Release: May 12, 2000
Contact: Kenneth Satterfield, 407-238-4161 (as of 5/12/2000)
FACIAL PLASTIC SURGEONS OUTLINES DANGER OF USING HERBAL MEDICINE BEFORE, DURING, AND AFTER PLASTIC SURGERY
Orlando, FL -- Unlike other forms of complementary and alternative medicine (CAM), herbal medicine (phytomedicine) employs remedies possessing significant pharmacological activity and consequently potential adverse effects and drug interactions. The explosion in sales of herbal therapies has brought many products to the marketplace that do not conform to the standards of safety and efficacy that physicians and patients expect. Unfortunately, few surgeons question patients regarding use of herbal medicines, and 70 percent of patients do not reveal their use of herbal medicines to their physicians and pharmacists.
The use of herbal medicine is widespread and growing. The actual and perceived relative safety of natural products is a major reason for their popularity with the general public. In 1997, sixty million Americans spent 3.24 billion dollars on herbs as medical therapy. In 1999, United States herbal sales were expected to exceed five billion dollars. Unfortunately, the explosion in sales of herbs, vitamins and supplements has brought many products to the marketplace that do not conform to the standards of safety and efficacy that physicians and patients expect.
A facial plastic surgeon has completed a research study that defines herbal medicine and discusses how plants are processed into remedies. He has summarized the history, use and regulation of botanical medicine in the United States and explored the adverse effects of common herbal remedies. Most importantly, he has outlined the potential for drug-herb interactions and examined potentially beneficial herbal therapies. The author of "Herbal Therapy-What Every Facial Plastic Surgeon Must Know," is Edmund Pribitkin, MD, Philadelphia, PA. He is presenting his findings to the American Academy of Facial Plastic and Reconstructive Surgery, meeting May 12-13 in Orlando, FL.
Defining herbal medicine: Dr. Pribitkin defines herbal medicines (phytomedicines) as medicinal products that contain plant materials as their pharmacologically active component. For most herbal medicines, the specific ingredients that determine the pharmacologic activity of the product are unknown. Most herbal preparations are marketed as dry or fluid extracts, which are made from dried plant parts by maceration or percolation. Herbal medicines can differ in strength and purity. For example, California investigators in 1998 found that nearly one third of 260 imported Asian herbal remedies were either spiked with drugs not listed on the label or contained potentially hazardous levels of lead, arsenic or mercury. When prescribing herbal medicines, practitioners are advised to select manufacturers who use methods such as high performance liquid.
Unlike other countries, no enlightened system of laws and regulations governing the sale and use of herbal medicines exists in the United States. The use of herbal medicines has depended largely on popular literature and has been driven by media and web-based outfitters to increasing levels of consumption. Because there is no regulation of herbs as drugs, there is no control over product standardization, either in terms of potency or contamination. Therefore the study suggests that each surgeon must take a focused, systematic look at commonly used herbal products, their adverse reactions and common drug interactions.
Adverse reactions: Dr. Pribitkin describes the following adverse reactions to herbal medicines.
Bleeding: Facial plastic surgeons commonly question patients with regard to aspirin use, yet few explore the use of herbals among their patients contemplating surgery. All surgeons should question patients regarding the use of the following common herbal remedies, which may increase the risk of bleeding during surgical procedures:
(1) Feverfew (Tanacetum parthenium), despite its name, has no fever-reducing powers and is most commonly used for migraines. Feverfew has been shown to inhibit platelet activity and must be avoided in patients using warfarin or other anticoagulants. Patients should be advised to discontinue feverfew use before surgery. Unfortunately, abrupt cessation of feverfew therapy may result in a withdrawal syndrome characterized by nervousness, tension headaches, insomnia, stiffness, joint pain, and tiredness.
(2) Garlic (Allium sativum) has been widely touted as a cure for colds, coughs, flu, chronic bronchitis, whooping cough, ringworm, asthma, intestinal worms, fever, and digestive, gallbladder and liver disorders. Recent research has explored its use as a treatment for mild hypertension and hyperlipidemia. Heavy consumption may lead to elevated clotting times and spontaneous hemorrhage. Numerous studies have documented garlic's inhibitory effect on platelet aggregation in humans, which occurs within 5 days of oral administration.
(3) Ginger (Zingiber officinale) has been used for millennia in China as a digestive aid and to remedy stomach upset, gassy indigestion, bloating and cramping. Recent studies have confirmed its use as an antinauseant in motion sickness. Ginger is a potent inhibitor of thromboxane synthetase and can theoretically prolong bleeding times if used long-term.
(4) Gingko (gingko biloba) was recognized by the 1994 German Commission E for treatment of cognitive disorders including dementia, intermittent claudication, and tinnitus or vertigo of vascular or involutional origin. Recent publicity as a treatment for Alzheimer's Disease has boosted sales of standardized gingko biloba extract to unprecedented levels. Reports of spontaneous hyphema and of spontaneous bilateral subdural hematomas underscore gingko's potent inhibitory effect on platelet activating factor and consequently on platelet aggregation.
(5) Asian Ginseng (Panax ginseng) has become popular as a key to vitality and longevity, the herb to take in cases of physical or mental fatigue or lowered resistance to infection. The herb exhibits antiplatelet effects, and its concomitant use with warfarin, heparin, aspirin and NSAID's should be avoided. This effect has not been shown with Siberian Ginseng (Eleutherococcus senticosus), which has also been promoted for its adaptogenic properties.
Skin reactions: Numerous herbal medicines may profoundly affect the skin and may thereby adversely interact with the facial plastic surgeon's efforts to improve skin quality through resurfacing techniques.
(1) Kava (Piper methysiticum) preparations are an herbal alternative to synthetic anxiolytics and tranquilizers and are frequently found in "herb drinks. A characteristic "kawa dermatopathy" may develop if the herb is used continuously for several months. Symptoms include reddened eyes, scaly skin eruptions, and a yellowish discoloration of the skin, hair and nails attributed to two yellow pigments in the plant. Fortunately, these effects appear to be reversible upon discontinued use of the herb.
(2) St. John's wort (Hypericum perforatum) is licensed in Germany for the treatment of mild depressive states, anxiety, nervous unrest and sleep disorders. Sales of the herbal preparation have boomed due to the public's perception that it is a safe alternative to prescription anti-depressants. St. John's wort poses a risk of photosensitivity reaction attributed to its hypericin component. Concomitant use with other photosensitizing agents such as tetracycline hydrochloride, flouroquinolones and sulfonamides should be avoided.
(3) Retinoids such as tretinoin and similar dermal irritants should be administered with caution in conjunction with St. John's wort because of the possibility of augmented phototoxicity. Certain medicinal plants of the carrot family (Apiaceae) contain furanocoumarins and can also cause a photodermatitis in humans from sensitization of the skin to ultraviolet light. Use of any herbal medicines containing furanocoumarins should be avoided while undergoing cosmetic ultraviolet light exposure or in conjunction with other photosensitizing agents or dermal irritants.
Estrogen effects: Many facial plastic surgeons advise post-menopausal patients to consult their primary care physicians regarding the risks and benefits of estrogen replacement therapy. Over 500 plant species contain phytoestrogens, naturally occurring substances functionally similar to estradiol. These herbal medicines potentiate estrogen effects, and their use in conjunction with estrogen replacement therapies may result in symptoms such as nausea, bloating, hypotension, breast fullness or tenderness, migraine headaches and edema. Among the more commonly used phytoestrogen containing herbs ares dong quai (Angelica sinensis), red clover (Trifolium pratense), alfafa (Medicago sativa var. italica), licorice (Glycyrrhiza glabra), and black cohosh (Cimicifuga racemosa).
Potentially Beneficial Herbal Medications
Wound healing:
(1) Aloe vera (Aloe vera) gel or mucilage is a thin, clear, jelly-like substance obtained from the parenchymal tissue making up the inner part of the aloe vera plant leaf. It must not be confused with aloe juice (a.k.a. latex), which is a cathartic, bitter yellow juice extracted from specialized cells of the plant's inner leaf. Aloe gel is commonly incorporated in a wide variety of cosmetic products for its wound-healing properties. Fresh aloe vera gel promotes the attachment and growth of normal human cells in vitro and enhances the healing of wounded monolayers of cells.
Conclusions: Facial plastic and reconstructive surgeons work with patients seeking to maintain their appearance of health and vitality. Clearly, all patients should be asked about the use of herbal medicines and should have their responses documented in the medical record. Surgeons must be aware of adverse reactions stemming from herbal medicine use, especially with regard to perioperative bleeding. They must caution patients that lack of standardization, quality control and regulation may result in variability in herbal content, efficacy and frank contamination. Well-controlled clinical trials may yield valuable new herbal medicines or validate ancient remedies, but each surgeon should discuss proven treatment options prior to the patient's considering the use of herbal therapies.
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