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Dina Ranade, RD, has practiced as a clinical dietitian in the healthcare setting for the past 24 years. She has completed formal studies in herbal medicine and now merges herbal and nutritional therapeutics. Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of Nutrition411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Corre-spondence may be sent to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process.

an introduction to Herbs for wound Healing ProfessionalsDina Ranade, RD; and Nancy Collins, PhD, RD, LD/N, FAPWCA, FAND

medicinal plants have played an important therapeutic role throughout history. Records of herbal remedies

date back 5,000 years and document the evolution of eth-nobotanical therapies from regional availability of plants and trade commerce to highly developed medical practice. Systems such as Ayurveda and Traditional Chinese Medicine use herbs extensively and are established facets of healthcare in India and China, respectively. In Europe and the United States, herbalism declined in the early 1900s as the pharma-ceutical industry expanded. Today, uneasiness with drug side effects along with the desire for natural options has catalyzed a resurgence in herbal use. As scientific research validates ef-ficacy, interest and use continue to rise. This article provides wound care professionals a review of the common herbs pa-tients may report taking and important facts to keep in mind, such as drug interactions and side effects.

definition of HerbAn herb is any plant whose leaf, stem, flower, root, or

seed is used for flavoring, food, medicine, or perfume.1

Herbs, classified as over-the-counter dietary supplements, are frequently purchased and managed without consulting a healthcare professional. When asked to list medications, peo-ple often forget or intentionally omit vitamin and mineral supplements as well as herbs.2 Clients fear physicians may not endorse botanicals and will recommend discontinuation. Physicians hold to their skepticism about herbal safety due to uncertainties, such as case reports citing nephrotoxicity and hepatotoxicity.3 Regardless of belief in plant medicine, it is critical for healthcare practitioners to have complete in-formation on herbal supplementation in order to make in-formed plan-of-care decisions.

Herbal therapy in wound CareNew approaches incorporating use of medicinal herbs

and botanicals have the potential to positively impact pa-tient care. Botanicals address all objectives of wound healing through both topical and internal applications. Honey, a bo-tanical known for its antibacterial and antifungal properties, has gained acceptance as a treatment to accelerate wound heal-ing. Aloe vera, a plant with a long tradition of topical use for burns and wounds, decreases inflammation, soothes itching

and burning, provides antimicrobial effects, and promotes overall healing. Numerous other plants contain chemical constituents that provide benefit for wounds. The astringent properties of herbs such as witch hazel help dry oozing and bleeding wounds. Mucilage, a constituent in herbs such as slippery elm and plantain, provides a soothing and protec-tive coating. The vulnerary herb calendula contains multiple beneficial components that are antiseptic, anti-inflammato-ry, and stimulate the immune responses and collagen forma-tion. Topical use of herbs has little risk of adverse effect, but occasional allergic contact dermatitis reactions warrant the use of skin testing before application. When taken internally, the effects of herbs are far-reaching, offering additional ben-efit for common concerns such as digestive disturbances or emotional imbalances.

When seeing patients for chronic or nonhealing wounds, it is important to specifically inquire if the patient is con-suming any herbal products or using any topical prepara-tions in addition to what has been prescribed by the wound healing professional.

today’s Herbal CommerceHerbs are sold in different forms, including teas, liquid ex-

tracts or tinctures, capsules and pills, syrups, oils, salves, and lotions. They can be purchased in mainstream markets such as Wal-Mart and health food stores and also are available on the Internet. In 2012, total herbal and botanical dietary supplement sales in the United States increased by 5.5%, continuing a steady growth trend over the past 9 years. This equates to 36 million adults who use herbal supplements, contributing to industry sales revenue of $5.6 billion.4

In 2013, 13% of consumers taking herbs reported increas-ing their usage; additionally, 23% of consumers reported herbs serve an important role in maintaining their well-being and health.5 Economic hardship coupled with high medical costs seems to lead people, especially women and younger genera-tions, to make more independent decisions about personal health. The trend toward increased self-medication with herb-al supplements is not without concerns. Consumers must be aware of product safety and purity, proper dosing recommen-dations, and reputable manufacturers and distributors. Table 1 lists some of the most commonly purchased herbs. DO N

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Herbal regulation and QualityAs herbalism gains impetus, the need for safety informa-

tion and quality control measures increases. Herbal prod-ucts categorized as dietary supplements are subject to regu-lation by the Food and Drug Administration (FDA) under the Dietary Supplement Health and Education Act of 1994 (DSHEA).6 Dietary supplements do not require FDA ap-proval before marketing. The FDA authorizes only any label claim of prevention, treatment, or cure for a disease or con-dition. The responsibility for ensuring safety and prevention of false or misleading claims falls to the supplement man-ufacturers who must comply with the Dietary Supplement Current Good Manufacturing Practices (CGMPs). These regulations are meant to prevent adulteration and contami-nation of herbal products and to ensure quality, consistency, and authentication of botanicals.7 In 2011, three nonprofit organizations joined to address concerns about adultera-tion of herbal ingredients: the American Botanical Council,

table 1. the 10 top-selling herbal dietary supple-ments in the united states in 20124

Mainstream Retail Market

Natural and Health Foods Market

1. Cranberry 1. Flax seed and/or oil

2. Garlic 2. Wheat and barley grass

3. Saw Palmetto 3. Turmeric

4. Soy 4. Aloe vera

5. Ginkgo 5. Spirulina/blue green algae

6. Milk thistle 6. Milk thistle

7. Black cohosh 7. Elderberry

8. Echinacea 8. Saw Palmetto

9. St. John’s wort 9. Echinacea

10. Ginseng 10. Cranberry

table 2. Herbs for improved circulation and wound healing

Herbs for improved circulation and wound healing

Specific indications

Contraindications Drug interactions

Adverse events

Turmeric Antioxidant, anti-inflammatory, anti-microbial; stimulates immune response

None None None

Aloe vera leaf gel Enhances wound healing by increas-ing blood circulation through the wound area; antimicrobial

Avoid internal use in presence of diar-rhea; avoid com-mercial products that combine aloe gel and latex

May decrease ab-sorption of medica-tions. Take 1 hour before or 2 hours after medications

Reports of adverse events involve the use of the aloe latex (juice), not the inner leaf gel, which has no adverse events reported; aloe latex may cause diarrhea, stomach cramps, and skin irritation

Goldenseal Antimicrobial, increases wound granulation and healing

Avoid in pregnancy and lactation

May inhibit drug metabolizing enzymes from the CYP3A4 and CYP2D6 pathways

None

Cayenne pepper Enhances blood circulation to ex-tremities, improves vascular integrity, relieves pain with topical application

Avoid use in or near eyes; topically avoid use for more than 2 days; inter-nally use in drop doses only

None Topical use can irritate mu-cous membranes and broken skin or cause burning sensa-tion; internal use may cause gastrointestinal irritation or heartburn in sensitive indi-viduals

Plantain Antioxidant, anti-inflammatory, anti-bacterial; promotes wound healing

None None None

Propolis Antiseptic, anti-oxidant; enhances wound healing topi-cally and internally

Avoid use in people with allergies to bees

None Contact dermatitis and al-lergic reactions; apply skin patch test before use

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the American Herbal Pharmacopoeia, and the University of Mississippi’s National Center for Natural Products Research focus on the accidental adulteration occurring due to poor quality control procedures as well as intentional adultera-tion with cheaper products for financial gain. Written reports are available on the adulteration of black cohosh, skullcap, bilberry, and grapefruit seed extract.8 A reliable and authori-tative reference on the safety of botanicals is the American

Herbal Products Association’s Botanical Safety Handbook9; a second edition was recently published.

Herb-drug interactionsHerb-drug interactions are less common than drug-drug

interactions; however, they do occur. Navigating the evidence is confounded by study errors, conflicting information, and reporting of adverse events with little clinical significance.10

table 3. Herbs to aid mental function

Herbs to aid mental function

Specific indications Contraindications Drug interactions Adverse effects

St. John’s wort Depression accompa-nied by gastro-intes-tinal distress, nervous anxiety, seasonal affective disorder

Avoid in combina-tion with photo-therapy (laser or ultraviolet)

Effects the drug metaboliz-ing CYP450 enzyme system, decreasing blood levels and therapeutic activity of drugs metabolized through this pathway. Avoid use with cy-closporine, warfarin, digoxin, nifedipine, verapamil, indi-navir, clopidogrel bisulfate, oxycodone, omeprazole, and statins (for full list refer to Botanical Safety Handbook); also may affect oral contra-ceptive pills

Fair-skinned people should avoid sun exposure while taking due to photosensitiz-ing properties

Lemon balm Mood elevator, es-pecially for seasonal affective disorder

None None None

Holy basil Mental fog; chronic depression

None Careful glucose monitoring for persons with diabetes on insulin or oral hypoglycemic agents due to blood glucose lowering activity

None

Gingko Enhances memory, especially for elderly

Discontinue use 7 days before under-going surgery

Concomitant use with anti-coagulants should be under healthcare practitioner supervision only; may lower plasma concentrations of nifedipine; should not be used with MAO inhibitors

None

Black cohosh Hormonal depression (doom and gloom)

Pregnancy None Adulterants have been identified and linked to liver toxicity; links to hepatotoxicity have not been confirmed; larger doses may cause gastrointestinal discomfort

Ginseng Enhances cognitive function; relieves fatigue

None Avoid concomitant use with warfarin or use only under the supervision of a health-care professional. Careful glucose monitoring in per-sons with diabetes

Allergic reactions have been reported; may be over-stim-ulating if used with caffeine or other stimulants

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The more knowledge and experience with botanicals, es-pecially for appropriate dose and indication, the better able the clinician to tackle these challenges. Natural does not equate with safe, but the effect and interaction of an herb is difficult to predict due to lack of regulation and standardization of products, as well as consumer self-prescribed usage.11 Taking herbs and drugs separately by at least 2 to 3 hours decreases likelihood of interac-tion.12 Particular caution should be used if taking herbs known to cause either increased or decreased blood val-ues of medications. The top three herbs causing this type of response are St. John’s wort, gingko, and kava-kava. Warfarin is by far the medication with which the most interactions may occur, but any medication that has a cardiovascular or central nervous system effect should be a red flag for possible interactions.10

side effectsBotanicals are essentially safe and nontoxic, but not

all herbs work gently, and if used in the wrong way or at the wrong dose there can be negative outcomes. Despite the growing volume of research and history of long tradi-tional use, much remains unknown. Discerning the truth from the abundant information in the media and Internet is challenging. Research studies and case reports must be evaluated for accuracy, specifically with regard to proper

botanical identification. Part of the problem is that in our age of abundance and technical advances, herbs now are sold in concentrated forms, either as capsules or standard-ized to a certain amount. This creates greater potential for overdosing than if herbs are taken in more traditional forms such as teas or tinctures. With plants, the concept more is better does not apply. Overall, in comparison to pharmaceuticals, risk of herbal side effects is mild.

toxicityIn 2010, more than 22,000 deaths occurred from

overdose of pharmaceuticals, 74% of which were un-intentional.13 In contrast, the US National Poison Data System reported zero deaths from dietary supplements, including herbs.14 Because toxic, poisonous plants ex-ist, self-collection of herbs must be done with botanical knowledge and confirmation the proper plant has been identified. In manufactured supplements, toxicity is of-ten a result of contamination with adulterants. Risk of this occurrence is higher for herbs imported from other countries or from suppliers more concerned with lower costs who may compromise purity. Dose is the essential consideration. A strong-acting herb can be toxic if taken at a higher dose than recommended. Effective dosing is based on age and body weight, criteria not often reflected on product package recommendations.15

table 4. Herbs to support urinary function

Herbs supporting urinary function

Specific indications

Contraindications Drug interactions Adverse effects

Cranberry Antibacterial, pre-vention and treat-ment of urinary tract infection (UTI)

None None None

Parsley leaf Anti-inflammatory, diuretic

None None None

Uva-ursi Antimicrobial to urinary tract for treatment of UTI, cystitis, and mild nephritis

Avoid in pregnancy, lactation, and in young children

Due to increase in potassium excretion, avoid use with lithium, digoxin, or lanoxin; take 2 hours before or after iron supplements

In large doses or prolonged use may cause nausea and gastric irritation; may turn urine a greenish-brown col-or; however, no problems are associated with this

Saw Palmetto Treatment of benign prostatic hyperplasia and interstitial cystitis; urinary antiseptic

None None None; concerns with liver toxicity and drug interac-tions have not been con-firmed in clinical trials

Stinging nettle leaf Mild, potassium- sparing diuretic; strengthens kidney function

None Careful glucose moni-toring for persons with diabetes on insulin or oral hypo-glycemic agents due to serum glucose-lowering activity

Fresh nettle may cause skin irritation on contact and should not be consumed unless cooked; no reaction occurs with ingestion of dried, powdered, extracted, or cooked nettle leaf

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Commonly used HerbsThere is a vast number of medicinal plants and an

herb or several herbs to cure or relieve every possible ailment. Many references offer extensive herbal Materia Medica lists.12,15,16 Most herbals provide information on all aspects of use for a specific herb; however, for con-cerns regarding safety, the Botanical Safety Handbook9 is the most comprehensive. Additionally, herbal databases are available on the Internet and include the American Botanical Council’s herbmed.org17 and the Natural Med-icines Comprehensive Database.18

Improved circulation and wound healing. Botanicals help reduce the risk of delayed wound healing, enhance the healing process, and decrease incidence of infections. Plant chemical constituents are classified into broad categories that assist with skin integrity such as antimicrobial, anti-inflam-

matory, antioxidant, cytotoxic, and immune stimulant. For support of circulation, herbs stimulate blood flow to bet-ter deliver oxygen and nutrients to the wound area as well as provide cleansing to prevent contamination. Herbs fight specific wound-compromising bacteria and aid in treatment of diabetic foot ulcers, pressure ulcers, and venous leg ulcers (see Table 2).

Aid to mental function. Botanicals influence cognition in two ways. The biochemical constituents of plants provide specific therapy for anxiety, depression, stress reduction, im-proving memory, and hormone-related imbalances. Plants also address the mind-body connection, offering energy that nourishes the spirit (see Table 3).

Support urinary function. Botanicals often act as mild diuretics, providing benefit to kidney function by decreas-ing excess accumulation of fluid. Many herbs are specifically

table 5. Herbs to aid digestion

Herbs for digestion Specific indications Contraindications Drug interactions Adverse effects

Peppermint Digestive aid, anti-spas-modic, relieves gas

None None May decrease esophageal pres-sure, exacerbating gastroesophageal reflux, or hiatal hernia

Chamomile Acute and chronic diges-tive distress; anti-spas-modic, calming

None Take 2 hours before or after iron supple-ments

Allergic reaction possible

Fennel seed Prevention and treatment of gas, reflux, bloating, constipation; stimulates appetite

None None Estrogenic activity reported in infants, although has been used safely for treatment of colic

Ginger Nausea, motion sickness None None None

Cinnamon Stimulates gastric hydro-chloric acid secretion, relieves gas, nausea, and low-grade diarrhea

Pregnancy in high doses (>2 g)

Careful glucose monitoring for persons with dia-betes on insulin or oral hypoglycemic agents due to blood glucose-lowering activity

None at doses used as a spice in cooking

Dandelion root Digestive aid, bitter tonic None None None

Licorice Anti-inflammatory to gas-tric mucosa, benefits for treating gastritis, ulcers, and inflammatory bowel disease

In pregnancy, use only under supervision of qualified healthcare practitioner; avoid in hy-pertension, liver disease, edema, severe kidney insufficiency, low serum potassium, congestive heart failure; not recom-mended for use >6 weeks or in high doses

None at therapeutic dose (1 to 5 g, three times a day); at high dose or prolonged use, may cause potassium deple-tion with diuretics, laxatives, corticoste-roids; may potentiate cardiac glycosides such as digoxin

Note: Cautions do not apply to deglycyrrhizinated licorice (DGL) products

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anti-inflammatory, antimicrobial, and soothingly demulcent to the urinary tract, providing treatment for infections and irritations (see Table 4).

Aid to digestion. Botanicals provide a multitude of heal-ing qualities for digestive imbalances, including heartburn, nausea, bloating, gas, diarrhea, and constipation. They act as adjunctive therapy for inflammatory bowel disease, gastro-esophageal reflux, leaky gut syndrome, and treatment of food allergies. Herbs often are calming, relieving stress-induced or emotion-related digestive responses (see Table 5).

Practice PointsAs today’s healthcare transforms, holistic medicine

continues to gain wider acceptance. The intricate sci-ence of herbalism is growing as a specialized field and has far-reaching benefits in the area of wound care. With rising popularity of alternative approaches, the clinician who takes the time to review existing herbal supplementation and then educate patients on safety, appropriate dosing, pure product availability, and the potential risks of mixing with prescrip-tion or nonprescription pharmaceuticals has made an im-portant contribution to patient autonomy and supported an all-inclusive approach to healthcare. Although the following list of considerations can help with safe herbal use, consulta-tion with a qualified herbal practitioner is recommended for complex issues and concerns.

• Detailed information on herbal products includes thedose, form (tea, extract, capsule, topical salve or lini-ment), brand, and length of time the herb has been used.

• Comparedosetakentorecommendeddoses.Thecon-cept that if a small amount is beneficial, more is better does not apply.

• Usewild-craftedororganicherbalproductsonly fromreputable sources that clearly advertise purity.

• Applypatchtestingonskinbeforetopicalapplicationofa botanical.

• ConsultreliablereferencessuchastheBotanical Safety Handbook for efficacy, interactions, side effects, and con-traindications, as well as safety during pregnancy and lactation.

• Red-flagmedications forpotential interactions includewarfarin, digoxin, lithium, cyclosporine, and protease inhibitors.

• Avoid use of herbs reported to cause hepatotoxicity(black cohosh, kava kava, chaparral) with hepatotoxic medications (tetracycline, acetaminophen, statins), or with excessive alcohol intake.

• Themoreprescriptionmedicationsapatienttakes,thegreater the likelihood of an herb-drug interaction. Risk is substantially increased if taking more than six medica-tions and is highest in the elderly population. n

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3. Bent S. Herbal medicine in the United States: review of efficacy, safety, and regulation. J Gen Intern Med. 2008;23(6):854–859.

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10. Tsai HH, Lin HW, Simon Pickard A, Tsai HY, Mahady GB. Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements. Int J Clin Pract. 2012;66(11):1056–1078.

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14. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2009 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 27th Annual Report. Clini-cal Toxicology (2010). 48, 979-1178. Available at: www.aapcc.org/annual-reports/. Accessed April 22, 2014.

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