Volume 35, Issue 6, Page 35 (June 2004)

Before the advent of modern medicine, most medical treatments were herbal. Many of the compounds discussed in this column appear as a result of their “rediscovery” by contemporary medicine. Aloe is probably the most popular example. St. John's wort, given its modern record of success in treating depression, is another.

An aromatic perennial herb native to Europe, western Asia, and northern Africa, St. John's wort (Hypericum perforatum L.) was brought to the northeastern region of North America by European colonists and is now grown throughout much of the world. Ancient Greeks are believed to have used St. John's wort for wounds, scars, burns, and myalgia (Hautarzt. 53[5]:316-21, 2002; Photodermatol. Photoimmunol. Photomed. 16[3]:125-28, 2000), and for dermatitis (Br. J. Dermatol. 142[5]:979-84, 2000). It was also used for sciatica and fevers and as an antivenom for poisonous snakebites.

One explanation for the derivation of its name supports the notion that the herb imparts dermatologic properties. According to legend, St. John of Jerusalem touted its use to treat battlefield wounds during the Crusades. A more mundane explanation is that the ancient holiday of Saint John's Day (June 24) occurs on the approximate date when the “wort” (Old English for plant) blooms.

From Depression to Skin Care

St. John's wort regained popularity in the 1980s when it was found to be a safe, effective remedy for mild to moderate depression (Hautarzt. 53[5]:316-21, 2002).

In December 1984, the German Commission E approved the systemic use of St. John's wort as an antidepressant. The commission also approved topical St. John's wort oil formulations for treatment and posttherapy of acute and contused injuries, myalgia, and first-degree burns.

St. John's wort contains several components known to confer antioxidant capabilities, such as catechin-type tannins and condensed-type proanthocyanidins (catechin, epicatechin, and leucocyanidin); flavonoids (hyperoside, rutin, quercitrin, isoquercitrin, quercetin, and kaempferol); bioflavonoids (biapigenin); phloroglucinol derivatives (hyperforin); phenolic acids (caffeic, chlorogenic, and ferulic); sterols (-sitosterol); vitamins C and A; xanthones; and choline (Zhongguo Zhong Yao Za Zhi. 27[2]:120-22, 2002).

Since hyperforin is considered to be the primary active ingredient in St. John's wort, it is important to note that recent research has identified anti-inflammatory and antibacterial effects of the lipophilic phloroglucin derivative hyperforin, one of the metabolites of Hypericum (Hautarzt. 53[5]:316-21, 2002; Phytomedicine [10, suppl. 4]:31-37, 2003; Hautarzt. 54[3]:248-53, 2003).

These effects point to the potential of St. John's wort as a topical treatment for wounds and other dermatologic conditions.

In a prospective, randomized, placebo-controlled, double-blind study with 21 volunteers, Hypericum-extract cream was superior to placebo vehicle at all clinical visits (days 7, 14, and 28) in the topical treatment of mild to moderate atopic dermatitis (Phytomedicine [10, suppl. 4]:31-37, 2003; Hautarzt. 54[3]:248-53, 2003).

Further study is needed to compare St. John's wort with therapeutic standards (Phytomedicine [10, suppl. 4]:31-37, 2003; Hautarzt. 54[3]:248-53, 2003).

There is also a dearth of research on the potential immunomodulatory properties of topical formulations of St. John's wort.

Current data suggest an inhibitory effect of Hypericum extract and hyperforin on the mixed epidermal cell lymphocyte reaction (MECLR) and on the proliferation of T lymphocytes; this effect indicates the potential efficacy of St. John's wort in treating inflammatory skin disorders (Br. J. Dermatol. 142[5]:979-84, 2000).

Unwanted Interactions

With the increase in self-administration of herbal remedies in recent years, physicians have observed significant interactions with prescribed medications. Decreased levels of digoxin, indinavir, and cyclosporine in the blood were shown in patients who were also taking St. John's wort (Hautarzt. 53[5]:316-21, 2002).

Use of the herb has also been associated with phototoxicity. Besides hyperforin, another photodynamic active plant pigment is hypericin, which is the other characteristic metabolite of St. John's wort (Br. J. Dermatol. 142[5]:979-84, 2000; Photodermatol. Photoimmunol. Photomed. 16[3]:125-28, 2000; Skin Pharmacol. Appl. Skin Physiol. 12[5]:299-304,1999). Photodermatitis, dubbed “hypericism,” is known to result from the consumption of high levels of compounds containing hypericin (Phytother. Res. 17[2]:141-46, 2003; J. Cosmet. Laser Ther. 3[3]:159-60, 2001; Photodermatol. Photoimmunol. Photomed. 16[3]:125-28, 2000). When standard oral doses are consumed, however, photosensitivity does not appear to increase.

Most reports on the potential phototoxicity associated with St. John's wort evaluated the effects of oral consumption. In a study of 16 subjects with skin types II or III, Hypericum-extract oil and ointment were applied to the volar forearms of patients who were exposed to solar-simulated radiation. Although no evidence of significant phototoxic potential was found, the authors cautioned that more sensitive photometric measurements might detect photosensitivity (Photodermatol. Photoimmunol. Photomed. 16[3]:125-28, 2000).

The oral form of St. John's wort should not be used by patients who are taking tetracycline or other photosensitizers (Arch. Facial Plast. Surg. 3[2]:127-32, 2001). Dermatologists should exercise caution when treating patients on oral St. John's wort with light therapies, such as intense pulsed light or light-emitting diodes, especially when these are combined with photo sensitizers, such as Levulan.

Marketing St. John's Wort

Since topical application of the oil from St. John's wort has been deemed apparently safe and nonphototoxic, several new product lines have emerged.

St. John's wort is included in Dr. Hauschka skin care products to confer skin soothing and strengthening in the Eye Contour Day Cream, Moisturising Day Cream, Normalising Day Oil, Cleansing Cream, St. John's Wort Body Oil, Lip Balm, Rose Day Cream, Blackthorn Body Oil, Toned Day Cream, and Fitness Foot Balm.

Wala Heilmittel GmbH manufactures Camphor-St. John's wort oil for various indications, including muscle pain. Aubrey Organics Inc. includes St. John's wort oil in its Vegecol Facial Cleansing Lotion and Vegecol With Organic Aloe and Oatmeal Soothing Mask. Shiseido Co.'s very expensive skin cream Clé de Peau Beauté contains H. perforatum, which is the botanical name of St. John's wort.

Exploring the Potential

The efficacy of St. John's wort for the treatment of depression is considered well established. Because St. John's wort is widely used as an herbal supplement, patients who take it should inform their physicians in order to avoid potentially adverse drug interactions.

The effectiveness of several known antioxidant compounds in St. John's wort provides the impetus for exploring other potential applications of this perennial plant and favorite home remedy. Anecdotal evidence of its success in healing and cleaning wounds suggests that its use should be expanded into the topical realm.

But much more research, in the form of randomized, double-blind, placebo-controlled clinical trials, is needed before the medical community should endorse the use of topical products with St. John's wort as the primary active ingredient.

DR. LESLIE S. BAUMANN is director of cosmetic dermatology at the University of Miami. To respond to this column, or to suggest topics for future columns, write to Dr. Baumann at our editorial offices or via e-mail at sknews@elsevier.com.

© 2004 International Medical News Group. Published by Elsevier Inc. All rights reserved.