A review of herbal medicines in wound healing.

Review

A review of herbal medicines in wound healing Tina Maver1, MPharm, Uros Maver2, PhD, MPharm, Karin Stana Kleinschek1, PhD, Dragica M. Smrke3, PhD, MD, and Samo Kreft4, PhD, MPharm

1 Laboratory for Characterisation and Processing of Polymers, Faculty of Mechanical Engineering, University of Maribor, Maribor, Slovenia, 2Faculty of Medicine, University of Maribor, Maribor, Slovenia, 3University Medical Centre Ljubljana, Ljubljana, Slovenia, and 4Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia

Correspondence Uro s Maver, PHD, MPHARM University of Maribor Faculty of Medicine Taborska ulica 8 SI-2000 Maribor Slovenia E-mail: [email protected]

Abstract Herbs have been integral to both traditional and non-traditional forms of medicine dating back at least 5000 years. The enduring popularity of herbal medicines may be explained by the perception that herbs cause minimal unwanted side effects. More recently, scientists increasingly rely on modern scientific methods and evidence-based medicine to prove efficacy of herbal medicines and focus on better understanding of mechanisms of their action. However, information concerning quantitative human health benefits of herbal medicines is still rare or dispersed, limiting their proper valuation. Preparations from traditional medicinal plants are often used for wound healing purposes covering a broad area of different skin-related diseases. Herbal medicines in wound management involve disinfection, debridement, and provision of a suitable environment for aiding the natural course of healing. Here we report on 22 plants used as wound healing agents in traditional medicine around the world. The aim of this review is therefore to review herbal medicines, which pose great potential for effective treatment of minor wounds.

Conflicts of interest: None. doi: 10.1111/ijd.12766

Introduction The human skin is the largest organ in the body and represents its first line of defense.1 Besides protection, the skin has two other main functions: regulation and sensation. More specifically, it provides protection from mechanical impacts and pressure, limits the influence of variations in temperature, fights micro-organism infections, restricts radiation effects, and prevents the entrance of chemicals. As the largest organ in the body, the skin also plays an important role in several physiological processes, including regulation of body temperature (via sweat and hair) and changes in peripheral circulation and fluid balance. It is also involved in the synthesis of vitamin D, for which it acts as a reservoir. With an extensive network of nerve cells, the skin enables detection and relaying of changes in the environment (heat, cold, touch, and pain). Damage to these nerve cells is known as neuropathy and results in the loss of sensation in affected areas. Because of all the aforementioned and other functions, the preservation of skin quality is of prime importance to maintain a healthy body.2,3 A wound is defined as the disruption of the cellular and anatomic continuity of a tissue and may occur due to ª 2015 The International Society of Dermatology

physical, chemical, thermal, microbial, or immunological tissue trauma.4 Wounds can compromise patients’ well-being, self-image, working capacity, and independence. Effective wound management is therefore necessary not only on the individual but also on the community level.5 The process of wound healing Wound healing is a complex and dynamic process of replacing devitalized and missing cellular structures and tissue layers. It is reflected in a set of biochemical events in a closely organized cascade to repair damaged tissue.6 In the human adult, wound healing is often divided into three phases, i.e., inflammatory, proliferative, and remodeling phases. The inflammatory phase starts immediately after injury with the launch of hemostatic mechanisms to stop bleeding straight away.7 It is characterized by vasoconstriction and platelet aggregation to induce vasodilatation and phagocytosis, hence inflammation of the wound site. The proliferative phase is characterized by granulation, wound contraction, and epithelialization. During granulation, fibroblasts form a bed of collagen, followed by the production of new capillaries.7 During International Journal of Dermatology 2015

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wound contraction, myofibroblasts decrease the size of the wound by gripping the wound edges and contracting using a mechanism that resembles that of smooth muscle cells. When the cells’ roles are close to complete, unneeded cells undergo apoptosis.8 Epithelialization involves proliferation of epithelial cells, which then crawl atop the wound bed, covering the new tissue. Finally, the remodeling phase takes place over a period of several months, during which the dermis responds to injury with the production of collagen and matrix proteins in an attempt to return to its pre-injury phenotype.9 The aim of wound treatment is to either shorten the time required for healing or to minimize the undesired consequences, hence scarring.10 Important activities in wound healing management Various physiological events can significantly affect the course of wound healing. Among the most important are the anti-inflammatory, antimicrobial, analgesic, and antioxidant activities, regardless of the underlying mechanism. The acute inflammatory response during the early stages of injury generates factors (cytokines and chemokines) essential for appropriate tissue growth and repair.11 Prolonged inflammation can prevent the wound from reaching the remodeling phase, as well as matrix synthesis. As a result, delays in wound closure and an increase in pain sensation in and beside the wound commonly appear, leading to even more hindered healing.12 Considering the aforementioned, the anti-inflammatory therapeutic interventions in wound care have been the subject of extensive research, particularly in relation to wound healing and improved patient comfort.13 Infections are known as one of the most important factors influencing efficiency of wound healing. It is reported that a high percentage of wound-related complications and hence costs in wound care can be directly linked to infected wounds.14 Reducing the bacterial load may be one of the most important necessary requirements for better wound healing, as wound infection (either secondary or primary by opportunistic microorganisms) can lead to reduction of local inflammation and consequentially avoid tissue destruction.15 An ideal treatment for the prevention of wound infection should act antimicrobially and at the same time stimulate the body’s natural immune activity without damage to surrounding healthy tissue.16 Most wounds induce a sensation of pain. Pain relates to patient discomfort, release of stress factors, and often reduces the patient’s quality of life. Hindered mobility, International Journal of Dermatology 2015

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psychological issues connected with pain-induced stress, and the financial burden caused by prolonged therapy all contribute to less effective wound healing. According to McGuire et al.,17 chronic pain lowers the patient’s capability of healing, prolonging the overall recovery process.17,18 Suitable and effective pain management can lead to an earlier ambulation, adequate oxygenation, nutrition, and stress reduction. All studies mentioned results in the facilitation of wound healing, while minimizing risk for the development of chronic pain, as well as finally in lowered treatment costs.19 Inflammation also causes a coordinated influx of neutrophils to the wound site. Neutrophils activate their socalled respiratory burst and produce free radicals.20,21 The presence of free radicals results in oxidative stress leading to lipid peroxidation, DNA breakage, and enzyme inactivation, including free-radical scavenger enzymes, which are known to limit the effects of reactive oxygen species. Evidence for the role of oxidants in the pathogenesis of many diseases suggests that antioxidants may be of therapeutic use in these conditions and hence improve efficiency of wound healing.22 Important characteristics to be considered in wound healing are the wound contraction rate, granulation tissue breaking strength, as well as the collagen content.23 Apart from the above-mentioned wound healing aiding activities, others are also reported in the literature, i.e., astringent activity, stimulated epithelization, and effective hydration of the wound site.24 Medical plants traditionally used in wound healing Nature has been a source of medicinal treatments for thousands of years, and plant-based systems continue to play an essential role in the primary healthcare of 80% of the world’s underdeveloped and developing countries. Many plants and their extracts have been used traditionally due to their great potential for management and treatment of wounds. Natural agents induce healing and tissue regeneration through multiple connected mechanisms. The so-called phytomedicines are affordable, and they mostly cause minimal unwanted side effects. However, increasing awareness of their activities, and potential and possible safety concerns, point out the need for their scientific standardization, validation, and systematic safety evaluation before efficient introduction to wound care.25 In recent years, extensive research has been carried out in the area of wound healing and management through medicinal plants.25–28 Table 1 provides an overview of the most important medicinal plants and their properties, with a known or proven effect on wound healing. ª 2015 The International Society of Dermatology

Scheme

Used parts

Formulations

Unwanted side effects

Clinical evidence

Commercial products

Whole plant, flower

Liquid dosage forms for cutaneous use

ª 2015 The International Society of Dermatology Skin reactions in patients with contact dermatitis

Animal trials, case studies and clinical trials43

Azadirachta Seed oil, bark Liquid extracts in organic Possibly allergic in high Animal studies and cell Neem extract AlignTM and neem fruits indica solvents doses45 cultures46–48 Description: Azadirachta indica (Family: Meliaceae). Neem has been used in India for over two millennia due to many pharmacological activities, particularly for skin diseases. Liquid neem extracts possess antibacterial, antifungal, antiviral, and anti-inflammatory activities. Neem oil aids the building of collagen and maintains skin elasticity.46,49 It also keeps the wound moist during the healing process. All mentioned mechanisms contribute to acceleration of wound healing27

Dried comminuted fruits and liquid extracts (aqueous and ethanol)

Colloidal Avena extracts are common in cosmetic formulations (shampoos, soap, creams, ointments, emulsions and gels) since 1982 Description: Avena (Family: Poaceae). Oats have been known for more than 4000 years as food, while its use in traditional medicine dates back to the 12th century. For cutaneous use, fruits of Avena are prepared as ‘colloidal oatmeal’ as described in USP (30th or later).43 In vitro investigations are indicative of anti-inflammatory activity of several oats preparations.43 Pasta made with oats flour mixed with beer yeast is used on infected ulcers and wounds to facilitate wound healing.44

Fruits

Avena

Liquid extracts, dried liquid extracts and strips

No specific unwanted side Animal studies and cell No commercially available products for effects are reported for cultures39,40 cutaneous use cutaneous use Description:Angelica sinensis (Family: Apiaceae). Chinese angelica is widely used in Chinese traditional medicine. Its isolate has been found to stimulate wound healing through its major active component, ferulic acid (acting proliferation-promoting)41,42 and increase the strength of the healed wounds.41 This effect is related to Angelica’s analgesic and antimicrobial properties

Whole herb, roots

Angelicasinensis

Aloe vera

Mucilage from innerleaf Gels and ointments for Hypersensitivity to aloe35 Animal studies and case Aloe extracts, gels and ointments for parts cutaneous use studies35 cutaneous use Description: Aloe vera (Family: Liliaceae). Aloe vera has been used for medicinal purposes in several cultures for centuries, especially in Greece, Egypt, India, Mexico, Japan and China.36 Three thousand and five hundred years ago, Egyptians already used aloe extracts in treating burns, infections, and parasites.37 Aloe gel was proven to aid wound healing, in treating ulcers and burns by forming a protective coating on the affected areas, hence speeding up the healing process. Various constituents of Aloe vera stimulate wound healing and have anti-inflammatory activity (through different connected mechanisms, cytokine production and enzyme inhibition)38

Achillea

Allergic reactions and Animal and case studies29 Extracts (in polypropylene glycol) used in photosensitivity after skin cosmetic products exposure29 Description: Achillea (Family: Asteraceae). Yarrow has been used as a medicine by many cultures for hundreds of years.30 Good antibacterial activity against Shigella dysenteriae,31 moderate activity against Streptococcus pneumoniae, Clostridium perfringens and Candida albicans, and weak activity against Mycobacterium smegmatis, Acinetobacter lwoffii and Candida krusei was reported.32 Yarrow was also proven to have a significant anti-inflammatory effect (most likely through protease inhibition)33,34

Name

Table 1 Overview of the most important traditionally used medicinal plants and their properties, with a known or proven effect on wound healing

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Flower

Calendula officinalis

Formulations


Clinical evidence

Commercial products


Leaves

Ointments, cutaneous powder as an adjuvant and cream

Allergy to plants of the Apiaceae family62

Leaves

Flower

Aqueous extracts and Not reported against Animal studies and cell Formulations prepared from the aqueous decoction from leaves, mammals, highly allelopathic cultures72–74 extract (Eupolin) of the leaves has been comminuted leaves against other plants71 licensed for clinical use in Vietnam ground into a paste Description: Chromolaena odorata (Family: Asteraceae). Aqueous extracts and decoctions from Chromolaena leaves have been traditionally used throughout Vietnam in treatment of soft tissue and burn wounds.75 This liquid preparation enhances hemostatic activity, inhibits wound contraction, stimulates granulation tissue and re-epithelization processes, and can therefore aid wound healing, and minimize post-burn scar contracture as well as deformities76,77

Chromolaena odorata

Chamomilla recutita

Powdered form, liquid Animal studies, case Kamillosan for wound healing and Hypersensitivity to the active extracts (tinctures, oil studies, and clinical eczema treatment substance and to other extracts, lotions and trials67 plants of the Asteraceae67 infusions) Description: Chamomilla recutita (Family: Asteraceae). Chamomile has been used for centuries as an antimicrobial, antioxidant, anti-inflammatory agent, and as a mild astringent and wound healing medicine.68 Chamomile contributes to wound drying and accelerates epithelization.69 It was shown that its extracts aid wound healing through other mechanisms as well, i.e. through increasing the granulation tissue weight and hydroxyproline content, by enhancing the rate of wound contraction and wound-breaking strength70

Centella asiatica

Animal studies, nonCentallase ointment for keloidal scars, controlled case studies, Madecassol for treatment of systemic and localized scleroderma clinical studies on small patient groups62 Description: Centella asiatica (Family: Mackinlayaceae). Brahmi is used extensively in the treatment of leprosy and a host of skin conditions, including different wounds. In experimentally induced open wounds in rats, the aqueous extract of Centella asiatica increased collagen content and thickness of the epithelium.63 Topical administration of the aqueous extract further increased cellular proliferation, promoted collagen synthesis at the wound site as evidenced by the increase in DNA, protein, collagen content of granulation tissue, and in tensile strength.64 Through all mentioned mechanisms, Centella asiatica promotes wound healing and facilitates repair of the connective tissues.65,66 Ointments made from Centella leaves are used to treat leg ulcers, decubitus scabs, gangrene, defective scars, fistula, traumatic and surgical wounds, burns, and skin grafts. Cutaneous powder is a common adjuvant on the cicatrisation of skin injuries62

Wood, leaves, sap, and Bark and twig oil and Essential oil is reported nonAnimal studies and cell Various products from Cedrus oil are used bark extracts toxic to mammals56 cultures57–59 as value added products Description: Cedrus deodara (Family: Pinaceae). Deodar possesses anti-inflammatory, antimicrobial, astringent, and wound healing activities. It is particularly effective in treatment of infected wounds.60 Oil extracted from the bark and twigs has been used as astringent, while sap and oil are often used to treat psoriasis and eczema61

Cedrus deodara

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Liquid extracts, ointments Hypersensitivity to members Animal studies and cell Oils, ointments and seeds are sold for and comminuted herbal of the Asteraceae family50 cultures50 various purposes substance Description: Calendula officinalis (Family: Asteraceae). In vitro pharmacological studies have shown antiviral, antigenotoxic, anti-inflammatory properties of marigold.51 It also possesses antimicrobial activity against Bacillus subtilus, Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans,52 Sarcina lutea, Klebsiella pneumoniae, and Candida monosa.53 In suspension or in tincture, it is used topically for reducing inflammation, control of bleeding,54 and to facilitate healing of poorly healing wounds55

Used parts

Name

Table 1 Continued

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Scheme

Used parts

Formulations


Clinical evidence

Commercial products


Green leaves

Roots, whole plant

Liquid extracts (tinctures, fluid extracts, glycerites)

Aqueous and ethanol extracts

Hypersensitive skin reactions101

Animal studies, cell Not in wound care cultures and case studies101 Description: Ginko biloba (Family: Ginkgoaceae). Extracts of leaves have been used therapeutically for centuries.102 Ginkgo exhibits a variety of pharmacological activities, such as increase in blood fluidity, antioxidant, membrane stabilizing, improvement in cognition, and pro-healing. Its preparations increase granulation tissue breaking strength and promote epithelization103

Ginko biloba

Euphorbia hirta

Hypersensitive reactions Animal studies,99 cell Naturtech Labs Inc. Euphorbia Hirta (photosensitive skin cultures98 and case (Tincture) studies100 reactions, especially on contact with open cuts)98 Description: Euphorbia hirta (Family: Euphorbiaceae). The aqueous plant extract shows analgesic, anti-inflammatory activities and inhibition of platelet aggregation. Ethanol extract of the entire herb was found to possess significant wound healing activity26

Herbal preparations in semi-solid or liquid dosage form

Hypersensitive reactions (local Animal studies, cell Echinacin, Madaus AG rash, contact dermatitis, cultures, case studies and eczema and angioedema of clinical trials87 the lips)87 Description: Echinacea (Family: Asteraceae). Preparations from Echinacea species are listed among the medicines with the longest reported use in the American people’s medicine.88 The three most used species in phytotherapy of Echinacea are: E. purpurea, E. angustifolia, and E. palida. Apart from these, there are some reports of use of E. simulata and E. paradoxa89 in traditional medicine as well. Echinacea purpurea was first mentioned in 1787. Information about the plants’ use from traditional healers ranges from topical application to heal wounds, burns, and insect bites to the chewing of roots for toothache and throat infections. Oral or other form of internal application is known to reduce pain, to diminish coughs and stomach cramps, and to decrease the effects of snake bites.90 Different studies have demonstrated antimicrobial activity against Vesicular Stomatitis virus, Escherichia coli, Pseudomonas aeruginosa, Aspergillus niger, Candida albicans, Staphylococcus aureus, Pseudomonas aeruginosa,91 Encephalomyocarditis virus, Vesicular Stomatitis virus,92,93 Saccharomyces cerevisiae, Candida shehata, Candida kefyr, Candida albicans, Candida steatulytica, and Candida tropicalis.94 Echinacea extracts inhibit cyclooxygenase-I, cyclooxygenase-II,95 and 5-lipoxygenase96 and are therefore anti-inflammatory. All mentioned activities contribute to better wound healing95–97

Whole plant

Echinacea

Rhizome in the form of paste, ointment or powder

May enhance antiAnimal studies, case Whole rhizome, powder , and liquid inflammatory effects of other studies and clinical trials82 extracts thereof are commercially medicines, leading to toxic available in different countries effects82 Description: Curcuma longa (Family: Zingiberaceae). Tumeric possesses antibacterial, antifungal, analgesic, and anti-inflammatory activities (curcuminoids decrease prostaglandin formation and inhibit leukotriene biosynthesis via the lipoxygenase pathway).83 The anti-inflammatory activity and the presence of vitamin A and proteins in turmeric result in early synthesis of collagen fibers by mimicking fibroblastic activity.84 Juice of the fresh rhizome is commonly applied to fresh wounds, bruises, and leech bites85,86

Rhizome

Curcuma longa

Commiphora Gummi-resina Tinctures Allergic contact dermatitis78 Case studies and animal Mirazid, marketed for treatment of 78 myrrha studies schistosomiasis Description: Commiphora myrrha (Family: Burseraceae). Myrrh appears to be one of the oldest medicines, since its use was recorded in the recipes from ancient Rome and in the texts of Hippocrates. Myrrh is also mentioned in both the Bible and the Koran.79 It has antibacterial and antifungal activities against several bacteria and funguses, as well as antiinflammatory, local anesthetic, and analgesic activities. The current reported cutaneous use of myrrh tincture is in topical application for treatment of minor wounds, abrasions, and to treat skin inflammation80,81

Name

Table 1 Continued

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Scheme

Used parts

Formulations


Clinical evidence

Commercial products

Seeds

Whole plant

Hydnocarpus wightiana

Hypericum perforatum

Liquid extracts (tinctures, fluid extracts)

Possible mild irritation104


Rosmarinus officinalis

Whole or cut dried leaves

Liquid or semi-solid dosage forms

Hypersensitivity to the active Animal studies, case Herbor rosemary extract substance (possible contact studies, safe for food dermatitis)129 applications (FDA)129 Description: Rosmarinus officinalis (Family: Lamiaceae). Rosemary is traditionally used for wound management and treatment. It reduces inflammation and enhances wound contraction, re-epithelization, and regeneration of granulation tissue, angiogenesis, and collagen deposition130

Pterocarpus Leaves, flower Liquid extracts (ethanol), Allergic dermatitis125 Animal studies and case Not in wound care santalinus gels and ointments studies126–128 Description: Pterocarpus santalinus (Family: Fabaceae). The wood of the red sanders is traditionally used due to astringent and tonic properties. Ethanol extracts of the leaf and stem bark of Pterocarpus santalinus has shown significant decrease in the period of epithelialization and an increase in the rate of wound contraction. Wound healing properties of the red sanders are also related to improved collagenation and breaking strength, and increased granulation tissue dry weight and hydroxyproline content26

Jasminum Leaves, flower Liquid extracts (ethanol) Hypersensitivity reactions after Animal studies121,122 Jasminum grandiflorum leaf extract auriculatum prolonged use120 Description: Jasminum auriculatum (Family: Oleaceae). The juice of the leaves was found to promote wound healing through improved tensile strength in the early phases of healing123 and due to acceleration of mucopolysaccharide accumulation124

Allergic skin reactions (fairCell cultures, animal St. John’s wort dry extract, quantified skinned individuals may react studies and case extract (Pharm. Eur. ref. 07/2008:1874) with intensified sunburn-like studies113 symptoms)113 Description: Hypericum perforatum (Family: Hypericaceae). St. John’s wort has a history of safe and effective usage in many folk and herbal remedies. It has anti-inflammatory,114,115 antiseptic,116 analgesic, astringent, and antibacterial activities.117 It also promotes healing when used externally on minor wounds.115 The pro-healing action of Hypericum perforatum tincture is evidenced by the enhanced epithelization phase, with an increase in the wound contraction rate and the granulation tissue breaking strength. Due to the mentioned effects, the tincture has a longstanding use as an aid in healing of minor wounds.118,119

Liquid extracts (for liquid and semi-solid dosage forms)

Oil extracts, comminuted Hypersensitive skin reactions Animal studies and case Hydnocarpus seed oil seeds in the form of if used as concentrated oil studies109–112 paste extracts109 Description: Hydnocarpus wightiana (Family: Achariaceae). The oil from chaulmoogra seeds has been widely used in Indian and Chinese traditional medicine.110 The wound healing effect is reportedly related to improved collagenation and strength of scar tissue, as well as through promoted epithelization109,111

Whole plant, leaves, flower

Helianthus annuus

Review

Animal studies,105 cell Oleozon for the treatment of tinea pedis cultures and case studies106 Description: Helianthus annuus (Family: Asteraceae). In traditional medicine, the sunflower herb is used by Indian tribes for treating inflammation of the eyes, sores, tiger bites, and to treat bone fractures.107 The whole plant ethanol extract applied on the excised wounds of rats led to significantly reduce healing times, which was explained by faster and increased accumulation of mucopolysaccharides108

Name

Table 1 Continued

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Tridax Leaf juice, flower Liquid extracts (aqueous Hypersensitivity to the active Animal studies131–133 Not in wound care procumbens and ethanol) substance Description: Tridax procumbens (Family: Asteraceae). The juice of Tridax procumbens accelerates two phases of wound healing: epithelization and collagenation, resulting in less rigorous scar formation and granulation132

Name Scheme

Table 1 Continued

Used parts

Formulations


Clinical evidence

Commercial products

Conclusion


Many plants promote the skin’s natural repair mechanisms and therefore have a huge potential for therapeutic use in wound care. As our familiarity with herbal extracts and isolates increases and while we employ commonly used scientific methodology to study plants and their extracts from the physiological and pharmacological point of view, the number of herbal products for wound treatment is steadily increasing. Clinical proof of the therapeutic effects of herbal products has led to the study of many more herbs for their therapeutic, either curative or preventative, roles. Further studies should aim at the isolation and identification of specific active substances from plant extracts, which could also disclose compounds with better therapeutic value. Such a combination of traditional and modern knowledge can produce novel drugs for wound healing with significantly lowered unwanted side effects. Acknowledgments The paper was co-produced within the framework of the operation entitled Centre of Open innovation and ResEarch UM (CORE@UM). The operation is co-funded by the European Regional Development Fund and conducted within the framework of the Operational Programme for Strengthening Regional Development Potentials for the period 2007– 2013, development priority 1: Competitiveness of companies and research excellence, priority axis 1.1: Encouraging competitive potential of enterprises and research excellence, contact no. 3330-13-500032. The authors also acknowledge the financial support from the Ministry of Higher Education, Science, and Technology of the Republic of Slovenia. Questions (See answers after references) 1 What are the functions of the human skin? (multiple correct answers) a First-line protection against infections b Hormone secretion c Body temperature regulation d Pain sensation e Water reservoir 2 Is wound healing affected if the patient suffers from pain? a True b False 3 Which are the main wound healing phases? (multiple correct answers) a Infection prevention b Inflammatory c Proliferative d Scarring e Remodeling International Journal of Dermatology 2015

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4 Does scarring occur in the inflammation phase of wound healing? a True b False 5 What are the characteristics of an ideal medicine for prevention of wound infection? (multiple correct answers) a Antimicrobial activity b Moisture control c Stimulation of innate immunity d Vasoconstriction 6 Which drugs are COMMONLY applied in wound treatment? (mutlitple correct answers) a Analgesics b Astringents c Anti-inflammatory drugs d Antimicrobials 7 Which medical plants possess anti-inflammatory activity? (multiple correct answers) a Achillea b Centella asiatica c Chamomilla recutita d Ginko Biloba e Rosmarinus officinalis 8 Can Angelica sinensis be used to lower the patients sensation of pain? a True b False 9 Can Echinacea be used to treat Candida infections? a True b False 10 Which plant has been approved by FDA for food applications? (one correct answer) a Rosmarinus officinalis b Pterocarpus santalinus c Commiphora myrrha d Azadirachta indica References 1 Zhang Z, Michniak-Kohn BB. Tissue engineered human skin equivalents. Pharmaceutics 2012; 4: 26–41. 2 Xu QY, Yang JS, Yang L, et al. Effects of different scraping techniques on body surface blood perfusion volume and local skin temperature of healthy subjects. J Tradit Chin Med 2011; 31: 316–320. 3 Kaymak Y, Taner E, Simsek I. Body dysmorphic disorder in university students with skin diseases compared with healthy controls. Acta Derm Venereol 2009; 89: 281–284. 4 Bennett RG. Fundamentals of Cutaneous Surgery. St. Louis: Mosby, 1988: Xii, 823 p., 822 leaves of plates. 5 Leach MJ. Making sense of the venous leg ulcer debate: a literature review. J Wound Care 2004; 13: 52–56.


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Answers 1 2 3 4 5 6 7 8 9 10

a, c, d a b, c, e b a, c b, d a, e a a a


Wound healing: a review. I. The biology of wound healing.

Wound healing: a review. II. Environmental factors affecting wound healing.

Review of Anti-Inflammatory Herbal Medicines.

Epithelialization in Wound Healing: A Comprehensive Review.

Nanotechnology-based drug delivery systems and herbal medicines: a review.

Skin wound healing and phytomedicine: a review.

Regulation of herbal medicines.

Wound Healing Activity of a Traditionally Used Poly Herbal Product in a Burn Wound Model in Rats.

Chinese herbal medicines.

Curbing Inflammation in Skin Wound Healing: A Review.

Cutaneous wound healing in aging small mammals: a systematic review.

A comprehensive review of advanced biopolymeric wound healing systems.

Biofilm delays wound healing: A review of the evidence.

Chronic Wound Healing: A Review of Current Management and Treatments.

The biology of fetal wound healing: a review.

Regulation of herbal medicines in Brazil.

"Herbal" medicines and rheumatoid arthritis.

"Herbal" medicines and rheumatoid arthritis.

"Herbal" medicines and rheumatoid arthritis.

"Herbal" medicines and rheumatoid arthritis.

"Herbal" medicines and rheumatoid arthritis.

Herbal medicines for cardiovascular diseases.

Herbal medicines for inflammatory diseases.

Chinese herbal medicines for hypothyroidism.