Download The Impact of Herbal Medicines on Dermatologic Surgery

The Impact of Herbal Medicines on Dermatologic Surgery
Lawrence K. Chang, MD and Duane C. Whitaker, MD
Department of Dermatology, University of Iowa College of Medicine, Iowa City, Iowa
background. In recent years herbal medicines and supplements have become increasingly popular. With their increased
popularity, more publications are warning about the potential
harmful effects of some of these products.
objective. To present scientific evidence of the benefits and
surgical risks of herbal products.
methods. A Medline search and review of the literature was
performed.
results. Many herbal medicines are relevant in dermatologic
surgery since Ginkgo biloba, garlic, ginger, ginseng, feverfew,
and vitamin E may increase the risk of bleeding, and ephedra
may potentiate the side effects of epinephrine.
conclusion. Dermatologists should be aware of these herbal
products and their uses. Many of these products prescribed by
alternative medicine physicians or purchased over the counter
should be discontinued prior to dermatologic surgery to minimize the risk of surgical complications.
ALTERNATIVE MEDICINE is becoming more popular
in the United States. In 1997 alternative medicine
practitioners had 629 million visits, exceeding total
primary care physician visits. In addition, approximately $5.1 billion was spent on herbal preparations.
The use of these products increased by 380% between
1990 and 1997, and appears to be growing by 15%
per year.1,2 Since herbal product use has become more
prevalent in recent years, more medical publications
have reported their potential uses, side effects, and drug
interactions, increasing awareness among physicians.3–
6 Furthermore, the general public is now more aware
of the potential benefits and side effects. For example,
the cover of the February 12, 2001 issue of U.S. News
& World Report, titled “The Risks of Natural Cures,”
is accompanied by an article addressing the potential
benefits, side effects, and drug interactions of some
popular herbal medicines and supplements.
Many herbal products have antiplatelet effects, therefore they may increase the bleeding risk in dermatologic surgery. Postoperative bleeding subsequently increases the risk of infection, flap and graft necrosis,
wound dehiscence, pain, and scar formation. Aspirin
and nonsteroidal anti-inflammatory drugs (NSAIDs)
are known to inhibit platelet function and increase
these risks. In order to minimize bleeding complications, aspirin is routinely stopped 10 days prior to surgery in patients without a prior history of a cardiovascular event, and NSAIDs are stopped 3 days prior to
surgery to minimize bleeding complications. Table 1
lists the medications that contain aspirin and NSAIDs.
In addition to aspirin, NSAIDs, and other physician
prescribed antiplatelet drugs, herbal products such as
Ginkgo biloba, garlic, ginger, ginseng, feverfew, and
vitamin E due to their antiplatelet effects should be
discontinued preoperatively if absolute hemostasis is
critical.
During the preoperative evaluation, patients sometimes mention that they are on herbal medicines.
However, less than 40% of people actually disclose alternative medicine use with their physicians.1 Therefore the practitioner should ask the patient about use
of specific herbal products which are known to inhibit
platelet function. Fifty-eight percent of patients who
take herbal medicines are using alternative medicine
for prevention and maintaining health. Conversely,
only 42% of people were using alternative medicine
for treatment of an illness.1 Furthermore, half of the
people use alternative medicine without a recommendation from a physician or a provider of alternative
therapy.7 Thus many herbal products can be stopped
prior to surgery. An understanding of the indications
as well as the scientific data regarding the antiplatelet
effects of herbal products is helpful to the physician
during the preoperative evaluation. There is scientific
evidence that Ginkgo biloba, ginger, garlic, ginseng,
feverfew, and vitamin E inhibit platelet function and
aggregation, and increase the risk of bleeding. A review of current literature on basic science research as
well as clinical reports of bleeding on these herbal
products are summarized.
L. K. Chang, MD and D. C. Whitaker, MD have indicated no significant interest with commercial supporters.
Address correspondence and reprint requests to: Duane C. Whitaker,
MD, Department of Dermatology, University of Iowa Hospital and
Clinics, Iowa City, IA 52242-1090.
Ginkgo biloba
Extracts for medicinal use are made from the dried
leaves of Ginkgo biloba (maidenhair tree). In Ger-
© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0512/01/$15.00/0 • Dermatol Surg 2001;27:759–763
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chang and whitaker: herbal medicine in dermatologic surgery
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Table 1.
Aspirin-Containing Products
Over-the-counter medications
Prescription medications
Alka-Seltzer
Aspirin
Aspirin Regimen Bayer
BC powders
Ecotrin
Excedrin Extra Strength
Goody’s Body Pain Formula powder
Goody’s Extra Strength Pain Relief
Momentum Backache Relief
Vanquish Analgesic Caplets
Easprin
Excedrin
Disalcid
Salflex
Trilisate
NSAIDs
Advil
Aleve
Motrin
Nuprin
Orudis KT
Anaprox
Arthrotec
Cataflam
Clinoril
Daypro
Disalcid
Dolobid
EC-Naproxyn
Feldene
Indocin
Lodine
Nalfon
Naproxyn
Oruvail
Ponstel Kapseals
Relafen
Salflex
Tolectin
Toradol
Trilisate
Voltaren
Celebrex and Vioxx are left out because they do not increase bleeding risk.
Sources: Physicians’ Desk Reference, 54th edition, 2000. Physicians’ Desk Reference, for nonprescription drugs and dietary supplements, 21st edition, 2000.
many and France, these extracts are the most commonly prescribed herbal drug.8 Ginkgo biloba has become a subject published extensively in the medical
literature. A meta-analysis by Oken et al. of 57 articles
concluded that Ginkgo biloba has shown some evidence of beneficial effect on memory function.9 In
most studies 120–160 mg of Ginkgo biloba were used
and divided into three times a day dosing. The beneficial effect usually starts around 4–6 weeks. Flavonoids
and terpenoids are the main components of ginkgo extracts, which are potent antagonists of platelet-activating factor.10 Platelet-activating factor induces platelet
aggregation and activation. The antiplatelet property
of Ginkgo biloba may be clinically significant.
Currently there are four reports of bleeding in association with Ginkgo biloba. In one case report, a
healthy 33-year-old woman developed spontaneous subdural hematomas after 2 years of taking 120 mg/day
of Ginkgo biloba. The patient’s bleeding time was prolonged while taking Ginkgo biloba and subsequently
normalized when checked at 35 days after discontinuing Ginkgo biloba.11 In another case report, a 72-yearold woman who had been taking Ginkgo biloba for
6 months developed a subdural hematoma. Furthermore, the combination of Ginkgo biloba with other
anticoagulants may increase the risk of hemorrhage.
In one case report, a 78-year-old who was on chronic
warfarin developed intracerebral hemorrhage with con-
comitant use of Ginkgo biloba.12 In another case report, a 70-year old who was on 325 mg of aspirin for
3 years developed bleeding from the iris into the anterior chamber 1 week after starting Ginkgo biloba.13
Since people are taking Ginkgo biloba to increase
memory function, a noncritical indication, and Ginkgo
biloba has been reported to increase bleeding time and
bleeding, Ginkgo biloba should be stopped prior to
surgery.
Garlic
Garlic (Allium sativum) most recently has been used
to lower cholesterol and blood pressure.14 Many studies have been published to show the beneficial effects
of garlic. A meta-analysis done by Silagy and Neil15
showed that 600–900 mg/day of garlic may lower
blood pressure over 1–3 months and lowers cholesterol by 10%. Adenosine, allicin, and paraffinic polysulfides are constituents of garlic that have antiplatelet
effects. The antiplatelet effects of adenosine last up to
1 day, and allicin and paraffinic polysulfides have a
much shorter time of action.16 In one study, 20 days of
garlic oil decreased platelet aggregation by 9%.17 In a
double-blind, placebo-controlled study, 800 mg/day
of garlic produced a continuous decline of platelet aggregation for 4 weeks. Furthermore, during the wash-
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chang and whitaker: herbal medicine in dermatologic surgery
out period, the platelet aggregation did not return to
normal for 4 weeks.18 Three cases of bleeding have
been reported with garlic. In one case report, a healthy
87-year-old man (not on anticoagulants) who ingested
four cloves of garlic per day presented with a spontaneous epidural hematoma. His bleeding time and prothrombin time (PTT) were significantly elevated at admission. Three days after stopping the garlic, his bleeding
time returned to normal.19 In another case report, a
72-year-old man on garlic supplement who underwent
a transurethral prostatectomy had excessive bleeding
and required a blood transfusion. Three months after
resuming garlic tablets, platelet aggregation in the presence of collagen was abnormal.20 Burnham21 reported
a patient on heavy dietary intake of garlic who had an
abnormal bleeding time at the time of surgery. One
week after the patient discontinued garlic, bleeding
time normalized.21,22 Garlic supplement may be indicated in patients with hypertension or hypercholesterolemia, and garlic ingested in large amounts appears
to have antiplatelet effects and should be stopped prior
to surgery.
Ginger
Ginger (Zingiber officinale) has been used as an antinauseant and antispasmodic agent. In a prospective,
randomized, double-blind trial, 1 g of ginger 1 hour
prior to surgery reduced postoperative nausea by
50%. In this study, no increase in bleeding was noted
during the postoperative period.23 In another study,
coagulation studies were not affected 24 hours after
ingesting 2 g of dried ginger. Therefore ginger should
be safe as a preoperative antiemetic with doses of up
to 2 g of dried ginger.24 Although short-term and relatively small doses of ginger appear to have no effect on
coagulation studies, it does have an anticoagulant effect
with larger doses or with chronic use. Ginger inhibits
thromboxane A2 synthesis and promotes prostacyclin
synthesis. Thromboxane A2 has a positive aggregatory
effect on platelets, while, prostacyclin has a negative
aggregatory effect.25 Therefore ginger inhibits platelet
aggregation. In a prospective human trial, consumption of 5 g of raw ginger for 7 days showed a statistically
significant reduction in thromboxane production.26
Small doses of ginger can be used as an antinauseant
prior to surgery; however, large amounts of ginger
may increase bleeding risk since ginger has an antiplatelet effect.
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laboratory, ginseng extracts have been shown to have
inhibitory effects on platelet aggregation and enhance
fibrinolysis.32 Ginseng has also been reported to raise
blood pressure; therefore it may increase bleeding risk.33
There are two reports of bleeding with ginseng use.
The first report involved a 72-year-old postmenopausal
woman who developed vaginal bleeding after ingestion of 200 mg of ginseng for 1 month.34 The second
report involved a 44-year-old postmenopausal woman
who had vaginal bleeding with the use of ginseng face
cream.35 Since ginseng has the potential to increase
blood pressure and has been reported to cause abnormal vaginal bleeding, ginseng is best stopped prior to
surgery.
Feverfew
Feverfew is used for migraine headaches and arthritis.
A double-blind, placebo-controlled trial has shown that
feverfew prevents migraine attacks.36 Feverfew contains
sesquiterpene lactone, which exerts its anti-inflammatory
effect by inhibiting phospholipase breakdown of arachidonic acid into prostaglandins and leukotrienes.37,38
Thromboxane A2 is also a by-product of the cascade
and induces platelet aggregation. Furthermore, the feverfew extract parthenolide inhibits platelet aggregation
induced by phorbol 12-myristate 13-acetate, adenosine
diphosphate, and sodium arachidonate.39,40 Feverfew
has antiplatelet effects; however, the clinical significance of the inhibition of platelet aggregation is unknown.
Vitamin E
Vitamin E has antioxidant effects, which have been
advocated for cancer prevention and reduction of oxidative damage of the central nervous system. Furthermore, vitamin E inhibits platelet aggregation and secretion.41 Therefore vitamin E has also been advocated
in cardiovascular disease prevention. However, a recent study has shown that vitamin E does not reduce
cardiovascular outcome in high-risk patients.42 Clinically vitamin E may cause bleeding. In one study, a
50 mg vitamin E supplement increased hemorrhagic
stroke by 50% compared to a control group.43 In another related study, vitamin E has been associated
with increased gingival bleeding.44 Vitamin E use in
premature infants causes retinal hemorrhage.45 Since
vitamin E has antiplatelet effects, vitamin E should be
stopped prior to surgery.
Ginseng
Ginseng has been used to treat diabetes and to improve subjective well-being. In laboratory rats, ginseng extracts have a hypoglycemic effect.27–31 In the
Ephedra
Ephedra is commonly used as a weight loss product.
Reported adverse reactions are insomnia, nervousness,
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chang and whitaker: herbal medicine in dermatologic surgery
tremor, headache, hypertension, seizure, arrhythmia,
heart attack, stroke, and death. Half of the reported
cases occurred in people younger than 40 years old.6
The potential interaction with epinephrine is of concern. In dermatologic surgery, epinephrine is often
combined with lidocaine to decrease bleeding during
surgery. The patient may feel palpitations when epinephrine is used. Since both epinephrine and ephedra
can add to cardiac stress during surgery, ephedra is
best avoided prior to dermatologic surgery.
Conclusion
Herbal medicines are gaining in popularity and are
here to stay. Physicians need to heighten their awareness of herbal products. If physicians notice a complication related to herbal medicines, a report should be
made to the U.S. Food and Drug Administration. The
decision to discontinue or initiate a medicine prior to
surgery should be made based on the overall wellbeing of the patient. However, the information provided herein about herbal medicines indicates that in
dermatologic surgery, Ginkgo biloba, ginger, garlic,
ginseng, feverfew, and vitamin E should be stopped
prior to surgery to minimize bleeding risk, while ephedra-containing products should be discontinued to
avoid potentiation of epinephrine.
Acknowledgment We would especially like to thank Donna
M. Pellowski, MD for assistance in reviewing and editing
this article.
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