopecia, it has also been tried for other
conditions associated with increased androgen levels in dermatology. This article will review a dermatologist’s perspective of this traditional herb.
Keywords: 5-alph reductase inhibitor, anti-androgen, serenoa repens
Address for correspondence: Dr.Varshini Reddy,
No.13/7, 7thMain Road, RA Puram, Chennai‑600028, Tamil Nadu, India.
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How to cite this article: Reddy V, Bubna AK, Veeraraghavan M,
Rangarajan S. Saw palmetto extract: A dermatologist's perspective. Indian
J Drugs Dermatol 2017;3:11-3.
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Reddy, et al.: Saw Palmetto: Dermatologist’s perspective
Indian Journal of Drugs in Dermatology ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017
help as therapy for hirsuitism.[8] A study done using a cream
containing SR extract (Nela Depil) twice a day for 2 months
in 31 women with idiopathic facial hirsuitism showed a
29% decline in hair counts 2 months posttreatment which is
statistically signicant (P < 0.0001).[9] However, further studies
maybe required to determine the effectiveness of SR extract
for this condition.
As SR lowers DHT levels, it inuences the production of sebum
by reducing the excessive oils contributing to the development
of acne.[10] SR is a dual inhibitor of cyclooxygenase and
5-lipoxygenase pathways according to in vitro research.
More recently, decreased expression of COX-2 has been
identied providing a further explanation for the observed
anti-inammatory activity. Further studies would only help
in elucidating the efcacy of SR both as monotherapy or as a
combination therapy in acne.
Polycystic ovarian syndrome
In polycystic ovarian syndrome, there are increased levels of
adrenal androgens. Furthermore, the peripheral tissues such
as skin, liver, and adipose tissue also take part in androgen
synthesis by converting the weaker androgens into, the more
potent ones. Androgen receptor activation takes place only
with circulating testosterone and DHT. Twenty-ve percent
of the circulating testosterone is produced individually
by the ovaries and adrenals. The remaining 50% is by the
peripheral conversion from androstenedione.[11] SR helps as an
antiandrogen and may also have anti-inammatory effects. An
ethanol extract of SR inhibited the lipid droplet accumulation
by attenuation of protein expressions of C-EBP alpha and
PPAR gamma. Phosphorylation of Erk 1/2 and Akt 1 were
also decreased by SR ethanol extract. Hence, SR extracts
could selectively affect the adipocyte differentiation through
the modulation of several key factors that play a critical role
in adipogenesis.[12]
As yet, there is no data available on absorption, distribution,
metabolism, and elimination for SR.
The dosage of SR for dermatologic indications has not been
clearly established. For benign prostatic hyperplasia 160 mg
twice daily of an extract standardized to contain 85%–95%
fatty acids or sterols is administered. Similarly, a single daily
dose of 320 mg may just be effective in this condition.[13,14] As
with many other herbs the quality of SR products may vary
widely,[15] owing to which a standardized dosing may pose to
be a serious problem.
adverse eFFects
Mild stomach discomfort is the most common side effect.
It can be alleviated by taking the drug after food. Hepatic
inammation is another serious problem with SR. There have
been two case reports showing this adverse reaction in patients
taking the medication for benign prostatic hyperplasia.[16,17]
Pancreatitis has been reported with SR extract. In general,
some potential mechanisms for drug-induced acute pancreatitis
include pancreatic duct constriction, cytotoxic and metabolic
effects, accumulation of a toxic metabolite or intermediary
and hypersensitivity reactions.[18] Another theory suggests that
pancreatitis may occur due to SR stimulating the estrogenic
receptors and induces a hypercoaguable state that leads to
pancreatic necrosis.[19] There is one report of SR apparently
causing excessive bleeding during surgery.[20] The signicance
of this isolated event is not clear, but it is probably prudent to
avoid SR before and just after surgery.
drug interactions
Drugs such as warfarin, heparin, aspirin, clopidogrel, and
ticlopidine should be avoided in patients taking SR, owing
to an increased tendency for bleeding. The exact mechanism
for the increased risk of hemorrhage while taking SR with the
above-mentioned drugs requires further elucidation.[21]
saFety in pregnant and nursing women
It has not been established till date.
SR is an herbal drug which has found to be useful in the
dermatologic indications mentioned above. It has been used as
a topical formulation and also systemically. Despite the easy
availability of saw palmetto extract and it being designated as
a food product by the US FDA there still remains paucity on
its regulations with regard to efcacy and safety. Moreover, we
also need to be aware of the low quality of evidence about saw
palmetto extract with regard to most dermatologic indications
where it has been utilized. With there being a number of side
effects with the systemic route the development of more topical
formulations in the near future in the form of creams, lotions,
and gels could help in getting a good therapeutic outcome with
the risks minimized. Finally, all patients need to be adequately
counseled regarding the paucity of literature with regard to
the exact mode of action, safety, and long-term effects of SR
and therefore its use should be limited in those patients where
there is a contraindication in the usage of other conventional
modalities of management.
Financial support and sponsorship
Conflicts of interest
There are no conicts of interest.
1. Grant P, Ramasamy S. An update on plant derived anti-androgens. Int J
Endocrinol Metab 2012;10:497-502.
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Indian Journal of Drugs in Dermatology ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 13
2. Wilt TJ, Ishani A, Stark G, MacDonald R, Lau J, Mulrow C. Saw
palmetto extracts for treatment of benign prostatic hyperplasia: A
systematic review. JAMA 1998;280:1604-9.
3. Murugusundram S. Serenoa Repens: Does it have any role in the
management of androgenetic alopecia? J Cutan Aesthet Surg 2009;2:31-2.
4. Prager N, Bickett K, French N, Marcovici G. A randomized,
double-blind, placebo-controlled trial to determine the effectiveness of
botanically derived inhibitors of 5-alpha-reductase in the treatment of
androgenetic alopecia. J Altern Complement Med 2002;8:143-52.
5. Chittur S, Parr B, Marcovici G. Inhibition of inammatory gene
expression in keratinocytes using a composition containing carnitine,
thioctic acid and saw palmetto extract. Evid Based Complement Alternat
Med 2011;2011:985345.
6. Rossi A, Mari E, Scarno M, Garelli V, Maxia C, Scali E, et al.
Comparitive effectiveness of nasteride vs. Serenoa repens in male
androgenetic alopecia: A two-year study. Int J Immunopathol Pharmacol
7. Fagelman E, Lowe FC. Saw Palmetto Berry as a Treatment for BPH.
Rev Urol 2001;3:134-8.
8. Sultan C, Terraza A, Devillier C, Carilla E, Briley M, Loire C, et al.
Inhibition of androgen metabolism and binding by a liposterolic extract
of “Serenoa repens B” in human foreskin broblasts. J Steroid Biochem
9. Behrooz B. The effectiveness of the extract of Serenoa repens in
idiopathic facial hirsuitism. Iran J Dermatol 2009;12:139-40.
10. Dobrev H. Clinical and instrumental study of the efcacy of a new
sebum control cream. J Cosmet Dermatol 2007;6:113-8.
11. Adashi EY. The climacteric ovary as a functional gonadotropin-driven
androgen-producing gland. Fertil Steril 1994;62:20-7.
12. Villaverde N, Galvis A, Marcano A, Priestap HA, Bennett BC,
Barbieri MA. Saw palmetto ethanol extract inhibits adipocyte
differentiation. J Nat Med 2013;67:619-25.
13. Braeckman J, Bruhwyler J, Vandekerckhove K. Efcacy and safety
of the extract of Serenoa repens in the treatment of benign prostatic
hyperplasia: Therapeutic equivalence between twice and once daily
dosage forms. Phytother Res 1997;11:558-63.
14. Stepanov VN, Siniakova LA, Sarrazin B, Raynaud JP. Efcacy and
tolerability of the lipidosterolic extract of Serenoa repens (Permixon) in
benign prostatic hyperplasia: A double-blind comparison of two dosage
regimens. Adv Ther 1999;16:231-41.
15. Feifer AH, Fleshner NE, Klotz L. Analytical accuracy and reliability
of commonly used nutritional supplements in prostate disease. J Urol
16. Singh YN, Devkota AK, Sneeden DC, Singh KK, Halaweish F.
Hepatotoxicity potential of saw palmetto (Serenoa repens) in rats.
Phytomedicine 2007;14:204-8.
17. Jibrin I, Erinle A, Saidi A, Aliyu ZY. Saw palmetto-induced pancreatitis.
South Med J 2006;99:611-2.
18. Underwood TW, Frye CB. Drug-induced pancreatitis. Clin Pharm
19. Kaurich T. Drug-induced acute pancreatitis. Proc (Bayl Univ Med Cent)
20. Cheema P, El-Mefty O, Jazieh AR. Intraoperative haemorrhage
associated with the use of extract of saw palmetto herb: A case report
and review of literature. J Intern Med 2001;250:167-9.
21. Avins AL, Bent S, Staccone S, Badua E, Padula A, Goldberg H, et al.
A detailed safety assessment of a saw palmetto extract. Complement
Ther Med 2008;16:147-54.
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ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Anti-androgens are an assorted group of drugs and compounds that reduce the levels or activity of androgen hormones within the human body. Disease states in which this is relevant include polycystic ovarian syndrome, hirsutism, acne, benign prostatic hyperplasia, and endocrine related cancers such as carcinoma of the prostate. We provide an overview and discussion of the use of anti-androgen medications in clinical practice and explore the increasing recognition of the benefits of plant-derived anti-androgens, for example, spearmint tea in the management of PCOS, for which some evidence about efficacy is beginning to emerge. Other agents covered include red reishi, which has been shown to reduce levels 5-alpha reductase, the enzyme that facilitates conversion of testosterone to dihydrotestosterone (DHT); licorice, which has phytoestrogen effects and reduces testosterone levels; Chinese peony, which promotes the aromatization of testosterone into estrogen; green tea, which contains epigallocatechins and also inhibits 5-alpha reductase, thereby reducing the conversion of normal testosterone into the more potent DHT; black cohosh, which has been shown to kill both androgenresponsive and non-responsive human prostate cancer cells; chaste tree, which has a reduces prolactin from the anterior pituitary; and saw palmetto extract, which is used as an anti-androgen although it shown no difference in comparison to placebo in clinical trials.
Full-text available
The fruits of saw palmetto have been used for the treatment of a variety of urinary and reproductive system problems. In this study we investigated whether the fruit extracts affect in vitro adipogenesis. Saw palmetto ethanol extract inhibited the lipid droplet accumulation by induction media in a dose-dependent manner, and it also attenuated the protein expressions of C-EBPα and PPARγ. Phosphorylation of Erk1/2 and Akt1 were also decreased by saw palmetto ethanol extract. This report suggests that saw palmetto extracts selectively affect the adipocyte differentiation through the modulation of several key factors that play a critical role during adipogenesis.
Full-text available
Serenoa repens is one among the many naturally occurring 5 alpha reductase (5aR) inhibitors which has gained popularity as a magical remedy for androgenetic alopecia. It is widely advertised on the web and sold by direct marketing. Used as a self-medication, there is a risk of missing the early detection of prostate cancer. There is little evidence to support its efficacy, warranting larger clinical trials on androgenetic alopecia.
Full-text available
Chronic inflammation of the hair follicle (HF) is considered a contributing factor in the pathogenesis of androgenetic alopecia (AGA). Previously, we clinically tested liposterolic extract of Serenoa repens (LSESr) and its glycoside, β-sitosterol, in subjects with AGA and showed a highly positive response to treatment. In this study, we sought to determine whether blockade of inflammation using a composition containing LSESr as well as two anti-inflammatory agents (carnitine and thioctic acid) could alter the expression of molecular markers of inflammation in a well-established in vitro system. Using a well-validated assay representative of HF keratinocytes, specifically, stimulation of cultured human keratinocyte cells in vitro, we measured changes in gene expression of a spectrum of well-known inflammatory markers. Lipopolysaccharide (LPS) provided an inflammatory stimulus. In particular, we found that the composition effectively suppressed LPS-activated gene expression of chemokines, including CCL17, CXCL6 and LTB(4) associated with pathways involved in inflammation and apoptosis. Our data support the hypothesis that the test compound exhibits anti-inflammatory characteristics in a well-established in vitro assay representing HF keratinocyte gene expression. These findings suggest that 5-alpha reductase inhibitors combined with blockade of inflammatory processes could represent a novel two-pronged approach in the treatment of AGA with improved efficacy over current modalities.
The objective of this open label study is to determine the effectiveness of Serenoa repens in treating male androgenetic alopecia (AGA), by comparing its results with finasteride. For this purpose, we enrolled 100 male patients with clinically diagnosed mild to moderate AGA. One group received Serenoa repens 320 mg every day for 24 months, while the other received finasteride 1 mg every day for the same period. In order to assess the efficacy of the treatments, a score index based on the comparison of the global photos taken at the beginning (T0) and at the end (T24) of the treatment, was used. The results showed that only 38% of patients treated with Serenoa repens had an increase in hair growth, while 68% of those treated with finasteride noted an improvement. Moreover finasteride was more effective for more than half of the patients (33 of 50, i.e. 66%), with level II and III alopecia. We can summarize our results by observing that Serenoa repens could lead to an improvement of androgenetic alopecia, while finasteride confirmed its efficacy. We also clinically observed, that finasteride acts in both the front area and the vertex, while Serenoa repens prevalently in the vertex. Obviously other studies will be necessary to clarify the mechanisms that cause the different responses of these two treatments.
The efficacy and safety of two dosage forms (160 mg b.i.d. and 320 mg o.d.) of the extract of Serenoa repens were compared during a 1-year treatment in 132 patients suffering from benign prostatic hyperplasia (BPH). Both dosage forms induced a significant improvement in the efficacy variables: international prostate symptom score (60% after 1 year), quality of life score (85% of patients were satisfied after 1 year of treatment), prostatic volume (12% after 1 year), maximum flow rate (22% after 1 year), mean flow rate (17% after 1 year) and residual urinary volume (16% after 1 year). No significant differences were found between the two dosage forms. The percentage of patients or investigators evaluating that the treatment had a medium or bad tolerance was never superior to 4%. Nineteen side effects were observed in 16 patients (12.1%), 8 patients in each group. The majority of these side effects (at least 75%) were related to the natural evolution of the disease itself rather than to the medication. We conclude that the extract of Serenoa repens in its two dosage forms is a safe and effective treatment for the mictional problems associated with BPH. Consequently, it appears to offer a potential pharmacologic alternative capable of improving BPH symptoms in patients with mild-to-moderate disease. © 1997 John Wiley & Sons, Ltd.
We previously suggested [Steroids33, (1979) 3; Steroids37, (1981) 6] that cultured genital skin fibroblasts should prove useful for screening of potential antiandrogens in human and living target cells. “Serenoa repens” lipidic extract (S.R.E.) was recently reported (Br. J. Pharmacoi., in press) to inhibit androgen action in animals. The present investigation was designed to study the antiandrogenicity of this compound in human cells: we therefore analyzed the effects of S.R.E. on the intracellular conversion of testosterone (T) to 5α-reduced derivatives, and we investigated interaction of S.R.E. with the intracellular androgen-receptor complex. Since the chemical structure of the active component of S.R.E. is still unknown, results are expressed in U/ml (one unit is defined as the amount of S.R.E. required to inhibit 50% of the specific binding (IC50) of [³H]1881 to rat prostate cytosol).
To assess the hypothesis that the climacteric ovary is a functional endocrine gland. Review of the English-speaking literature as it relates to the physiology and pathophysiology of the climacteric ovary. By several accounts, the climacteric ovary appears to be a gonadotropin-dependent androgen-producing gland. Although the estrogen-producing potential of the climacteric ovary remains a matter of controversy, most studies would suggest limited aromatase activity. [1] The climacteric ovary is not a defunct endocrine organ. [2] The climacteric ovary is a site of gonadotropin reception and action. [3] The climacteric ovary contributes few if any estrogens to the circulating pool by way of direct production. [4] Circulating estrogens are derived virtually exclusively from the extraglandular conversion of androgens, a proportion of which are of ovarian origin. [5] The climacteric ovary contributes 40% and 20% of the total production rates of T and androstenedione, respectively. [6] Androgen biosynthesis by the climacteric ovary is partially gonadotropin-dependent.
Recent information about drugs implicated in causing pancreatitis is summarized. Although the frequency of drug-induced acute pancreatitis is generally low, the disease is associated with substantial morbidity and mortality, which makes timely identification of the offending agent important. Mechanisms suggested for drug-induced pancreatitis include pancreatic duct constriction; immunosuppression; cytotoxic, osmotic, pressure, or metabolic effects; arteriolar thrombosis; direct cellular toxicity; and hepatic involvement. Agents reported to have a definite association with pancreatitis are asparaginase, azathioprine, didanosine, estrogens, furosemide, mercaptopurine, pentamidine, sulfonamides, sulindac, tetracyclines, thiazides, and valproic acid. Agents reported to have a probable association with pancreatitis include cimetidine, clozapine, corticosteroids, endoscopic retrograde cholangiopancreatography contrast media, methyldopa, metronidazole, salicylates, and zalcitabine. Agents reported to have a questionable association with pancreatitis include acetaminophen, cyclosporine, cytarabine, erythromycin and roxithromycin, ketoprofen, metolazone, and octreotide. When ethanol abuse and biliary disease are ruled out as etiologies for pancreatitis, the possibility of drug-induced disease should be investigated.
To conduct a systematic review and, where possible, quantitative meta-analysis of the existing evidence regarding the therapeutic efficacy and safety of the saw palmetto plant extract, Serenoa repens, in men with symptomatic benign prostatic hyperplasia (BPH). Studies were identified through the search of MEDLINE (1966-1997), EMBASE, Phytodok, the Cochrane Library, bibliographies of identified trials and review articles, and contact with relevant authors and drug companies. Randomized trials were included if participants had symptomatic BPH, the intervention was a preparation of S repens alone or in combination with other phytotherapeutic agents, a control group received placebo or other pharmacological therapies for BPH, and the treatment duration was at least 30 days. Two investigators for each article (T.J.W., A.I., G.S., and R.M.) independently extracted key data on design features, subject characteristics, therapy allocation, and outcomes of the studies. A total of 18 randomized controlled trials involving 2939 men met inclusion criteria and were analyzed. Many studies did not report results in a method that permitted meta-analysis. Treatment allocation concealment was adequate in 9 studies; 16 were double-blinded. The mean study duration was 9 weeks (range, 4-48 weeks). As compared with men receiving placebo, men treated with S repens had decreased urinary tract symptom scores (weighted mean difference [WMD], -1.41 points [scale range, 0-19] [95% confidence interval (CI), -2.52 to -0.30] [n = 1 study]), nocturia (WMD, -0.76 times per evening [95% CI, -1.22 to -0.32] [n = 10 studies]), and improvement in self-rating of urinary tract symptoms; risk ratio for improvement (1.72 [95% CI, 1.21-2.44] [n = 6 studies]), and peak urine flow (WMD, 1.93 mL/s [95% CI, 0.72-3.14] [n = 8 studies]). Compared with men receiving finasteride, men treated with S repens had similar improvements in urinary tract symptom scores (WMD, 0.37 International Prostate Symptom Score points [scale range, 0-35] [95% CI, -0.45 to 1.19] [n = 2 studies]) and peak urine flow (WMD, -0.74 mL/s [95% CI, -1.66 to 0.18] [n = 2 studies]). Adverse effects due to S repens were mild and infrequent; erectile dysfunction was more frequent with finasteride (4.9%) than with S repens (1.1%; P<.001). Withdrawal rates in men assigned to placebo, S repens, or finasteride were 7%, 9%, and 11%, respectively. The existing literature on S repens for treatment of BPH is limited in terms of the short duration of studies and variability in study design, use of phytotherapeutic preparations, and reports of outcomes. However, the evidence suggests that S repens improves urologic symptoms and flow measures. Compared with finasteride, S repens produces similar improvement in urinary tract symptoms and urinary flow and was associated with fewer adverse treatment events. Further research is needed using standardized preparations of S repens to determine its long-term effectiveness and ability to prevent BPH complications.