Nutrition 411: An Introduction to Herbs for Wound Healing Professionals

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Dina 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 ethnobotanical 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 pharmaceutical 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 efficacy, interest and use continue to rise. This article provides wound care professionals a review of the common herbs patients may report taking and important facts to keep in mind, such as drug interactions and side effects.

Definition of Herb

  An 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, people 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 information on herbal supplementation in order to make informed plan-of-care decisions.

Herbal Therapy in Wound Care

  New approaches incorporating use of medicinal herbs and botanicals have the potential to positively impact patient care. Botanicals address all objectives of wound healing through both topical and internal applications. Honey, a botanical known for its antibacterial and antifungal properties, has gained acceptance as a treatment to accelerate wound healing. 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 protective coating. The vulnerary herb calendula contains multiple beneficial components that are antiseptic, anti-inflammatory, and stimulate the immune responses and collagen formation. 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 benefit 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 consuming any herbal products or using any topical preparations in addition to what has been prescribed by the wound healing professional.

Today’s Herbal Commerce

  Herbs are sold in different forms, including teas, liquid extracts 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 increasing 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 generations, to make more independent decisions about personal health. The trend toward increased self-medication with herbal supplements is not without concerns. Consumers must be aware of product safety and purity, proper dosing recommendations, and reputable manufacturers and distributors. Table 1 lists some of the most commonly purchased herbs.

Herbal Regulation and Quality

  As herbalism gains impetus, the need for safety information and quality control measures increases. Herbal products categorized as dietary supplements are subject to regulation 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 approval before marketing. The FDA authorizes only any label claim of prevention, treatment, or cure for a disease or condition. The responsibility for ensuring safety and prevention of false or misleading claims falls to the supplement manufacturers who must comply with the Dietary Supplement Current Good Manufacturing Practices (CGMPs). These regulations are meant to prevent adulteration and contamination of herbal products and to ensure quality, consistency, and authentication of botanicals.7 In 2011, three nonprofit organizations joined to address concerns about adulteration of herbal ingredients: the American Botanical Council, 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 adulteration 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 authoritative reference on the safety of botanicals is the American Herbal Products Association’s Botanical Safety Handbook9; a second edition was recently published.

Herb-Drug Interactions

  Herb-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 The more knowledge and experience with botanicals, especially 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 interaction.12 Particular caution should be used if taking herbs known to cause either increased or decreased blood values 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 Effects

  Botanicals 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 traditional 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 standardized 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.

Toxicity

  In 2010, more than 22,000 deaths occurred from overdose of pharmaceuticals, 74% of which were unintentional.13 In contrast, the US National Poison Data System reported zero deaths from dietary supplements, including herbs.14 Because toxic, poisonous plants exist, self-collection of herbs must be done with botanical knowledge and confirmation the proper plant has been identified. In manufactured supplements, toxicity is often 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

Commonly Used Herbs

  There 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 concerns 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 Medicines 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-inflammatory, antioxidant, cytotoxic, and immune stimulant. For support of circulation, herbs stimulate blood flow to better 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, improving 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 decreasing excess accumulation of fluid. Many herbs are specifically 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 healing 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 Points

  As today’s healthcare transforms, holistic medicine continues to gain wider acceptance. The intricate science 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 prescription or nonprescription pharmaceuticals has made an important contribution to patient autonomy and supported an all-inclusive approach to healthcare. Although the following list of considerations can help with safe herbal use, consultation with a qualified herbal practitioner is recommended for complex issues and concerns.

    • Detailed information on herbal products includes the dose, form (tea, extract, capsule, topical salve or liniment), brand, and length of time the herb has been used.
    • Compare dose taken to recommended doses. The concept that if a small amount is beneficial, more is better does not apply.
    • Use wild-crafted or organic herbal products only from reputable sources that clearly advertise purity.
    • Apply patch testing on skin before topical application of a botanical.
    • Consult reliable references such as the Botanical Safety Handbook for efficacy, interactions, side effects, and contraindications, as well as safety during pregnancy and lactation.
    • Red-flag medications for potential interactions include warfarin, 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.
    • The more prescription medications a patient takes, the greater the likelihood of an herb-drug interaction. Risk is substantially increased if taking more than six medications and is highest in the elderly population.

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. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process.

References: 

1. Oxford Dictionary. Oxford University Press; 2014. Available at: www.oxforddictionaries.com/us/definition/american_english/herb. Accessed April 12, 2014.

2. Mehta DH, Gardiner PM, Phillips RS, McCarthy EP. Herbal and dietary supplement disclosure to health care providers by individuals with chronic conditions. J Altern Complement Med. 2008;14(10):1263–1269.

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

4. Lindstrom A, Ooyen C, Lynch ME, Blumenthal M. Herb supplement sales increase 5.5% in 2012: herbal supplement sales rise for 9th consecutive year; turmeric sales jump 40% in natural channel. Herbalgram. 2013;99:60–65.

5. Natural Marketing Institute. Consumer and Market Trends of Botanicals. Engredea News & Analysis; March 2014. Available at: http://newhope360.com/consumer/consumer-and-market-trends-botanicals. Accessed April 25, 2014.

6. Commission on Dietary Supplement Labels. Dietary Supplement Health and Education Act of 1994. US Department of Health and Human Services; November 24, 1997. Available at: www.health.gov/dietsupp/ch1.htm. Accessed April 20, 2014.

7. US Food and Drug Administration. Dietary Supplements. US Department of Health and Human Services; March 2014. Available at: www.fda.gov/Food/Dietarysupplements/default.htm. Accessed April 18, 2014.

8. Smith T. Nonprofit Collaboration Addresses Adulteration of Botanical Dietary Ingredients. HerbalGram. 2011;92:14–15.

9. Gardner Z, McGuffin M (ed). American Herbal Products Association’s Botanical Safety Handbook 2nd ed. Boca Raton, FL: CRC Press:2013.

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.

11. Ulbricht C. What every clinician should know about herb-supplement-drug interactions. Altern Complement Ther. 2012;18(2):67–70.

12. Winston D. Herbal Therapeutics, 10th ed. Herbal Therapeutics Research: Broadway, NJ: Library;2013. 

13. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657–659.

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. Clinical Toxicology (2010). 48, 979-1178. Available at: www.aapcc.org/annual-reports/. Accessed April 22, 2014.

15. Hoffmann D. Medical Herbalism. Rochester, NY: Healing Arts Press;2003.

16. PDR for Herbal Medicine, 4th ed. Montvale, NJ: Thomson Healthcare, Inc;2007.

17. American Botanical Council. Available at: www.herbmed.org/index.html#param.wapp?sw_page=index. Accessed April 18, 2014.

18. Natural Medicines Comprehensive Database. Therapeutic Research Faculty; 2014. Available at: http://naturaldatabase.therapeuticresearch.com/home.aspx?cs=&s=ND. Accessed April 18, 2014.