Actinic Keratoses and Herbal Medicine Interventions

Actinic Keratoses and

Herbal Medicine Interventions

A thesis submitted in fulfilment of the requirements for the degree of

Master of Science

Karina Anna Hilterman Dip. Med Herb. (Waikato Centre For Herbal Studies) B.H.Sc. (Nat Med) Victoria University

School of Health and Biomedical Sciences

College of Science, Engineering and Health

RMIT University

January 2020

DECLARATION BY THE CANDIDATE

I, Karina Anna Hilterman, declare that:

I certify that except where due acknowledgement has been made, the work is that of the author alone; the work has not been submitted previously, in whole or in part, to qualify for any other academic award; the content of the thesis is the result of work which has been carried out since the official commencement date of the approved research program; any editorial work, paid or unpaid, carried out by a third party is acknowledged; and, ethics procedures and guidelines have been followed. I acknowledge the support I have received for my research through the provision of an Australian Government Research Training Program Scholarship.

Signed: Date: 31st January 2020

Karina Anna Hilterman

ACKNOWLEDGEMENTS

There have been many amazing, wise and brave individuals and groups of people who have walked the ‘herbalist path’ before me; not all were treated with the respect they deserved. Some have published books and manuscripts, others have not. They learnt from those that went before them, as I have…

My gratitude to Professor Stephen Robinson, as senior supervisor; he has guided me to ensure this thesis is a positive contribution to the field of herbal medicine.

To Dr Iris Wenyu Zhou, who assisted with the systematic review.

Thanks to Dr Marie Pirotta, Associate Professor, School of General Practice, Melbourne University (retired), for her encouragement and guidance as my External Supervisor.

For his advice and information, regarding his dermatology specialty, as an External Consultant, Dr Tony Dicker, please accept my thanks.

To Julie Wilkinson-Flores, Western Herbal Medicine Practitioner, my thanks for reviewing this thesis; from your practice experience and perspective of Western Herbal Medicine.

For reviewing Chapter 2.1.6. my gratitude to Dr Peter Gies, Senior Research Scientist, Ultraviolet Radiation, Radiation Health Services Branch, Australian Radiation Protection and Nuclear Safety Agency (ARPANSA).

To Nancy Patton, Sheila Jolley and Sharon Fredriksson, for your editing advice, I thank you. For editing assistance, Pam Kershaw, you are a gem and Laura Stephenson; for formatting.

My heartfelt gratitude for Miss Lilly, my beautiful, furry four-legged companion, who kept me comforted with her contented purring on my lap as I typed, often late into the night. Sadly, she passed away during this thesis preparation...

“To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science” – Albert Einstein (1879-1955). iii

CONTENTS PAGE Cover Page Declaration By The Candidate i Acknowledgements ii Contents iv List of Figures ix List of Tables xi Abbreviations P1 Summary Background P2 Aims P2 Methods P2 Results P3 Implications P4

Chapter 1 Introduction 1.1 Background P5 1.2 Overview of Thesis Structure P6 1.3 Rationale for Undertaking this Study P7 1.4 Objectives P9

Chapter 2 Background 2.1 What are Actinic Keratoses [AKs] P10 2.1.1 History P10 2.1.2 Pathophysiology P12 2.1.3 Differential diagnosis P17 2.1.4 Epidemiology P17 2.1.5 Development of AKs into non-melanoma skin cancer P18 2.1.6 The sun’s effect on skin P20 2.1.7 Melanocytes and vitamin D regulation and immune support P24 2.2 Topical Medical Treatments for AKs P26 2.2.1 Cryotherapy/Cryosurgery P26 2.2.2 Electrodessication P27 2.2.3 Surgical removal P27 2.2.3a Excisional biopsy P27 2.2.3b Incisional biopsy P27 2.2.3c Punch biopsy P27 2.2.3d Curettage P28 2.2.3e Shave biopsy P28 2.2.3f Moh’s micrographic surgery P28 2.2.4 Chemical peels P28 2.2.5 Dermabrasion P28 2.2.6 Retinoids P29 2.2.7 Photodynamic therapy [PDT] P29 2.2.8 Chemotherapy P29 2.2.9 Radiotherapy P30 2.2.10 Topical immune-modulating agents P30 2.2.11 Picato P30 2.2.12 Application of medical treatments P31 2.3 Prevention of Sun-Induced Skin Damage P31

Chapter 3 Herbal Medicine, Skin Disease and Herbs As Skin Treatments 3.1 Herbs for Treating Skin Disease P33 3.1.1 Background of herbs as medicine P33 3.1.2 Standardisation of herbal medicines P35 iv

3.1.3 Extraction methods and availability of herbal constituents P37 3.1.4 Safety and efficacy of herbal medicines P38 3.1.5 Herbal, complementary and alternative medicine research P39 3.1.6 Historical treatments for skin conditions P40 3.2 Herbal Medicine Approaches to Treating Skin Disease P42 3.2.1 Clinical considerations for herbal treatment of AKs P42 3.3 Herbs for Topical Treatment of AKs P45 3.4 Indicated Therapeutic Actions P46 3.5 Selected Herb Profiles P50 Chapter 4 Systematic Review: Efficacy and Safety of Herbal Treatment of AKs 4.1 Background P51 4.1.1 Considerations for undertaking a systematic review P51 4.1.2 Rationale for conducting a systematic review P51 4.1.3 Expected outcomes P52 4.2 Methodology for Systematic Review P52 4.2.1 Inclusion and exclusion criteria P52 4.2.1a Types of studies P52 4.2.1b Criteria for inclusion P52 4.2.1c Types of participants P52 4.2.1d Types of interventions P53 4.2.1e Types of outcome measures P53 4.2.2 Search methods for identification of studies P53 4.2.2a Databases searched P53 4.2.2b Searching other resources P53 4.2.2c Search terms P53 4.2.2d Selection of studies P53 4.2.3 Data extraction and management P54 4.2.4 Evaluation of bias risk of included studies P54 4.3 Results P54 4.3.1 Results of search P54 4.3.2 Summary of studies P55 4.3.3 Excluded studies P55 4.3.4 Included studies P55 4.3.5 Characteristics of included studies P56 4.3.5a Number of participants P59 4.3.5b Age range P59 4.3.5c Treatment ranges, dosages and controls P60 4.3.6 Herbal preparations used in the included studies P63 4.3.6a Colchicum autumnale P63 4.3.6b Betula species P63 4.3.6c Hypericin P64 4.3.6d Euphorbia peplus P64 4.3.6e Perillyl alcohol P65 4.3.6f Solanum incanum P65 4.3.7 Risk of bias assessment of included RCTs P65 4.3.7a Sequence generation P66 4.3.7b Allocation concealment P66 4.3.7c Blinding of participants and personnel P66 4.3.7d Blinding of outcome assessments: P66 Self-reported and subjective outcomes 4.3.7e Blinding of outcome assessments: P67 Non-self-reported and objective outcomes 4.3.7f Incomplete outcome data P67 4.3.7g Selective outcome reporting P67 4.3.7h Other potential threats to validity P67 4.3.8 Assessment of the included Non-RCTs P68 4.3.9 Instruments used for assessment and monitoring P70 4.3.10 Outcome measures P71

4.3.10a RCTS P71 4.3.10b Non-RCTs P72 4.3.11 Effects of the interventions P73 4.3.11a Colchicine studies P73 4.3.11b Birch Bark studies P73 4.3.11c Hypericum perforatum study P74 4.3.11d Euphorbia peplus studies P75 4.3.11e POH study P76 4.3.11f Solanum incanum study P76 4.3.12 Adverse events P79 4.3.12a Colchicine studies P80 4.3.12b Birch Bark studies P81 4.3.12c Hypericum perforatum study P81 4.3.12d Euphorbia peplus studies P81 4.3.12e POH study P82 4.3.12f Solanum incanum study P82 4.4 Discussion P83 4.4.1 Summary of main findings P83 4.4.2 Adverse events P83 4.4.3 Overall completeness and evidence applicability P84 4.4.3a Dosage rates P84 4.4.3b Differences in dropout rates P84 4.4.3c Different types of participants P85 4.4.4 Potential biases in review process P85 4.4.5 Discussion on the effect of individual substances P85 4.4.6 Search limitations P85 4.5 Conclusions P86 4.5.1 Clinical Implications P87 4.5.2 Implications for future research P87

Chapter 5 Survey of Herbalist’s Use of Herbal Medicine in AK Treatment 5.1 Survey Preparations P92 5.2 Survey Responses P93 5.3 Choices of Herbs as AK Treatments P95 5.4 Effectiveness of Treatments P98 5.5 Adverse Effects of AK Treatments P99 5.6 Awareness of AKs P100 5.7 Summary P101

Chapter 6 Discussion and Conclusions 6.1 Discussion P103 6.2 Conclusions P105

References P107

Appendices Summary P125

Appendix A A1 Elaboration of Herbs Included in Systematic Review P126 A1.1 Colchicum autumnale A1.2 Betula species A1.3 Hypericin A1.4 Euphorbia peplus A1.5 Perillyl alcohol A1.6 Solanum incanum

Appendix B B1 Selected Monographs of Herbs for Consideration as AK Treatments P138 vi

B1.1 Aloe vera (Aloe) B1.1.1 Constituents B1.1.2 Therapeutic actions B1.2 Arctium lappa (Burdock) B1.2.1 Constituents B1.2.2 Therapeutic actions B1.3 Avena sativa (Oats) B1.3.1 Constituents B1.3.2 Therapeutic actions B1.4 Berberis vulgaris (Barberry) B1.4.1 Constituents B1.4.2 Therapeutic actions B1.5 Calendula officinalis (Calendula/Marigold) B1.5.1 Constituents B1.5.2 Therapeutic actions B1.6 Echinacea purpurea and angustifolia (Echinacea) B1.6.1 Constituents B1.6.2 Therapeutic actions B1.7 Galium aparine (Cleavers) B1.7.1 Constituents B1.7.2 Therapeutic actions B1.8 Hypericum perforatum (St John’s Wort) B1.8.1 Constituents B1.8.2 Therapeutic actions B1.9 Matricaria chamomilla (chamomile) B1.9.1 Constituents B1.9.2 Therapeutic actions B1.10 Phytolacca americana (decandra/Poke Weed) B1.10.1 Constituents B1.10.2 Therapeutic actions B1.11 Prunella vulgaris (Self Heal) B1.11.1 Constituents B1.11.2 Therapeutic actions B1.12 Stellaria media (Chickweed) B1.12.1 Constituents B1.12.2 Therapeutic actions B1.13 Taraxacum officinale (Dandelion) B1.13.1 Constituents B1.13. 2 Therapeutic actions B1.14 Trifolium pratense (Red Clover) B1.14.1 Constituents B1.14.2 Therapeutic actions B1.15 Viola odorata (Sweet Violet) B1.15.1 Constituents B1.15.2 Therapeutic actions B1.16 Viola tricolor (Heartsease) B1.16.1 Constituents B1.16.2 Therapeutic actions B1.17 Zingiber officinale (Ginger) B1.17.1 Constituents B1.17.2 Therapeutic actions Appendix C C1 Therapeutic Action Descriptions P178

Appendix D D1 Differing Extraction Methods and Availability of Herbal Constituents P188 D1.1 Water as an extracting medium D1.2 Alcohol as an extracting medium D1.3 Acetic acid and vinegar as extracting medium D1.4 Glycerine as an extracting medium vii

Appendix E E1 Ethics Committee Application Approval Letter P192 E2 Invitation to Herbalists to Participate in Survey P193 E3 Data From the Survey of Herbalist’s Use of Herbal Medicine For Treating AKs P194

Appendix F F1 Series of Practice Case Studies P214 F1.1 Patient A F1.2 Patient B F1.3 Patient C F1.4 Patient D F1.5 Patient E F1.6 Patient F F1.7 Patient G F1.8 Patient H

viii

LIST OF FIGURES

Figure 1 AK on Nose P5 Figure 2 Multiple AKs on Feet P10 Figure 3 AKs on Ear P10 Figure 4 Multiple AKs on Balding Scalp P10 Figure 5 Dorsal Surface of a Hand with Multiple AKs P10 Figure 6 Diagram of a Profile of Human Skin P13 Figure 7 Diagram of Human Skin Demonstrating P13 Sun-Induced Skin Diseases Figure 8 Von Luschan’s Chromatic Scale of Skin Colours P15 Figure 9 A Progressed AK P19 Figure 10 Electromagnetic Wavelength Scale P20 Figure 11 The Effect of UV Light on DNA P21 Causing Distortions Figure 12 Melanocytes in Human Skin P24 Figure 13 Sanguinaria canadensis (Bloodroot) P41 Figure 14 Chelidonium majus (Greater Celandine) P48 Figure 15 PRISMA Flow Diagram: AK Clinical Trials P58 Figure 16 Colchicum autumnale (Autumn Crocus) P125 Figure 17 Betula lenta (Black Birch) P127 Figure 18 Betula lenta (Black Birch) P127 Figure 19 Betula pendula (Silver Birch) P128 Figure 20 Betula papyrifera (White Birch) P128 Figure 21 Hypericum perforatum (St John’s Wort) P129 Figure 22 Hypericum perforatum (St John’s Wort) P129 Figure 23 Euphorbia peplus (Radium Weed) P131 Figure 24 Structure of perillyl alcohol P134 Figure 25 Solanum incanum (Bitter/Thorn Apple) P135 Figure 26 Solanum incanum flowers and fruit P135 (Bitter/Thorn Apple) Figure 27 Aloe vera (Aloe) P137 Figure 28 Aloe vera (Aloe) P137

Figure 29 Arctium lappa (Burdock) P141 Figure 30 Avena sativa (Oats) P143 Figure 31 Berberis vulgaris (Barberry) P145 Figure 32 Calendula officinalis (Calendula/Marigold) P147 Figure 33 Calendula officinalis (Calendula/Marigold) P147 Figure 34 Echinacea purpurea (Echinacea) P149 Figure 35 Echinacea purpurea (Echinacea) P149 Figure 36 Galium aparine (Cleavers) P150 Figure 37 Galium aparine (Cleavers) P150 Figure 38 Hypericum perforatum (St John’s Wort) P152 Figure 39 Hypericum perforatum (St John’s Wort) P152 Figure 40 Matricaria chamomilla (Chamomile) P154 Figure 41 Phytolacca americana (Poke Weed) P156 Figure 42 Phytolacca americana (Poke Weed) P156 Figure 43 Prunella vulgaris (Self Heal) P158 Figure 44 Prunella vulgaris (Self Heal) P158 Figure 45 Stellaria media (Chickweed) P162 Figure 46 Stellaria media (Chickweed) P162 Figure 47 Taraxacum officinale (Dandelion) P164 Figure 48 Taraxacum officinale (Dandelion) P164 Figure 49 Trifolium pratense (Red Clover) P166 Figure 50 Viola odorata (Sweet Violet) P169 Figure 51 Viola odorata (Sweet Violet) P169 Figure 52 Viola tricolor (Heartsease) P172 Figure 53 Viola tricolor (Heartsease) P172 Figure 54 Zingiber officinale (Ginger) P174

LIST OF TABLES Table 1 Fitzpatrick Scale Skin Typing P15 Table 2 Cutaneous Mediators of Inflammation Whose Expression P22 Is Up-Regulated by UV Radiation Table 3 Descriptions of Mediators P22 Table 4 Examples of the Historical Use of Herbs for Treatment P40 of Skin Abnormalities Table 5 Therapeutic Actions of Herbs – Considerations for P46 Skin Treatments Table 6 The Six RCT Studies Included in this Review P56 Table 7 The Five Non-RCT Studies Included in this Review P56 Table 8 Characteristics of Included RCT Studies P61 Table 9 Characteristics of Included Non-RCT Studies P62 Table 10 Herbal Preparations Used in the Included Studies P63 Table 11 Risk of Bias Assessment (RCT Studies) P69 Table 12 Participant Monitoring and Assessment Instruments P70 Utilised Table 13 Results of Included Studies (RCTs) P77 Table 14 Results of Included Studies (Non-RCTs) P78 Table 15 Reported LSRs and Mild to Moderate Adverse Events [AE] P79 Table 16 Reported Severe Adverse Events [SAE] P80 Table 17 PRISMA Checklist P89 Table 18 Individual Herbs and Herbal Substances Used Internally P95 Table 19 Respondents Formulations of Herbs and Herbal P96 Substances Used Internally Table 20 Individual Herbs and Herbal Substances Used Externally P96 Table 21 Respondents Formulation of Herbs and Herbal P97 Substances Used Externally Table 22 Descriptions of Therapeutic Actions P177 Table 23 Water as an Extracting Medium P183 Table 24 Alcohol as an Extracting Medium P185 Table 25 Acetic Acid and Vinegar as Extracting Mediums P185 Table 26 Glycerine as an Extracting Medium P186

xi ABBREVIATIONS

Acronym Description AK Actinic Keratosis (plural keratoses) AIDS Acquired ImmunoDeficiency Syndrome BCC Basal Cell Carcinoma BD Bowen Disease β-HPV Beta-Human Papilloma Virus CAM Complementary and Alternative Medicine CT Computed Tomography DNA Deoxyribonucleic Acid EV Epidermodysplasia Verruciformis FDA Food and Drug Administration (US government agency) GP General Practitioner HIV Human Immunodeficiency Virus HPLC High-Performance Liquid Chromatography HPV Human Papilloma Virus IAK Inflamed Actinic Keratosis IC Immuno-Incompetent or Immune-Compromised ID Immunodeficient IS Immunosuppressed KIN Keratinocytic Intraepidermal Neoplasia LOH Loss of Heterozygosity LSR Local Skin Response/s MCC Merkel Cell Carcinoma MRI Magnetic Resonance Imaging mtDNA Mitochondrial Deoxyribonucleic Acid or Mitochondrial DNA NHMRC National Health and Medical Research Council (Australia) NK Natural Killer Cells (immune system lymphocyte cells) NMSC Non-Melanoma Skin Cancer NS Not Specified OTR Organ Transplant Recipient p53 Tumour Protein 53 (a tumour suppressor protein) PAK Proliferative Actinic Keratosis PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses PV Papilloma Virus ROS Reactive Oxidative Species RTR Renal Transplant Recipients SCC Squamous Cell Carcinoma SD Standard Deviation SE Standard Error SK Solar Keratoses SLE Systemic Lupus Erythematosus SPP/spp Species TCM Traditional Chinese Medicine TGA Therapeutic Goods Administration TNF-α Tumour Necrosis Factor Alpha UK The United Kingdom US The United States of America UV Ultra-Violet UVR Ultra-Violet Radiation WHM Western Herbal Medicine

SUMMARY

Background An actinic keratosis [AK] is a common form of sun-induced skin disease, which may develop after many years exposure to the sun. An AK may progress to become a non-melanoma skin cancer [NMSC]. Considering Australia has the highest prevalence of sun-induced skin disease world-wide and has an ageing population, seeking effective and safe remedies for AKs is prudent. Through recorded history herbs have been used for treating skin disease, yet little research has been undertaken to validate historical and traditional claims of use, efficacy and safety. Thus, in treating sun-damaged skin, it is reasonable to investigate natural herbal treatments that have been used historically for skin conditions to assess whether extracts from plants can provide effective AK treatments with minimal adverse effects.

Aims This study aims to assess AKs from the perspectives of biomedical science and herbal medicine, and to review the classical and modern literature relating to the use of herbal and pharmaceutical medicines for treating sun-damaged skin and AKs. An additional aim is to assess whether professional herbalists and naturopaths recognise and treat AKs, and if so, what treatments are favoured.

Methods The initial investigation of AKs included the history of its nomenclature, the pathophysiology, epidemiology and the effects of solar radiation on human skin. A priority was to discern the range of current treatments; both herbal and medical. The traditional use of herbal medicine for treating skin conditions was investigated.

A systematic literature review was undertaken, following the ‘Cochrane Systematic Review’ methods, to determine what clinical research had been conducted on AKs using herbal medicines and to discern the efficacy and safety of the treatments. Six major databases and search engines namely Science Direct, PubMed, CINHAL, Scopus, EBSCOhost and Cochrane were searched to identify relevant literature. This review focused on clinical studies on humans and excluded in vitro and in vivo designs or research on animals.

Further investigation of the literature was undertaken to assess the traditional use of herbal medicine for treating skin conditions and to discern which therapeutic actions are relevant for treating sun-induced skin damage.

An anonymous survey of herbalists and naturopaths from professional associations was conducted to discern their knowledge of AKs and to assess the range of herbs and methods used to treat patients. To endorse the various herbs considered to be potentially suitable as AK treatments, a series of monographs has been written utilising the format and style familiar to practitioners of Western Herbal Medicine [WHM].

Results AKs were only named as such in 1958. Therefore limited references to them exist in both historical and modern literature. However, information on herbal medicine for treating skin conditions is well documented in classical literature.

Within the systematic review, 11 clinical studies were identified. The herbs or herbal extracts utilised in these studies were: Colchicum autumnale, Betula species, Hypericum perforatum, Euphorbia peplus, Perillyl alcohol and Solanum incanum. They were all topical treatments; the dosages and treatment durations reported in the literature varied considerably. Due to the diversity of herbal treatments and differing treatment protocols discerned from this review, data pooling and meta-analysis could not be performed. Therefore the results were assessed by comparative, descriptive and narrative methods.

No study fulfilled all the desired outcomes without any adverse events. Two studies that investigated birch bark extracts reported a lesion clearance response rate of 79% to 86% with minimal adverse effects.

From the survey of herbalists, only eight percent (8%) were confident in identifying an AK and only four percent (4%) stated that that they would always treat an AK, whereas 52% would never treat them. In addition, many respondents lacked an understanding of AKs. Of those who would treat, a diverse range of treatments was revealed. The following herbs were the most frequently used: Symphytum spp (Comfrey), Trifolium pratense (Red Clover), Viola odorata (Sweet Violet), and Sanguinaria canadensis (Bloodroot).

Implications The findings from the systematic review strengthen the need for further research to be conducted to discern herbs which have the indicated constituents and therapeutic actions required for efficacious treatments. It is important to research herbs that have recorded historical or traditional benefits for skin diseases, in addition to those containing suitable phytochemical profiles. Further examination of these herbs, under the scrutiny of well- designed and conducted clinical trials is required, to satisfy the demand for safe, effective natural treatments.

From the survey of herbalists, a gap in training was identified. This indicates scope for continuing practitioner education and a review of student curriculum content. For those that do treat AKs, a diverse range of herbal and other medications is available. Further professional protocol development for treating this skin condition is required.

CHAPTER 1 - INTRODUCTION

1.1 Background Australia has the highest incidence of actinic keratoses [AKs] worldwide. It is suggested that approximately half of adult Australians have at least one AK, followed in incidence, by New Zealand and the United States of America. These numbers are expected to increase as the population ages (Rowert-Huber, Patel, et al., 2007); (J. Spencer, 2013). There is evidence of a long tradition of using herbs to treat skin conditions and this includes many diverse species and varieties of plants, (Gerard, 1998 (original work 1597)); (Shenefelt, 2011); (Bone & Mills, 2013). (Frost & Green, 1994)Figure 1: AK on Nose

Source: (Primary Care Dermatology Society, 2017).

AKs, a specific form of sun-induced skin damage, were selected for this study. AKs are not usually considered to be a skin cancer per se, but are known to be a potential precursor to the non-melanoma types of skin cancers [NMSCs]: squamous cell carcinomas [SCCs] and basal cell carcinomas [BCCs].

AKs usually appear on ageing skin. As we have an ageing population, assessing treatments with minimal adverse effects is becoming increasingly important. There are potential future health implications of AKs, which are further elaborated on in Chapter Two: Pathophysiology and Epidemiology.

This thesis has been designed to systematically evaluate the clinical evidence relating to AKs, to assess the current medical treatments, the traditional and historical uses of herbs for treating this type of lesion, and to identify any current herbal medicine treatments for AKs.

1.2 Overview of Thesis Structure The thesis has been developed within the following structure: Chapter 1 is the overall introduction of the research topic, thesis structure, rationale and objectives of conducting this project.

Chapter 2 investigates AKs from a medical science perspective: pathophysiology and epidemiology of AKs, the effects of solar radiation, the disease and the medical classification and management of AKs.

Chapter 3 covers the history and traditional use of herbal medicines (more specifically for skin disorders), clarifies the extraction methods, the use of standardisation of herbal medicines and examines clinical considerations for treating sun-induced skin disease; the indicated therapeutic activities and herbs of relevance.

Chapter 4 is a systematic review of published literature in which herbal extracts or substances were used for treating AKs.

Chapter 5 describes the development, implementation and results of an anonymous survey of herbalists to assess the current use of herbal medicine for treating AKs.

Chapter 6 concludes the thesis with discussion, recommendations for future research assessing herbal medicine and the conclusions which have been developed from the processes involved throughout this project.

The six appendices are important supplements to this thesis. These are:

Appendix A: Elaboration of the Herbs Included in the Systematic Review Monographs of the herbal extracts assessed from included studies of the systematic review (Chapter 4).

Appendix B: Selected Monographs of Herbs for Consideration as AK Treatments Monographs of herbs which are recommended for evaluation as potential AK treatments.

Appendix C: Therapeutic Action Descriptions Elaborations and explanations of therapeutic actions referred to within the thesis, including examples.

Appendix D: Differing Extraction Methods and Availability of Herbal Constituents Elaboration of information relating to extraction of therapeutic constituents referred to in Chapter 3.

Appendix E: Data Collated From the Survey: Screening and Treatment of Actinic Keratoses by Herbalists (Chapter 5). Included is the Science Engineering and Health CHEAN Approval Letter

Appendix F: Series of Practice Case Studies Supportive information for the efficacy of herbal medicine for topically treating AKs and other sun-induced skin diseases.

1.3 Rationale for Undertaking This Study As referred to in the introduction, in recent years, there has been a significant increase of knowledge about AKs. Innovations in pathology have enabled closer scrutiny of lesions and improved pathology testing techniques have demonstrated the evidence of changes at a cellular level (Frost & Green, 1994); (Salasche, 2000). Epidemiological assessments have discerned causes and exacerbating factors for the development of AKs and their potential progression to become NMSCs (Nelson, Einspahr, Alberts, & al., 1994); (Marks, 2001); (Fuchs & Marmur, 2007); (McBride, Neale, Pandeya, & Green, 2007). Medical research has answered many of the questions relating to the pathology and epidemiology of AKs (see Chapter 2).

The incidence of sun-induced skin damage causes concern to many; including health practitioners, government health regulators (Treasury., 2014), health insurers, people with immuno-suppression (Dyall-Smith, Trowell, Mark, & Dyall-Smith, 1991) and in particular, the fair-skinned population who have a greater chance of developing sun-induced skin disease than most (Fitzpatrick, 1975); (Frost & Green, 1994); (Salasche, 2000) (Parrish, 2005); (Cancer Council of Australia, 2013a); (J. M. Spencer, 2018); (ARPANSA, 2019). Even with the nebulous state of statistics for AKs (numbers are not rigorously recorded, so are considered to be estimates), AKs are still a problem. Without definite figures of incidence, it

7 is difficult to develop treatment programs. Above all, prevention is a better option as it reduces the chance of a NMSC developing, reduces costs, pain of treatments and potential development of scar tissue.

As AKs are generally considered to be pre-cancerous lesions (Cockerell, 2000); (Anwar, Wrone, Kimyai-Asadi, & Alam, 2004), this condition requires scrutiny. It is important not only to find effective treatments but also to determine what can be done to prevent AKs from becoming NMSCs. There is recorded folklore about herbs and substances that can clear warts and lumps and bumpy skin lesions, including radium weed, bloodroot, banana skins, pawpaw juice and snail exudate (A. C. Green & Beardmore, 1988). Green and Beardmore published the results of a survey of home treatments of AKs which they had undertaken in Nambour, a community in Queensland, Australia during December 1986. They surveyed 2095 citizens aged between 20 and 69 years of age and found that 7.8% of people used a variety of substances (some herbal), on their AKs and skin cancers. Most did this without medical supervision and while the success of treatments varied, radium weed (Euphorbia peplus) was consistently the most effective. The notion that self-treatment implies self-diagnosis concerned the researchers. Their research supports the need for easy-to-use, effective treatments, but there is an onus on medical and allied healthcare providers to provide information and resources for the general public to understand when changes to their skin, especially lesions and abnormalities, should be assessed and identified (A. C. Green & Beardmore, 1988). Huyke et al., (2006) suggest that current medical treatments have adverse effects which include pain, inflammatory responses, scarring and pigmentation changes. The researchers identified the need for treatments that are more effective and easier to use than existing treatments and have fewer adverse effects (Huyke, Laszczyk, Scheffler, Ernst, & Schempp, 2006).

In Australia, as in many countries, there is an ageing population: the estimation is that by 2050 the number of people aged between 65 to 85 will be doubled and the numbers of those over 85 will be at least quadrupled, when compared to current numbers (Treasury., 2014); (Australian Institute of Health and Welfare, 2018). As cumulative sun exposure leads to the development of abnormalities on exposed skin, the numbers of sun-induced dermatological lesions will continue to increase as the population ages (Salasche, 2000); (J. M. Spencer, 2018). Herbal medicine is yet to be accepted by the mainstream medical profession as an effective treatment option, despite its long tradition of use by some members of the general

8 public and trained, registered herbalists and naturopaths. An intention of this research project is to raise awareness of the potential contribution that herbal medicine could make to treating AKs.

1.4 Objectives The objectives of this thesis are to:  Provide a comprehensive summary of AKs, in terms of epidemiology, pathogenesis, prognostics and treatment principles from both biomedical and herbal medicine perspectives;  Describe the effects of solar radiation on human skin, specifically relating to the development of AKs and the contribution of solar radiation to Vitamin D synthesis;  Evaluate the historical and modern literature on the safety and efficacy of using herbal medicine to treat AKs. Identify the constituents, therapeutic actions and potential mechanisms;  Identify herbs which could be considered in treatments for AKs;  Survey and evaluate the recognition of AKs by herbalists, and the herbs or herbal products they use to treat these lesions;

The specific research questions are:  Have there been any herbal substances assessed that could provide effective, safe treatments for AKs?  If so, which herbs would be indicated as feasible for further assessment?  What levels of efficacy have been obtained and what degrees of safety have been recorded for the herbal substances which have been assessed?  In clinical practice, which herbs are used by herbalists to treat AKs; either topically or internally, or by both methods?

In Chapter 2, the history and rationale for nomenclature of AKs is investigated; also the pathophysiology, epidemiology and current medical treatments of these lesions. In addition, determining the potential for an AK to develop into a NMSC, how various human skin and racial types respond to UV radiation; and details of which mediators initiate cellular changes, including the synthesis of Vitamin D.

CHAPTER 2 - BACKGROUND

2.1 What are Actinic Keratoses (AKs) 2.1.1 History During the ageing process, human skin has a propensity for developing changes and abnormalities. These can include a variety of lesions which may appear as thickened, roughened, or occasionally scaly skin and there may also be changes to skin pigmentation (Evans & Cockerell, 2000). Changes are more likely to develop in people who have received long-term solar radiation exposure; people who have occupations predominately outdoors and those who partake in outdoor sports and recreations. Figure 2: Multiple AKs on Feet Figure 3: AKs on Ear

Source: (DermNet New Zealand, 2017c). Source: (DermNet New Zealand, 2017a)

Figure 4: Multiple AKs on a Balding Scalp Figure 5: Dorsal Surface of a Hand with Multiple AK

Source: (DermNet New Zealand, 2017b). Source: (Howard, 2011)

Additionally, persons with fair skin colouring, typical of Northern Europe have a higher risk of sun-induced skin damage with chronic sun exposure, compared to darker skin types (Cockerell, 2000; Salasche, 2000). One common type of sun-induced skin lesion is an actinic

10 keratosis, sometimes called a solar keratosis or simply, a sunspot Historically, there was no specific name for them and there is still continuing debate regarding their nomenclature. To avoid confusion in this thesis, they will be referred to as actinic keratoses or AKs. (Figures 1- 5 indicate the sites of most common development of AKs).

During the International Congress of Dermatology in 1896, William Dubreuilh debated with his fellow dermatologists, Brooke and Unna, on the subject of the “aetiology and varieties of keratosis”. In his paper on this subject, he discussed the difference between types of keratotic lesions, suggesting that the lesion he described as “verrue séborrhéique” (seborrhoeic keratosis) required nomenclature distinction from “keratoma senile” (which came to be known as actinic keratosis) and “verrucae vulgaris” or common wart. Dubreuilh also commented that seborrhoeic keratosis lesions do not progress into skin cancers, as AKs may (Schwartz, 1996).

Frudenthal, a physician from the early 20th century, ascribed the name of ‘keratoma senilis’ to a type of lesion, appearing on the skin of the aged (Freudenthal, 1926). Schwartz (1996) noted that for many years, differing types of keratoses were considered as precursors to squamous cell carcinomas [SCCs]. He says that when AKs are given histological assessment, they display microscopic changes in the epidermis which are consistent with pre-malignant SCCs; therefore AKs ought to be re-categorised. When there is further lesion progression, indicating development of ‘field cancerisation’, he suggests this most commonly occurs when the skin is exposed to carcinogens such as ultra-violet radiation. Schwartz suggests that his hypothesis of the development of skin cancer is a multistep process, and adds that this could explain the delay of up to 20 to 50 years before invasive skin cancer develops (Schwartz, 1996).

In 1958 Pinkus published his considerations of these lesions (cited in Evans & Cockerell, 2000) and recommended a change in name to actinic keratosis. His rationale was to name them by their cause and description: ‘actinic’ refers to sunlight whilst ‘keratosis’ refers to a thickening or coarsening and scaly growth on the skin. More recently, there have been other suggestions for a change to the naming of AKs. Cockerell suggested that AKs should be regarded as an early stage cancer, rather than a potential pre-cancer, and proposed they be called ‘keratinocytic intraepidermal neoplasia' [KIN], while acknowledging that calling AKs a cancer may unduly alarm patients (Cockerell, 2000).

Babilas and colleagues proposed that AKs be called ‘intraepidermal SCCs', as this would provide a clearer definition of the lesion type, given the risk of AKs progressing to SCCs (Babilas, Landthaler, & Szeimies, 2003). Anwar and colleagues (2004) refer to Cockerell’s theory and other suggestions for classification and categorization of AKs, including the KIN system, also the concept proposed by Goldberg of ‘proliferative actinic keratosis’ [PAK]. Additionally, the approach taken by Berhane, who described this type of lesion as ‘inflamed actinic keratosis’ (IAK) (Anwar et al., 2004). Anwar et at., suggest that instead of disparate classifications there could be a single pragmatic approach, which clarifies and defines the indicated pathophysiological processes from an AK to an NMSC (Anwar et al., 2004). Cockerell states that although the while the pathological descriptions of AK or SCC are utilised for the “gross identification” of these lesions, he considers they are not reflective of their underlying pathobiology and disease progression (Cockerell, 2000).

Some dermatologists suggest that calling an AK a cancer (a neoplasia or a carcinoma), may unduly alarm patients (Cockerell, 2000). The present author considers this thoughtful approach to have merit, due to the uncertainty of whether AKs will progress to become a NMSC. Rowert-Huber and colleagues also recommended reclassifying AKs as early stage SCCs and proposed three progressive stages: early in situ SCC Type AK I, early in situ SCC type AK II and in situ SCC Type AK III. They considered this would provide better guidance to clinicians for diagnosis and treatment recommendations for AKs (Ro¨wert-Huber et al., 2007). Babilas et al., (2003) recommends that AKs be renamed as ‘intraepidermal squamous cell carcinomas', thus providing a clearer definition of the lesion type. The rationale for this proposition is the risk of progression of AKs becoming SCCs is “about 16% over 10 years” (Babilas et al., 2003). However, not all AKs will become SSCs: Parrish’s research findings suggest that 1-10% of AK lesions will become a squamous cell carcinoma (Parrish, 2005). Therefore he suggests 90-99% of AKs will not develop into SCCs. He said this statement was not made to denigrate the risk, but to reduce fear of risk. He also encourages awareness of early interventions. From these academic discussions, further name changes or reclassification of this type of lesion appear possible, depending on future research findings and discussion.

2.1.2 Pathophysiology AKs are a proliferation of abnormal skin cells in the epidermis, the outer layer of the skin (see Figure 6 as an identifier of healthy skin (clearly demonstrating the three layers of composition), whereas Figure 7 identifies the progression of cellular abnormalities through

12 the dermal layer), mostly due to frequent and prolonged exposure to sun. They may vary from barely visible, slightly rough spots of skin to clearly visible, raised rough to hyperkeratotic (scaly) lesions. Varying in size from 3-10 mm, the lesion size tends to increase in both width and depth over time. The most common areas for AKs are those which receive the most sun exposure: the face, ears, balding scalps, forearms and dorsal surface of hands. Other areas where they may develop include the back, chest and legs (Salasche, 2000); (Anwar et al., 2004); (Rowert-Huber, Patel, et al., 2007).

Figure 6: Diagram of a Profile of Human Skin

Source: (Osovo, 2012).

Figure 7: Diagram of Human Skin Demonstrating Sun-Induced Skin Diseases

Source: (LifeVantage, 2017).

AKs develop predominantly on fair-skinned persons or those with long-term sun-exposed skin (Beers & Berkow, 1999). They are usually pink, occasionally red, but may be light grey or

13 darker, and generally lack clearly defined outlines. Upon palpation, lesions feel slightly rough, therefore palpation is an important step in diagnosis (Rowert-Huber, Stockfleth, & Kerl, 2007). With histopathologic assessment, AKs display dysplastic keratinocytes in the epidermis. The dysplastic cells are dispersed within the basal layer in early development, and then can extend into the full depth of the epidermis. Other abnormalities identified within AK tissues are parakeratosis, where the epidermal keratinocytes fail to mature, resulting in an abnormal retention of these nuclei within the stratum corneum (Ruchusatsawat et al., 2011), additionally, there may develop orthokeratosis, a proliferation of scaly skin (Johnston, 2011).

When a lesion develops to the full depth of the epidermis it is generally diagnosed as an SCC (Djohan, Tung, Fernandez-Faith, & Karai, 2010). If an AK lesion is suspected to be either advanced, or to have invaded beyond the epidermis (see Figure 7), a shave or punch biopsy is taken for histopathological analysis (Dicker, 2011). There is almost no call for blood testing for AKs. If metastatic disease is suspected from an AK progressing into an SCC, there is usually palpable lymph node involvement, which is confirmed through needle biopsy of lymph nodes and MRI scans to verify the stage and site/s of the disease. Metastatic progression of BCCs occurs very rarely (Dicker, 2011), (Dicker, 2012). T. B. Fitzpatrick, (1919–2003), a Harvard Medical School dermatologist, developed a classification of skin types based on how skin reacts to UVR. The Fitzpatrick Scale (see Table 1) continues to be the standard tool for assessing the risk of being affected by solar radiation (Fitzpatrick, 1975, 1988). Due to increased sensitivity to solar radiation for those people with either Fitzpatrick type I or II, there is a greater chance of developing AKs. These characteristics are often associated with fair-skinned people from the British Isles and Northern Western Europe. AKs are less frequent in skin types III, IV and V skin (light and medium to dark brown skin), as naturally darker skin is less likely to develop AK lesions. AKs are usually absent on those with Fitzpatrick type VI skin (black). However if a skin neoplasia does develop on darker skins, tumours can develop very aggressively (Salasche, 2000); (Gloster & Neal, 2006). The skin types of peoples of Asian descent are a significant omission from the Fitzpatrick Scale.

Table 1: Fitzpatrick Scale Skin Typing matched with Von Luschan’s Chromatic Scale

Skin Type Scale Genetic Disposition Reaction to the Sun and Von Luschan's Tanning Habits Chromatic Scale Type I scores 0-7 White; very fair; freckles; Always burns, never tans 1–5 typical albino skin

Type II scores 8-16 White; fair Usually burns, tans with 6–10 difficulty Type III scores 17-25 Beige; very common Sometimes mild burn, 11–15 gradually tans to a light brown Type IV scores 25-30 Beige with a brown tint; Rarely burns, tans with ease to 16–21 typical Mediterranean a moderate brown Caucasian skin. Type V scores over 30 Dark brown Very rarely burns, tans very 22–28 easily Type VI Black Never burns, tans very easily, 29–36 deeply pigmented Source: (Fitzpatrick, 1988; von Luschan, 1927).

Another assessment based on skin colour is Von Luschan's Chromatic Scale of Skin Colours (von Luschan, 1927) (see Figure 8). Felix von Luschan, an anthropologist, pioneered the classification of racial types by skin colour. His numbered scale has been added to Table 1 above to directly compare with Fitzpatrick’s scale. While Von Luschan’s scale is rarely used today, it does include the skin colours of Asian people. This is relevant to the present thesis because hereditary skin pigmentation is an important predictor of risk for the development of AKs.

Figure 8: Von Luschan's Chromatic Scale of Skin Colours

Source: (von Luschan, 1927) (Salasche, 2000).

There has also been research undertaken to assess physiological differences between the skins of different racial groups. A review of studies by Berardesca and Maibach (2003) concluded that there are racial differences in skin function, particularly in reactivity to pathologic and physiologic conditions (Berardesca & Maibach, 1996). Corcuff et al., (1991) researched the

15 differences of corneocyte surface area and spontaneous desquamation between the skins of three racial groups: Afro-Americans, Caucasians and Asians. Though they found no difference between the groups, for corneocyte surface area, they did find that black skin had about 2.5 times increased spontaneous desquamation (peeling or shedding of the epidermis). They considered this was likely to be linked to a differing composition of the intercellular structure of the stratum corneum or the epidermal lipid composition (Corcuff, Lotte, Rougier, & Maibach, 1991). Sugino et al., (1993) investigated the intercellular structure of the stratum corneum between four different racial groups: Asians, Hispano–American, Afro–Americans and Caucasians. They found there was a variance in ceramide levels (waxy lipid molecules found in cellular membranes) between these groups: people with black skin had the lowest levels, followed by white skin, then Hispanic, with Asian skin having the highest levels. Ceramide levels have been linked to cell hydration, with low levels leading to increased transepidermal water loss which impacts on the barrier function of the skin and changes in skin permeability (Sugino, Imokawa, & Maibach, 1993). This is a field requiring further investigation, specifically, as it does relate to development of AKs.

Studies have investigated the effects solar radiation on humans, in particular, the ultra-violet (UV) section of the light spectrum, as it appears this has the predominant effect on human DNA (deoxyribonucleic acid), and how this affects cellular functions compared to other sections of the spectrum. These UV radiation-initiated changes include interference to the signal transduction processes in the body which minimise the body’s own natural ability to control such functions as cell cycle arrest, apoptosis (programmed cell destruction), cell proliferation and cell differentiation. Reactive Oxygen Species [ROS] are another potential facilitator of cellular damage; they are directly generated by UV and secondarily during the inflammatory response to sunburn (Gupta et al., 2012). p53 protein (also referred to as tumour protein 53 or protein 53) has a suppressive effect on tumour development (Babilas et al., 2003) and regulates cellular processes and cell proliferation, cell cycle checkpoints and apoptosis, therefore helps to prevent cellular abnormalities and cancer development. Assessment of cellular changes in AKs indicates there are mutations to cells (including p53) and impairment to, or deletion of, the gene coding for p16 tumour suppressor protein. The malfunction of this gene is believed to be significant in the progression of AKs to SCCs (Nelson et al., 1994). Data from Leffel (2000) indicated a strong relationship between UVR and mutations in the tumour suppressor gene p53, stating that they are usually found in AKs and in more than 90% of SCCs (Leffell, 2000).

Another possible factor involved in the development of AKs is the presence of the Human Papilloma Virus [HPV] (Weissenborn et al., 2005). HPV DNA is often present in AK lesions, and most notably in people with compromised immune systems including immune- compromised or immuno-incompetent [IC], immune-deficient [ID], immunosuppressed [IS], organ transplant recipients [OTR] and renal transplant recipient [RTR] patients (Dyall-Smith et al., 1991). A variant of HPV, referred to as beta-papilloma virus [β-HPV], has been detected in apparently healthy skin, as well as in AKs, BCCs and SCCs (Weissenborn et al., 2005). Even with clinically healthy skin, when HPV is present there may be no signs or symptoms of papilloma virus infection (Hsu, Chen, Keleher, McMillan, & Antonsson, 2009). In a study assessing β-HPV and the incidence of NMSCs in the population, Karagas et al., (2010) found that there is a relationship between β-HPV and SCC. There was a higher prevalence of β-HPV when compared to the control group, but there was not a higher prevalence in the BCC group (Karagas et al., 2010).

An association exists between β-HPV and AKs. However, in the context of known risk factors including a person’s age, skin colour and history of sun damage, it is considered that the presence of β-HPV increases the risk of AKs developing by up to 13-fold (Weissenborn et al., 2005). How and why the HPV exacerbates tumour development and other pathological changes is yet to be verified (Pfister et al., 2003); (Weissenborn et al., 2005); (McBride et al., 2007); (Forslund et al., 2007). Howley and Pfister (2015) suggest that HPVs initiate carcinogenesis rather than progressing the growth of the tumour (Howley & Pfister, 2015). This is supported by recent research by Borgogna et al., (2018) which shows that β-HPV+ and ΔNp63+ hyperplasic epidermal cells from AKs can develop into aggressive SCCs, which can metastasise. ΔNp63+ is involved in the differentiation and maintenance of stem cells in stratified epithelia (Y. Li et al., 2013).

2.1.3 Differential diagnosis Several chronic skin conditions can be confused with AKs, including warts (HPV), seborrhoeic keratosis [SK], SCC, BCC, Merkel cell carcinoma [MCC], Bowen Disease [BD], lupus (either SLE or discoid), porokeratosis and epidermodysplasia verruciformis [EV]. It is important to obtain a clear diagnosis of the lesion to enable the most effective treatments (Moloney & Halliday, 2008). It is recommended that practitioners refer patients to a skin specialist for an accurate lesion diagnosis before treatment.

2.1.4 Epidemiology Long-term UV light exposure is directly associated with development of AKs. The frequency of occurrence of AKs correlates with prolonged or repeated exposure of skin to solar

17 radiation. AKs may develop in people as young as 20 years old, though the incidence increases for patients aged 50 years and older (Salasche, 2000). Higher incidences are found in countries with more sunshine hours, and on people who work outdoors or have outdoor recreations (Salasche, 2000). Australia has the world’s highest skin cancer incidence and the highest occurrence of AKs in the adult population, particularly those 40 years and older (Frost & Green, 1994). Approximately half of adult Australians have at least one AK (J. M. Spencer, 2018). Statistics from Lai et al., (2018) state that for Australians aged 60-69, the approximate incidence of AKs are 79% of men and 68% of women (Lai, Cranwell, & Sinclair, 2018). Similarly, in the USA, 11-26% of the adult population is estimated to have at least one AK, and they are the second most common reason for visiting a dermatologist (Frost & Green, 1994). There is a higher incidence of AKs in men, presumably because more men have outdoor occupations than women (Parrish, 2005).

2.1.5 Development of AKs into non-melanoma skin cancer When attempting to discern the proportion of AKs that develop into an SCC, there appears to be substantial discrepancies between estimates, varying between 0.1% to 10% of AK lesions (Marks, Rennie, & Selwood, 1988). At one extreme, it has been suggested that from the time an AK has been identified, it takes only two years to develop into a SCC (Fuchs & Marmur, 2007). However, a review of the pathology and pathobiology of AKs found the expected progression of an individual AK into an invasive SCC ranges from 0.25% to 20% per year. In addition, 60% of invasive SCCs are thought to have developed from an AK (Rowert-Huber, Stockfleth, et al., 2007). Criscione and colleagues, assessed patients with verified AK for six years; 55% of the AKs were not present at the one-year follow-up, while at the five-year follow-up, 70% were not present. However, they assessed the risk of progression to a NMSC as being 0.60% at 1 year and 2.57% at 4 years. They estimated that 65% of SCCs and 36% of all BCCs developed from a clinically verified AK (Criscione et al., 2009). Although a relatively low percentage of AKs become malignant, a single malignancy can be life- threatening, therefore, vigilance and treatment are important (Criscione et al., 2009). There are neither established rules nor indicators as to the progression or regression of AKs, or, if the regressed AK may regrow, at some stage. Though, increased use of sunscreens and other sun-protection measures may increase regression rates and as already referred to, diet and lifestyle are also indicated factors.

It is difficult to predict the course of progression of an individual AK, as they can remain unchanged for many years, regress for no apparent reason or progress into a SCC. However,

18 most SCCs show evidence of a pre-existing AK (Marks et al., 1988). Observations from Fuchs suggest that progression to an SCC generally takes approximately two years (Fuchs & Marmur, 2007). Figure 9 illustrates a progressed AK lesion.

Figure 9: A Progressed AK

Source: (Interactive Medical Media, 2007).

The stages that an AK passes through in becoming a NMSC involve: indurations or inflammation, increased diameter > 1 cm, rapid enlargement, bleeding, erythema and ulceration: This has led to the acronym IDRBEU for assessment of progression of an AK (Quaedvlieg, Tirsi, Thissen, & Krekels, 2006). Limited research has shown that AKs can also develop into BCCs, even though this was originally not considered a pathway of AK progression. Further research will be required to confirm this (Jancin, 2008).

A systematic review of the worldwide incidence of NMSCs confirms the occurrence of these skin cancers is high when compared to other malignancies, however, researchers had difficulty accurately measuring incidence because most countries do not register NMSCs or AKs (Lomas, Leonardi-Bee, & Bath-Hextall, 2012). Even in Australia there is a paucity of data for NMSCs and AKs because they are not officially notifiable diseases (Pollack, McGrath, Henderson, & Britt, 2014).

Assessment of the staging of progression of AKs and therefore treatment protocol choices has been assisted by two recent developments: a new quantitative assessment to evaluate the severity of AKs on the head, which determines the ‘actinic keratosis area and severity index’ [AKASI]. It could improve lesion evaluation, management and assist with treatment protocols (Dirschka, Pellacani, et al., 2017). The second assessment is a simplified treatment algorithm

19 which can assist dermatology practitioners to differentiate between the types of AKs (Dirschka, Gupta, et al., 2017).

2.1.6 The sun’s effect on skin Exposure to UV solar radiation causes AKs to develop. The following summary shows how solar radiation affects the DNA of human skin cells, including immunological and inflammatory changes in the skin, and how UV influences the metabolism of Vitamin D in its immune function role. The range of wavelengths of electromagnetic radiation emanating from the sun is shown in the following illustration.

Figure 10: Electromagnetic Wavelength Scale

Source: (Simmon, 2011).

The longer the wavelength, the less energy it has, conversely, the shorter the wavelength, the more energy. The ultraviolet segment of the spectrum, which is just below the wavelength of light visible to human beings, is divided into three sub-lengths: UVA, UVB and UVC (Giacomoni, 2001). UVA is measured between 315-400 nanometres (320-400 nm is the range used in the US) (Gies, 2014); this part of the UV spectrum is not absorbed by the ozone (O3) layer. Considered to be the least harmful of the three UV groups, it assists with the formation of vitamin D, though in excess it causes sunburn and can lead to the formation of cataracts in eyes (Giacomoni, 2001).

UVB is between 280-315 nm (290 and 320 nm is the range used in the US), (Gies, 2014) and there is partial absorption of it by the ozone layer. UVB radiation, which is not filtered out, can cause sunburn. It also causes damage to DNA at a molecular level which can alter genetic coding and potentially lead to mutations which can affect body repair of organisms and replication of cells (Giacomoni, 2001).

UVC is measured between 100 and 280 nm. It is completely absorbed by the ozone layer and is considered the most damaging form of UV to humans. Artificial forms of UVC can be

20 produced with some electrical activities, for example, it is emitted during metal welding therefore face shields and protective clothing must be worn (Giacomoni, 2001). There appears to be an increased risk of skin malignancies in welders; which is accompanied by an increased risk of ocular melanoma (Dixon & Dixon, 2004). All exposure to UVC requires full protection, regardless of the source.

Efficient DNA repair mechanisms ensure that most of these ‘faulty bonds’ (see Figure 11) are repaired promptly (Goodsell, 2001); (Fuss & Cooper, 2006); (Zhovmer, Oksenych, & Coin, 2010). This is a nucleotide excision repair, after which normal DNA replication can re- commence. If faulty bonds are not repaired or deleted, the cell will continue to replicate faulty DNA which can lead to permanently mutated genetic information. UVA photons can cause such DNA damage (Goodsell, 2001).

Figure 11: The Effect of UV Light on DNA Causing Distortions

Source: (Herring, 2011).

From the diagram (Figure 11), the description by David Goodsell states:

“This diagram exhibits the reaction to DNA molecules to the stress from ultra violet radiation. On the DNA strands, the thymine bases attach and bond with each other, instead of bonding across to the other strand. This causes distension to the DNA strand, known as a thymine dimer; which can lead it to not functioning effectively and therefore goes on to replicate as a faulty strand” (Herring, 2011).

It has been proposed that the accumulation of mutations in mitochondrial DNA (mtDNA) is an underlying cause of ageing and the development of skin cancers (Birch-Machin & Swalwell, 2010). It has been shown that mutations of mtDNA are increased with UV

exposure, which is also a cause of the oxidative stress, a key mediator of apoptosis or cell death (Birch-Machin & Swalwell, 2010). Oxidative stress triggers an injury response in skin cells, leading to an inflammatory cascade of cytokine activation (see Table 2) (Giacomoni, 2001).

Table 2: Cutaneous Mediators of Inflammation Whose Expression is Up-Regulated by UV Radiation Mediator Produced By Function TNF-α Keratinocytes, mast cells, dermal Langerhans cell migration, sunburn cell formation, fibroblasts, Langerhans cells stimulates PG synthesis, changes in adhesion molecule expression IL-1α Keratinocytes, Langerhans cells Stimulates PG synthesis, increases TNF-α and IL-6, inhibited by IL-1 receptor antagonist IL-1β Keratinocytes, Langerhans cells Langerhans cell migration IL-6 Keratinocytes, Langerhans cells Fever IL-10 Keratinocytes (mouse), macrophages Decreases IL-1, TNF-α, IFN- γ, IL-12, decreases (human), melanocytes antigen presentation, increases IL-1 receptor antagonist IL-12ρ40 (not Keratinocytes, dendritic cells, Decreases Th1 responses, decreases antigen bioactive) Langerhans cells presentation PGE2 Keratinocytes, mast cells Erythema, decreases antigen presentation, increases IL-4, deceases IL-12 Histamine Mast cells Increases PG Source: (Giacomoni, 2001). Professor Mary Norval (University of Edinburgh) has given permission for this table to be reproduced.

The information from the first column of Table 2 is elaborated upon in Table 3, where brief descriptions of the primary cytokines and inflammatory mediators are presented; these are involved in cellular dysfunctions, leading to the development of AKs.

Table 3: Descriptions of Mediators

Mediator Name Function TNF-α Tumour necrosis Produced from the keratinocytes, mast cells, dermal fibroblasts and factor alpha Langerhans cells, the primary role of TNF-α is to regulate system immune cells. It stimulates an inflammatory response, can induce fever response and apoptosis. It is predominantly activated by macrophages, though it can be produced by other cells e.g. natural killer cells, lymphocytes (Giacomoni, 2001). PG Prostaglandins Prostaglandins are lipid autacoids derived from arachidonic acid. They assist in maintaining homeostatic functions and in mediating pathogenic mechanisms, including the inflammatory response (Giacomoni, 2001; Ricciotti & FitzGerald, 2011). IL-1α Interleukin-1 alpha Interleukin-1 alpha, a cytokine protein, from the keratinocytes. Langerhans cells production is stimulated by macrophage activity, assists with maintenance of skin barrier function and is responsible for the production of inflammation, promotes fever and inflammation at the acute stage of infection or skin damage (Giacomoni, 2001). IL-1β Interleukin-1 beta Interleukin-1 beta, a cytokine protein, from the keratinocytes, Langerhans cells. Production is stimulated by macrophage activity, a mediator of an inflammatory response, assist in apoptosis and differentiation of cell proliferation (Giacomoni, 2001), (HUGO, 2014).

IL-4 Interleukin 4 Interleukin 4, a cytokine protein, production that can induce differentiation of naive helper T cells. Over-production of IL-4 has been linked to allergic reactions. Similar to IL-13 in function (Sokol, Barton, Farr, & Medzhitov, 2008). IL-6 Interleukin 6 Interleukin 6, a cytokine protein which is secreted from the keratinocytes, Langerhans cells, macrophages and T cells. It is an anti-inflammatory myokine as well as a pro-inflammatory cytokine. It stimulates immune response after trauma i.e. burns, sunburn and tissue damage or with infection (Banks, Kastin, & Gutierrez, 1994). IL-10 Interleukin 10 Interleukin 10, a cytokine protein, is secreted by T cells keratinocytes, macrophages and melanocytes, and has multiple functions. In inflammatory and immuno-regulation responses; it down-regulates Th1 cytokines (see below for functions), stimulates macrophages and enhances B cells, antibody production and is part of the body’s immune response to viral infections. It can inhibit the activity of natural killers cells (NK); has regulatory functions within the immune system (Pestka et al., 2004). IFN-γ Interferon gamma Interferon gamma is a cytokine, is mainly produced by natural killer cells, is classed as an interferon, an integral part of the immune system, also known as macrophage activating factor. Its functions are essential for an effective immune system, immuno-modulatory and immuno-stimulatory for infection control and against tumour development (Giacomoni, 2001). IL-12 Interleukin 12 Interleukin 12 is created when responding to a challenge to the body’s immune system by B cells and is macrophages and dendritic cells. Also named T cell stimulating factor, it assists in differentiating naive T cells to become Th1 cells and fully functioning T cells. Stimulates TNF-α and IFN-γ production and NK cell and T lymphocyte activity. As an anti-angiogenic, it can assist to block angiogenesis, thereby inhibiting tumour development (Kaliński, Hilkens, Snijders, Snijdewint, & Kapsenberg, 1997). IL-12ρ40 Interleukin 12 rho Interleukin 12 rho 40 is produced by keratinocytes, dendritic and 40 Langerhans cells. It mediates apoptosis suppression, inhibits Th1 responses and antigen presentation (Gómez, Martínez-A, Giry, García, & Rebollo, 2005). Th1 T Helper 1 T Helper 1 is part of a group of T Helper cells, which assist immune function. Th1 is stimulated by IL2, IL12 and IFN-γ, after antigen stimulation; in turn it assists a variety of immune cells including activating and optimising B cells, macrophages and phagocytes, antimicrobial and anti- protozoal activity. (Mosmann, Cherwinski, Bond, Giedlin, & Coffman, 1986). PGE2 Prostaglandin E2 Prostaglandin E2, formed in the skin by keratinocytes and mast cells withPGE2 receptors activation, as part of the mediator response cascade. It can induce fever and inflammatory responses, activates erythema, increases IL-4, decreases antigen presentation, and IL-12, it can affect angiogenesis, apoptosis and cell proliferation (Kabashima et al., 2007). Histamine Histamine Histamine, derived from the amino acid histidine, is released from cutaneous mast cells when they degranulate as a response to an antigen or an inflammatory response. Histamine continues the cascade reaction by increasing PG and TNF (Giacomoni, 2001). Bcl‐2 B-cell lymphoma 2 Apoptosis inhibitor, found in increased levels with inflammatory disease states, including AKs progressing to SCCs. Bcl-2 overexpression on tumour cell lines has been shown to induce tumour progression and to reduce the tumour cells dependence on growth factors (Berhane, Halliday, Cooke, & Barnetson, 2002). Fas and Fas L Fas and Fas ligands Found to be decreased in inflammatory AKs. Fas is a cell surface receptor, an apoptosis signalling molecule. FasL is found on activated T lymphocytes; it is thought that tumour cells may kill lymphocytes via FasL. Interaction with target cells results in receptor aggregations & signals to cause apoptosis of target cells (Berhane et al., 2002).

Using immunochemistry to assess the progression of AKs to SCCs, Berhane et al., concluded that an inflammatory response appeared to drive this and noted that the inflamed AK had increased numbers of Langerhans cells, T-lymphocytes, with an increase in the apoptosis inhibitor bcl‐2 and immunoreactive p53.There was a concurrent decrease in decrease in Fas and Fas ligands (Berhane et al., 2002). The inflammatory response is indicated as the driver of progression to malignancy, although it appears to diminish rapidly after conversion (Berhane et al., 2002).

2.1.7 Melanocytes and vitamin D regulation and immune support Melanocytes are epidermal cells, found in the stratum basale, the base layer of the epidermis. These cells produce melanin, a protein pigment (Nordlund, 2007); (Brenner & Hearing, 2008), which is responsible for skin coloration and for protection against UV. The presence of the enzyme tyrosinase is required for melanocytes present in the skin to produce melanin. It is derived from tyrosine, an amino acid (Marieb, 1995); (Nordlund, 2007). UV stimulates the functionality of melanocytes, which have receptors for vitamin D; this vitamin enhances melanogenesis and the regulation of melanin in the dermal layer. The presence and levels of melanin in the skin determines skin colour, that is, the more melanin present, the darker the skin. Melanin is also found in other places in the body including in the eyes, within the inner ear and in hair (Nordlund, 2007) (see Figure 12).

Figure 12: Melanocytes in Human Skin

Source: (Seer, 2011).

The process of natural vitamin D3 production is a complicated cascade process, initiating with sun exposure, specifically UVB, reacting with melanocytes, resulting in 7-dehydrocholesterol conversion into vitamin D3, which diffuses into the circulatory system from the capillaries. Within circulation it is bound to vitamin D binding protein (VDBP), in addition there is a known association with serum albumin. The next step, 25-hydroxylation, is in the liver from the mitochondrial form of 25-hydroxylase (CYP27A1), to develop 25-hydroxyvitamin D3 (25(OH)D3 or calcidiol); this is considered to be activated by the cytochrome P450 enzyme. In addition, another activation stage occurs predominantly in the kidneys, also by the cytochrome P450 enzyme where 25(OH)D-1α-hydroxylase (CYP27B1) forms the active metabolite of D3; 1,25-dihydroyxvitamin D3 [1,25(OH)2D3] or calcitriol. These steps are the predominant forms of vitamin D3 circulating in plasma. The concentrations in individuals will vary considerably; the variables which effect levels include sun exposure, latitude, air pollution, clothing (blocking the skin from sun exposure), gender and diet (Jeon & Shin, 2018), (Karras, Wagner, & Castracane, 2018), (Passeron et al., 2019). Vitamin D2 (ergocalciferol) is derived from the plant sterol ergosterol (Bikle, 2014). Vitamin D receptors (VDR); there are activated transcription factors which bind to sites in the DNA; these are called vitamin D response elements (VDREs) and there are very large numbers of these and they regulate genes, this transcription is dependent on co-modulators, which are cell specific. This is essential for cellular activity; therefore deficiencies can impair cellular function, gene transcription and immune function (Bikle, 2014), (Karras et al., 2018) This vitamin has many functions in the human body; these include anti-proliferative, anti- tumour and apoptosis inducing effects (Deeb, Trump, & Johnson, 2007), (Bikle, 2014). There is an indicated correlation between mortalities and low Vitamin D levels (Garland et al., 2014). It is essential for bone health, metabolism and remodelling; with deficiencies causing rickets, osteomalacia and potentially osteoporosis (Bikle, 2014). Deficiencies have also been associated with Age-Related Macular Degeneration (Layana et al., 2017).

Shannan et al., conducted in vitro research of primary cutaneous malignant melanomas, metastases of malignant melanomas and acquired melanocytic naevi (Shannan et al., 2006), which demonstrated that Vitamin D was able to lower the spread of melanoma cells by up to 50%. A survey, conducted by Melamed et al., (2008) showed that having low 1-apha,25- hydroxy-Vitamin D levels was associated with poorer health outcomes compared to those with optimal levels. Those in the lowest quartile, with levels of (25[OH]D levels <17.8ng/mol) had a 26% increase of mortality rates, from all causes (Melamed, Michos, Post, & Astor, 2008). Grant (2002) considers that careful, moderate, regular sun exposure

25 outweighs the risks of developing skin cancer (Grant, 2002). There are some food sources of Vitamin D3: small amounts occur naturally in egg yolks and oily fish, and it is added as a supplement to some milk and margarine products. Additionally, Vitamin D2 can be obtained from mushrooms that have been exposed to UV. This may assist in boosting levels, though relying on food, is not considered sufficient to maintain optimal Vitamin D levels, hence supplementation is often required for optimal levels, particularly in winter (Cancer Council of Australia, 2013a; National Institute of Health, 2016) (Layana et al., 2017). The importance of Vitamin D in the regulation of the immune system was supported by the 2009 study of Jeng et al., (Jeng et al., 2009). In addition, nicotinamide (Vitamin B3) has been indicated to have some protective benefits from damage caused by UV radiation; In a phase 3, double-blind, randomized, controlled trial, Chen et al., 2015, concluded that oral consumption of nicotinamide was both effective and safe method to reduce the risk of development of AKs and NMSC; of particular benefit to people with an increased risk (Chen et al., 2015). Some of the herbs which are good sources of this vitamin are; Arctium lappa (burdock), Laminaria spp (kelp), Medicago sativa (alfalfa), Petroselinum spp (parsley), Salvia officinalis (sage), Taraxacum officinale (dandelion), Trigonella foenum-graecum (fenugreek) (Hass, 1992). Sun exposure appears to be rather like the story of Goldilocks and the Three Bears (Southey, 1837), too much sun causes harm to the body, too little sun causes health problems; and the goal is finding the amount that is just right for each individual (Wright, 2012).

2.2 Topical Medical Treatments for AKs The following medical treatments may be utilised to eradicate AKs: electrodessication (burning), cryogenic therapy (freezing with liquid nitrogen), curettage or surgical removal (cutting); there are medical therapies that use chemicals, such as 5-Fluorouracil (5-FU) and retinoids; and dermatological chemical peeling agents. Other treatments include laser skin resurfacing, escharotic (eroding) paints, creams and lotions (Hardman, Limbird, & Gilman, 2001); (Jain, 2012); (Clarke, Clarke, & Helm, 2014). Following are brief descriptions of the current range of medical treatments for AKs, their modes of action, suitability, efficacy and the potential adverse effects.

2.2.1 Cryotherapy/Cryosurgery Cryotherapy is considered the first-line treatment for AKs. Liquid nitrogen is used to freeze the area being treated. If the lesion is known to be malignant and therefore no longer an AK, a longer exposure time is given, causing a deeper, more invasive freezing burn. This often

26 causes blisters to develop, so care must be taken to avoid infection, particularly for the elderly or immune-compromised patients, where there is slow-healing, as ulcerations may occur. Unless it is a small and early stage lesion, it will usually need to be re-treated one month later. Possible long-term side-effects include permanent scarring and pigmentation aberrations (Craig & Stitzel, 2004).

2.2.2 Electrodessication The lesion is cauterised or burnt off by an electrically heated wire. Occasionally cauterisation is performed with the addition of a chemical that causes a burn to the treated area. As with cryotherapy a blister will form and the same cautions apply regarding similar side effects occurring (Gawkrodger & Ardern-Jones, 2003).

2.2.3 Surgical removal There are several methods by which AKs may be removed surgically, depending on the site and number of lesions. A general practitioner, dermatologist, plastic or cosmetic surgeon may use: 2.2.3a Excisional biopsy An elliptical shape is drawn around the lesion and under local anaesthetic: the marked area of skin is excised. The wound is carefully sutured to minimise the scarring and to ensure there is no tight pulling on the skin, which can cause long-term functional impairment and disfigurement. Care must be taken to prevent infection. A scar will form when the skin heals (Gawkrodger & Ardern-Jones, 2003).

2.2.3b Incisional biopsy Compared to an excisional biopsy, a smaller area of the dermal layer is excised primarily for pathological diagnosis of the lesion, rather than entire removal of it. This method is used if there is suspicion of progression of an AK to a NMSC (Dicker, 2011), (Dicker, 2012). Local anaesthetic is used on the treatment area and some scarring may develop. The remaining lesion may be completely removed after diagnosis is confirmed (Gawkrodger & Ardern- Jones, 2003).

2.2.3c Punch biopsy This is the most frequently used method, for removal of a lesion for histological testing. The area for biopsy is anaesthetised and the punch (a surgical instrument) cuts into the skin removing a core or sample of the lesion. Occasionally this may require suturing. The procedure may leave a small scar (Gawkrodger & Ardern-Jones, 2003).

2.2.3d Curettage After the area surrounding the lesion is anaesthetised, a curette (a surgical instrument) removes the abnormal tissue in a scoop-like way, usually requiring one or two sutures. A small scar will form (Gawkrodger & Ardern-Jones, 2003).

2.2.3e Shave biopsy This method is used primarily for the removal of superficial lesions, where there is no sign of invasion into the dermis or malignancy. A thin slice of the epidermis is shaved off with a surgical instrument and the area is cauterised to stop any bleeding. Care must be taken to ensure sterile procedures, to reduce the risk of infection. Additional care must be taken with the wound until it has healed, to reduce the risk of infection to the treatment site. Some scarring will result and potentially dyspigmentation (Gawkrodger & Ardern-Jones, 2003).

2.2.3f Mohs’ micrographic surgery This is a very precise form of surgery which is controlled and conducted using a microscope. It is particularly useful where lesions are in an area of critical importance to body function, for example, around the eyes or lips. This procedure minimises the amount of tissue extracted. Diagnostic testing of tissue can be done before the incision is sutured to determine any degree of malignant invasion beyond the epidermis. This procedure is undertaken using local anaesthetic. By enabling minimal tissue removal, this potentially reduces the amount of functional impairment and scarring (Gawkrodger & Ardern-Jones, 2003).

2.2.4 Chemical peels This procedure is usually performed by dermatologists, cosmetic surgeons or beauty therapists, and involves applying a chemical solution to the area of lesions and eroding the dermal layer. This can be very painful and is usually only done when the patient has a large area affected with lesions, such as a bald scalp; a form of ‘field treatment’. There is a risk of post-treatment infection; often there is ongoing pain and great care must be taken to protect the new skin formation, particularly from sun exposure (MacKie, 2003; Marks & Motley, 2011).

2.2.5 Dermabrasion Dermabrasion is performed with a surgical instrument that has a rotating disc that abrades the lesion (removing as finely shaved skin) into the dermis. This treatment, known as field

28 therapy, is usually used when there is a proliferation of lesions in close proximity. A wound is created and care must be taken to prevent infection. This is considered to be a painful treatment and it is usual for some scarring to develop (Gawkrodger & Ardern-Jones, 2003).

2.2.6 Retinoids Tretinoin: used topically, this chemical changes the way skin becomes keratinised. It also has a positive effect of inhibiting the aberration of some dermal cell abnormalities that are a consequence of long-term exposure to sunlight. The negative side effects of Tretinoin are inflammation and irritation to the treatment area. This can be exacerbated by increased moisture to the skin. A major caution with use of retinoids is that the treatment medication has known teratogenic actions (induces foetal abnormalities) (Gollnick & Krautheim, 2003). Even though there are limited amounts of dermal absorption, it should be used with caution with women of childbearing age, is contraindicated for use by women who are breastfeeding and should not used at all during the first trimester of pregnancy (MacKie, 2003, p. 73).

2.2.7 Photodynamic therapy [PDT] This is a two-stage process, using photo-chemical destruction of the abnormal skin lesions. It is more likely to be used if there are multiple AK lesions in close proximity; as a field treatment. A light-sensitive chemical (aminolaevulinic acid, more commonly known as either ALA, HCI, Levulan or Kerastick) is applied to the treatment area, followed by a laser beam which produces red light of a specific wavelength (630 nanometres). Although this treatment has had some success in clearing skin abnormalities, it also has a serious limitation. The patients continue to be very photosensitive (sensitive to sunlight) for at least six weeks (requiring them to avoid sunlight). The mode of action of PDT is the use of chemical/s which, are potent photosensitising intermediates in heme synthesis. This is thought to accumulate in malignant cells and they are then destroyed by the laser light exposure. An immediate side effect is stinging and burning pain, which may be tolerable with a small exposed site, but may be of greater concern if a large area is being treated (Craig & Stitzel, 2004); (Marks & Motley, 2011).

2.2.8 Chemotherapy Topical chemotherapy is usually only used when field-treating extensive areas of keratoses. 5- Fluorouracil [5-FU] and Masoprocol (aka Actinex), are some of the chemotherapy drugs used. There is usually inflammation and irritation to the treatment area that lasts for a period of time post treatment. Consideration is needed prior to using 5-FU topically, as it potentially can

29 aggravate concurrent skin conditions such as rosacea, acne or melasma (Reeves & Maibach, 1998); (Marks & Motley, 2011).

2.2.9 Radiotherapy As with chemotherapy treatment, this is only used rarely and usually only with extensive keratoses. More modern modalities are tending to render radiotherapy obsolete (Reeves & Maibach, 1998); if used, it is utlised as a ‘field treatment’, where other treatments such as 5- fluorouracil and effudix has not been effective, as it is a more expensive, requires access to a radiation therapy centre and time commitment for the treatments (Dinehart, Graham, & Maners, 2011). Care is required to protect the treated area until healed; some of the side effects are; erythema, crusting radiation dermatitis, impairment to the microcirculation in the treatment area, either hypo or hyperpigmentation and alopecia (Dinehart et al., 2011).

2.2.10 Topical immune-modulating agents Imiquimod: this chemical, used topically, is a potent immunostimulant. It was developed originally to treat warts, though it has no apparent anti-viral action. It has been registered by the TGA in Australia to treat AKs and superficial skin cancers. Research has shown it to be effective for treating AKs (Craig & Stitzel, 2004). A side effect of this agent is irritation to the treatment area (Craig & Stitzel, 2004); (Marks & Motley, 2011).

2.2.11 Picato Picato is the commercial name for topical AK treatment in a gel formulation, containing ingenol mebutate (as either 0.015% or 0.05%), an inducer of cell death (RxList., 2012). It is derived from the common herb Euphorbia peplus, commonly known as radium weed. Four trials related to the development of this product are included in the Systematic Review (see Chapter 4). Significant research has been undertaken on this herb, to discern how it induces cell death, when used as a treatment for AKs. Picato was initially approved for use in the US by the FDA for use on AKs. It was approved by the Australian TGA in 2013 (Leo Pharma, 2012b).

The company commercialising this product states that the recommended treatment regime for use of Picato is application for two days consecutively for AKs on the body and limbs, and consecutively for three days on the face and scalp (Leo Pharma, 2012b). Adverse effects include local skin reaction, application site pain, application site pruritus, application site irritation, application site infection, periorbital edema, nasopharyngitis, headache (Medsafe.,

2017). The U.S. Food and Drug Administration [FDA) reported severe allergic reactions and anaphylaxis. In addition, for some immuno-compromised people it has caused of reactivation of the herpes zoster virus, causing outbreaks of shingles. This has led to the requirement for revised label warnings and product application (Medsafe., 2017).

2.2.12 Application of medical treatments Of the treatments above, cryotherapy and electrodessication are frequently performed at a general practitioner’s rooms, often by a practice nurse. Other forms of treatment are usually performed or prescribed by a specialist dermatologist after the patient has been referred by their general practitioner (Gawkrodger & Ardern-Jones, 2003); (MacKie, 2003); (Craig & Stitzel, 2004); (Dicker, 2011); (Dicker, 2012). A common effect from the majority of medical treatments, in particular chemical treatments, is an inflammatory response, for which an assessment scale has been developed (Rosen, Marmur, Anderson, Welburn, & Katsamas, 2014).

Does the framing of the presentation of the diagnosis and prognosis of an AK influence how the patient makes treatment choices? This question formed the basis of an investigation (Berry, Butt, & Kirby, 2017), which found that there were significant differences in the treatment choices by patients for AKs, depending on the way the physician explained the lesion and its potential to transform into a skin cancer and whether it was described as a ‘non- life-threatening’ lesion, or a ‘pre-cancer’ lesion. 539 dermatology patients completed the survey and of those who were told the lesion “could possibly go away without treatment and not turn into life-threatening skin cancer”, 57.7% and 60.9% chose treatment. 92.2% of the group, who had the AK framed as a ‘pre-cancer’ chose treatment (Berry et al., 2017). These results demonstrate that the fear of cancer is effective at motivating patients to seek treatment for AKs.

2.3 Prevention of Sun-Induced Skin Damage As AKs are a direct result of cumulative exposure to the sun, avoidance of over-exposure, is recommended. Most countries with light-skinned populations have ‘Sun Smart’ type campaigns to minimise the risks, and with regular use of sunscreen, there is a 36% reduction of the development of AKs (Farmer & Naylor, 1996). Olsen et al., (2015) consider that most skin cancers are preventable with regular use of, at least, sun protection factor (SPF) 15+ sunscreen. They believe that sunscreen usage has resulted in a 10-15% reduction of skin cancer incidence; therefore, increased use is likely to further reduce the occurrence (Olsen et

31 al., 2015). While Stege and Krutmann (2017) endorse the efficacy of very high SPF sunscreens, they suggest that regular oral intake of Vitamin B3 has indicated photoprotective benefits, (as referred to in 2.1.7) (Stege & Krutmann, 2017).

The Cancer Council Australia's Skin Cancer Committee has released a National Cancer Prevention Policy, relevant to the prevention of AKs. This 2010-2011 policy was updated in 2013. It is available online and discusses the causes, health implications and interventions to assist with reducing the incidence of sun-damage. Included are policies, strategies and proposed actions, stakeholders involved, timetables, proposed budgets and potential benefits (Cancer Council of Australia, 2013b).

CHAPTER 3 - HERBAL MEDICINE, SKIN DISEASE, AND HERBS AS SKIN TREATMENTS

3.1 Herbs for Treating Skin Disease 3.1.1 Background of herbs as medicine From the introduction of ‘The Healing Garden’, Minter wrote that all of life on earth is dependent on plants, including plants as medicines. For many people the healing properties of these plants have been hidden and are presented to them by modern medicine in pill form (Minter, 1993). Herbal Medicine is the use of plants to relieve or heal ‘dis-ease’ or un- wellness, and can include fruits and vegetables used as food. Historically, locally grown herbs were readily available, though seasonal, and thereby provided inexpensive remedies for local populations (Bone & Mills, 2013). Depending on the plant species, different parts can be used as medicines including the leaves, flowers, seeds, bark, sap, resins and roots (Johns, 1996); (Ody, 2000); (Halberstein, 2005).

As long as humans have been on earth, they have experimented, most likely by trial and error, to ascertain what was food, medicine or poison (Grieve, 1992 (1931)); (Fisher & Painter, 1996); (Mills & Bone, 2000). The origins of plants, as medicines, probably developed from observations of animals ‘self-medicating’ with certain plants (Fürst & Zündorf, 2015). Archaeological evidence, thus far, indicates that humans have been using herbs as medicines for at least 60,000 years. The earliest written records of the use of herbal medicine are from the third century BC Mesopotamia (Fürst & Zündorf, 2015). In 1990, a tomb was discovered at Abydos, in Egypt, dated to one of the earliest known kings from Egyptian history, Scorpion I, around 3150 BC. Approximately 700 pottery jars contained the residues of wines to which had been added herbs, figs and tree resins. The herbs identified were; a Satureja species (savory family), Artemisia seibeni (wormwood family), Tanacetum annuum (blue tansy), Melissa species (balm family), Cassia species (senna family), Coriandrum species, (coriander family), Mentha species (mint family), Salvia species (sage family) and Thymus thymbra (thyme). This greatly assisted to identify the herbs which were used historically in ancient Egypt (McGovern, Mirzoian, & Halla, 2009). Over time, the plants which proved efficacious for treating disease were often referred to as ‘herbs’. Some were proven to be very powerful, with only small doses required for medicinal treatments. Larger doses could be toxic (Fisher & Painter, 1996).

Hippocrates of Cos, 460-377 BC, is considered to be the ‘Father of Western Medicine’ and said: “Let your food be your medicine and your medicine be your food” and “Everyone has a doctor in him or her; we just have to help it in its work. The natural healing force within each one of us is the greatest force in getting well”. These words are still valued in the traditional western herbalist philosophy (Painter, 2007a).

In the past, the primary responsibility for herbal healing was placed with the ‘community healer’, who usually invoked spiritual rituals alongside the physical use of herbs (Johns, 1996). From the European Renaissance, academically trained doctors took over this role without the spiritual component. New plants were brought to Europe from newly colonised countries, some of which were heralded as effective treatments for diseases, for example, Cinchona officinalis, native to South America, which was used to treat malaria (Poser & Bruyn, 1999); (Reiter, 2000). Generally, these medicines were expensive and exclusive to doctors and pharmacists, who dispensed them. With the development of chemical engineering, the major therapeutic constituent chemicals in medicinal herbs were identified, isolated, purified, and then produced on an industrial scale, enabling medicines to become cheaper and more widely available. This approach often made for more potent medicine, but with an increased potential for negative side-effects (Ody, 2000).

As chemists gained a greater understanding of phytochemistry, they could synthetically create the major active constituents of the plants. Modern pharmaceutical companies could manufacture masses of pills and liquid preparations without a plant in sight. The prescription of these medicines was generally by medical practitioners (Ody, 2000). The advances made with extracting, purifying and manufacturing herbs and herbal extracts has brought benefits: standardised doses, the improved shelf life of products and the convenience of dispensing (Lehmann, 2004). There are also disadvantages: an increased risk of adverse reactions compared to using unrefined plant material. In some ways we seem to have outsmarted ourselves and it appears to be a good time to re-evaluate what nature provides (Fisher & Painter, 1996). As noted by Hilda Leyel (1880; as cited in Painter, 2007) (Painter, 2007b):

“Botany and medicine came down the ages hand in hand until the seventeenth century; then both arts became scientific, their ways parted, and no new herbals were compiled. The botanical books ignored the medicinal properties of plants and the medical books contained no plant lore”.

Modern herbal texts now integrate herbal medine and medical science, thus providing valuable resouces to those seeking information on integrative medicine, for example ‘Principles and Practice of Phytotherapy’ (Bone & Mills, 2013) and ‘Herbal Medicine: Biomolecular and Clinical Aspects. 2nd edition’ (Benzie & Wachtel-Galor, 2011).

Nowadays, knowledge of herbs is moving back to interested people, potentially bringing more self-awareness or empowerment to their health choices and wellbeing. This would be preferably with the guidance of a qualified and experienced herbalist, as some herbs are easily confused with other less therapeutic species, and some are very toxic (Bone & Mills, 2013). A qualified herbalist usually does not just treat the symptoms; it is considered best practice to treat the underlying causes of the lack of wellness It is most important to look at the wider picture; of diet, lifestyle, work, exercise and social habits, so that the practitioner can guide patients towards greater understanding and self-care management (Ody, 2000); (Bone & Mills, 2013).

3.1.2 Standardisation of herbal medicines An area of herbal medicine which is of relevance when seeking potential AK treatments is the increasing standardisation of herbal medicines. There is variability in the levels of constituents present in plants (usually due to the differing growing environments) which can affect the phytochemical levels, e.g. diversity in soil nutrients, soil moisture, time of year and climate (Di, Liu, Ma, & Jiang, 2003). There are arguments for the standardisation of key constituents in herbal remedies (Bone, 2003); (Di et al., 2003); (Lehmann, 2004). If the pharmaco-medical approach is taken, there would be a requirement for defined levels of specific active constituents through selective extraction (Wohlmuth, 1999).

In determining such markers, consideration would need to be made of the natural variabilities. Kerry Bone, a phytopharmacist and herbalist, states that these key compounds may not actually be the active compounds for specific therapeutic actions for specific medical conditions. From Bone’s perspective (Bone, 2000-2001), the phytochemicals which have the greatest therapeutic activity are key, whereas other important phytochemicals have other therapeutic effects. Some consider that standardised herbal extracts will be the herbal therapy of the future, that this method of extraction will ensure consistency, and a more effective and higher quality medicine than a traditional extract (also known as a Galenical extract) (Bone, 2000-2001). Bone says that some standardised extracts have significantly higher levels of the

35 active constituents than would occur naturally, and consequently they ought to be considered to be pharmaceutical medicines rather than herbal medicines (Bone, 2000-2001).

Describing the methods of extraction for standardisation, organic chemist (Lehmann, 2004) writes that the plant material of herbs is basically a matrix of inert cellulose which contains a diverse number of phytochemicals. He states that when a herb is put into an extraction process, the phytochemicals extracted depend on the solvent or menstruum used (see Appendix D: Differing Extraction Methods and Availability of Herbal Constituents). It is possible, through the choice of a particular solvent or combination of solvents, to achieve very selective extraction of groups of phytochemicals or a specific individual chemical. Lehmann considers that when herbs are manipulated in such ways, the phytochemical profile of the raw herb may be considerably altered and thus become more a pharmaceutical product than a herbal medicine. He questions the practice of stating the levels of herb equivalence on labels of herbal medicines, when so many constituents have been left out or altered in order to create the product (Lehmann, 2004). Perhaps herbal medicines containing levels of constituents that are much higher than occur naturally, ought to not be referred to as 'natural'? (Bone, 2000- 2001). However, the creation of an industry standard would be challenging due to the natural diversity of constituents in plants grown in varying conditions and environments (Santos- Gomes & Fernandes-Ferreira, 2001). The variability of raw plant materials and the different extraction methods used, make it extremely difficult to compare the efficacy of different herbal products (Dreikorn, 2002).

Of relevance to this subject is a review of the consistency of key markers in Ginseng species (Harkey, Henderson, Gershwin, Stern, & Hackman, 2001) which analysed 25 commercially available Ginseng products (containing either Panax species or Eleutherococcus senticosus). The equipment and method utilised for this analysis was HPLC and liquid chromatography– tandem mass spectrometry to discern key marker levels of seven ginsenosides (from the Panax species, including Asian and American ginseng) and two eleutherosides from Eleutherococcus, (aka Siberian Ginseng). Their findings and suggestions were that ginseng products produced in the USA were labelled correctly, according to the plant genus; however, there was variability in marker compounds. This suggests that standardisation of specific marker compounds may be necessary to ensure quality assurance. They propose that in future, the evaluation and design of herbal products ought to be developed with consideration of the key markers (Harkey et al., 2001). They concluded that until all herbal products are tested for their phyto-therapeutic activity or are based on standardisation of key markers, the reliability

36 of products cannot be assured. They recommended that it is of particular importance to develop protocols for future clinical research of herbal products, otherwise results maybe inconclusive if the phytochemical profiles are not known (Harkey et al., 2001).

It is often necessary to tailor a herbal extract to ensure that specific active constituents are in the right concentrations to suit a particular health condition. Such products may not be as therapeutically efficacious for other conditions if certain relevant constituents, which are usually present in the plant, are missing. The product is then changed from the original herb, therefore clear labelling of specific constituents and the amounts of each would be essential (Bone, 2000-2001); (Lehmann, 2004). Dreikorn (2002) considers that because of the variability of raw plant materials and the different extraction methods used, it is difficult to compare the efficacy of different herbal products so there is a likelihood of misleading results (Dreikorn, 2002).

Another issue is authenticity and integrity of herbal products. For example, a survey of constituent levels in botanical dietary supplements, assessed 17 products containing Indian frankincense (Boswellia serrata) available for sale in the US and Europe (Meins et al., 2016). The testing included assessment of the boswellic acid composition profile, claimed health benefits and label compliance. Only 5 of the 17 products disclosed the relevant information, despite claiming that Frankincense was an ingredient, and 41% did not comply with labelling laws. They concluded that mislabelling is rife and must be addressed by the product manufacturers to enable consumers to have confidence in these products (Meins et al., 2016).

3.1.3 Extraction methods and availability of herbal constituents Extraction of specific constituents requires comprehensive phytopharmaceutical knowledge The extraction method can influence the effectiveness of the herbal treatment, for example, if the therapeutic benefits of alkaloids are required, then ethanol as the menstruum will ensure their availability. If water is used as an extraction method (as an infusion or decoction), then some constituents, such as alkaloids may not be as available. On the other hand, if the minerals are required for extraction, then water or vinegar would be better extracting mediums than ethanol (Painter, 1998); (Bone, 2003).

For example, flavonoids (glycoside compounds), whose therapeutic actions include anti- inflammatory, anti-oxidant and anti-cancer activity, are soluble in water and most organic solvents (Chebil et al., 2007; Pengelly, 1996). Resins, such as those present in ginger, benzoin, myrrh, cannabis, capsicum and opium, have therapeutic actions that include

37 antiseptic, anti-tumour, stimulant, and pain relieving and are soluble in both alcohol and oil (Pengelly, 1996). More detailed information relating to differing extraction methods and availability of herbal constituents are provided in Appendix D (Appendix D Differing Extraction Methods and Availability of Herbal Constituents).

3.1.4 Safety and efficacy of herbal medicines Halberstein, 2005, states that a variety of distinct paths provide evidence that the use of plants is the oldest and most diverse form of medicine for humans, and that in many cases, the phytochemical constituents of botanical medicines have been proven as either primary or as supplementary medications when dispensed in a considered manner (Halberstein, 2005). As stated, further research of the traditional methods of extraction, the method of application and the dosage of herbs is recommended, particularly as the type of extraction method can influence the availability of constituents (Pengelly, 1996); (Mills & Bone, 2000); (Halberstein, 2005). With knowledge of the popular use of herbs throughout the world Cravotto and colleagues (Cravotto, Boffa, Genzini, & Garella, 2010), sought proof of evidence and efficacy for commercially available herbal medicines. They surveyed nearly 1000 different herbs to assess the degree of research which had been undertaken, as opposed to recorded folklore or traditional use. Their findings revealed that for one-fifth of the total number of herbs, the only studies available were their phytochemical analyses and the evidence as a whole plant extract was not evidenced (Cravotto et al., 2010). There were however, clinical trials published for 156 herbs; 50.9% of this group had been tested either in vitro or in vivo on animals, 20.8% had been investigated for the phytochemical constituents. A further 0.5% was assessed as being either allergenic or toxic; they state that the use of these herbs ought to be discouraged or forbidden. They find it disconcerting that some herbs which have widespread public use are not supported by research assessment for efficacy, optimal dosing or for pharmacological constituents. Cravotto and colleagues state that the potential of herbal remedies remains largely unexplored, and that establishing efficacy and identifying the therapeutic actions and constituents, are major challenges which require addressing (Cravotto et al., 2010). In the US, the majority of herbal and complementary and alternative medicine (CAM) remedies are marketed as ‘dietary supplements’, to avoid the FDA requirements for researched proof of efficacy and safety (Bartels & Miller, 1998). They consider that because herbs have a tradition of use, it might be more appropriate to follow the German approach of approving herbal remedies on the basis of absolute proof of safety and reasonable proof of efficacy. They suggest that such an approach might encourage manufacturers to conduct research into

38 safety and effective dosage, rather than having to commit to expensive full-scale drug trials. As herbal products are usually not patentable, the amount of money required for full-scale trials is unlikely to be recouped by product sales (Bartels & Miller, 1998).

3.1.5 Herbal, complementary and alternative medicine research A significant difference between modern medicine and herbal medicine is that the former generally use a single, highly purified chemical constituent to treat the symptom, whereas herbal medicine uses plant extracts containing hundreds of active compounds to holistically treat the disease. These compounds are thought to act in parallel on multiple target sites, as well as acting synergistically to enhance the beneficial properties of each other while diminishing their potential adverse effects (See Appendix C) (Cravotto et al., 2010). For instance, Degner and Romagnolo, 2008, consider that a combination of plant chemicals ought to be more effective at targeting cancers and other cellular abnormalities than a single chemical (Degner & Romagnolo, 2008). Similarly, while assessing the oestrogenic activity of five traditional Japanese medicines, used for treating menopausal symptoms, it was found that while the individual herbs had oestrogenic activity, they were more effective in combination, suggesting synergistic activity, the underlying mechanisms are unknown (Wang, Kanda, Shimono, Enkh-Undraa, & Nishiyama, 2018). Viewed from this perspective, reductionist approaches to assessing the efficacy of herbal preparations, by isolating and testing individual constituents are likely to be less successful, as the whole preparation is more effective than the sum of its parts (Fønnebø et al., 2007).

Regarding the popularity of CAM, which includes herbal medicine, a population survey (Xue, Zhang, Lin, Da Costa, & Story, 2007) concluded that in Australia, there are estimated to be as many visits to CAM practitioners as there are to medical practitioners. It was been calculated that annually there are 69.2 million visits of adult Australians to CAM practitioners, as compared to 69.3 million visits to medical practitioners. The annual, personal cost for Australians for their CAM expenses has been evaluated at $AU 4.13 billion. In addition this study found that less than half of patients informed their medical practitioner of their use of CAM (Xue et al., 2007), therefore this raises concerns of ‘concurrent use’ of allopathic and CAM medications. With the potential risks of herb-drug interactions, healthcare practitioners need to be mindful of asking patients what medications or therapies they are taking and patients need to be better educated about informing all relevant therapists of medications, herbal medicines or supplements they are using. Greater awareness may potentially bring a

39 reduction in herb-drug interactions or adverse events derived from ‘self-medication’ of herbs, nutritional medicine or pharmaceutical medicines.

With the rising use and increasing public acceptance of herbal medicines, there is a growing body which refers to it as ‘original medicine’. This term is now in popular use and there are degrees available in the subject (International Institute of Original Medicine, 2013). However some are concerned by the lack of clinical trials to assess safety and efficacy (Fürst & Zündorf, 2015), this includes herbal treatments for sun-induced skin damage and AKs.

3.1.6 Historical treatments for skin conditions Historically, the type of lesion we now identify as AKs, have been called lumps or bumps, or considered as cankers or growths. The use of herbs for treating skin damage and disease is an ancient tradition of peoples of the earth (Halberstein, 2005). Some examples of herbs which historically were used as treatments for abnormal skin lesions are included in Table 4. Many of these are regarded as common garden weeds, in line with the German proverb ‘The garden is the poor man's apothecary’. To support the historical and traditional use of herbs for treating skin abnormalities Table 4 was prepared predominantly with information primarily from ‘Materia Medica of Western Herbs for the Southern Hemisphere’ (Fisher & Painter, 1996) and also ‘A Modern Herbal’ (Grieve, 1992 (1931)).

Table 4: Examples of the Historical Use of Herbs for Treatment of Skin Abnormalities Author(s) Year Herb Historical Uses

Culpeper 1653 Viola odorata “The green leaves... make plaisters and poultices for inflammations and swellings” (Culpeper, 1981 (originally published 1653)) Fisher & Painter 1996 “Internally and externally for cancer…Externally for swellings; inflammations…” (Fisher & Painter, 1996) “The fresh leaves, crushed and applied as a poultice, Palaiseul 1986 have been advocated for benign tumours...” (Palaiseul, 1986) Grieve 1931 “Of late years, preparations of fresh violet leaves have been used both internally and externally in the treatment of cancer... with benefit to allay the pain in cancerous growths...” (Grieve, 1992 (1931)) Fisher & Painter 1996 Apium graveolens “…as a lotion for treating sores and cankers.” (Fisher & Painter, 1996) Fisher & Painter 1996 Sanguinaria “…cancer; skin growths. A paste was made of canadensis Sanguinaria extract, zinc oxide, flour, and water and Lewis and 2003 applied to skin cancers.” (Used successfully in Elvin-Lewis Middlesex Hospital for superficial cancers of the nose and external ear) (Lewis & Elvin-Lewis, 2003).

Fisher & Painter 1996 Hypericum “…Externally to dissolve swellings; hard tumours…” perforatum (Fisher & Painter, 1996) López-Muñoz 2007 Hypericum perforatum; main ingredient of Aparicio’s Oil, used for wound healing, created by Aparicio de Palaiseul 1986 Zubia (died 1566) (López-Muñoz, Alamo, & García- García, 2007). “This balm... is prescribed for abrasions, badly healing wounds, sores... which it immediatly soothes” (Palaiseul, 1986) Fisher & Painter 1996 Viscum alba “A heal all…tumours, to cure ulcers and sores and to draw out bad nails" (Fisher & Painter, 1996) Fisher & Painter 1996 Filipendula “Externally for cancerous ulcers and sores” (Fisher & ulmaria Painter, 1996) Fisher & Painter 1996 Galium aparine “Internally and externally for cancer” (Fisher & Painter, 1996) Grieve 1931 Trifolium “…Fomentations and poultices of the herb have been pratense used as local applications to cancerous growths” (Grieve, 1992 (1931)) Culpeper 1653 Chelidonium “It is good in old filthy, coroding, creeping ulcers majus wheresoever, to stay their malignity of fretting and running...” (Culpeper, 1981 (originally published Palaiseul 1986 1653)) “...externally, the fresh plant is irreplaceable... it will Fisher & Painter 1996 cause ugly cutaneous excrescences to vanish within the space of eight days...” (Palaiseul, 1986) “...used for itch, scurvy, ringworm, corns, tetters, old sores and ulcers...” (Fisher & Painter, 1996) Palaiseul 1986 Calendula “... the freshly crushed leaves are as effective as the sap officinalis of Greater Celandine ... removes warsts, corns and Fisher & Painter 1996 callouses... the advantage of not being toxic...” (Palaiseul, 1986) “...juice used externally for psoriasis, swollen glands, warts...” (Fisher & Painter, 1996)

Figure 13: Sanguinaria canadensis (bloodroot)

Source: (Fyles, 1919).

3.2 Herbal Medicine Approaches to Treat Skin Disease

Elaborating on the WHM approaches in 3.1.1, regarding ‘best practice’ are the philosophies and methods utilised to treat skin diseases, which include both internal and external treatments and advice for modifying diet and lifestyle and the uniqueness of each individual (Hoffmann, 1990). Herbal medicines taken internally can assist with treating internal manifestations of disease or dysfunction which may exacerbate the skin disease, as well as herbal medicines which may be applied directly to skin lesions (Bone & Mills, 2013). For instance, a quotation by Grieve, 1931, relating to Sanguinaria canadensis (see Figure 13) describes its topical uses: “It is applied to fungoid growths, ulcers, fleshy excrescences, cancerous affections and as an escharotic” (pp. 115-6) (Grieve, 1992 (1931)).

3.2.1 Clinical considerations for herbal treatment of AKs Before using herbal medicines to treat AKs, there are serious questions to be asked, for example, how deeply into the dermal layer has a topical treatment penetrated? Has the lesion cleared completely? Are these treatments safe? Can one be certain they will not come back? Can herbs taken internally clear sun-induced lesions on the skin? Despite the dearth of clinical trials of herbal medicine on humans for treating AKs or NMSCs, some herbal extracts show promise with preliminary experimental data on human skin cancer cells in vivo or in animal studies. These include St Marys Thistle (Silybum marianum), Turmeric (Curcuma longa) and resveratrol (an extract obtained from grape seeds) (Alschuler & Gazella, 2010).

Clinical practice experience of using herbs as treatments, presented in a case-study format, could assist to redress the lack of clinical research. While academically they may be considered ‘anecdotal’, case studies do have some intrinsic value. Jensen and Rogers (2001) describe case studies as an “intellectual goldmine awaiting discovery...” (p. 235); they note there is some value in all research methods and it is important to accumulate knowledge and experience, which may be later used for further evaluation (Jensen & Rodgers, 2001). Stake suggests that when a case has special interest they study it, for both its commonality and uniqueness (Stake, 1995). Therefore, it could be suggested, that herbalists ought to accumulate case studies, for publication and dissemination to further strengthen the case for the safety and efficacy of herbal medicine, for treatment of specific conditions, including AKs.

If someone is to use any of the following herbs as AK treatments or for any other skin diseases; Sanguinaria canadensis (Bloodroot); either freshly harvested from the garden, or in

42 a commercial product such as the ‘black salves’, (in line with Australian TGA regulations, the Australian site which marketed these products has recently been forced to cease sales) (Centerforce, 2004). The TGA, assisted by other government agencies; the Police and Taxation Office executed a search warrant at a business on the Gold Coast of Queensland, where they seized suspected bloodroot products on the 9th of May 2019 (Therapeutic Goods Administration, 2019). With Chelidonium majus sap (Greater Celandine), or the sap of Euphorbia peplus (Radium Weed), it is important to understand that these herbs have an escharotic mode of action to erode abnormal skin lesions. The sap of these herbs will erode any skin it comes in contact with, whether diseased or healthy, therefore during the treatment process they will generally cause burning, pain, and often weeping sores. These herbs that have this escharotic action have a long tradition of use as part of folk or home-grown medicine; usually without medical guidance. Within traditional herbal literature, it is written to not apply these herbs on normal healthy skin (Fisher & Painter, 1996; Grieve, 1992 (1931)) (Herbal Healers, 2019). When preparing to treat AKs with herbal medicine, there are a number of considerations:  What are the desired or required therapeutic actions to result in an effective treatment for this skin condition?  Which herbs contain the phytochemicals to deliver these therapeutic actions?  Is it preferable to use a single herb or does using a formulation of herbs offer greater efficacy?  When there are answers to these questions, it is then easier to make choices of what herbs to select to create a topical or internal (or both) treatment for AKs

The following section presents research undertaken to identify therapeutic activity of herbal medicines and thus informing WHM practitioners, for when treatments are prescribed and dispensed to treat sun-induced skin damage and AKs.

More recently, research into phytochemicals has been directed onto antioxidants; in particular polyphenols and flavonoids (Paur, Carlsen, Halvorsen, & Blomhoff, 2011). When specifically focussing on the use of herbal medicine for treating AKs, polyphenols hold promise, due to their anti-tumour, anti-oxidant and anti-inflammatory activity (Table 5); relevant as AK treatments, due to the pathophysiology of these lesions, involving cellular abnormalities and inflammation (Epstein, 2004).

This group of chemicals can act as ‘hydrogen donors’ and are able to react with reactive nitrogen and reactive oxygen species to block the cyclic generation of free radicals (Pereira,

Valentão, Pereira, & Andrade, 2009). Flavonoids have been referred to as ‘biological stress modifiers' (Lin, 2004), as they have anti-oxidant and anti-inflammatory actions, and can protect cells from environmental stressors. They also assist with stabilising cellular membranes, which can reduce the effects of UVR damage on human skin and assist with cell membrane repair (Lin, 2004).

In Germany a regulatory commission (generally known as Commission E), deliberates on the preparation and uses of herbal medicines, whereas no comparable body operates in the US; consequently there are no regulations controlling how herbs can be marketed for the treatment of ailments, nor for purity, safety or standardisation of constituent levels (Bedi & Shenefelt, 2002). They consider that this situation is challenging, as it does not provide the consistency required to ensure safety and efficacy. Their investigations were aimed at providing useful information of clinical efficacy of commercial herbal medications and herbs that are commonly used for skin conditions. In addition, they assessed the common drug-herb interactions and side effects of herbal medicines (Bedi & Shenefelt, 2002). They found that there have been many reported skin reactions to herbal preparations, the most common being allergic contact dermatitis, which is contrary to the public view that herbal treatments, being ‘natural’, are safe and without adverse effects (Bedi & Shenefelt, 2002). They observe that physicians may compound this disconnection, by only few of them asking their patients if they use herbs and supplements. In turn, patients may not declare what CAM treatments they may use, for fear of judgements from their physician (Bedi & Shenefelt, 2002). It is important that patients and clinicians are aware that herb-drug interactions do exist; for some medications and herbs these are not significant, whereas between others, they can be quite serious (Mills & Bone, 2000). To minimise the risks of herb-drug interactions and better assist with the effectiveness of treatments, it is recommended that patients be encouraged to declare all medications, including herbs and supplements; to their herbalist or naturopath and physician.

Bedi and Shenefelt (2002) state that dermatologists are becoming more aware of the possible side-effects or interactions of herbs, this assists to enable better diagnoses and treatments, particularly with the rapid increase in the use of herbs as medicine. They conclude that despite a long history of use and promising anecdotal results, only a few RCTs have shown benefits of herbal medicine for treating skin disorders. They suggest that more research is required; in the meantime, they consider that it is important to obtain knowledge and understanding of the common herbs that exist, which may provide alternative treatments, also their potential

44 adverse effects, and therefore their interactions with patients may be more effective (Bedi & Shenefelt, 2002). A selection of herbs which have been considered as suitable AK treatments has been included in Appendix B.

3.3 Herbs for Topical Treatment of AKs As referred to in Chapter 2, research indicates a link between HPV and sun-induced skin abnormalities, suggesting that it may be beneficial to add specific anti-viral herbs into topical herbal formulations for AKs. As yet, there appears to be no evidence of this occurring. Mills and Bone state that the application of scientific research approaches to dermatological uses of herbal medicine, thus far has been predominantly to validate the therapeutic activities, with most clinical research experiments of therapeutic actions, such as anti-inflammatory, antioxidant and anti-neoplastic as they relate to skin conditions, are conducted in laboratories, often in vitro or in vivo animal experiments rather than on human subjects (Mills & Bone, 2000). Assessment with clinical research is essential to have these treatments verified and accepted for use; both as effective treatments and for chemoprevention. A 2009 in vitro study by Mazzio and Soliman investigated a diverse range of plants for potential tumoricidal properties, utilising an established malignant tumour cell line. Using 374 natural extracts, their findings show that many of the plants examined had properties and constituents indicating anti-cancer activity (E. A. Mazzio & Soliman, 2009). This direction of research was continued using in vitro screening to assess the tumoricidal properties of 264 herbs, which are used in Chinese and Egyptian traditional medicines, against malignant neuroblastoma (E. A. Mazzio & Soliman, 2010). Using low concentrations of herbs against the tumour cell lines, the three most cytotoxic plants were Lithospermum erythrorhizon (Gromwell root, Hong Tiao Zi Cao or Zicao), Trillium pendulum (Beth root) and Ferula galbaniflua (Galbanum). The researchers suggest that these herbs require further exploration to identify if these plants, or selected constituents from them, could provide potential cancer treatments (E. A. Mazzio & Soliman, 2010). Despite this research not being specifically for AKs or NMSC cell lines, the implications from Mazzio’s research are relevant for AKs because of their potential to develop into a NMSC, and thus warrants further exploration.

Though not specifically ‘herbal research’, Bialy et al., (2002), conducted a literature review investigating the use of nutrients for prevention and treatment of skin cancers; they state that the endogenous dermal immune system scavenges ROS and reduces UV induced damage to the skin. Additionally, it is suggested that the use of topical or oral antioxidants may provide effective strategies for the treatment and prevention of sun-induced skin disease (Bialy,

Rothe, & Grant-Kels, 2002). These authors reviewed the available literature for evidence that topical and/or dietary CAM substances which may treat or prevent NMSCs or melanomas. It was found that the supplement of most significant benefit is selenium (particularly to reduce the incidence of internal cancers, which may include metastatic disease), while Vitamin D3 (as referred to in Chapter 2) and the combined use of Vitamins C, E with β-carotene exhibited protective benefits against sunburn and reactive oxygen radicals (Bialy et al., 2002). Although there is little scientific literature on the use of herbal medicines to treat AKs, the properties of herbs are widely understood by herbalists. Based on this lore, it is possible to compile a list of herbs that could contribute to the treatment of AKs. Table 5 provides such a list, and indicates the range and diversity of plants that have relevant therapeutic actions. It is evident that there are a variety of therapeutic actions, which may contribute to clear and heal an AK lesion.

3.4 Indicated Therapeutic Actions For each therapeutic action, there are many herbs that provide that action, to a greater or lesser degree. The examples included are predominantly drawn from the tradition of WHM and obtained from the Western Herbal materia medicas. There has been little research conducted to assess or verify their claimed efficacy. For a description of the therapeutic actions named in this table, refer to Appendix C.

Table 5: Therapeutic Actions of Herbs—Considerations for Skin Treatments

Therapeutic Herbs with this Therapeutic Action Action Withania somnifera, (L.) Dunal (Solanaceae), Eleutherococcus senticosus, (Araliaceae), Glycyrrhiza glabra var. glabra (Leguminosae), Schisandra chinensis Adaptogen (Turcz.) Baill. (Schisandraceae), Panax ginseng C.A.Mey. (Araliaceae) Echinacea spp, (Compositae), Eupatorium cannabinum (L.) (Compositae), Trifolium pratense (L.) (Leguminosae), Rumex crispus (L.) (Polygonaceae), Urtica dioica (L.) Alterative (Urticaceae) Salix alba (L.) (Salicaceae), Hypericum perforatum (L.) (Hypericaceae), Gaultheria procumbens (L.) (Ericaceae), Rosmarinus officinalis (L.) (Lamiaceae), Linum usitatissimum (L.) (Linaceae), Harpagophytum procumbens (Pedaliaceae), Phytolacca americana (L.) (Phytolaccaceae), Anemone pulsatilla (L.) (Ranunculaceae), Populus Analgesic alba (L.) (Salicaceae) Ginkgo biloba (L.) (Ginkgoaceae), Thymus vulgaris (L.) (Lamiaceae), Phytolacca americana (L.) (Phytolaccaceae), Leptospermum scoparium J.R.Forst. & G.Forst. Anti-fungal (Myrtaceae), Calendula officinalis (L.) (Compositae)

Salix alba L. (Salicaceae), Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Echinacea spp (Compositae), Matricaria chamomilla (L.) (Compositae), Solidago spp (Compositae), Berberis vulgaris (L.) (Berberidaceae), Betula alba (L.) (Betulaceae), Symphytum spp (Boraginaceae), Commiphora molmol (Engl.) Engl. ex Tschirch (Burseraceae), Sambucus nigra (L.) (Adoxaceae), Hypericum perforatum L. (Hypericaceae), Dioscorea villosa (L.) (Dioscoreaceae), Gaultheria procumbens (L.) (Ericaceae), Glycyrrhiza glabra var. glabra (Leguminosae), Ginkgo biloba (L.) (Ginkgoaceae), Hamamelis virginiana (L.) (Hamamelidaceae), Aesculus hippocastanum (L.) (Sapindaceae), Iris versicolor, (L.) (Iridaceae), Glechoma hederacea (L.) (Lamiaceae), Allium sativa (L.) (Amaryllidaceae), Smilax spp (Smilacaceae), Harpagophytum procumbens (Pedaliaceae), Phytolacca americana (L.) (Phytolaccaceae), Plantago spp (Plantaginaceae), Agrimonia eupatoria (L.) (Rosaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae), Populus spp (Salicaceae), Euphrasia rostkoviana (L.) Anti- (Orobanchaceae), Viola odorata (L,) (Violaceae), Viola tricolor (L.) ((Violaceae), inflammatory Zingiber officinale (Roscoe) (Zingiberaceae), Rheum palmatum (L.) (Polygonaceae), Trifolium pratense L. (Leguminosae), Aesculus hippocastanum (L.) (Sapindaceae), Allium sativa (L.) (Amaryllidaceae), Viscum album (L.) (Santalaceae), Phytolacca americana (L.) (Phytolaccaceae), Viola odorata (L,) (Violaceae), Sanguinaria Anti-neoplastic canadensis (L.) (Papaveraceae), Bellis perennis (L.) (Compositae) Stellaria media (L.) Vill. (Caryophyllaceae), Smilax spp (Smilacaceae), Glycyrrhiza glabra var. glabra (Leguminosae), Avena sativa (L.) (Poaceae), Rumex crispus L. (Polygonaceae), Matricaria chamomilla (L.) (Compositae), Plantago spp Anti-pruritic (Plantaginaceae) Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Echinacea spp, (Compositae), Berberis vulgaris (L.) (Berberidaceae), Commiphora molmol (Engl.) Engl. ex Tschirch (Burseraceae), Humulus lupulus (L.) (Cannabaceae), Quercus robur (L.) (Fagaceae), Mentha spp (Lamiaceae), Rosmarinus officinalis (L.) (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Thymus vulgaris (L.) (Lamiaceae), Allium sativa (L.) (Amaryllidaceae), Smilax spp (Smilacaceae), Sanguinaria canadensis (L.) (Papaveraceae), Piper methysticum G.Forst. (Piperaceae), Plantago spp (Plantaginaceae), Rumex crispus L. (Polygonaceae), Hydrastis canadensis (L.) (Ranunculaceae), Populus spp (Salicaceae), Euphrasia rostkoviana (L.) Antiseptic (Orobanchaceae), Rheum palmatum (L.) (Polygonaceae) Phytolacca americana (L.) (Phytolaccaceae), Thuja occidentalis (L.) (Cupressaceae), Hypericum perforatum L. (Hypericaceae), Allium sativa (L.) (Amaryllidaceae), Anti-viral Echinacea spp (Compositae) Geranium maculatum (L.) (Geraniaceae), Salix alba L. (Salicaceae), Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Solidago spp (Compositae), Symphytum spp (Boraginaceae), Commiphora molmol (Engl.) Engl. ex Tschirch (Burseraceae), Viburnum spp (Adoxaceae), Hypericum perforatum L. (Hypericaceae), Equisetum hymale (L.) (Equisetaceae), Thuja occidentalis (L.) (Cupressaceae), Arctostaphylos urva-ursi (L.) Spreng. (Ericaceae), Vaccinium myrtillus (L.) (Ericaceae), Quercus robur (L.) (Fagaceae), Hamamelis virginiana (L.) (Hamamelidaceae), Aesculus hippocastanum (L.) (Sapindaceae), Glechoma hederacea (L.) (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Thymus vulgaris (L.) (Lamiaceae), Trillium erectum (L,) (Melanthiaceae), Myrica cerifera (L.) (Myricaceae), Hydrastis canadensis (L.) (Ranunculaceae), Agrimonia eupatoria (L.) (Rosaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae), Rubus idaeus (L.) (Rosaceae), Galium aparine (L.) (Rubiaceae), Euphrasia rostkoviana (L.) (Orobanchaceae), Ficaria verna Huds. (Ranunculaceae) (Syn: Ranunculus ficaria), Astringent Rheum palmatum (L.) (Polygonaceae)

Collagenic Avena sativa (L.) (Poaceae), Echinacea purpurea (L.) Moench (Compositae)

Borago officinalis (L.) (Boraginaceae), Symphytum spp (Boraginaceae), Drosera rotundifolia (L.) (Droseraceae), Glycyrrhiza glabra var. glabra (Leguminosae), Trigonella foenum-graecum (L.) (Leguminosae), Linum usitatissimum (L.) (Linaceae), Althaea officinalis (L.) (Malvaceae), Fucus versiculosus (L.) (Fucaceae), Plantago spp (Plantaginaceae), Elytrigia repens (L.) Nevski (Poaceae), Zea mays (L.) (Poaceae), Verbascum thapsus (L.) (Scrophulariaceae), Ulmus rubra Muhl. (Ulmaceae), Demulcent Glycyrrhiza glabra var. glabra (Leguminosae) Scrophularia nodosa (L,) (Scrophulariaceae), Taraxacum officinale (L.) Weber ex Depurative F.H.Wigg. (Compositae), Arctium lappa (L.) (Compositae) Euphorbia peplus (L.) (Euphorbiaceae), Chelidonium majus (L.) (Papaveraceae), Discutient Avena sativa (L.) (Poaceae) Sanguinaria canadensis (L.) (Papaveraceae), Euphorbia peplus (L.) (Euphorbiaceae), Escharotic Thuja occidentalis (L.) (Cupressaceae)

Keratolytic Chelidonium majus (L,) (Papaveraceae), Euphorbia peplus (L.) (Euphorbiaceae) Galium aparine (L.) (Rubiaceae), Phytolacca americana (L.) (Phytolaccaceae), Lymphatic Calendula officinalis (L.) (Compositae) Urtica dioica L. (Urticaceae), Equisetum hymale (L.) (Equisetaceae), Trifolium pratense L. (Leguminosae), Trigonella foenum-graecum (L.) (Leguminosae), Ulmus rubra Muhl. (Ulmaceae), Stellaria media (L.) Vill. (Caryophyllaceae), Avena sativa Nutritive (L.) (Poaceae), Rubus idaeus (L.) (Rosaceae) Calendula officinalis (L.) (Compositae), Echinacea spp (Compositae), Matricaria chamomilla (L.) (Compositae), Symphytum spp (Boraginaceae), Stellaria media (L.) Vill. (Caryophyllaceae), Hypericum perforatum L. (Hypericaceae), Equisetum hymale (L.) (Equisetaceae), Geranium maculatum (L.) (Geraniaceae), Althaea officinalis (L.) (Malvaceae), Verbascum thapsus (L.) (Scrophulariaceae), Ulmus rubra Muhl. Vulnerary (Ulmaceae) Source: (Fisher & Painter, 1996).

It is important to emphasise that herbalists follow a holistic approach, whereby they aim to find the source of the illness and treat it by a combination of herbs, that work in synergy, to return the body systems to improved wellness or homeostasis (Marieb, 1995). For instance, when treating AKs, the major requirement is to ‘normalise’ the cellular abnormalities. To achieve this, herbs would be selected that have anti-inflammatory, anti-neoplastic, and alterative therapeutic actions. In addition, healing and soothing actions, for example, demulcent, emollient and vulnerary, could assist with healing by reducing inflammation, normalising abnormal cellular activity, nourishing and rejuvenating the dermal layer.

The multiple therapeutic activities in each herb make it likely that there will be an overlap in function when several herbs are used in a formulation. There are a considerable number that contain both the constituents and actions required, for example: Echinacea species (Compositae), are anti-inflammatory, vulnerary, alterative, antiseptic, collagenic and anti-viral (Mills & Bone, 2000).

Calendula officinalis (Compositae) is anti-inflammatory, anti-fungal, antiseptic, vulnerary, lymphatic, and astringent (Fisher & Painter, 1996).

Phytolacca americana (Phytoccaceae) has anti-inflammatory, anti-neoplastic, anti-viral, anti- fungal, lymphatic, depurative and analgesic therapeutic actions (Fisher & Painter, 1996).

Herbs for inclusion as ‘simples’ or as part of a formulation are chosen for their combined therapeutic benefits. Practitioners must be wary of using herbs which have some favourable therapeutic activity but have known therapeutic activities which cause adverse events, such as escharotics which can cause irritation and blistering. For example herbs such as; Sanguinaria canadensis, Chelidonium majus, (see Figure 14) (Bone & Mills, 2013; Fisher & Painter, 1996), or Euphorbia peplus (S. M. Ogbourne et al., 2007) fit this criteria. Though these herbs have efficacy for treating skin lesions, this benefit is negated by negative side-effects.

Figure 14: Chelidonium majus (greater celandine)

Source: (Koehler & Pabst, 1887b).

Escharotic skin treatments using Bloodroot (Sanguinaria canadensis), (previously refered to on pp 42-43), which are often referred to as ‘black salves’ (Fisher & Painter, 1996) can be purchased from some naturopaths and internet web-sites. As mentioned above, due to its escharotic actions, it must be used with great care as it erodes any skin that it comes into contact with. It is usual to feel significant amounts of pain and discomfort throughout the treatment process. After the lesion heals, some scarring may remain at the treatment site, which may be more susceptible to sunburn (Herbal Healers, 2019).

Euphorbia peplus is the source of an extracted herbal chemical known as Peplin or PEP005 also IM gel or ingenol mebutate, which has been assessed for efficacy and safety for treating AKs (see Chapter 4). As with the other eschotics, the common adverse side effects of

49 treatment use can include; irritation, blistering and itching and as with many of the medical AK treatments, care must be taken to protect the treatment area from infection until the wound has healed.

3.5 Selected Herb Profiles Selected profiles of individual herbs which could be considered as AK treatments, either as a simple or blended into a formulation are profiled in Appendix B. It is not an exhaustive list, as the selection was based on perceived relevance, desired therapeutic activity and availability. Herbs were only included if sufficient information was available in the literature, both materia medica, published research and the author’s own experience in herbal practice. For some of the herbs, there is very little published research, while for others there is research utilising a specific extracted constituent. Literature involving research on animals was generally not considered, as this thesis deals with a condition of human skin.

Synergistic interactions with herbs are accepted by herbalists, yet, there has little research to support it. With the known chemical complexity of herbs, this would be complicated research (Degner & Romagnolo, 2008).

Thus far, there has been research conducted using a variety of herbal extracts and isolated compounds as treatments for AKs. As yet, no substance or formulation assessed within the scope of this project fulfils the ideal requirements for an effective AK treatment. According to historical records of treatments for skin afflictions, there are still other herbs to be assessed under clinical research conditions (Fisher & Painter, 1996). Anne Wilson Schaef wrote “We have finally started to notice that there is real curative value in local herbs and remedies. In fact, we are also becoming aware that there are little or no side effects to most natural remedies” (Schaef, 2012).

To assist with finding answers to some of the questions raised around the efficacy, safety, relevance and evidence required for using herbs to treat sun-induced skin damage, a systematic review was undertaken to discern which herbs had been assessed by clinical trials for the treatment of AKs. The next chapter seeks to verify what research has been conducted, what herbs or herbal extracts have been used, the clinical trial methods used and the assessment of the efficacy and safety of the treatments.

CHAPTER 4 - SYSTEMATIC REVIEW: EFFICACY AND SAFETY OF HERBAL TREATMENT OF AKS

4.1 Background Regarding the adverse events that may be caused by current medical AK treatments and escharotic herbs referred to in Chapter 3: that is, pain during treatment, discomfort post- treatment, possible scarring at the treatment site, and the possibility of increased sun- sensitivity of scar tissue (Velangi & Rees, 2001), it is desirable to seek alternative AK treatments and to assess the efficacy, safety and adverse events. It is important to discern if there have been any herbal substances which have been validated by rigorous clinical research for efficacy and safety when treating AKs.

4.1.1 Considerations for undertaking a systematic review Systematic reviews, including of CAM, can be excellent vehicles to assess and summarise the evidence both for and against treatments and interventions for health care. They may indicate the best treatments to assist with improved patient outcomes and identify the least efficacious or the most harmful treatments. In addition, a systematic review may demonstrate when sufficient research has been conducted on a specific substance and therefore funding can be directed to other areas which are requiring further scrutiny (Cochrane Collaboration, 2011). A well prepared review can clearly present the case for the pros and cons of the subjects of the review, enabling the reader to comprehend whether the reviewed papers stand up to the rigour of the scrutiny that is specified for research design by institutions. In Australia, for example, the National Health Medical Research Council [NHMRC] and also for guidelines such as the

CONSORT [CONsolidated Standards of Reporting Trials] (Keech, Gebski, & Pike, 2010), and the National Statement on Ethical Conduct in Human Research (National Health Medical Research Council, 2015). It will be reported during the discussion of this review if any of the research publications selected mention the authorising ethics institutions or use of such guidelines.

4.1.2 Rationale for conducting a systematic review The intention of this systematic review has been to assess what clinical research has been conducted on AKs using herbal medicine or naturally derived herbal substances on humans; which herbs have been used, what plant part has been used, what extraction method was utilised and what method of application was made? Most importantly, the goal is to find out

51 how effective the treatments are, the condition of the skin at the conclusion of treatment, and whether they have been assessed and scrutinised under clinical research guidelines. If it is identified that there has been neither significant nor effective research, then potentially this will clarify some of the research questions and provide clearer directions for targeting future research, particularly when considering preferred therapeutic actions to treat AKs.

4.1.3 Expected outcomes The clear outcomes that are sought from this review are:  A list of herbs or herbal extracts which have conclusive evidence to encourage their use for treating AKs  That the herbs or herbal extracts on that list which are effective for treating AKs cause no or minimal adverse effects  A list of herbs that indicate promise with early stage assessments but require further, well conducted research  A list of herbs that would be not recommended for further research for treating AKs

4.2 Methodology for Systematic Review 4.2.1 Inclusion and exclusion criteria 4.2.1a Types of studies The criteria for this systematic review is to seek clinical research trials, preferably double- blind, randomised, placebo controlled trials, which used herbal medicine in at least one arm of the trial; specifically with humans having verified AKs as the research participants. No distinctions were made regarding whether the treatment route was topical or internal.

4.2.1b Criteria for inclusion The criteria for inclusion in this review are:  Human studies, people who have at least one verified AK  Clinical trials, at any phase, which used herbal medicine in at least one arm of the trial (this could include an extract from a plant), without limitations on treatment methods  English language publications

4.2.1c Types of participants The type of participants for inclusion studies are: human subjects, who had at least one AK, which had been verified by a physician.

4.2.1d Types of interventions Herbal medicines, formulations of herbal medicines, extracts or specific phytochemicals extracted from herbs, in at least one arm of the study. There is no limitation as to the treatment route.

4.2.1e Types of outcome measures Clinical appearance, visual observation, palpation, photographic recording, multi-point scales to determine degrees of lesion change, histological examinations (including biopsies), and participant study diaries. All recorded adverse events that occurred in any of the treatment groups.

4.2.2 Search methods for identification of studies 4.2.2a Databases searched The following databases and search engines were searched: Science Direct, Pub Med, Scopus, EBSCOhost and the Cochrane library. These databases were considered to be the most relevant. Databases were searched from their respective inception dates to August 2017.

4.2.2b Searching other resources Contacting researchers directly for any other known relevant research in pre-publication stages or unpublished studies was also carried out (elaborated on in 4.3.4 Included studies).

4.2.2c Search terms (Keratosis, Actinic) OR (Actinic Keratoses) OR (Actinic Keratosis) OR (Solar keratosis) OR (Solar Keratoses) OR (Sun-Induced Skin Damage) OR Sunspots AND (Complementary Therapies) OR (Herbal Medicine) OR (Complementary Alternative Medicine) OR (Alternative medicine) OR (Natural Medicine) OR (Chinese Medicine) OR (Chinese Herbal Medicine) OR (Topical Treatments) OR (Herbal Treatment) AND (Randomised Controlled Clinical trials) OR (Controlled Trials) OR (Pilot Studies) OR (Randomised placebo controlled Trials) OR (Clinical Trials) OR (Crossover trials) OR (Parallel trials).

4.2.2d Selection of studies

All abstracts were read in order to assess whether the paper was relevant. For those which met the inclusion criteria, the full text publication was obtained and read.

4.2.3 Data extraction and management A PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] checklist was used to guide the writing of the review. Relevant data obtained from the publications assessed as eligible was extracted and collated using tools as presented in the following Figures and Tables.  PRISMA Flow Chart  Characteristics of Included Studies  Risk of Bias Assessment  Table of Results of Included Studies

4.2.4 Evaluation of bias risk of included studies The Cochrane Risk of Bias Assessment tool (Cochrane Collaboration, 2011) was used to assess for bias in the following key areas of clinical research (see Table 11):  Sequence generation  Allocation concealment  Blinding of participants and personnel  Blinding of outcome assessment (participant self-reported outcomes, subjective outcomes)  Blinding of outcome assessment (non-self-reported outcomes, objective outcomes)  Incomplete outcome data reporting  Selective outcome reporting of research  Other potential threats to validity of research

Results 4.3.1 Results of search The following results were found:  Pub Med: 178 hits  Scopus: 341 hits  EBSCOhost/Cinhal: Eight hits  Science Direct: 265 hits  Cochrane Collaboration: One hit

4.3.2 Summary of studies Each individual search was saved into a search-specific Endnote library (Endnote Version Ten, 2011). In total, 793 results were relevant. When duplicates were removed, 665 papers remained.

4.3.3 Excluded studies A total of 708 were excluded because they were either duplicates or had no relevance or they were trials of non-herbal pharmaceutical treatments for AKs.

After reviewing the entire search results for relevance and reading the available abstracts, the research papers for the ‘Inclusion’ folder (11 references, with potential relevance), were obtained. The study screening process is presented in a PRISMA Flow Chart (Figure 16 Flow Diagram: AK Clinical Trials) (Moher, Liberati, Tetzlaff, & Altman, 2009).

4.3.4 Included studies Emails were sent to the authors of the identified studies to discern if they had conducted more recent research of herbal substances for AKs or if indeed they knew of additional research in this field. In two cases, the researchers were contacted by telephone, as the original authors’ contact email addresses were no longer valid. These contacts resulted in one other relevant research paper for inclusion and one other result, for an abstract of a paper, which had been accepted, but not yet published, and the full text of a pre-publication paper was supplied by the head researcher.

After the initial reviewing of the papers and assessing there were only five that fitted all of the search criteria (Huyke et al., 2009; Grimaitre et al., 2000; Akar et al., 2001; Anderson et al., 2009; Siller et al., 2009), and after supervisorial discussion, a decision was made to extend the scope of the review to include publications that were allied to the search terms, though not strictly within them. The new inclusion criteria included:

 Publications that were based on trials of AKs, or where AKs were one of the lesions being trialled  Open label studies, assessing a herbal-based treatment on AKs  Non-randomised trials, assessing a herbal-based treatment on AKs

This broadened search included pilot studies (Huyke et al., 2006; Kacerovska et al., 2008; Wu et al., 2011a), an open label trial (Hampson et al., 2005) a conference report (Ogbourne et al.,

2007), together with clinical trials for substances that were from synthetic derivations of natural substances (Stratton et al., 2010). The total number of studies included in the review is 11.

4.3.5 Characteristics of included studies

The summary characteristics of the 11 included studies are presented in Tables 6 and 7. Six of the 11 included studies that fitted the original search criteria of being a double-blind, randomised, placebo controlled clinical trial (Table 6). The balance of the other studies (five) included are presented in Table 7. It was decided it was preferable to present the included studies in two separate groups; the randomised controlled trials [RCTs] and the non- randomised controlled trials [Non-RCTs]. Table 6: The Six RCT Studies Included in this Review

Researcher Year Type of Study Place

Grimaitre (Grimaitre, Etienne, Geneva, 2000 Double blind placebo controlled clinical trial Fathi, Piletta, & Switzerland Saurat, 2000) Akar (Akar et al., 2001 Comparative randomised clinical trial Ankara, Turkey 2001) Huyke (Huyke et Prospective, randomised, three treatment arm monocentric Freiburg, 2009 al., 2009) clinical trial Germany Anderson Phase 2b randomised, double-blind, double dummy, vehicle- (Anderson et al., 2009 Texas, USA controlled, multi-centre (n=22) clinical trial 2009) Siller (Siller, Gebauer, Welburn, Phase 2a randomised, double-blind, 4 treatment arms, Brisbane, 2009 Katsamas, & vehicle-controlled, multicentre, clinical trial Australia Ogbourne, 2009) Stratton (Stratton et Phase 2a randomised, double-blind, placebo controlled 2010 Arizona, USA al., 2010) clinical trial

Table 7: The Five Non-RCT Studies Included in this Review

Researcher Year Type of Study Place

Huyke (Huyke et Freiburg, 2006 Prospective, non-randomised pilot study al., 2006) Germany Kacerovska (Kacerovska, Pilsen, Czech 2008 Single treatment group pilot study Pizinger, Majer, & Republic Smid, 2008) Hampson (Hampson, Wang, 2005 Open label phase one non-randomised pilot study Birmingham, UK & Lord, 2005) Ogbourne (S. M. Conference report (Proceedings of the First International 2007 Not Specified Ogbourne et al., Conference on PEP005)

2007) Wu (C.-H. Wu et 2011 Preliminary pilot study Taipei, Taiwan al., 2011)

Ogbourne et al., (2007) does not give trial design information nor reports the place in which the research was conducted. This paper gave only some of the research information of a relevant AK trial; which was a phase 2a trial including three differing concentrations in the doses of the PEP005, the active treatment and a placebo treatment. The participant numbers were not stated in the report. Despite the incomplete data, this research was included as it was the trial phase between other trials of Euphorbia peplus, and the ongoing research of its extract development, to become PEP005. The author was contacted, but further information regarding this study was not provided. The Anderson and Siller RCT studies are trials of this substance; PEP005. The tools utilized to assist with the data organization and assessments include:  Characteristics tables: to present the characteristics of the included studies (see Tables 8 and 9: Table of Characteristics of Included Studies, RCT and Non-RCT)  Results tables: containing results as included in the research publications (see Tables 14 and 15). If the data is not in the report, that could be considered as missing information and recorded as NS, Not Specified.  Table of country of research: the countries where the research included in this review was conducted are Switzerland, Turkey, Germany, Czech Republic, England, America, Australia and Taiwan.

All study designs were to specifically treat AKs, apart from the Hypericin pilot study, which included AKs, Basal Cell Carcinomas and Bowen’s Disease (Kacerovska et al., 2008). Only the data relating to the AK participants was extracted.

Figure 15: PRISMA Flow Diagram: AK Clinical Trials

Records identified through Additional records identified through other database searching (n = 793) sources (n = 1, by contacting a research

team) Identification

Records after duplicates removed (n = 665)

Total number of records excluded from original search Records screened (n = 665)

Screening (n =708) (CNKI n = 87) Not relevant to inclusion criteria

Full-text articles assessed for Full-text articles eligibility (n = 44) excluded, with reasons

Eligibility (n = 33) 1) Duplicates (6)

2) Animal trials (2) 3) Review papers (5) 4) Topical Vitamin therapy (4) 5) Poster abstract (2) Studies included in qualitative 6) Pharmaceutical synthesis (n = 11) treatment (1) 7) No English translation (1) 8) Internal treatment (1) 9) Genetic bacteria

Included modification (1) Studies included in quantitative 10) One group design synthesis (n = 11) (3) 11) Non- randomisation design (2) 12) Not AK studies (Moher et al., 2009) (5)

The tools utilized to assist with the data organization and assessments include:  Characteristics tables: to present the characteristics of the included studies (see Tables 8 and 9: Table of Characteristics of Included Studies, RCT and Non-RCT)  Results tables: containing results as included in the research publications (see Tables 13 and 14). If the data is not in the report, that could be considered as missing information and recorded as NS, Not Specified.  Table of country of research: the countries where the research included in this review was conducted are Switzerland, Turkey, Germany, Czech Republic, England, America, Australia and Taiwan.

4.3.5a Number of participants The total number of participants with AKs was 426, excluding the Ogbourne report, of which the number of participants was not specified. The range of numbers of participants in the included 11 studies was from 13 in the Wu pilot study up to 222 in the Anderson study, the second highest number of participants was in the Siller study with 58. In the Kacerovska study, though having 34 enrolled participants, only eight of these had AKs being assessed (information about the other 26, who had other types of lesions are not included in this review). This study was included as it was specifically treating AKs and there was a herbal substance as part of the trials treatment medication.

The Huyke 2009 study acknowledged that they were underpowered, and would have required at least 150 participants to reach significance, which would have exceeded the capacity of their single site research centre. They support the patient recruitment numbers in each treatment group, (n = 15, total of 45 participants), as commensurable with the previous pilot study (Huyke 2006, n = 14, total of 28 participants), allowing a comparison of the two studies (Huyke et al., 2009).

4.3.5b Age range Though AKs are generally considered a condition of older people, the age range of participants in the included studies was between 32 to 87. The mean age, where this information was included, ranged from 63.8 to 70 years between the studies. There was no information regarding either the ages or the gender of the participants in the Ogbourne report

(S. M. Ogbourne et al., 2007) (see Tables 8 and 9: Table of Characteristics of Included Studies, Non-RCT).

4.3.5c Treatment ranges, dosages and controls There is a diversity of treatment substances, with different dosages, application methods, treatment periods and the use of comparators. There were no internal AK treatments; therefore all the included studies are for topical treatments.

Of the six RCTs, the longest duration of the treatment period was 90 days (POH Cream), followed by a colchicine (Colchicum autumnale) study with treatment duration of 30 days. Three studies indicated that the treatment duration was 10 days or less. The study using the Betula species was not clear on the treatment duration. Due to the chronic nature of the condition being studied, ongoing clinical observation post-treatment is important. Half of the studies (n=3) reported a follow-up period of 56-85 days, while in the other three studies it was not indicated whether they included a follow-up observational period. Placebo controls were used in four studies and two studies did not use control comparison. The detailed descriptions were: identical-appearing placebo, matching placebo and vehicle gel control. The frequency of application for the included topical study medications ranged from a single dose, twice daily (four studies), to two doses on two separate days.

For the Non-RCTs, the treatment durations were indicated in four studies, being: one (a single dose), eight, 42 and 112 days. The birch bark study did not clearly indicate a treatment period but reported a follow-up assessment at 60 days, and was the only study that reported a follow- up period. Only one of the five Non-RCT studies used a placebo-controlled design, while the remaining four studies applied no control arm in their studies. The dosages were provided for all the studies but the specific amount per dose was not indicated.

Tables 8 and 9 present the extracted data from the included papers, where there was no data reported for each specific field NS (not specified) was entered. As there were a variety of study methods, the tables were divided into two sections; the randomised studies (RCTs) and the non-randomised studies (Non-RCTs).

Table 8: Characteristics of Included RCTs Studies No. of Treatment Condition Adverse Events/ First Author, partici Mean Age Duration/ Herb Used/Herb Design (Site of Intervention, Control (Dosage) Withdrawals due Year, Location pants (age range) Follow-up of Origin Lesions) to adverse events (R/A) Assessment Grimaitre, 2000, Double-blind placebo AKs on scalp 20/20 70 (54-87) T1: 1% colchicine in hydrophilic 30 days/NS Colchicum NS/0 Geneva, controlled gel autumnale Switzerland C: Placebo gel (twice daily) Akar, 2001, Comparative 2 AKs (face, 16/16 64 (50-82) T1: 0.5% colchicine cream, (twice 10 days/NS Colchicum 11/0 Ankara, Turkey treatment Arms; dose scalp, dorsal daily) autumnale response study forearms, T2: 1% colchicine cream, (twice hands) daily) No control Huyke, 2009, 3 treatment arms AKs (face, 45 /42 T1: 68 (50-84) T1: Topical betulin-based oleogel NS/30, 60, Betula species NS/0 Freiburg, scalp & other) T2: 68 (56-81) (twice daily) 90 days Germany T3:69 (60-92) T2: cryotherapy with liquid nitrogen (1 dose) T3: combination of cryotherapy (1 dose) with topical betulin-based oleogel (twice daily) No control Anderson, 2009, Phase 2b double- AKs (arm, 222/22 67 (43-85) T1: 0.025% IM gel (1 dose daily for 2-3 days/56 Euphorbia NS/0 Tyler, Texas, blind double dummy, shoulder, 2 3 days) days peplus USA vehicle-controlled, chest, back, T2: 0.05% IM gel (day 1 vehicle multi-centre (22) scalp - face gel, days 2-3 IM gel) lesions T3: 0.05% IM gel (1 dose daily for excluded) 3 days) C: placebo vehicle control gel (1 dose daily for 3 days) Siller, 2009, Phase 2a multicentre, AKs (arms, 58/58 63.8 (46-78) T1: 0.025% IM gel 8 days/85 Euphorbia NS/0 Brisbane, randomised, double- shoulders, T2: 0.01% IM gel days peplus Australia blind, vehicle- chest, face, T3: 0.05% IM gel controlled, 4 arms scalp) C: placebo vehicle gel1 Stratton, 2010, Phase 2a double- Sun damaged 83/79 67.7 years T1: 0.76% POH cream 90 days/NS Perillyl Alcohol NS/0 Tucson, blind, placebo forearms with T2: 0.3% POH cream (POH) Arizona, USA controlled AKs C: placebo cream (Twice daily) #1: Not clear if all T groups were divided into each Arm (2 doses; on day 1 and 2 or day 1 and day 8) Key: AK = actinic keratosis, R/A = Randomised/Assessed, A = assessed, T1 = treatment group 1, T2 = treatment group 2, T3 = treatment group 3, C = control, NS = not specified, RG = randomised group, AE = Adverse Event, IM = ingenol mebutate

Table 9: Characteristics of Included Non-RCTs Studies Adverse Number Treatment Herb Condition Events/ First Author, of Mean Age Duration/ Used/Her Research design (Site of Intervention, Control (Dosage) Withdrawals Year, Location participan (age range) Follow-up b of Lesions) due to adverse ts (Rec/A) Assessment Origin events Huyke, 2006, Prospective, pilot AKs (glabella, 28/28 T1: 69 (51- T1: Birch bark ointment only, N S/60 days Betula NS/0 Freiburg, study face, back of 80) (twice daily, duration not clear) species Germany hands) T2: 73 (65- T2: Combination therapy with 83) cryotherapy (1/2 treatments) and Birch Bark ointment. No control (Treatment dosage & duration not clear) Kacerovska, Pilot Study AKs, BCC, 34 (8 with AK Extract of Hypericum perforatum 42 days/NS Hypericum 8/0 2008, Pilsen, BD (AK AKs)/8 participants applied on the skin lesions under perforatum Czech Republic lesion sites not (63-83) occlusion, followed by Photo specified) Dynamic Therapy, irradiation with (Only data for 75 J cm (-2) of red light 2 hours AK later. (1 treatment per week for 6 participants weeks) used) No control Hampson, 2005, Phase 1 Open Label AKs (sites not 16/16 NS T1: 0.01%PEP-005 gel (single 1/21 days Euphorbia 16/0 Birmingham, Trial specified) dose) peplus UK No control Ogbourne, Phase 2a 3-arm AKs (sites not N S NS T1: PEP-005 gel 0.025% 8/NS Euphorbia NS/NS 2007, NS Comparative Trial specified) T2: PEP-005 gel 0.01% peplus T3: PEP-005 gel 0.05% C: Placebo gel (1x daily for 2 days, either days 1 & 2 or days 1 & 8) The dosage for each T group is not stated Wu, 2011, Preliminary Pilot AKs (face, 13/13 66-87 T1: SR-T100 topical 112 days/NS Solanum 13/0 Taipei, Taiwan Study hand, arm) No control incanum (1 dose daily)

Key: AK = actinic keratosis, Rec/A = Recruited/Assessed, A = assessed, T = Treatment, T1 = treatment group 1, T2 = treatment group 2, T3 = treatment group 3, C = control, NS = not specified, RG = randomised group, AE = Adverse Event

4.3.6 Herbal preparations used in the included studies Six herbs and herbal extracts were used in the included papers, a brief summary of them is presented in Table 10; a more comprehensive elaboration of each is included in Appendix A. They are Colchicum autumnale (two studies), Betula species (two studies), Hypericum perforatum (one study), Euphorbia peplus (four studies), Perillyl Alcohol (one study), Solanum incanum (one study).

Table 10: Herbal Preparations Used in the Included Studies

Plant Part Used Extract Author, Year

Colchicum Bulb Colchicine cream, 0.5% and 1% Grimaitre, 2000 autumnale

Colchicum Bulb Colchicine cream, 0.5% and 1% Akar, 2001 autumnale Betula species Bark Birch Bark ointment Huyke, 2006 Betula species Bark Betulin-based oleogel Huyke, 2009 Hypericum Hypericin extracted Hypericin extract of H. perforatum Kacerovska, 2008 perforatum from aerial parts Euphorbia peplus Extracted isolate PEP-005 gel Hampson, 2005 Euphorbia peplus Purified substance Ingenol mebutate gel 0.025%, 0.05% Anderson, 2009 Euphorbia peplus Purified substance PEP-0.025%, 0.01%, 0.05% Ogbourne, 2007 Ingenol mebutate gel 0.025%, 0.01%, Euphorbia peplus Purified substance Siller, 2009 0.05% POH; Origin not Perillyl Alcohol, Hydroxylated Not stated Stratton, 2010 declared monocyclic monoterpene Extracted Solanum incanum solamargine SR-T100 Wu, 2011 alkaloid

4.3.6a Colchicum autumnale Colchicine is a constituent of this herb, of the Colchicaceae family and had been indicated as a possible cancer treatment. To assess this substance as a potential treatment of a precancerous lesion, Grimaitre et al. (2000) used a 1% concentration of colchicine added to a hydrophilic gel base as a delivery vehicle, using the inactive gel base as the placebo. For the active treatment the colchicine was added in powder form at 2.3mg per dose, and the amount of each dose delivery was 230mg of both active and placebo. In 2001 Akar et al. followed with a comparative randomized clinical trial, in Ankara, Turkey. This trial assessed both 0.5% and 1% concentrations of colchicine in a cream base (Grimaitre et al., 2000); (Akar et al., 2001).

4.3.6b Betula species It is stated in the Huyke et al., (2009) paper that the extract used in trial was obtained from White Birches (Betulaceae), but the exact species used is not mentioned. There are two

63 consecutive phases of the birch bark research: the first, a pilot study, Huyke et al. (2006) used an ointment made from birch bark. It contained a standardized extract: the composition of this triterpenoid extract was 80% betulinic acid, 3% oleanolic acid, 2% lupeol and 1% erythrodiol in an ointment base (Huyke et al., 2006). The following phase research project, Huyke, 2009, used a refined extract, Betulin-based oleogel (Huyke et al., 2009). This substance is obtained by extracting triterpenes from birch bark, and contains betulin, oleanolic acid, lupeol and erythrodiol in a gel base. Information regarding the ratio of these constituents was not included (Huyke et al., 2009).

4.3.6c Hypericin Hypericin is a constituent of Hypericum perforatum (Hypericaceae), commonly known as St John’s Wort. It is often considered to be a noxious weed, particularly by farmers, who find that stock grazing on it are more likely to become hyper-sensitive to the sun. It is considered the most powerful naturally-sourced photosensitiser (Kacerovska et al., 2008). The hypericin, which was extracted from the aerial parts of H. perforatum, was used as a photosensitizing agent in conjunction with Photodynamic Therapy [PDT] in the pilot study (Kacerovska et al., 2008).

4.3.6d Euphorbia peplus (L.) (Euphorbiaceae)

An isolated constituent from the sap of this herb, a hydrophobic diterpene ester, named ingenol 3-angelate (PEP-005), is the main active constituent used for treating skin lesions. The development of this chemical involves the dried plant (a specific selected cultivar), going through a five-month process involving extraction, purification and crystallization processes, to obtain a purified chemical (Leo Pharma, 2012a). Though technically this is considered to be a pharmaceutical product, it is derived from a plant source. The clinical trials using this substance have been included in this review as a continuity of the development of a raw plant substance (the sap of Euphorbia peplus) through to a pharmaceutical medicine (Hampson et al., 2005). Hampson et al., 2005 used a concentration of 0.01% PEP005 gel.

The largest of the included studies, the Anderson 2009 multi-centre study, assessed ingenol mebutate gel [IM] in two concentrations: 0.025%, and 0.05% with a vehicle gel control. There was a difference in dosages: Group 1, with 60 participants, used a vehicle gel control, for days one, two and three. Group 2, with 50 participants, used an IM gel of 0.025% concentration on days one, two and three. Group 3, with 55 participants, used the vehicle gel on day one, and

64 then IM 0.05% on days two and three. Group 4, with 57 participants, used IM 0.05% on days one, two and three.

For all groups, the initial application was under the supervision of a research team member, the second dose was applied at home. An inspection was required by the research team, which included a dermatologist, prior to the day three application. The participants were reviewed at day eight, after the first treatment, then at days 15, 29 and a final visit on the trial completion, at day 57 (Anderson et al., 2009). A conference report of the AK trial used PEP005 topical gel in concentrations of 0.0025%, 0.01%, 0.05% plus a placebo treatment, unfortunately, neither the number of treatment applications, nor the duration of the study treatment medications were reported (S. M. Ogbourne et al., 2007). For the Siller et al. (2009) trial, IM gel was used in 0.025%, 0.01% and 0.05% concentrations, plus a vehicle gel control (Siller et al., 2009).

4.3.6e Perillyl alcohol Stratton’s Phase 2a study used Perillyl Alcohol [POH]. This is a naturally occurring hydroxylated monocyclic monoterpene, sourced from a wide number of plant species, including lavender and cherries (Stratton et al., 2010). The Stratton study used POH at concentrations of 0.76% and 0.3% in a cream base with the third arm of this study using a placebo cream. The source of the treatment medications was not reported.

4.3.6f Solanum incanum SR-T100 contains substances isolated from solamargine, a glycoalkaloid, extracted from Solanum incanum, a species of the Solanaceae family. It is indigenous to the Middle East and the North West of Africa, where there is a tradition of use for treating infections (C.-H. Wu et al., 2011). Research assessed the chemotherapeutic effects of this plant (Cham & Meares, 1987), with a preliminary pilot study of SR-T100 assessing its efficacy for treating AKs (C.- H. Wu et al., 2011). SR-T100 contains two constituents obtained from Solanum incanum, solamargine and solasonine in a 2:1 ratio. No comparator treatment or placebo was used in this trial (C.-H. Wu et al., 2011).

4.3.7 Risk of bias assessment of included RCTs There were six RCT studies, which fitted the criteria for risk of bias assessment, using the Cochrane Risk of Bias Assessment tool (Table 11). The inclusion studies for risk of bias assessment are:  Grimaitre, 2000, Double blind placebo controlled clinical trial

 Akar, 2001, Comparative randomised clinical trial  Huyke 2009, Prospective, randomised, three treatment arm monocentric clinical trial  Anderson, 2009, Phase 2b randomised, double-blind, double dummy, vehicle-controlled, multi-centre (n=22) clinical trial  Siller, 2009, Phase 2a randomised, double-blind, 4 treatment arms, vehicle-controlled, multicentre, clinical trial  Stratton, 2010, Phase 2a randomised, double-blind, placebo controlled clinical trial

4.3.7a Sequence generation Two studies (Huyke and Anderson) supplied information about the sequence generation used in their studies and is considered to be a low risk of bias. Akar stated that the patients were randomly assigned, but the method used was not stated. The other two studies, though named as randomised, did not declare the methodology to obtain this. The Grimaitre study did not disclose any information regarding this aspect.

4.3.7b Allocation concealment One study (Anderson) was rated at low risk, as they clearly stated their methods of allocation concealment; five studies (Grimaitre, Akar, Huyke, Siller and Stratton) did not elaborate on their methods. Where there is no placebo or control group included, as with Akar and Huyke, it is known that all the participants are on an active treatment, but it is not clear whether or not the group allocation was concealed.

4.3.7c Blinding of participants and personnel In the Huyke study, which was unblinded, due to the comparative treatment types, where it would be clear to both the participants and study personnel of each study group, this aspect was considered high risk. The Anderson, Siller, Stratton and Akar studies all clearly stated their methodologies, and are therefore considered low risk. Though the Grimaitre study stated it was double-blinded, their report states: “After seven days of application, as the patients applying the placebo gel noticed no effect, those using the 1% colchicine get were easily recognized” (p. 347), which indicated there perhaps was bias. It was not stated if the clinicians overseeing the study were the same ones that conducted the assessments.

4.3.7d Blinding of outcome assessments: Self-reported and subjective outcomes With the Huyke study, being non-blinded, it cannot be judged; therefore is given an assessment of high risk of bias. They could have blinded the outcome assessors, but it appears

66 that this did not occur. Again, the Anderson, Siller, Stratton and Akar studies are rated as low risk but it is not clear whether the assessor was blinded in the Grimaitre study, though they did state that this was the first double-blind study of the efficacy and tolerance of this substance.

4.3.7e Blinding of outcome assessments: Non-self-reported and objective outcomes The Anderson study was assessed as low risk as they clearly stated the blinding methods utilised, in their research report. An assessment of unclear was given to the remaining five studies; for the latter, there were no subjective outcomes.

4.3.7f Incomplete outcome data Huyke and Anderson clearly reported the reasons for participant withdrawals and therefore the reduced participant numbers in the results data. The Stratton study did not explain the reason for the four withdrawals, and the Akar study was considered unclear: though there were no withdrawals, some non-responding participants were given a second treatment dose and it is not stated which results were used, the non-responding or the second dose results. The Grimaitre study had no withdrawals and all participants were accounted for.

4.3.7g Selective outcome reporting Very limited information was provided in the Grimaitre and Akar study reports, therefore this component is considered unclear. All the other studies addressed all matters relating to outcomes and were assessed as a low risk of bias.

4.3.7h Other potential threats to validity The Grimaitre study made no disclosures of any conflict of interests, or any mention of funding or sponsorship of the study. A point that raises the risk of bias in the Huyke study is that 2 of the 8 authors of the publication work for the sponsoring company. Additionally, this aspect of high risk of bias on pharmaceutical company-sponsored trial applies to the Anderson study as well, as 5 of the 7 of the author’s list affiliations to Peplin, the company funding the trial. The highest risk of bias is the declaration that 4 out the 5 authors in the Siller study had business associations with the sponsor, at the time of research. The Huyke study was a comparative study and thus a vehicle control group was not used. The Siller study reported that scheduling errors were made with the application of trial medications. This is a clear indication of potential breaking of the trial protocol.

4.3.8 Assessment of the included non-RCTs For non-RCT AK studies, Risk of Bias tool was not applied and thus the key methodological information for each individual study is presented below:

Huyke 2006 study is a prospective, non-randomised pilot trial comparing two treatments; there was no mention of blinding with the allocation process.

Kacerovska is also a prospective pilot study assessing a treatment on three different types of skin lesions (AKs n=8, BCC n=21 and Bowen disease n=5). The study was a concept-approve study design and it clearly reported the procedures and results.

Hampson is a phase 1 open label trial. This was a concept-approve study design assessing the safety of a single dose application of the treatment substance. There was very little information included in the publication, therefore assessing the risk of bias and methodological quality of the study is not possible.

Ogbourne is a phase 2a, 3-arm comparative trial. Each arm was an active treatment, as in the Hampson study (same trial substance) there was insufficient information provided about this study to make any decision regarding any bias. It was noted that the author of the paper was an employee of the company which developed the product.

Wu is a pilot study using a single treatment substance on a small group of participants to assess efficacy and safety on humans, after animal studies. All stages of the study were well reported.

Table 11: Risk of Bias Assessment (RCT Studies) Author, Sequence generation Allocation concealment Blinding of participants Blinding of outcome Blinding of outcome Incomplete outcome Selective outcome Other potential threats to year and personnel assessment 1 assessment 2 data reporting validity J Support J Support J Support J Support J Support J Support J Support J Support (Quote/comment) (Quote/comment) (Quote/comment) (Quote/comment) (Quote/comment) (Quote/comment) (Quote/comment) (Quote/comment) Grimaitre, UC Comment: No UC Quote: We used a UC Quote: We used a UC Comment: No UC Comment: No LR Comment: All UC Comment: Very UC Comment: Very limited 2000 mention made of double-blinded double-blinded mention made of mention made of patients completed limited information information provided, randomisation or of protocol. protocol. methods. methods. the study provided no disclosure if there methods used to Comment: No other Comment: No was any conflict of generate allocation information provided mention of methods. interest. Akar, 2001 UC Quote: Patients UC Comment: Not LR Quote: Both the LR Quote: Both the UC Comment: No UC Comment: There is UC Comment: Very UC Quote: Some patients, were randomly sufficient information investigator & the investigator & the information no mention of any limited information 2nd course of therapy, assigned... provided patients were patients were provided, no patient not provided Comment: Rationale not Comment: method unaware... unaware. subjective outcomes completing the clear for this 2nd not mentioned Comment: Blinding Comment: Blinding treatment treatment information not information not provided provided Huyke, LR Quote: Assigned to UC Comment: Insufficient HR Comment: No HR Comment: Not UC Comment: LR Quote: 3 patients LR Comment: All HR Comment: 2/8 of the 2009 a computer- information provided blinding mentioned blinded Insufficient withdrew due to outcomes addressed authors work for the generated information personal reasons. sponsoring company randomization plan provided Comment: Clear reporting Anderson, LR Quote: Each centre LR Quote: Assigned LR Quote: Investigator, LR Quote: Investigator LR Quote: The LR Quote: …1 patient LR Comment: All HR Comment: 5/7 of the 2009 was allocated an according to the block centre personnel & centre personnel and investigator centre lost to follow-up & outcomes addressed authors list affiliations initial block of 4 of numbers allocated to patients were blinded patients were personnel and 1 patient had a to Peplin, the company randomization the centre. . Comment: …. Comment: blinded…,Comment: patients were scheduling issue" funding the trial numbers no other information Methods not provided Blinding methods not blinded Comment: Clear provided provided Comment: methods explanation not provided Siller, 2009 UC Comment: UC Comment: No LR Quote: Identical LR Quote: Identical UC Comment: UC Comment: No LR Comment: All HR Quote: errors made; 5 Randomisation information provided packaging was used to packaging was used to Insufficient reason is given for outcomes addressed minor, 1 significant... method not maintain blinding. maintain blinding. information the withdrawals Comment: Unclear how described Comment: clear Comment: No provided mistakes were description of method information provided recognised,4/5 authors associates with the sponsor Stratton, UC Comment: UC Comment: Elaboration LR Quote: Personnel and LR Comment: No UC Comment: UC Comment: No LR Comment: All LR Comment: Broad 2010 Randomisation of method not provided participants were information provided Insufficient information was outcomes addressed recruitment from a wide method not blinded information provided regarding range of sources described Comment No provided the four withdrawals information provided Key: #1: Participant self-reported outcomes, subjective outcomes. #2 Participant non-self-reported outcomes, objective outcomes. J = Judgement; UC = Unclear; LR = Low Risk; HR = High Risk 69

4.3.9 Instruments used for assessment and monitoring Despite the diversity of treatment interventions and study types, there is a commonality between these studies of the instruments utilised for the assessments of the measures of lesion clearance and the participant’s response to the treatment experience. From the instruments reported in each study, the following table demonstrates the comparative use.

Table 12: Participant Monitoring and Assessment Instruments Utilised

Assessment Instruments Studies Utilising this Instrument (No. of studies)

Grimaitre, Akar, Huyke 2006, Huyke 2009, Kacerovska, Anderson, Visual appearance Siller, Wu (8) Palpation Huyke 2006, Huyke 2009, Kacerovska, Wu (4) Dermatologic or Histological Akar, Huyke 2009, Anderson, Stratton, Wu (5) Assessment

Biopsies Akar, Stratton, Wu (3)

Akar, Huyke 2006, Huyke 2009, Kacerovska, Hampson, Clearance of lesions Anderson,Ogbourne and Wu (8) Photographic documentation Huyke 2006, Huyke 2009, Kacerovska, Siller, Stratton (5)

Identification templates Siller (1)

Weighing trial medications, as a Akar, Huyke 2009 (2) compliance measure

Participant study diaries Stratton (1)

Clinical Laboratory tests Grimaitre, Akar, Anderson, Siller, Stratton (5)

ECG Stratton (1)

4 point Subjective-Objective Scale Grimaitre (1)

6 point efficacy assessment Siller (1)

7-Point Likert Scale questionnaire (psychometric response scale of Anderson (1) attitudes)

4.3.10 Outcome measures The following section lists the outcome measures utilized for each of the individual studies:

4.3.10a RCTs 1. Visual appearance: The topical, superficial examination of the lesion or treatment site, to confirm the diagnosis of the condition or to assess the degree of lesion clearance post-treatment. This was utilised by five studies as a method of outcome assessment (Grimaitre et al., 2000). 2. Palpation: The use of touch to assess the condition of the skin; AKs often have a slightly roughened surface and therefore this is considered to be an effective diagnostic assessment method. As AKs often are not pigmented, they are more easily felt than seen, particularly in the early development stage. It is also useful to assess if there is any erosion to the post-treatment site (Huyke et al., 2009). 3. Dermatologic or Histological Assessment: The use of clinical laboratory tests is to assess the degree of change histologically to the skin and the lesion at the treatment site (this may include the use of biopsies). One study (Stratton et al., 2010) used histopathologic measures to assess the whole treatment site (one forearm of each participant) to assess for quantitative skin changes (Huyke et al., 2009). 4. Biopsies: Involves taking samples of tissue at the treatment site; before treatment to confirm the status of the condition; post-treatment to assessment the intra-dermal or sub-dermal presence or clearance of the disease state. The tissue is usually preserved with formalin and set in paraffin wax to enable fine shavings of the sample to be viewed microscopically and assessed for cellular abnormalities or presence of disease. The use of clinical laboratory tests and biopsies was to assess the degree of change histologically to the skin and the lesion at the treatment site (Huyke et al., 2009). 5. Clinical laboratory tests: A range of laboratory assessments may be used to detect a range of substance in blood or urine. Liver function tests are commonly used to detect treatment toxicities. Blood testing was to confirm if there was any transdermal absorption of the treatment substances (Grimaitre et al., 2000). 6. Clearance of lesions: The clearance, or percentage of clearance of a verified AK lesion post-treatment. This was the primary outcome measure, recorded as the clearance, or percentage of clearance of the AK lesions that were treated, and was used by five studies (Grimaitre et al., 2000). 7. Photographic documentation: Using photographs can enable clear, easy comparison pre- and post-treatment of any change. It is usual for a measuring device to be

included in the image as well as the participants study number, for easy identification. It is mandatory that photographs do not identify the participant (Siller et al., 2009). 8. Identification templates: Though not used to measure results, specific identifying templates may be used to ensure the correct identification of each individual participant for treatment medication and assessment thereby improving the accuracy of recorded results. These were utilised in one study (Siller et al., 2009). 9. Weighing trial medications: This is a method of recording the amount of treatment substance used during a treatment period: to either, measure compliance, to ensure its use, or as a means to discern the amount of product required to treat a specific site over a specified duration. The latter is important when determining the amount of treatment substance to package as a commercial product (Huyke et al., 2009). 10. Participant study diaries: These diaries were used by the participants to record their treatment administration and to comment on any symptoms or changes for them. Used by one study (Stratton et al., 2010). 11. ECG (electrocardiogram): The ECG tests are used to monitor the cardiac health of the participants; this is in accordance with the ethical requirements of the FDA, which have mandated cardiac monitoring when new drug products are being assessed. In the Stratton study they were conducted at baseline, at steady state between four and six weeks during the treatment duration and at completion (Stratton et al., 2010). 12. 4-point Subjective-Objective Scale: This scale uses a four-point grading for lesion change post-treatment (Grimaitre et al., 2000). 13. 6-point efficacy assessment: This scale uses a six-point grading for lesion change post-treatment (Siller et al., 2009) 14. 7-point Likert scale questionnaire: This is a psychometric response scale to measure the attitudes of the trial participants, which uses a seven-point assessment scale (Anderson et al., 2009).

4.3.10b Non-RCTs  Visual appearance: (See description in #1 above, RCT Outcome Measures). This was utilised by three studies as a method of outcome assessment (Huyke et al., 2006).  Palpation: (See description in #2 above). This method was used to assist with assessing lesion clearance on three Non-RCT studies (Kacerovska et al., 2008).  Dermatologic or Histological Assessment: (See description in #3 above) was undertaken in one study (C.-H. Wu et al., 2011).

 Biopsies: (See description in #4 above). These were used in one Non-RCT study (C.- H. Wu et al., 2011).  Clearance of lesions: (See description in #6 above). The clearance or percentage of clearance of the AK lesions that were treated was the primary outcome measure of five studies (Huyke et al., 2006).  Photographic documentation: (See description in #7 above). This was utilised by two studies to record the treatment site pre and post-treatment (Huyke et al., 2006).

4.3.11 Effects of the interventions

4.3.11a Colchicine studies The Grimaitre study (Grimaitre et al., 2000), which used visual clinical assessments and a 4 point Subjective-Objective Scale to obtain their results, found there were 3 participants in the active 1% colchicine treatment group who had the least inflammatory response with the treatment, showing only slight or moderate improvement to the clearing of their AK lesions. Those with the strongest inflammatory response had complete clearance of their lesions. Grimaitre et al. assessed that there was no change to the AK lesions in the control group. In the active treatment group there were 7/10 still clear of the treated AKs at the 60-day revisit. They stated that results varied, but it appeared that only those who had a strong inflammatory response showed a particularly good cosmetic result.

With the Akar study (Akar et al., 2001), the 1% colchicine treatment group there was a 73.9% reduction of AK lesions and in the 0.5% colchicine treatment group there was a 77.7% reduction, with no significant difference between outcomes in the two groups. After a six- month follow-up, there was a relapse of AK lesions in two participants in each treatment group.

In both the colchicine studies, Grimaitre and Akar used blood testing to assess for any dermal absorption of the topical colchicine treatment. In both studies, there were no systemic signs of colchicine toxicity, and there was no colchicine detected in post-treatment blood tests (Grimaitre et al., 2000). These two studies have supported the efficacy of using colchicine for treating AKs, despite significant adverse events that occurred with the study medication.

4.3.11b Birch bark studies The (Huyke et al., 2006) pilot study divided participants into two groups; responders were those with >75% lesion clearance, while non-responders had <75% lesion clearance. In

Treatment Group 1 (birch bark mono-therapy treatment group) 79% of participants were responders, while in Treatment Group 2 (combined birch bark and cryotherapy treatment) 93% of participants were responders.

The results for the Huyke 2009 study after the 90 day assessments were graded into three groups:  Complete clearance where there was 100% lesion clearance  Therapy responders where there was ≥75% lesion clearance  Non-responders where there was ≤75% lesion clearance

In Treatment Group One (topical betulin-based oleogel twice daily), there was complete clearance on 64% and 86% of therapy responders. In Treatment Group Two (cryotherapy with liquid nitrogen), there was complete clearance on 79% and 93% of therapy responders. In Treatment Group Three (combination of cryotherapy with topical betulin-based oleogel), there was complete clearance on 100% and 100% of therapy responders. There was no control group (Huyke et al., 2009).

When assessing the results of the two birch bark papers, they cannot be directly compared as they are two different substances, albeit, derived from the same raw plant material. A positive feature is that they both utilised similar instruments for assessment of the results, and these results indicate that when used alone the Birch Bark treatment is efficacious, and when combined with cryotherapy it has a greater efficacy.

As secondary outcome measures for the Huyke 2009 study, 8 pre- and post-treatment pair biopsies were taken, which were evaluated for the number of dyskeratoses (degree of dysplasia and the thickness of both the stratum corneum and epidermis). Six of the post- treatment biopsies showed a reduction in dyskeratoses and dysplasia, and a reduction of both the stratum corneum and epidermis. This pattern of improvement was consistent for all three treatment groups (Huyke et al., 2009).

4.3.11c Hypericum perforatum study In the Kacerovska 2008 study, 8 of the participants had the treatment applied to AKs (the balance of the recruited participants had BCCs and Bowen Disease lesions treated). Visual observation and palpation, with photographic recording were utilised to assess the results. Of the eight participants, there were no non-responders, 5 had complete clearance of the AKs and 3 had partial clearance. At six months after treatment, only 3 participants with complete

74 clearances presented for examination of the treatment site. Of these, 2 still had complete clearance, the other had signs of the re-occurrence of the AK. After six months, the partial responder group had no cleared lesions (Kacerovska et al., 2008).

4.3.11d Euphorbia peplus studies The Hampson (Hampson et al., 2005) open label pilot study reported a clinically relevant effect within 21 days. However, they did not report the methods of assessment nor were the outcome measures specified.

The Ogbourne study (S. M. Ogbourne et al., 2007) reported that the treatment group (T3) which used PEP-005 gel at the dosage of 0.05%, had a clearance rate of 100%. For the three active treatment groups combined this gave an overall clearance rate of 71%, whereas the control group had a clearance rate of 27%. This gave the Ogbourne study a significance of effect of ρ<0.0001. There was no information provided of the assessment instruments utilised to obtain these results.

The Anderson study (Anderson et al., 2009) utilised visual, dermatological assessments and a 7-point Likert scale questionnaire with clinical laboratory tests. The primary efficacy endpoint was the partial clearance rate, defined as the proportion of participants who had a clearance rate of ≥75% of their AKs by day 57 of observations. They reported a significant relationship between the concentration of ingenol mebutate gel and the treatment response. Anderson’s secondary outcome was the complete clearance rate, defined as the proportion of participants who had a complete visible clearance of their AK lesion at the day 57 observation. The results were: T1: 40.0%, T2: 43.6%, T3: 54.4% and the placebo group 11.7% (Anderson et al., 2009). Their stated objective was to assess the IM gel at three differing dosage regimens for safety and efficacy.

The Siller study (Siller et al., 2009), reported that there were no statistically significant differences between Treatment group 1 (IM gel 0.0025%) and Treatment group 2 (IM gel 0.01%) but that Treatment group 3 (IM gel 0.05%) consistently had the highest clearance rates of AK lesions. The numbers of participants with ≥80% lesion clearance were: T1: 33%, T2: 13%, T3: 67%, compared to the placebo group: 17%. Furthermore, the numbers of participants with complete clinical clearances of AKs were T1: 40%, T2: 25%, T3: 71% and the placebo group 32%. After the early stage pilot studies of this series of treatments, the Anderson and Siller studies were powered to detect differences between groups, therefore validating the efficacy of this substance as a potential new treatment for AKs. The efficacy of

75 this treatment has been consistently confirmed throughout this series of trials, from plant extract to a purified substance.

4.3.11e POH study For assessing the efficacy of POH, the Stratton study (Stratton et al., 2010) used histopathologic measures to assess the treatment site (a 4mm punch biopsy from an area of sun-damage on one forearm of each participant) to assess for quantitative skin changes, measured by baseline and end-of-study biopsies to obtain differences, including the nuclear chromatin pattern; measured with karyometric analysis. They reported a modest reduction in histopathic scoring of the lower dose group, compared to placebo, which was not observed in the high dose treatment group. The higher dose treatment group did show changes to the nuclear chromatin pattern; this group showed reduction in the nuclei deviation from normal, ρ<0.01, which was not observed in the lower dose treatment group.

Stratton’s end of study biopsies assessed by the study dermatopathologist, who registered the results using a histopathic score system. The high-dose treatment group did not indicate a statistical significance when compared to the placebo group (ρ=0.41); however, the low-dose treatment group trended towards significance compared to the placebo (ρ=0.10). When assessing change for cellular proliferation, p53 expression or apoptosis, there were no statistical differences of significance for these groups (Stratton et al., 2010).

4.3.11f Solanum incanum study The Wu study (C.-H. Wu et al., 2011), when assessing the efficacy and safety of SR-T100, obtained the following results from their 13 participants: 10 had a 100% clearance of lesions and the other three had at least a 75% clearance of their AK lesions.

In summary, as reported above, most of the treatments demonstrated efficacious outcomes, apart from the Stratton POH study (which despite its 12-week treatment duration, minimal clearance of AK lesions occurred) and the Kacerovska study, using Hypericin as a photosensitising agent as part of an AK treatment, which did not result in significant clearance of lesions at the six-month assessment.

Tables 13 and 14 present the results of the 11 included studies.

Table 13: Results of Included Studies (RCTs)

First Author, Instruments Relative to Baseline (or sample size) End of Treatment Instrument Domains Year Outcome Measures Treatment groups Control group Treatment groups Control group Visual clinical assessment Grimaitre, 2000 100% lesion clearance rate T: 7/10 cleared of AKs, still 4-point Subjective-Objective Scale C: no change clear at 60 day revisit Blood tests Distribution of lesions, clinical No of lesions on face Akar, 2001 4.3±2.2 4.4±1.9 1.0±1.9 0.8±2.4 appearance (Mean±SD) No of lesions on scalp 1.5±1.4 2.0±1.9 0.5±0.9 0.5±1.4 (Mean±SD) No of lesions on upper extremity 12.2±1.1 1.8±1.5 0.6±1.1 0.5±1.4 (Mean±SD) Total No of lesions (Mean±SD) 2.7±2.0 2.7±2.1 0.7±1.3 0.6±1.7 Visual, touch & photographic Huyke, 2009 100% lesion clearance rate (%) T1:64%; T2:79%; T3:71% No control group evaluation T1: 15; T2: 15; T3: 15 No control group

75% lesion clearance rate (%) T1: 86%; T2: 93%; T3: 71% No control group Visual assessment, Dermatologic T1: 28 (56.0%); T2: 34 Anderson, 2009 Lesion Partial clearance rate, n(%) C: 13 (21.7%) assessment & monitoring (61.8%); T3: 43 (75.4%) T1: 20(40.0%); T2: 24 Lesion complete clearance rate, n(%) T1: 50; T2: 55; T3: 57 C: 7(11.7%) (43.6%); T3: 31 (54.4%) 60 T1: 21 (42.0%); T2: 24 Lesion baseline clearance rate, n(%) 8 (13.3%) (43.6%); T3: 33 (57.9%) Median percentage reduction in T1: 75.0; T2: 83.3; T3: 100 0 baseline lesion (n) Visual assessment, 6 point efficacy Patients with ≥80% lesion clearance, T1: 5 (33%); T2: 2 (13%); Siller, 2009 assessment, *Fisher's exact test & 2 (17%) n(%) T3: 10 (67%) Photography T1: 15; T2: 16; T3: 15 12 Patients with histological clearance, T1: 4 (27%); T2: 7 (47%); 5 (42%) n(%) T3: 6 (40%) Complete clinical clearance of lesions, T1: 30 (40%); T2: 19 (25%); 19 (32%) n(%) T3: 53(71%) T1: 75; T2: 75; T3: 75 60 Complete and marked clinical T1: 38 (51%); T2: 40 (53%); 32 (53%) clearance of lesions, n(%) T3: 61(81%) T1: 0.2747 (0.2200±0.3293) Discriminate function score T1: 0.367 (0.1786±0.948) 0.2392 0.1498 Stratton, 2010 T2: -0.1705 (-0.2145 ±- (Mean±SD) T2:0.2492 (0.1982±0.3002) (0.1822±0.2962) (0.0998±0.1997) .01265)

Key: T1 = treatment group 1; T2 = treatment group 2; T3 = treatment group 3; C = Control

*Fisher's exact test is a statistical test used to determine if there are non-random associations between two categorical variables. 77

Table 14: Results of Included Studies (Non-RCTs)

First Author, Instruments Relative to Results Results Results Results Year Outcome Measures continued continued continued Huyke, 2006 T1: (>75% lesion clearance) 79% Visual & touch T2: (>75% lesion clearance) 93% Photographic documentation Kacerovska, 2008 Visual & touch Clinical response Post treatment 3 months 6 months Photographic Complete clearance 50% (4/8) 50% (4/8) 29% (2/7) documentation Partial clearance 50%(4/8) 0 0 No Response 0 0 0 Hampson, 2005 A clinically relevant effect on the lesions within NS 21 days Ogbourne, 2007 Overall active treatments (T1, T2, T3) 71% clearance T3: 100% clearance C: 27% clearance, statistical significance NS P<0.0001 Wu, 2011 100% lesion clearance n=11 Visual & touch assessment >75% cleared n=3 Histology assessment Post-treatment biopsy Clear n=10: AK present Skin biopsies n=4 Key: AK = actinic keratosis A = assessed Gp = group, T = treatment group, T1 = treatment group 1 T2 = treatment group 2 T3 = treatment group 3 C = control NS = not specified

4.3.12 Adverse events Table 15 is a collation of localised skin reactions (LSRs) and mild to moderate adverse events reported in the inclusion publications.

Table 15: Reported LSRs and Mild to Moderate Adverse Events [AE]

Numbers of patients (end of treatment/ Outcome of Author Reported LSR follow-up) (if any) LSR Grimaitre (T=10) Grimaitre RBEOS Akar1 (NS) Akar RBEOS Huyke(2009) (T1=1; T2=1) Huyke (2009) RBEOS Itching or stinging or Siller NS burning Siller (C=0; T1=1; T2=4; T3=1) Stratton RBEOS Stratton2 (C=3; T1=3; T2=1) Kacerovska RBEOS Kacerovska (8, one group study) Wu NS Wu (NS) Grimaitre Grimaitre (T=10) RBEOS Akar Akar1 (2, group NS) NS Anderson Anderson3 (T=158/55) NS Kacerovska Erythema, rash, redness or Kacerovska (8) RBEOS Hampson sunburn Hampson (NS) NS Ogbourne Ogbourne (NS) NS Siller Siller (C=7; T1=10; T2=15; T3=13) NS Stratton Stratton2 (C=12; T1=15; T2=15) RBEOS Anderson Anderson3 (T=124/47) NS Stratton Stratton2 (C=5; T1=7; T2=5) RBEOS Flaking/scaling Siller Siller (C=6; T1=13; T2=12; T3=13) NS Ogbourne Ogbourne (NS) NS Grimaitre Grimaitre (T=10) RBEOS Anderson Anderson3 (T=71/15) NS Crusting/scabbing Ogbourne Ogbourne (NS) NS Siller Siller (C=4; T1=9; T2=12; T3=10) NS Akar Akar1 (NS) NS Anderson Anderson3 (T=25/3) NS Erosion/ulceration Siller Siller (C=2; T1=2; T2=4; T3=4) NS Wu Wu (NS) RBEOS Siller Siller (C=0; T1=0; T2=4; T3=4) NS Oedema Akar Akar1 (NS) NS Anderson Vesicles or vesiculation or Anderson3 (T=63/0) NS Siller pustulation Siller (C=0; T1=0; T2=1; T3=2) NS Siller Weeping, exudates Siller (C=0; T1=0; T2=2; T3=0) NS Akar Akar1 (NS) NS Wu Pain Wu (NS) RBEOS Kacerovska Kacerovska (8) RBEOS Grimaitre Pustules Grimaitre (T=10) NS Ogbourne Dryness Ogbourne (NS) NS Anderson Swelling Anderson3 (T=72/0) NS Pigmentation Anderson Anderson3 (T=35/32) NS (hyper/hypo) Anderson Scarring Anderson3 (T=2/1) NS Stratton Pruritus Stratton2 (C=6; T1=4; T2=5) NS Key: RBEOS = Resolved by end of study NS = Not Specified #1 Akar study: A little erythema or hypo-pigmentation remained at the conclusion of the study; numbers not specified. #2 Stratton study: Mild and moderate LSR added up. #3 Anderson study: LSRs were transient and resolved spontaneously, generally within one to two week after treatment.

Table 16 includes the reported severe adverse events (SAEs) from the trials.

Table 16: Reported Severe Adverse Events (SAE)

Numbers of Patients Outcome of Withdrawal Author Reported SAE Reported with SAE SAE Due to SAE

Anderson1 Symptoms not specified C=4; T1=5; T2=2; T3=1 NS 0

3 NS, 1 still an Crusting/scabbing 4 (not specified which group) SAE3

Erythema 2 (not specified which group) NS Siller2 0

Severe Itching 1 (not specified which group) NS

Flaking/scaling/ 1 (not specified which group) NS Dryness

Akar Erythema 11 (not specified which group) NS 0

#1 Anderson study: 25 participants were not eligible for the Day Three dose because of LSRs. Worsened pigmentation in six patients, hyper-pigmentation in three, and hypo-pigmentation in one. #2 Siller study: One patient withdrew on Day Eight, prior to second treatment dose. #3 Siller study: At completion one patient remained with severe crusting/scabbing. Skin condition at completion, participants with either hyper or hypo-pigmentation T1 n=2; T2 n=4; C n=1.

4.3.12a Colchicine studies For the two colchicine trials, the Grimaitre paper recorded that there was initial redness with the treatment of 30 days treatment with the 1% concentration of colchicine in a gel base. Those using the placebo gel had no reactions, whereas the 1% colchicine gel group had initially reported as feeling ‘like sunburn’, followed by strong itching. By day 5, pustular, inflammatory responses were recorded at the treatment site, which continued progressively until at day 10, when it is stated that treatment was interrupted. It is not clear whether treatment was stopped, deferred, or if it was continued intermittently, or how many participants had their treatment interrupted. It is stated that either an antiseptic or an antibiotic cream was applied to the lesions for between one to two weeks. It is not clear if this occurred in addition to the treatment or after treatment was halted (Grimaitre et al., 2000).

Akar reported that there was a strong inflammatory reaction in 11 of the 16 participants. This included; burning, itching and pain (using a 10-day treatment with either the 0.5% or the 1% concentration of colchicine in a cream base). After treatment it is reported that the skin at the treatment site generally returned to normal, although some showed erythema or hypo-

80 pigmentation (Akar et al., 2001). There were no recorded withdrawals from either of these two colchicine trials (Grimaitre et al., 2000).

4.3.12b Birch bark studies The least of the adverse reactions were for the birch bark ointment treatment, which was described as having “no undesirable effects associated with the ointment use” and “it was generally regarded as pleasant and well tolerated” (Huyke et al., 2006). There was no specific mention of any adverse symptoms from either the birch bark ointment or the cryotherapy combination treatment.

In the 2009 Huyke study, which assessed a more refined substance extracted from birch bark, betulin-based oleogel, which was compared with cryotherapy alone and both betulin-based oleogel and cryotherapy in conjunction, it was reported that there was some itching and stinging, and that it was not severe. There were no withdrawals due to adverse events in either of the two Huyke studies.

4.3.12c Hypericum perforatum study In the Kacerovska study (Kacerovska et al., 2008) Hypericin was used to photosensitize the treatment site. This was done prior to treatment with PDT (Photo-Dynamic Therapy). All patients complained of burning during the irradiation part of the treatment process, this was relieved by using a cooling fan. It is reported that there was no redness or swelling post- treatment, and no serious adverse events were reported.

4.3.12d Euphorbia peplus studies The reported adverse events from the series of studies for Euphorbia peplus and its derivatives commences with (Hampson et al., 2005), for which there is little mention of adverse events. While they report that “the most common local skin reaction was a localized, mild erythema” they do not report if all participants had this reaction, nor was there mention of any other, less common reactions, as alluded to in the adverse events description. This was a single dose treatment, with no mention of any participant withdrawals. Overall they consider that PEP005 has a favourable safety profile.

The Anderson study (Anderson et al., 2009) anticipated a variety of local skin responses [LSR], this being a continuation of previous research using this treatment. The reported responses were erythema (with 97.5% of participants), flaking or scaling, crusting and either hyper- or hypo-pigmentation to the treatment site. They state that across all active treatment

81 groups 15.4% of the participants were not able to receive the Day Three dose of treatment because of an LSR, and they add that “there were no discontinuations from the study because of an AE, there were no serious treatment-related AEs”.

Ogbourne (S. M. Ogbourne et al., 2007) reported no serious adverse events. The treatment reaction responses were described as “mild to moderate erythema, scabbing/crusting and flaking/scaling/dryness”.

Descriptions of the adverse events from the Siller study (Siller et al., 2009) include erosion or ulceration, erythema, flaking, itching, oedema, scabbing or crusting, vesicles and weeping. They recorded 14 severe LSRs, all of which had resolved by the end of the study, except one, which had had severe scabbing and crusting. One participant had skin reactions severe enough not to be given the second treatment, which was due on day eight. There was one participant withdrawal from the study at day 8, prior to the second treatment dose.

4.3.12e POH study For the Stratton study (Stratton et al., 2010) one participant in the high dose treatment group reported tenderness at the treatment site. Furthermore, 54% of the high dose and 56% low dose groups of participants had erythema or redness with treatment during the 12-week period. The placebo group recorded 43% of similar events. They considered that this high response rate was due to the vehicle cream used. The study comprehensively detailed the adverse events related to the treatment groups. Interestingly, they declared that 83 participants were assessed for adverse events, although it is stated that a total of 79 participants completed the study. Thus 4 participants are unaccounted for.

4.3.12f Solanum incanum study Wu (C.-H. Wu et al., 2011)reported the following LSRs: mild stinging, itching, shallow erosion to treatment site, also transient pruritus where the treatment substance was applied. There were no reported withdrawals of participants from the study.

In summary, from the perspective of adverse events, the treatment that had the least negative adverse events was the birch bark treatment (T1), from the Huyke 2006 study, while the POH from the Stratton study caused less erythema and the least severe adverse events compared to the other studies.

4.4 Discussion A meta-analysis was not possible with this review, because of the diversity of the included studies. Though all are using topical treatments, the trials have differing designs and different substances were being assessed, differing treatment periods and methods. There are however, similarities in assessment methods, thus a comparative, descriptive, narrative analysis was the most appropriate review method. When reviewing and assessing the results of the studies, it was clear there was no consistency of assessment or instruments used. Some of the results were very specific and clear, for others, they were barely mentioned. For the latter, this appeared to be more common in the pilot studies, where it seems that proof of concept and efficacy were the primary findings being sought.

The majority of the included studies are early stage research projects, which were not adequately powered to enable a significant difference to be obtained (Huyke et al., 2006; Huyke et al., 2009). The primary aims are to assess the treatments on humans, after previous in vitro and animal studies. As previously mentioned, this initially created some concern, as six of these studies did not meet the original inclusion criteria. The inclusion criteria was broadened to allow them to be included, as it was considered that the more diverse range of substances and the progression of trials for some substances (for example, the colchicine, birch bark and the Euphorbia peplus extract series of studies) gave greater value to this field of research.

As with the discussion of the range of treatments and dosages above, the same points apply to the discussion of the length of treatment times. Due to the diversity of treatment substances and application methods, comparing the length of treatment times is not possible. These trials were assessing, in some cases, a potential new treatment for AKs and their aim was to obtain optimal treatment doses and to assess the safety of these substances. If the herb has indicated potential and the treatment duration is not allowing sufficient time to obtain efficacy, then that potential treatment may be abandoned or considered ineffective. It may be shown to have efficacy if it is given a longer treatment duration.

4.4.1 Summary of main findings The following sections summarise findings from this review.

4.4.2 Adverse events When considering the design of the birch bark study, which was a comparative treatment group using cryotherapy initially followed with birch bark ointment, cryotherapy is known to

83 generally cause blistering to the treatment site (Craig & Stitzel, 2004). It would be expected that this treatment group would have had some degree of pain and skin destruction. On the other hand, the birch bark ointment, with its anti-inflammatory, antiseptic and astringent therapeutic actions (Mills & Bone, 2000) would probably have eased and healed the freeze burns and blistering.

Pain was mentioned as an adverse event by Akar, yet not by Grimaitre, who trialled a similar substance and described adverse events that sounded painful: a feeling of sunburn, followed by itching and inflammation so strong that the treatment was interrupted. The treatment site developed pustules and crusting which required treatment of antibiotic or antiseptic ointment. It would be surprising if there was no pain during such a treatment. This comment applies to all the treatments, apart from perhaps the birch bark-only treatment of the Huyke 2006 study.

4.4.3 Overall completeness and evidence applicability Regarding two criteria mentioned at the outset of this review:  Validation of the identification of AK lesions: all studies clearly stated that they clinically assessed AK lesions  Adequate description of therapeutic intervention/s: all studies adequately described the interventions utilised during the AK research

4.4.3a Dosage rates All studies stated the dosages of the treatments used, though in the Siller study, the distribution of treatment arms was not clear, and treatment dosage in the Ogbourne was not stated. Direct comparisons of dosages can only be made across similar treatments, such as the Euphorbia series of studies, where there was a progression of trials to discern the preferred treatment dosage and duration for both an effective and safe treatment (Hampson, Anderson, Ogbourne and Siller). This also applied to the two colchicine studies (Grimaitre and Akar) and the birch bark studies (Huyke 2006 and 2009).

4.4.3b Differences in dropout rates In all of the included studies the participant drop-outs from the trials were mentioned, except for Siller, where no reason is given for withdrawals prior to commencement of the treatment, or for the withdrawn consent of a participant from T2, the 0.01% IM treatment group on Day 8 of treatment. From the Stratton study, no information was provided regarding the 4 withdrawals.

4.4.3c Different types of participants All the participants from the included studies were recruited because they had at least one AK, which was verified for inclusion in the study. Differences in age, gender, or country of origin were not considered to be points of difference for this review.

4.4.4 Potential biases in review process The Ogbourne and Hampson publications had insufficient information to review them thoroughly. The following publications included disclosures which stated that some of the research team was either an employee or shareholder of the research sponsors, providing a potential risk of bias:

Huyke et al., (2009) states the following as disclosure of conflict of interest: that Birken GmbH was the study sponsor and that Laszczyk and Scheffler are employees of this company.

Anderson et al., the affiliations of the authors are not clear. One of the listed authors, Katsamas has become Head of Dept Clinical Operations in Brisbane, Australia for LEO Pharma, the company which has commercialised the Peplin product.

Siller et al., Ogbourne was listed one of the authors. He is a representative of Peplin Ltd, the sponsor.

Ogbourne: the author and a representative of Peplin Ltd, the sponsor.

There were no disclosures of any conflict of interest for the following publications: Huyke 2006, Wu, Kacerovska, Akar, Hampson or Grimaitre.

4.4.5 Discussion on the effect of individual substances The Kacerovska study did not obtain the results that were hoped for by the research team, they stated that with this first trial assessment “this result could be regarded as disappointing”. They added that they had “possibilities for improvement in the process”.

4.4.6 Search limitations This review limits the included studies to English language publications only. There was one publication that may have met inclusion criteria, but was excluded from the original search because only the abstract was in English and a translation of the research paper was not available. There appears to be considerable research of herbal medicines being conducted in

Eastern Europe and Asia, where it is generally considered that traditional herbal medicines have greater acceptance. It is therefore likely that some relevant papers in other languages were excluded from the present review.

4.5 Conclusions At the outset of this review, some of the intended outcomes were lists of the following:  Herbs that have enough evidence to encourage use for treating AKs: some of the substances that have evidence as effective AK treatments are: Colchicine, birch bark, Euphorbia peplus and its derivatives and the Solanum incanum extract SR-T100  The herbs are that are effective for treating AKs with no or minimal adverse effects: birch bark treatment alone, rather than with cryotherapy was shown to have reasonable efficacy with some irritation, though, minimal when compared with the other treatments  A list of herbs that indicate promise from early stage assessments that require further, well conducted research. Birch bark extract has promise, with efficacy comparable to other treatments  A list of herbs indicating insufficient efficacy for recommendation for treating or further researching on AKs: POH does not show sufficient efficacy, despite treatment duration of 12 weeks. The same case can be made for Hypericin, as a photosensitising agent, to be used in conjunction with PDT. While there is no doubt that Hypericin is an excellent photosensitising agent, perhaps the PDT treatment is not the preferred method for treating AKs. Though the Solanum incanum extract SR-T100, indicated efficacy, from its reported description of significant adverse events it is suggested that there are other efficacious AK treatments, with fewer side-effects.

One of the objectives of these early stage studies was to define the optimal dose rates and treatment durations for the substances assessed, this was realised for all the studies who reported this as an objective. Of concern though, was that while the Huyke 2006 study indicated efficacy and a good safety profile, the duration of this treatment was unclear in the report.

Were these studies well conducted? There was no opportunity to assess this of the Hampson or Ogbourne studies, as the relevant information was missing. This indicates either poor study design or poor study reporting, unlike the other studies, which were generally well conducted and reported upon. The Siller study reported errors made during the treatment duration, which were significant and there were participants that which not accounted for within the report.

These were both points of concern relating to this study. The Grimaitre study presented a very brief report of their Colchicine trial, but despite this being an early stage study, there was information not reported on (as mentioned in the risk of bias assessment).

When reading the Akar study, there was poor reporting of some information; either, it was not provided or it was unclear or insufficient information added in some key areas. Of most concern was the repeat treatment given to non-responders. There was no mention that this possibility for re-treatment had been approved prior to the commencement of the study, or if the application for ethics approval had been made to re-treat during the study; if not, this is a serious ethical breach.

4.5.1 Clinical implications Some of these treatments were shown to be effective at clearing AKs, both with clinical observations and with histological assessment. The Euphorbia peplus derivative (IM gel) trials have shown efficacy, to the point where it has been developed as a new AK treatment, marketed under the name of Picato. There are still significant adverse events listed in the promotional material (Leo Pharma, 2012a). From a clinical perspective, there are still no treatments available that a health professional could prescribe to patients who have AKs, which would not cause, at the very least, discomfort during the treatment process.

4.5.2 Implications for future research The reviewed research that has been conducted using herbs or herbal extracts for AKs provides a baseline to guide direction for future research. Having conducted this review, there are clearer indications of the efficacies of some herbal-based treatments which appear to have promise for this condition but are yet to be clinically examined.

A major limitation, which applied to the most of the studies included in this review, was the small scale of the individual trials. Most were not adequately powered to determine clear differences of efficacy between the active treatment and placebo groups. This can limit the results for efficacy and potentially the acceptability of the studies. As mentioned, some of the studies were early stage, or proof-of-concept for the herbal extracts being assessed.

The costs of conducting research are a significant part of the evaluation of potential products. Therefore pilot studies, though unpowered, do provide valuable data, as long as the studies are rigorously and ethically conducted, preferably randomised and blinded, with a placebo for

87 comparator. Once efficacy and safety are proven, then it is important to further assess with a powered sample size.

There is scope for the herbal formulation approach to be clinically researched, requiring careful consideration of the therapeutic actions indicated for treating AKs, and then applying that to the choice of herbs or herbal extracts to be combined. Ideally, a multi-arm study could compare the efficacies between formulations and single substances.

In addition, it appears that with the apparent differences between differing racial skin types, a multifactorial approach to AK treatment could be considered, particularly in regard of the apparent lack of research on Asian skin and AKs. With Fitzpatrick Skin Types IV and V, despite a lower incidence of AK and skin neoplasms, they may be significantly more aggressive in development than Types I to II (Gloster & Neal, 2006).

To enable the consistency of this review a PRISMA Checklist was used to record the 27 key points, ensuring that the optimal information has been assessed, where relevant to this review: Key point numbers 2, 5, 16 and 23 are not applicable [NA] to this review and therefore NA has been entered. The page numbers indicate where each specific key point has been addressed. This has been included in Table 17, The PRISMA Checklist, which follows.

Reported on Section/topic # Table 17: The PRISMA Checklist: Checklist item page # TITLE Title: Actinic Keratoses and Herbal Medicine 1 Identify the report as a systematic review, meta-analysis, or both. #51-52 Interventions ABSTRACT Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility Structured summary 2 criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions NA and implications of key findings; systematic review registration number. INTRODUCTION Rationale 3 Describe the rationale for the review in the context of what is already known. #51-52 Provide an explicit statement of questions being addressed with reference to participants, interventions, Objectives 4 #52 comparisons, outcomes, and study design (PICOS). METHODS Indicate if a review protocol exists, if and where it can be accessed (e.g. Web address), and, if available, provide Protocol and registration 5 NA registration information including registration number. Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g. years considered, Eligibility criteria 6 #52-53 language, publication status) used as criteria for eligibility, giving rationale. Describe all information sources (e.g. databases with dates of coverage, contact with study authors to identify Information sources 7 #53-55 additional studies) in the search and date last searched. Present full electronic search strategy for at least one database, including any limits used, such that it could be Search 8 #53-57 repeated. State the process for selecting studies (i.e. screening, eligibility, included in systematic review, and, if Study selection 9 #53-59 applicable, included in the meta-analysis). Describe method of data extraction from reports (e.g. piloted forms, independently, in duplicate) and any Data collection process 10 #53-58 processes for obtaining and confirming data from investigators. List and define all variables for which data were sought (e.g. PICOS, funding sources) and any assumptions and Data items 11 #52-54, 55-56 simplifications made.

Risk of bias in individual Describe methods used for assessing risk of bias of individual studies (including specification of whether this 12 #65-69, 85 studies was done at the study or outcome level), and how this information is to be used in any data synthesis. Summary measures 13 State the principal summary measures (e.g. risk ratio, difference in means). #54, 71-78 Describe the methods of handling data and combining results of studies, if done, including measures of Data Synthesis Synthesis of results 14 consistency (e.g. for each meta-analysis. #71-78, 86 Reported on Section/topic Checklist item page # Specify any assessment of risk of bias that may affect the cumulative evidence (e.g. publication bias, selective Risk of bias across studies 15 #65-69, 85 reporting within studies). Describe methods of additional analyses (e.g. sensitivity or subgroup analyses, meta-regression), if done, Additional analyses 16 NA indicating which were pre-specified. RESULTS Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for Study selection 17 #52-53, 55-62 exclusions at each stage, ideally with a flow diagram. For each study, present characteristics for which data were extracted (e.g. study size, PICOS, follow-up period) Study characteristics 18 #55-62 and provide the citations. Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). #65-69, 85 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each Results of individual studies 20 #73-78 intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. Present the main results of the review. If meta-analyses are done, include for each, confidence intervals and Synthesis of results 21 #77-78 measures of consistency" in accordance with the text in the Explanation and Elaboration document Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). #65-69, 85 Additional analysis 23 Give results of additional analyses, if done (e.g. sensitivity or subgroup analyses, meta-regression; see Item 16). NA DISCUSSION Summarize the main findings including the strength of evidence for each main outcome; consider their Summary of evidence 24 #83-85 relevance to key groups (e.g. healthcare providers, users, and policy makers). Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g. incomplete retrieval Limitations 25 #85-86 of identified research, reporting bias).

Provide a general interpretation of the results in the context of other evidence, and implications for future Conclusions 26 #86-88 research. FUNDING Describe sources of funding for the systematic review and other support (e.g. supply of data); role of funders for Funding 27 Self Funded the systematic review.

Source: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 For more information, visit:www.prisma-statement.org (PRISMA Statement, 2009) (Moher et al., 2009).

Chapter 5 further explores the approaches of herbal medicine to treating AKs; reviewing the responses from a survey of herbalists, to assess both their knowledge of AKs and the herbal medicines used to treat them.

CHAPTER 5 - SURVEY OF HERBALIST’S USE OF HERBAL MEDICINE IN AK TREATMENT

5.1 Survey Preparations As a continuation of an investigation into which herbs may be used for the treatment of AKs, an anonymous survey was developed to assess the knowledge and recognition that herbalists have of AKs, and if they do treat them, an understanding of what treatment protocols and herbs they use.

The National Herbalists Association of Australia [NHAA], a professional association for herbalists and naturopaths with approximately 1200 members, was selected as a suitable source of survey participants. The members practise predominantly in Australia, though there are some from New Zealand and other countries. After gaining a letter of authorisation to participate from the NHAA board, an anonymised Qualtrics survey (Qualtrics.com.au) was developed and submitted to the RMIT Human Research Ethics Committee for approval; the proposed study was assessed by the College Human Ethics Advisory Network [CHEAN] Committee and given the approval registration of Ethics number ASEHAPP08-15, (approval letter is included in Appendix E).

In addition to the NHAA an offer to participate was extended to the following professional associations which include herbalists as members: The Australian Traditional Medicine Association [ATMS], the Australian Natural Therapists Association [ANTA] and the New Zealand Association of Medical Herbalists [NZAMH]. The NZAMH accepted the opportunity and an application to the CHEAN committee to extend the survey approval was made and granted. The same protocol was followed for the NHAA. The ATMS board also accepted the opportunity for their members to participate and this participation was approved by the CHEAN committee. The survey text and the response report are presented in Appendix E.

It should be noted that since the commencement of the survey, the NHAA has been renamed as the Naturopaths and Herbalists Association of Australia (Naturopaths and Herbalists Association of Australia, 2016).

92 5.2 Survey Responses The number of responses was low, even after each association emailed members to encourage their participation. Of the 38 responses there was a 34 percent (34%) ‘drop-out rate’, with only 25 completed surveys. The primary reason for not continuing to the second part of the survey was because respondents either did not recognise an AK lesion or if they did, they did not treat them. The low number of responses does not provide the study with sufficient power to conduct statistical analyses.

The range of years in practice ranged from a student who had just completed training, to one with 28 years in practice, providing a wide range of practice experience. The experience of disclosed, professionally relevant training included: WMH 22, Naturopath 11, and 5 had additional qualifications (pharmacist, two registered nurses, nutritionist and Master of Health Science).

Due to the higher incidence of AKs in the northern parts of Australia (A. Green et al., 1999), it was hoped that respondents would be based at a range of latitudes; however, only 17 participants disclosed their practice location: one north of Sydney, the 16 others south of Sydney.

Of the 25 respondents, only 2 (8%) were confident they could always identify an AK, 8 (32%) considered that mostly they could identify an AK, 7 (28%) thought they could ‘sometimes’ identify them, whereas 6 (24%) thought that they occasionally could, and 2 (8%) reported that they would not be able to identify an AK.

Regarding the approximate percentage of patients with sun-damaged skin, the responses were as follows: 11 (46%) respondents said that 0–20 percent (%) of their patients had sun- damaged skin, 9 (37%) indicated 21–40%, while two respondents each (8%) indicated 41– 60% and 61–80%. In addition, the approximate percentage of patients with AKs was as follows: 17 (68%) respondents nominated 0-20 percent (%) of patients, 5 (20%) indicated 21–40% of patients and 3 (12%) indicated 41–60%.

An indication that there is not a widespread knowledge of the use of herbal medicine for treating sun-induced skin damage comes from the following figures: only 1 (4%) respondent's patients had always requested herbal treatment for their AKs, 2 (8%) indicated

93 that patients had mostly requested such treatment, 5 (20%) indicated sometimes, a further 5 (20%) indicated occasionally, whereas 11 (46%) respondents said their patients had never asked.

The question which asked if the respondent did treat AKs resulted in the following answers: Only one (4%) stated that they would always treat an AK, two (8%) said mostly, three (12%) indicated sometimes, six (24%) said occasionally, while 13 (52%) of respondents said they would never treat AKs.

The following are comments which were added by some of the survey respondents relating to their observations and experiences of patients with sun-induced skin damage:  “I do have several herbal approaches I'd be happy to recommend if a client requested a herbal treatment”  “In NZ people seem to just accept these as 'ageing'”  “I have not been asked to treat this condition. However I have probably noticed it in some of my elderly clients”  “My practice is an area of many retired people, near the sea; most over 50 have sun damage to their skin”  “Usually someone will go to a doctor with AK and do not see us as the primary care provider for treatment”  “Older people, almost all, have sun damaged skin in NZ”  “If people request assistance with AK's then I will help. Most people I find just accept them and do nothing unless they notice changes to the lesion”  “I recommend to patients to get a mole map, if an area looks like AK I use a poultice we have developed and which typically resolves the issues within a 2-3 week period. If the area is unresponsive I refer to GP”  “In the past few years I have not had any patients requesting an appointment for skin lesions such as actinic keratoses. When they have been discussed in a consultation it is as a secondary or minor concerns to their main reason for making an appointment. Often they will have been cleared by their doctor as being ' not cancer'. Occasionally I have noticed lesions and have asked further about the history of such lesions and taken their presence into account in their prescription”

94  “I have DSAP and thought it was AK. My partner has AK. I became aware of Euphorbia peplus sap when researching AK 12 years ago. I know about Picato (prescribed to my partner, but also was aware of its development when researching AK). And am appalled at how much it cost $140!!”  “We have a visiting skin specialist that comes to our clinic to do skin screening once per month”  “I do not treat the AKs directly and everyone's internal treatment will be different. You have to find the environmental triggers, the skin signs are just a sign. So liver and other detox herbs may be relevant, gut remedies often are useful. Treatment would not differ as from other conditions, treat the whole person”

5.3 Choices of Herbs as AK Treatments The following four tables (Tables 18–21) include the survey responses relating to herbs, phytochemicals or nutraceuticals utilised by practitioners for treating AKs. There is considerable variation in treatments, with relatively little duplication between responses. Where there are multiple responses for a herb, this is shown by the number of times in brackets.

Table 18: Individual Herbs and Herbal Substances Used Internally

Specific Herbs & Substances Used Internally To Treat AKs (x = number of mentions) Trifolium pratense (Red Clover) (x 4) Phytolacca decandra (Poke Weed) (x 2) Conifer pine needle concentrate Pinus pinaster (Maritime Pine extract) Viola odorata (Sweet Violet) (x 3) Glycyrrhiza glabra var. glabra (Leguminosae) (Licorice) Larrea sp (Chaparral) Medical Mushroom extracts (species not specified) Resveratrol (Grape seed extract) Angelica sinensis (Dong Quai) Taraxacum officinalis (Dandelion) Symphytum spp (Comfrey) Arctium lappa (Burdock) Thuja orientalis (Thuja) (x 2) Rosmarinus officinalis (Rosemary) Curcuma longa (Turmeric)

95 Calendula officinalis (Calendula) Galium aparine (Cleavers/Clivers) Silybum marianum (St Mary's Thistle) Echinacea sp (Echinacea) Centella asiatica (Gotu Kola) (x 2) Camellia sinensis (Green Tea) (x 2) “Quite a number of herbs depending on the person” Other internal treatments include Fish Oils Minerals and vitamins and antioxidants

Table 19: Respondents Formulations of Herbs and Herbal Substances Used Internally

Formulations of herbs and substances used internally Trifolium pratense, Phytolacca decandra (Phytolaccaceae), Viola odorata, Glycyrrhiza glabra var. glabra (Leguminosae) Conifer pine needle concentrate, Chaparral, Maritime Pine, various Mushroom extracts, Resveratrol Red clover, Poke Root, Violet Calendula, Comfrey, Echinacea, Clivers, St Mary's Thistle, Thuja Minerals, Vitamins, Antioxidants Viola, Trifolium, Rosemary, Turmeric (quite a number of herbs depending on the person) Centella, green tea Red clover, Dandelion, Burdock, Thuja

Table 20: Individual Herbs and Herbal Substances Used Externally

Specific Herbs and Substances Used Topically To Treat AKs (x = number of mentions) Euphorbia peplus (Radium weed) Trifolium pratense L. (Leguminosae) (Red Clover) (x 4) Phytolacca decandra (Phytolaccaceae) (Poke Weed) Arctium lappa (Burdock) Viola odorata (Sweet Violet) (x 3) Sanguinaria canadensis (Bloodroot) (x 4) Calendula officinalis (Marigold) Lavandula angustifolia (Lavender essential oil) Hamamelis virginiana (Witch Hazel) Zingiber officinalis (Ginger) Annona cherimola (Graviola or Soursop) Curcuma longa (Turmeric) Larrea sp (Chaparral) Achillea millefolium (Yarrow) Symphytum spp (Comfrey) (x5) Stellaria media (Chickweed) Picato (Refined extract of Euphorbia peplus - Radium Weed) Rosa spp (Rose hip oil) Pomaderris kumeraho (Kūmarahou)

96 Avena sativa (Wheat germ oil) Cinnamomum spp (Cinnamon) Viola (could be odorata or tricolour, not distinguished) Plantago spp (Plantain/Ribwort) Vinca spp (Periwinkle) Chelidonium majus (Greater Celandine) Macropiper excelsa (Kawakawa) Matricaria chamomilla (Chamomile) Thymus vulgaris (Thyme essential oil Helichrysum italicum (Everlasting Daisy) Daucus carota (Carrot) Boswellia carterii (Frankincense) Herbs with good levels of salicylates Commiphora myrrha (Myrrh) Other external treatment substances include: Salicylic acid Bepanthen (includes Chlorhexidine hydrochloride & Pro-Vitamin B5)

Table 21: Respondents Formulations of Herbs and Herbal Substances Used Externally

Formulations of herbs and herbal substances used externally Trifolium pratense, Phytolacca decandra, Arctium lappa, Viola odorata, Calendula officinalis, Aloe vera, Hamamelis virginiana, essential oil of Lavandula angustifolia Bloodroot, Graviola, Chaparral, Turmeric, made up into a salve, with some other non herbal ingredients Concentrated herbal extracts (essential oils, types not specified) Comfrey root decoction in with a Vitamin E cream base, with a Calendula oil, Rose hip oil, Wheat germ oil Yarrow, Comfrey, Chickweed Comfrey, Myrrh as a poultice Trifolium, Kumerahou, Cinnamon, Periwinkle, Viola, Plantain, Chelidonium, any herb with good levels of salicylates Comfrey, Centella, plantain. chickweed, kawakawa, chamomile, plus thyme essential oil Essential oils or CO2 extracts of Calendula officinalis, Lavandula angustifolia, Helichrysum italicum, Daucus carota, Boswellia carterii Red clover, Calendula, Gotu Kola (I have only used Black salve paste for BCC's not AK's) Use infused herbal oils i.e. plantain oil mixed with red clover and kumeraho tincture, cinnamon e/o or other oils/ tinctures/ infusions/ essential oils of choice, have added in salicylic acid to some creams Make my own and dispense it on a bona fide basis (no specific ingredients mentioned) Black salve paste Black salve, Blood root Kalonji oil, Vit E with Calendula, Hypericum, Chamomile one or all of these. Usually a tincture of any of the herbs above, gentle heating to extract the alcohol, and then added to Vit E water based cream Papaya cream Own ointment inc. Comfrey root, Kawakawa, Thyme, Centella plus some essential oils Commercial products—Bepanthen; dermatologist suggested Bepanthen for people not wanting a herbal

97 ointment Mebo Oil (“multiple botanic components and nutritional ingredients cooperated with patented dosage form with net-frame structure, Sesame oil, beeswax” - “Moist Exposed Burn Ointment”) (MEBO, 2018).

There were 12 respondents to Question 16: Do you make your own topical treatments? Of these, ten did make topical treatments, two did not. For those who did make their own, all utilised more than one herbal substance in a formulation and there was considerable variabilty, with little overlap between respondents. One of the treatment choices is black salve, a product developed from Sanguinaria canadensis (Bloodroot). There have been strong warnings against using these products by dermatologists and government health departments, which technically, makes selling or using these products as illegal, though in Australia they are permitted for use on animals (American Academy of Dermatology, 2016).

Some commercially manufactured and proprietary products were included in the treatment choices. Interestingly, none of the herbs referred to in the systematic review (Chapter 4) were mentioned by herbalists who completed the survey. Thus, there appears to be no industry standard approach to the treatment of AKs by herbalists, and the treatment choice seems to be largely determined by the experience of the individual herbalist.

5.4 Effectiveness of Treatments Of the 12 survey respondents who commented on the effectiveness of herbal treatments for AKs, 3 respondents (25%) reported that they are always effective, 4 (33%) that they are mostly effective, 3 (25%) said that they are sometimes effective, while 1 (8%) each said they were occasionally effective or never effective. Of the 11 that reported some degree of effectiveness, the reported treatment duration required to clear an AK ranged between 1-4 weeks (4 respondents; 33%), 1-3 months (4 respondents; 33%), or longer than 3 months (3 respondents; 25%). A comment regarding assessment of treatments was: “It is not always possible to evaluate long-term effect of a prescribed treatment, due to ongoing costs to client in having follow-up appointments”. One respondent (8%) reported treatments as ineffective. There were no reports of an AK clearance in less than one week.

The results confirm that some herbal treatments are capable of treating AKs, while the long duration of treatment required for resolution of an AK indicates that herbal medicines tend to act slowly. Furthermore the substantial variability in treatment time and proportion of claimed effectiveness suggests that some herbal treatments are substantially more effective than others.

98 5.5 Adverse Effects of AK Treatments Eight of the 12 respondents who treat AKs reported adverse outcomes. These outcomes included: reddening of the skin (4; 50%), rash (1; 12%), blistering (3; 37%), sloughing (3; 37%), pain (2; 25%), and ulceration (1; 12%). No respondents reported any of the following adverse effects: infection, skin pigment alterations, scarring or transformation into a carcinoma. Further to these figures, some of the comments left by respondents are listed below:  “No adverse effects”  “None outside of a temporary reddening or discomfort if using my own poultice recipe”  “Mostly the creams I make up cause no adverse effects, I have started to use some Ginger in the creams, to stimulate the circulation to the treatment area and this, being a rubefacient, can cause some initial reddening to the treatment area, it lasts for about 30 minutes, sometimes there is no reddening”  “No real problems with the cream it is just ongoing and takes time”  “Not painful, doesn't scar, no side effects and about 80% clearance in 1-3 months”

There were some notable comments made about the use of the black salve treatments:  “You will be familiar as to how the Black Salve works. Sometimes needs to be repeated if there has not been a good enough response first time and smaller sites appear in the area”  “On areas of skin where circulation is poor (e.g. around the ankle or shin), the reddening is more pronounced and painful. The lesion, where the salve is applied, often appears to blister around the edges, and looks like it is infected with pus, but this dries into a scab, and when the scab sloughs away, the skin is generally good underneath. Very occasionally, if the keratosis returns in a smaller size, I recommend to apply the salve again and repeat the process”  “Black Salve is illegal for us to use and so treatment needs to be specific for patients that you trust because in some instances a patient may go to the hospital when the ulceration phase occurs worried about infection. If

99 your studies could legalize the salve for herbalists you would have achieved a great step forward in assisting many people with AKs. The other think about the salve is that the skin does not change at all if cancer cell changes are not present”

The results and comments relating to adverse effects indicate that the majority of treatments are associated with no adverse outcomes or very minor outcomes. The blistering, sloughing, pain and ulceration reported for a small number of treatments are consistent with the side- effects of Bloodroot, the primary constituent of black salve. It is surprising that some practitioners continue to use and prescribe black salve, despite the fact that they know it is illegal to use on humans, as stated by the Therapeutic Goods Administration) (Therapeutic Goods Administration, 2011). The demand for this type of escharotic treatment to be legalised suggests that some practitioners consider that the benefits of this herbal treatment outweigh the associated risks and discomfort. Respondents were given the opportunity to add further comments regarding AK treatments:  “A dermatologist suggested Bepanthen to me years ago so if people aren't keen on using a herbal ointment I've made myself then I suggest they use Bepanthen. Not ever had any adverse effects with either my own ointment or with the Bepanthen”  “I am in the process of making the poultice I use commercially available. I will be looking to run trials on it”  “I find that the herbs I use seem not to cause any negative reactions, apart from the initial reddening, which is caused by the Ginger. I have found that the people who use the creams I make come back for more and they tell their friends about it too. The most effective treatment I find is when patients take an internal formula in conjunction with using the topical treatment”

These comments indicate that there is some degree of communication between herbalists and dermatologists, and they also highlight that some herbalists have learned that concurrent internal treatments can boost the effectiveness of topical treatments.

5.6 Awareness of AKs Despite the small number of responses, the data obtained from the survey provided some interesting insights. Considering that Australia and New Zealand have the highest incidences

100 of sun-induced skin damage, it is concerning that of the practitioners who responded, only 2 (8%) were confident they could identify an AK, while almost a third were not confident about identifying AKs (24% occasionally and 8% never). This lack of recognition suggests there may be inadequacies in the training of CAM practitioners with respect to sun-induced skin disease. With hindsight, it would have been informative to ask if the respondents had been taught about utilising herbs for treating sun-damaged skin during their professional training.

Nonetheless, the verbatim comments of some participants support the need for further professional training:  “I would treat more if I had a reasonable protocol to use for these conditions”  “I would love more information on how to treat these conditions. Thanks”  “I have never seen/treated this condition”

Additionally, indicated is the apparent lack of knowledge of utilising herbal medicine for treating sun-induced skin diseases, the following survey response reflecting this:  “Most patients accept that they will need to see a skin or skin/cancer specialist, because they believe that's the only way to resolve skin cancers”  “Sometimes patients become alarmed with the diagnosis and return to doctor who removes it thru the usual methods”  “I find that the herbs I use seem not to cause any negative reactions, apart from the initial reddening, which is caused by the Ginger. I have found that the people who use the creams I make come back for more and they tell their friends about it too. The most effective treatment I find is when patients take an internal formula in conjunction with using the topical treatment”

There is evidently a need to review, amend and update college training for herbalists regarding sun-induced skin damage, as well as making this topic a specific subject for continuing education.

5.7 Summary According to the survey, conducted within Australia and New Zealand, a diverse range of treatments for AKs are utilised by herbalists. While the effectiveness of these treatments varies, the reported adverse effects are mild. However, only eight percent of respondents were confident they could identify an AK. When considering that Australia and New Zealand have the highest incidence of AKs world-wide, this is a significant deficiency within the

101 profession and indicates scope for improved training for identification of sun-induced skin damage and treatment protocols.

When assessing for any similarities of differences between the systematic review (Chapter 4) and the survey of herbalists (Chapter 5), only one herb which was common to both: Euphorbia peplus as the natural herb, and Picato, the product manufactured from the extract of this herb. The majority of herbs used as treatments by herbalists and naturopaths for AKs have not been assessed for efficacy or safety with clinical research. This survey indicates there is much scope for future research of herbs as AK treatments.

The text of the survey and additional support of clinical evidence for the topical use of herbal medicine is included in Appendix E.

Chapter 6 is the overall discussion of the thesis and the conclusions drawn from the research undertaken.

102 CHAPTER 6 - DISCUSSION AND CONCLUSIONS

6.1 Discussion This study examined AKs from the perspectives of biomedical science and herbal medicine, and has reviewed the classical and modern literature relating to the use of herbal and pharmaceutical medicines for treating sun-damaged skin and specifically, AKs. The study also assessed whether professional herbalists recognise and treat AKs, and what treatment protocols are favoured.

A general finding is that AKs have received relatively little attention, either from the long tradition of herbal medicine or from western medicine. This neglect probably stems from the fact that AKs are a chronic disorder that has not been linked, until recently, to significant pain or increased mortality. Thus clinical attention has focussed on the higher profile diseases such as infections and cancers. The cause of AKs has been further hampered by a lack of consensus regarding of both their nomenclature and disease classification status, at least until relatively recently.

As portrayed in Chapter Two, during recent decades there has been a growing appreciation that sun-induced damage of the skin, mainly due to UV exposure, leads to mutations of DNA in epidermal cells and the subsequent proliferation of carcinomas. Some of these are melanomas, while others are non-melanoma skin cancers, both BCCs and SCCs. All forms of skin cancer are associated with increased rates of secondary cancers elsewhere in the body; therefore early diagnosis and treatment may the reduce mortality rates. In the past two decades, research has made it increasingly clear that AKs are a precursor of NMSCs; primarily, SCCs, and to a lesser extent, BCCs. Thus, there is growing recognition within the medical profession that AKs are not to be viewed as benign 'sun spots’; instead they ought to be treated or removed surgically before they have the opportunity to progress into a malignancy. Medically, there are a wide range of treatments available, though all have some adverse side-effects ranging from minimal to severe, including pain with treatment, inflammations, skin erosion and the risk of scar formation. Also introduced were other factors which have been linked to the development or exacerbation of AKs; including HPV infections, nutrient deficiencies, diet and lifestyle.

103 Since Australia has the highest incidence of skin cancer in the world, it is in our national interest to become research leaders in the identification and treatment of AKs. This imperative provided much of the motivation for the research in this thesis, and the main findings to emerge, following the initial investigations from the first two chapters of the thesis, are summarised below:

Chapter Three presented the background and methodologies of the use of herbal medicines, including for treating skin conditions. Though this is a wide and comprehensive field, it has had, compared to allopathic medicine, little clinical research on humans. There are a considerable number of herbs which demonstrate therapeutic actions which could be useful for treating AKs. There are also some which may erode these lesions and are known to cause adverse reactions. A collection of herbs which indicate promise as treatments has been included in Appendix B, in a monograph format.

The fact that plants have complex chemical compositions, limits researchers from deducing the constituents responsible for treatment efficacy. Though paradoxically, herbalists consider that this complexity (synergistic activity) may improve treatment efficacy while reducing the incidence and severity of adverse events.

The systematic review from Chapter Four indicated that 6 different herbs or their extracts have been assessed for the clinical treatment of AKs, though there have been no published trials since 2011. The majority of these clinical trials were relatively small, often as phase 2 or 3 trials, or as ‘proof-of-concept’. While the studies varied in the rigor of their design, all demonstrated a degree of clinical effectiveness, though some were associated with significant adverse events. These studies provide a good foundation for future trials of herbal treatments.

From the survey, presented in Chapter Five, it was disappointing to discover that there was so little recognition of AKs by the herbalists and naturopaths in Australia and New Zealand, particularly considering these two countries have the highest rates world-wide. This indicates considerable scope for additional education in student training and professional continuing education in this field. Of those who were confident to treat AKs, a wide diversity of herbal medicines and other substances were utilised; there appears to be no consensus regarding the optimal treatment protocols.

104 The six appendices that accompany this thesis provide supplementary information for the interested reader. They include: brief monographs of herbs included in the systematic review (Appendix A), monographs of additional herbs that may be relevant for the treatment of AKs (Appendix B), further elaboration on the therapeutic actions of herbs (Appendix C), the rationale for different extraction methods (Appendix D), data from the survey of herbalists (Appendix E), and a series of practitioner case studies (Appendix F).

6.2 Conclusions Many pharmaceutical medicines originated from traditional herbal medicines, and the fact that this continues to be a productive line of investigation, validates herbal medicine. There have been significant advances in discerning the causes of AKs and researching substances as potential treatments. As indicated in the systematic review, there has yet to be a trialled substance which does not cause erythema or pain at the treatment site during the treatment process, or that leaves the skin healed with no sign of scarring, though the Huyke 2006 birch bark study is the best thus far. There are a considerable number of herbs which indicate promise as AK treatments and this author is looking forward to reviewing any future studies.

The survey of herbalists exposed deficiencies in both the recognition and treatment of AKs, and established a need for further professional training. Unexpectedly, the herbs utilised in the published papers of the review of AKs differed greatly from the range of herbs used by herbalists in the survey. In addition, the author has further identified herbs, whose reputed properties (as yet not confirmed by scientific studies) could be beneficial for the treatment of AKs (Appendix B). Together, this data supports two important conclusions: first, no consensus yet exists regarding the optimal herbal treatment protocols for AKs; second, that considerable potential exists with respect to candidate herbs for the treatment of AKs, with the likelihood that formulations containing multiple herbs will be found to have better therapeutic efficacy. When considering the therapeutic actions required for normalising AKs, for example, anti-inflammatory, anti-neoplastic and vulnerary, it appears that the formula approach has merit for assessment with clinical research. Rather than focussing on a specific therapeutic constituent, it is recommended that thoughtful design of herbal formulations be assessed in well-designed clinical trials.

It is the countries with the highest incidence of AKs that also have ageing populations, providing incentives to further explore the contribution herbal medicine can make to this

105 increasing problem. Aside from the personal implications of cosmetic appearance, discomfort or pain and the financial cost to the person with AKs, the progress of some AKs into NMSCs places a significant burden on healthcare systems. There is a need in the health marketplace for alternative, effective treatments for AKs, without the adverse side effects of currently available options, for prescribed medical, dermatologist or herbalist practitioner-dispensed treatments or as over-the-counter remedies.

This dermatological condition is still being assessed by pathologists and epidemiologists to determine its nomenclature, causations, progressions and exacerbations. Despite these uncertainties, developing new treatments, both medical and herbal, which have less adverse side-effects is desired. In addition, increasing overall public awareness of both the benefits and harms of sun exposure are to be recommended.

In conclusion, it is hoped that this thesis may help to raise awareness of AKs. From the field of herbal medicine there is positive, significant supportive evidence to indicate that there are potential treatments for AKs and there are a lot of ageing sun-damaged people waiting for these remedies.

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124 APPENDICES: SUMMARY

Because there were so few herbal substances found to have been researched as treatments for AKs (see Chapter 4), and when there are a great number of herbs, which have both the traditional use and include the therapeutic actions indicated as potentially effective, that the first two appendices have been prepared. Overall, these appendices have been developed and included to support the body of the thesis and to ensure that with this relatively under- researched subject that it becomes a cohesive and unified information source.

Appendix A: Elaboration of the Herbs Included in the Systematic Review, which elaborates on the herbs, extracts and substances which were included in Chapter 4.

Appendix B: Selected Monographs of Herbs for Consideration as AK Treatments; this presents monographs of herbs which through traditions of use, indicated therapeutic activity and of preliminary research could provide potential treatments for AKs, either as a single herb, or included in formulations.

Both Appendix A and Appendix B have been presented in a format and style familiar to the field of western herbal medicine (WHM), which details the plant family, the country or countries of origin, the major phytochemical constituents and therapeutic actions. These are accompanied by traditional use and supported by clinical research where possible. To make each herb more identifiable an illustration is included for each monograph, and to reflect the herbal history, historical quotes have been incorporated where possible. In addition there are three further appendices:

Appendix C: Therapeutic Action Descriptions: Elaborating further on Table 5: Therapeutic Actions of Herbs—Considerations for Skin Treatments, from Chapter Three.

Appendix D: Differing Extraction Methods and Availability of Herbal Constituents: This elaborates on the reference to bioavailability of constituents, due to varied extraction methods in Chapter Three; Differing Extraction Methods and Availability of Herbal Constituents.

Appendix E: Data Collated From the Survey: Screening and Treatment of Actinic Keratoses by Herbalists of Herbalists, from Chapter 5.

Appendix F: Series of Practice Case Studies.

125 APPENDIX A

A1 Elaboration of Herbs Included in Systematic Review A monograph is included of each herb or herbal extract or substance which is included in Chapter 4, the systematic review. Each monograph, includes; the nomenclature, origins, therapeutic activity and where possible information of additional research undertaken for each.

A1.1 Colchicum autumnale (L.) (Colchicaceae)

This bulb is commonly known as the autumn flowering crocus; it belongs to the Colchicaceae family, which originates from Europe, more specifically, the Eastern and Mediterranean regions. Historically, this herb has been used with extreme care, as it is considered to be poisonous; it is though used as a medicine—its therapeutic actions are; mitosis inhibitor, cathartic, emetic, antiphlogistic, anti-rheumatic, anti-chemotactic and analgesic. It causes irritation to the digestive tract and in larger doses can stimulate cathartic vomiting and diarrhoea. In low doses it is used to treat gout and rheumatism. There have been deaths recorded after ingestion of Colchicum bulbs, having confused them for onions or ramsons (Grieve, 1992 (1931)).

Figure 16: Colchicum autumnale (Autumn Crocus)

Source: Koehler & Pabst, 1887c (Koehler & Pabst, 1887c)

126 In 1999, Hong-Ping, Lin and Fu-Chu, researchers from Kunming, published their analysis of this herb and their findings are that C. autumnale contains twelve known compounds, colchicine, 2-demethylcolchicine, 2-demethyldemecolcine, 2-demethylcolchifoline, 2- demethyl-lumicolchicine, lumicolchicine, demecolcine, luteolin, apigenin, n-hentriacontane, n-triacontanol and sitosterol. These substances were extracted from the flowers and corms of C. autumnale, which were grown in Zhaotong Prefecture, in the Yunnan Province of China. Originally, this herb had been introduced to China from Europe. The levels of colchicine found in the corms were 0.015% and 0.04% from the flowers. The demecolcine level extracted from the corms was 0.043% (Hong-Ping, Lin, & Fu-Chu, 1999).

Initially, colchicine had been indicated as a possible cancer treatment, and a synthetic substance, named ICT2588, was developed to imitate the effects of colchicine. In early stage research it has shown to be successful for treating a number of different cancers in conjunction with doxorubicin, a commonly used chemotherapy drug (Atkinson et al., 2010). Natural colchicine, as a chemical extracted from the bulbs has been trialled in a base cream using two different concentrations: 0.5% and 1% colchicine cream; both the Grimaitre and the Akar studies, included in Chapter Four, utilised colchicine at those rates (Grimaitre et al., 2000), (Akar et al., 2001).

A1.2 Betula species (Betulaceae)

Commonly known as Birch trees, they are members of the Betulaceae family, of which there are approximately 50 different species which originate from the Northern areas of Europe, Asia and North America. There is a very long tradition of using birch as a medicine and a healing herb throughout these lands.

One of the North American species, Betula lenta, or the American Black Birch, (aka sweet birch, mahogany birch, cherry birch or spice birch) can used in the production of Wintergreen Oil, (as it is very similar to the oil obtained from Gaultheria procumbens (L.) (Ericaceae), which is used as a rub on aching muscles and rheumatic joints. Birch oil, extracted from Betula lenta, contains 98% of methyl salicylate, which is known to be anti-inflammatory, analgesic, and antipyretic (Khan & A., 2010).

127 Figure 17: Betula lenta Figure 18: Betula lenta (American Black Birch) (Sweet Black Birch)

Source: (Plants For A Future, 2016) Source: (Koehler & Pabst, 1887a) With the assessment of their therapeutic constituents of Betula species, these traditions are validated—though there may be variation of chemical composition within Birch species; they generally all have flavonoids (including luteolin, quercetin glycosides, and hyperoside), bitter glycosides, volatile oils (including betulin), resins, saponins and tannins. Generally, it is the bark which has the highest tannin levels—when used in herbal medicines tannins have astringent effects on skin and body tissues. Birch Bark has the following therapeutic actions; anti-inflammatory, antiseptic, astringent, diuretic, diaphoretic and cholagogue (Fisher & Painter, 1996). From Chapter Four, it is stated in the Huyke et al. (2009) paper that the extract used in trial is obtained from White Birches, but the exact species used is not mentioned: it is most likely to be either Betula pendula or Betula alba, which are both indigenous to Northern Europe (as opposed to Betula papyrifera which is also known as White or Silver Birch, but originates from Northern America). With the ‘Birch Bark’ research there are two consecutive phases: the first, a pilot study, Huyke et al. (2006), using an ointment made from Birch Bark (Huyke et al., 2006). It was a standardized extract; the composition of this triterpenoid extract was 80% betulinic acid, 3% oleanolic acid, 2% lupeol, and 1% erythrodiol in an ointment base. The following 2009 phase research project was a refined extract, Betulin-based oleogel (Huyke et al., 2009). This substance is obtained by extracting standardised triterpenes from

128 Birch Bark, which contain betulin, oleanolic acid, lupeol and erythrodiol in a gel base. The ratio was not included (Huyke et al., 2009).

Figure 19: Betula pendula Figure 20: Betula papyrifera (Silver Birch) (White Birch)

Source: (Plants For A Future, 2011) Source: (Scottish Rock Garden Club, 2016b)

A1.3 Hypericin

This is an active constituent of Hypericum perforatum (L.) (Hypericaceae), more commonly known as St John’s Wort, a member of the Clusiaceae family. This herb grows as an herbaceous perennial and it is often considered to be a noxious weed, particularly by farmers, who find that stock grazing on it are more likely to become hyper-sensitive to the sun. Thus far, it is considered to be the most powerful photosensitising agent obtained from a natural source. It is this photosensitizing activity of Hypericum that was utilized by Kacerovska et al., in association with Photodynamic Therapy [PDT] on AK lesions (Kacerovska et al., 2008). This herb does however have a number of other beneficial therapeutic actions; anti- inflammatory, anti-viral (specifically for enveloped viruses), astringent, relaxant, anxiolytic and anti-depressant. Topically it is antiseptic, analgesic and vulnerary. These are due to the cumulative effects of its therapeutic constituents that include: volatile oils, flavonoids (including quercetin and rutin), glycosides, (including hypericin and pseudohypericin), resins,

129 tannins, hyperflorin, oligomeric procyanidins, coumarins, cholorogenic acid, caffeic acid and pectin (Fisher & Painter, 1996; Mills & Bone, 2000).

Figure 21: Hypericum perforatum Figure 22: Hypericum perforatum (St John’s wort) (St John’s wort)

Source: (Scottish Rock Garden Club, 2016f) Source: (Alberti, 1800)

H. perforatum does have significant Herb-Drug interactions, which must be taken into consideration especially when taken internally. It is considered that this herb (particularly the constituent hyperforin) induces CYP450, P-glycoprotein and isoenzymes, the net result being that drug medications are processed more rapidly and have reduced plasma concentrations, leading to shorter treatment durations and therefore having reduced efficacy. This does not appear to be relevant for topical applications, though the potential for interaction ought to be considered for persons on certain medications, for example, warfarin (or other blood-thinning medications), cyclosporine (or other anti-rejection medications), protease inhibitors, or just prior to surgery (Steinhoff, 2012).

A review of topical applications of Hypericum perforatum conducted by Wölfle et al., (2014) acknowledges the long tradition of topical use for this herb and though little research has been undertaken, they consider this herb has potential for utilisation in medical skin care treatments.

130 Cecchini et al., in their 2007 paper titled ‘Antimicrobial Activity of Seven Hypericum Entities from Central Italy’, used methanol-acetone extraction methods to assess the Hypericum species and subspecies that grow in their area of Italy.

The in vitro study tested the extracts for their antimicrobial action against the following pathogens: Enterococcus faecalis and Staphylococcus aureus (both gram-positive bacteria); Pseudomonas aeruginosa and Escherichia coli (both gram-negative bacteria) and Candida albicans (a yeast). The Kirby-Bauer agar diffusion method was used for this study (Cecchini et al., 2007), they found that two of the sub-species had significant anti-bacterial or antimicrobial activity for both the gram-positive and the gram-negative bacteria, which is supportive for the traditional use of these Hypericum species in the Central Italy vicinities, for treating wounds and a diverse range of skin diseases.

The research findings indicate that the key actives for the anti-bacterial or anti-microbial activities are predominantly hyperforin and hypericin; there are though, other constituents indicated. They added that they were continuing to assess pure active extracts to confirm this, suggesting that the Hypericum species warrant further research as potential anti-microbial agents (Cecchini et al., 2007).

Research conducted by Fox, Niu, Tobia and Rook (1998), showed that using hypericin and light sources was effective at inhibiting proliferation of a number of neoplastic (cancer) cell types. The inhibition was through hypericin concentration and light source dependent—this treatment induced apoptosis; the hypericin is photo-activated and impedes and obstructs the proliferation of malignant cells (Fox, Niu, Tobia, & Rook, 1998).

Of great relevance to the subject of AKs is the research of Hostanskaa et al., whose in vivo research was published in 2003, in which they assessed hyperforin [HP], hypericin [HY] and polyphenolic procyanidin B2 [B-2]. They found that both HP and PB-2 had the ability to inhibit the growth of K562 and U937 leukaemia cells, additionally for brain glioblastoma cells LN229 and normal human astrocytes. They also discerned that HP and HY exhibited synergistic action to inhibit the K562 and U937 leukaemia cells. Apoptosis occurred after 24 hours of using HP and PB-2 treatments (Hostanskaa, Reichlingb, Bommerc, Weberc, & Sallera, 2003). Apoptosis is a therapeutic action that could assist, as an active, in a treatment for AKs and for NMSCs. In conclusion they summarise that their research data has established that:

 HP has anticarcinogenic activity, which induces apoptosis and this involves a

131 caspase-dependent pathway  HY and HP act synergistically as antiproliferative agents  PB-2, a phenolic constituent of Hypericum perforatum, exhibits apoptotic and cytostatic actions on malignant cells (Hostanskaa et al., 2003).

In an earlier time Hypericum was used as a wound-healing herb; the writer Cervantes (1547- 1616), in his story Don Quixote, relates how the character of the title, when wounded, used a poultice of Aparicio’s Oil, which had been created by Aparicio de Zubia (who died in 1566) and the main ingredient of this remedy is Hypericum perforatum (López-Muñoz et al., 2007).

A1.4 Euphorbia peplus (L.) (Euphorbiaceae)

This annual is a member of the Euphorbiaceae family. It has many common names including petty spurge, milk weed, radiation weed, radium weed and cancer weed. Originating from Europe, Africa and Asia, it has found its way to colonise most of the world and is considered a nuisance weed in most lands. The following quote may support the value of ‘weeds’: “And what is a weed? A plant whose virtues have not been discovered” (p 10) by Ralph Waldo Emerson, (1803-1882), a U.S. philosopher and writer (Emerson, 1878). When the plant is damaged it exudes milky, latex-like sap—it is this substance which has been traditionally used on warts and skin lesions, to erode them off (A. C. Green & Beardmore, 1988; Grieve, 1992 (1931)). Figure 23: Euphorbia peplus (Radium weed)

Source: (Kops, 1822)

132 It is this traditional use which has led to ongoing investigations, research and drug development (A. C. Green & Beardmore, 1988). The ancient Gaels named it lus leighis, meaning ‘healing herb’; they knew though, that it was poisonous to take internally, except for small doses to cause a ‘violent purge’! They valued it for topical use, to treat warts and skin ‘lumps and bumps’ (Beith, 2011).

In 1976 the Medical Journal of Australia published a case study of a patient observed at the Royal Brisbane Hospital, who had used the sap of E. peplus repeatedly for five days on a previously biopsy-verified BCC. After the lesion site was healed, the investigators excised small sections of the residual scar tissue. In this paper, written by Weedon and Chick, it was found that though the treatment site contained a few chronic inflammatory cells, there was no evidence of residual tumour (Weedon & Chick, 1976).

Initial research assessed the sap of the plant—the 'Peplin E. peplus sap' studies, then an isolated constituent extracted from this herb, a hydrophobic diterpene ester which was named ingenol 3-angelate (PEP-005), was identified to be the main active for treating skin lesions. To isolate this chemical, the plants of a specific cultivar of E. peplus are dried, and put through an extraction, purification and crystallisation process, which takes approximately five months (Leo Pharma, 2012a). It technically becomes a pharmaceutical product, it is though, derived from a plant. It is particularly interesting to follow the research and development of a simple herb and view its development to a pharmaceutical medicine (S. M. Ogbourne et al., 2007).

Correspondence with Steven Ogbourne (14/11/2011) includes the following extract of an email, which gives clarification of the Euphorbia peplus herb and its evolving product development: “The Peplin story started by conducting a clinical trial using the sap of E. peplus to treat several skin cancers and this study was recently published in the Australasian Journal of Dermatology. In terms of highlighting some data that supports the anti-cancer activity of E. peplus (i.e. a potential herbal remedy) this paper should be very useful. The Peplin story matured not by the development of a botanical product, but via the identification and purification of the active compound found in E. peplus (PEP005 or ingenol mebutate) and the initiation of a formal pharmaceutical drug development program. I attach a second reference that refers to not only the use of E. peplus sap in mouse models, but of the purification of PEP005, confirmation of the activity of PEP005 relative to E. peplus sap in the same animal models and the elucidation of the mechanism of action of PEP005. “Peplin and now LEO” (the company which purchased the intellectual property for this product development) “have completed a large number of clinical trials using PEP005 (ingenol mebutate)

133 (www.clinicaltrials.gov) in an alcoholic gel formulation to fully explore the safety and efficacy of this fully purified and characterised New Molecular Entity (http://www.fda.gov/Drugs/InformationOnDrugs/ucm079436.htm). Whilst extremely interesting, this information is not really relevant to a review of botanicals, because PEP005 is not a botanical remedy. It is however, relevant as an example of the potential of drugs identified and isolated from botanical sources. LEO will in due course (if they have not already) file formal New Drug Applications” (S. Ogbourne, 2011).

There have been a series of trials conducted on Euphorbia peplus and its derivatives during its research and development evolvement to become a new pharmaceutical medicine—though not all the published studies have been solely trialled on AKs, it had been assessed for treatment of a range of conditions and dosage rates to discern the optimal treatment dose and length. This process was initiated with using a whole, simple herb, (as opposed to a refined chemical substance), which had a tradition of use for treating skin cancers.

Hampson et al., used a concentration of 0.01% PEP005 gel in their 2005 pilot study(Hampson et al., 2005). The largest of the included studies, the Anderson 2006 multicentre study assessed IM gel in two concentrations: 0.025%, and 0.05% (Anderson et al., 2009). Ogbourne et al. in the conference report of the AK trial, states that PEP005 topical gel was used in concentrations of 0.0025%, 0.01%, 0.05% (S. M. Ogbourne et al., 2007). With the Siller et al. (2009) trial, ingenol mebutate (IM) gel was used in 0.0025%, 0.01%, 0.05% concentrations, plus a vehicle gel control.

A1.5 Perillyl alcohol Perillyl alcohol or POH is a naturally occurring hydroxylated monocyclic monoterpene, which may be sourced from a wide number of species of many plants; including lavender, perilla, lemongrass and cherries. Monoterpenes are a major class of chemicals that are most commonly found in the essential oils of many plants (Belanger, 1998; Pengelly, 1996). They are hydrocarbons, composed of the condensation of two isoprenes (Gould, 1997). There are two specific natural monoterpenes that have shown effectiveness as potential cancer treatments; they are perillyl alcohol and limonene (Gould, 1997). Ongoing research with these chemicals has continued including the development of synthetic versions of them. When conducting the systematic review, it was not clear from which source the treatment medication was obtained—was it naturally extracted from plant material, or was it a synthetically produced substance? Because this was unknown and there was no initial

134 response from the researcher, regardless of source, this trial was included, as it gives a greater diversity to the substances to assess.

Figure 24: Structure of perillyl alcohol

Source: (Sigma-Aldrich., 2014) The Stratton et al. research used POH at concentrations of 0.76% and 0.3% in a cream base in this study.

The researcher of this paper was emailed with the request for this specific information in December 2011. A reply was received in February 2012 with the following response:

“Anyway, the answer to your question is that the perillyl alcohol drug substance that we used was obtained from the National Cancer Institute in Maryland, and we formulated the final drug product cream. It is my understanding that the original source of the perillyl alcohol is a synthetic route from limonene. I can’t be positive about that since we didn’t produce the original substance and that information was not given to us. However, enantiomerically 1pure POH exists in such low levels in plants; I can’t imagine that they obtained it through extraction. So the short answer is “synthetic” (Associate Professor Steven P. Stratton, 2012).

The systematic review had been completed before the response had been received and thus, it remained in the review.

A1.6 Solanum incanum (L.) (Solanaceae)

This plant has a number of common names including bitter apple or thorn apple, and occasionally it is called Apple of Sodom (there are other, entirely different plants which also have this common name). It is a species of the Solanaceae family; commonly known as the Nightshade family. This species is native to the Middle East and the North West of Africa, where it has a tradition of use for treating infections. One of its African folk names is

1 ‘Enantiomerically’ is a term from organic chemistry. It refers to a sample of molecules having the same chirality; enantiomers; a pair of stereoisomers whose molecules as a whole display chirality, i.e. are mirror images of each other and thus not superposable (Cammack et al., 2006)

135 umthuma omkhulu. It is reported to be an important herb in TCM, being used in the treatment of chronic liver disease (C. H. Wu et al., 2011). In Kenya, where it is traditionally used to treat fungal skin and other infections, clinical research had indicated that it had therapeutic levels of glycosidal, glycol-alkaloids and steroidal alkaloids, which are associated with antimicrobial activity. Other constituents which were identified supported its antifungal activity. Further research had shown that there was anti-tumour activity from glycol-alkaloids.

Figure 25: Solanum incanum Figure 26: Solanum incanum flowers and fruit (bitter/thorn apple) (bitter/thorn apple)

Source: (Hameed, 2008) Source: (Africa Museum, NA)

In a paper, published in 1976, by Beaman-Mbaya and Muhammed, a refined extract of the fresh fruits, (both ripe and unripe), of Solanum incanum were used (Beaman-Mbaya & Muhammed, 1976). Their research established that the extract had antibacterial activity for both gram-negative and gram-positive bacteria and had strong antifungal activity, for candida and more specifically for dermatophytes. Another finding was that when used in high concentrations, the substance they were assessing caused the disruption or breakdown of red blood cells (aka haemolysis of erythrocytes). They considered that further research be conducted to assess the chemotherapeutic effects of this plant. SR-T100 is an isolated substance of solamargine, a glycoalkaloid, which is extracted from Solanum incanum. A preliminary pilot study of SR-T100, assessing for its efficacy on AKs, was undertaken by Wu et al., in Taipei, Taiwan and published in 2011. The composition of SR-T100 contains predominantly two constituents from Solanum incanum, being solamargine

136 and solasonine in a 2:1 ratio: there was no comparator treatment nor was a placebo used in this trial (C.-H. Wu et al., 2011).

137 APPENDIX B

B1 Selected Monographs of Herbs for Consideration as AK Treatments These monographs are a continuation of Chapter 3: Herbs as Skin Treatments, they are presented in a format which is most commonly used in the field of western herbal medicine; divided into specific areas of information, including their general uses, references of historical uses have also been included. The herbs contained in this appendix have been selected because they have some of the therapeutic actions, which could be considered to be efficacious when developing a treatment for a skin condition such as AK. Where there has been research conducted to support this, it is included, there is though, a paucity of clinical research in this area. (NB: There is an entry of Hypericum perforatum in Appendix A; it is a brief summary of this herb which was a substance from the systematic review, of relevance to that review; whereas, the Hypericum perforatum entry in Appendix B provides detailed information, in a traditional monograph format, indicating its significant potential for use as an ingredient for AK treatments.

B1.1 Aloe vera (L.) Burm.f. (Xanthorrhoeaceae) (Aloe)

The character of Aloe is considered to be; a) Leaf skin: Bitter, moist, hot. b) Gel: Moist, bitter, cool, salty (Ody, 2000). This species is also known as A. barbadensis.

Figure 27: Aloe vera (aloe) Figure 28: Aloe vera (aloe)

Source: (Villis, 2003a) Source: (K. A. Hilterman, 2016a)

138 B1.1.1 Constituents Despite that whole raw pulp of A. vera contains approximately 98.5% water, and that the gel consists of about 99.5% water, it has a complex and diverse range of constituents; resins, phenols and phenolic glycosides, sterols, anthraquinones; including emodin, ester of cinnamic acid, isobarbaloin, aloetic-acid, aloin A and B, also known as barbaloin, emodin, oils, mucilage, fibre, specific sugars, saccharides and polysaccharides; including glucose, L- rhamnose, aldopentose and mannose. Its carbohydrate content includes; pure mannan, acetylated mannan, acetylated glucomannan, glucogalactomannan, galactan, galactogalacturan, arabinogalactan, galactoglucoarabinomannan, pectic substance, xylan and cellulose. Saponins, gelonins, and chromones (including isorabaichromone, neoaloesin A, isoaloeresin D, 8-C-glucosyl-noreugenin, 8-C-glucosyl-7-O-methyl-(S)-aloesol, and 8-C- glucosyl-(2’-O-cinnamoyl)-7-O-methylaloediol A, 8-C-glucosyl-(S)-aloesol, 8-C-glucosyl-7- O-methylaloediol). Protein lectins and lectin-like substances, 18 non-essential and essential amino acids; including alanine, arginine, aspartic acid, glutamic acid, glycine, histidine, hydroxyproline, isoleucine, leucine, lysine, methionine, phenylalanine, proline, threonine, tyrosine, valine. Enzymes; including superoxide dismutase, alkaline phosphatase, lipase, catalase, amylase, carboxypeptidase, oxidase, cyclooxidase, cyclooxygenase and phosphoenolpyruvate carboxylase. Also, organic compounds and lipids; including arachidonic acid, α-linolenic acid, steroids; campestrol, cholesterol, ß-sitosterol, triglicerides, triterpenoid, gibberillin, lignins, potassium sorbate, salicylic acid, uric acid. Vitamins: AB1, B2, B6, folic acid, choline and C, ß-carotene and α-tocopherol. Minerals: calcium, chlorine, chromium, copper, iron, magnesium, manganese, phosphorus, potassium, selenium, silicon, sodium, tin, zinc. Vitamins: A, B, B2, B6 and C.

B1.1.2 Therapeutic actions These differ depending on the part used; the green outer skin is the more bitter part and has a more purgative action than the gel; the anthraquinone glycosides, which are in greater concentration in the green skin are cathartic and purgative, it is a bile flow stimulant (as are most bitter tastes), emmenagogue, vulnerary, tonic, demulcent, anti-fungal, vermifuge, sedative and nutritive.

There are than 400 species of the genus Aloe, though only a small number are cultivated for commercial use, they include Aloe vera, predominantly, Aloe ferox, and Aloe arborescens. Aloe vera originates from the African continent and belongs to the Xanthorrhoeaceae family, having recently been reclassified; it was formerly of the Liliaceae family. Nowadays, it has

139 spread worldwide due to its widely known therapeutic properties and uses. Traditionally, in addition to its use in internal treatments, it has been used externally. Aloe has been used for healing wounds and burns, as it stimulates skin cells to proliferate and is vulnerary and demulcent (Ody, 2000).

The whole leaf is used mostly, as it is much more stimulating than just the gel. It is a potent digestive and appetite stimulant and used for constipation. It is also a stimulant and vermifuge. Externally, the bitter skin can be rubbed on fingers to deter nail biting and thumb sucking (Ody, 2000).

The gel can be taken internally to stimulate digestion and to help heal gastric ulcerations (Ody, 1993). In Traditional Chinese Medicine [TCM], Aloe is known as Hsiang-Dan, a processed form of Aloe is called Lu Hui, which is the dried gel. It is used to “purge accumulations, to drain fire from the body and to cool the liver” (p. 393); the latter two reflect the anti-inflammatory actions of Aloe (Lu, 1994). The medical use of this herb was recorded in the Ebers’ Papyrus, a medical text, which is believed to have been written in about 1500 BC; it is now is in the library of the University of Leipzig (Ebers Papyrus, 1500 BC). In recent years, the therapeutic activities of this herb have been clinically assessed—in a 2012 study, Ali, Galgut and Choudhary used aloin, an extract of A. vera on melanophores (pigment cells which contain melanin; they are commonly found in the skin of reptiles and amphibians). Aloin assisted with regulating melanin aggregation in the skin; this finding has indicated that this herb has potential for treating hyper-pigmentation as a non-toxic melanolytic agent (Ali, Galgut, & Choudhary, 2012).

Jia, Zhao and Jia (2008) evaluated the effects of two Aloe species (Aloe ferox and Aloe arborescens) for topical wound healing on animal models and in addition, they assessed Aloe gel in vitro on four strains of bacteria and three types of fungus. Their results indicate that Aloe does facilitate the healing process of dermal wounds and in addition, it inhibited all the bacteria strains, but only one of the fungi; Cryptococcus neoformans. They state that further clinical trials are required to confirm the potential health benefits of Aloe species (Jia, Zhao, & Jia, 2008). A systematic review conducted by Radha and Laxmipriya (2015) discusses the constituents and therapeutic actions of A. vera and the findings which indicate that these actions can assist to improve health and act as a disease preventative (Radha & Laxmipriya, 2015). This further endorsed by the Hamman 2008 review of the composition and therapeutic uses of the gel of Aloe vera (Hamman, 2008).

140 Research using animal models, which were exposed to UVB-induced sunburn, provided the findings for Silva et al. (2014); that the topical use of Aloe saponaria demonstrates both anti- inflammatory and anti-nociceptive effects; their considered that this was caused by the antioxidant constituents of Aloe (Silva et al., 2014).

Recent research by Tanaka, Misawa, Yamauchi, Abe and Ishizaki (2015) has confirmed that when regular daily ingestion of Aloe vera gel powder, which has standardised levels of Aloe sterols significantly reduced facial wrinkles in women aged over 40 years. They have found that the sterols extracted from Aloe vera have a stimulating effect to with the production of collagen and hyaluronic acid by human dermal fibroblasts (Tanaka, Misawa, Yamauchi, Abe, & Ishizaki, 2015). Further research by Tanaka et al., 2016, trialled Aloe sterols, taken orally, on a group on men, who were regularly exposed to sunlight, concluded that this oral treatment increased the elasticity of skin which has been sun damaged (Tanaka et al., 2016). An aspect of the efficacy of Aloe as a topical treatment, which has been researched, is its ability to better penetrate the dermal layer than many substances. Cole and Heard (2007) assessed the potential permeation enhancement of Aloe vera, which was supported by their in vitro research, though their proposed mechanism of action requires further investigation for confirmation; they suggest that Aloe gel does enhance transdermal delivery (Cole & Heard, 2007).

 “There are many uses for it, but the chief one is to relax the bowels, for it is almost the only laxative that is also a stomach tonic”  AD77, Pliny (aka Gaius Plinius Secundus 2379 AD), Roman philosopher and writer.  “…when all purging medicines are hurtfull to the stomacke, Aloes onely is comfortable.”  “is good against a stinking breath proceeding from the imperfection of the stomacke; it openeth the piles or hemorrhoides of the fundament; and being taken in a small quantity, it bringeth downe a monthly course.”  "forasmuch as it clenseth and drieth without biting” - The English Herbalist, Gerard recommended most highly aloe juice as a purgative and vermifuge and medicine for the eyes. From his book Herball, Generall Historie of Plants (Gerard, 1998 (original work 1597)).

141 B1.2 Arctium lappa (L.) (Compositae) (Burdock)

The character of Burdock is cool, drying, and bitter (Ody, 2000).

B1.2.1 Constituents The root is considered to be a nutritive tonic, containing a wide variety of vitamins and minerals. It also contains flavonoids, bitter glycosides, polyacetylenes, mucilage, resin, volatile acids (including acetic, butyric, costic, isovaleric, propionic, 3-hexonic and 3- octenoic), nonhydroxy acids (including lauric, myristic, palmitic and stearic), phenolic acids (including caffeic and chlorogenic), dehydrocostuslactone, volatile oils and inulin.

Figure 29: Arctium lappa (burdock)

Source: (Hilterman, 2012a)

B1.2.2 Therapeutic actions Its primary use is as an alternative; acting as a blood cleanser and tonic, when taken internally—it can assist the body attain an improved state of wellness. It is useful treatment for a wide range of conditions, especially for skin such as acne, eczema, boils, ulcers, psoriasis and dry scaly skin. Due to its purifying effect, it is prescribed for digestive disturbances, rheumatic and urinary conditions and it also has antibiotic activity. It assists the body purify itself and eliminate toxins (Fisher & Painter, 1996).

142 It is the root which is used primarily: For external conditions, it is used as a poultice or wash. The leaves can be used as a digestive tonic infusion or as a poultice. The ground-up seeds are traditionally used for coughs and colds and to help reduce blood sugar levels.

In TCM, Burdock is called Niu Bang Zi, or Great Burdock. It is used for reducing internal heat inflammation dissipating gasses and detoxifying, in addition to ‘pushing out measles that fail to erupt’; this is an example of a skin alterative. Niu Bang Zi is an ingredient of the TCM formulation ‘Yin Qiao San or Honeysuckle and Forsythia Powder’ for reducing heat (Tang & Craze, 1995).

Burdock belongs to the Asteraceae family, previously the Compositae family. It originates from Europe and Asia and because of its therapeutic benefits, has spread its way around the world. The Japanese cultivate Burdock roots, known as Gobo, traditionally they were eaten for its aphrodisiac qualities and also to assist with strength and endurance, perhaps any herb, which helps the body function better, could be called an aphrodisiac. The peeled stalks are either eaten raw or boiled and dipped in butter like asparagus. As a root vegetable, slice the root cross ways and boil for half an hour or until tender. It is suggested that the cooking liquid be either drunk as a juice or use it as stock as it will contain many nutrients, especially minerals, which are extracted out of the root with cooking water. In Europe ‘Dandelion and Burdock’ is a traditional drink—It is a fermented brew of the roots of both these herbs and has a taste that is similar to sarsaparilla (Fisher & Painter, 1996).

 “…it is so well known, even to the little boys who pull off the burrs to throw and stick on each other, that I shall omit writing any description of it… The roots helpeth them that spit foul mattery and bloody phlegm” (Culpeper, 1981 (originally published 1653)).

B1.3 Avena sativa (L.) (Poaceae) (Oats)

The character of Oats is considered to be warm, sweet and moist (Ody, 2000).

143 B1.3.1 Constituents Alkaloids; including avenine, trigonelline, saponins, silicic acid, flavonoids, sterols; including avenasterol, vitamins A, B-complex including thiamine, riboflavin, niacin, and folic acid, C, E and K. Minerals silica, calcium, iron, potassium & phosphorus. As well as fibre, Oats has a wide range of amino acids. These minerals are best extracted with water or vinegar.

Figure 30: Avena sativa (Oats)

Source: (Sendelbach, 2005)

B1.3.2 Therapeutic actions Nutritive, thymoleptic, anti-depressive, cardiac tonic; the alkaloids are stimulating and silica is a specific tissue healer. There is a folk saying “he’s feeling his oats”, which refers to a person (or horse) that was not so well has perked up after eating oats; a classic example of food as medicine (Fisher & Painter, 1996; Ody, 1993).

Oats belong to the Poaceae family; it is a tall annual grass species, with the inflorescence (seed heads) rising above the foliage of the plant. Originating in Northern Europe, where it had been part of the diet for eons, Oats are now grown worldwide in cooler climates. Culpeper said of oats that they “are so well known that they need no description” (Culpeper, 1981 (originally published 1653)). He often wrote this, of plants that grew commonly in England during his lifetime (1616-1664).

Internal Uses: Dosage: Oats are considered a very safe herb. Eat oats as porridge or muesli. Drink Oat straw infusions, using up to 12 grams of dried herb per day. Prepare Oat straw as a

144 decoction, simmer at least 20 minutes. Fresh Green Oats can also be juiced, as wheat grass and barley grass are; consume up to 10mls daily. It is useful to drink this juice or Oat straw tea when going through withdrawal from tobacco or other addictive substances. The author has used green oat tincture in a herbal formula to assist patients with tobacco withdrawal, with excellent results. It is also beneficial for nervous system conditions such as depression including menopausal induced, general debility, insomnia, neuralgia, peripheral neuropathy and shingles (Bone & Mills, 2013).

In a review of herbal therapy in dermatology, Bedi and Shenefelt identified that there has been a long traditional history of using Oats for its anti-pruritic and soothing actions; for these actions it is approved for use by the German Commission (Bedi & Shenefelt, 2002) The following quote certainly supports Oats as good medicine: “Taking Oats is a complete body overhaul from the inside to the outside” (Holmes, 1989).

External Uses: Oats are used as compresses, scrubs, washes for such conditions as eczema, dry skin, neuralgia, shingles, wounds and burns (Fisher & Painter, 1996).

 “Oats fried with bay salt, and applied to the sides, take away the pains of stitches and wind in the sides or the belly. A poultice made of meal of Oats, and some oil of Bays put thereunto, helps the itch and the leprosy, as also the fistulas of the fundament, and dissolves hard imposthumes. The meal of Oats boiled with vinegar, and applied, takes away freckles and spots in the face, and other parts of the body” (Culpeper, 1981 (originally published 1653)). Current research findings are supportive of Culpeper’s writings.

B1.4 Berberis vulgaris (L.) (Berberidaceae) (Barberry)

The character of Barberry is bitter, astringent cooling (Ody, 2000).

B1.4.1 Constituents Inner bark: Cheladonic, malic, citric, and tartaric acids, alkaloids; including berbamine, berberine, bervulcine, columbamine, jatrorrhizine, isotetrandine, magniflorine, palmatine and oxyacanthine, tannins, resins, wax and carotene.

145 oxyacanthine, tannins, resins, wax and carotene.

Berries: Antioxidants, anthocyanins, phenolic compounds, protein, fibre, very high levels of vitamin C, ascorbic acid, and minerals. They are considered by research scientists to be highly beneficial for human nutrition.

Figure 31: Berberis vulgaris (barberry)

Source: (Scottish Rock Garden Club, 2016a)

B1.4.2 Therapeutic actions Anti-protozoal, anti-bacterial, anti-haemorrhagic, cholagogue, spleen tonic, anti-pyretic, anti- inflammatory, antibiotic, anti-convulsant, sedative, hypotensive, alterative, carminative, anti- emetic, and anti-diarrhoeal (Fisher & Painter, 1996).

Barberry belongs to the Berberidaceae family, of which there are over five hundred species. B. vulgaris grows throughout Europe, Western Asia, across Northern Africa and into the Middle East, as well as North America, though it has naturalised on other continents. The Ancient Egyptians used the juice of the berries to treat fevers and because of its bitter taste; the juice was traditionally made as a drink that was sweetened with sugar and syrup of roses. Iran produces more than 5,000 tonnes of the seedless variety of Barberry, Berberis vulgaris var. asperma, is grown each year for use as a highly valued food additive. This is known in Iran as Zereshk (Tehranifar, 2003). In 2009, Akbulut et al., assessed some of the physicomechanical and nutritional properties of wild harvested Barberry berries in Turkey

146 where it is also considered to be a valuable culinary and medicinal product (Akbulut, Çalisir, Marakoglu, & Çoklar, 2009). They warrant this herb requires further research to investigate its therapeutic activities. Imanshahidi and Hosseinzadeh conducted a review of both the therapeutic effects and pharmacological activities of Berberis vulgaris; their specific investigations were of its isoquinoline alkaloids, which include berberine, berbamine and palmatine—they consider these are important constituents. The review focused on berberine content and use (Imanshahidi & Hosseinzadeh, 2008). They found that research over twenty years has shown varying pharmacological and therapeutic effects of Barberry. Soil type and growing conditions may account for this (Di et al., 2003). This herb has had a tradition of use in Iran, where traditional folk medicine uses the fruit, leaves and the bark (Imanshahidi & Hosseinzadeh, 2008).

Using optimized HPLC method, Di et al., assessed four alkaloids (berbamine, jatrorrhizine, berberine and palmatine) obtained from Berberis species. They used methanol as an extracting medium, to obtain extracts from the following plant parts of Barberry: stem bark and stem, the root bark and root. With using this method, they were able to discern differences to verify what species, where it was grown or which plant part was being tested. This research showed that there are differences in the alkaloid components of Berberis grown in different areas as well as a variation of constituents between species (Di et al., 2003).

 “The inner rind of the Barberry-tree boiled in white wine, and a quarter of a pint drank each morning, is an excellent remedy to purge the body of choleric humours, and free it from such diseases as choler causes, such as scabs, itches, tetters2, ringworms, yellow jaundice, boils…” (Culpeper, 1981 (originally published 1653)).

B1.5 Calendula officinalis (L.) (Compositae) (Calendula/Marigold)

The character of Calendula is considered to be slightly bitter, pungent, drying and slightly cooling (Ody, 2000). The petals of the flowers are considered to be the most therapeutic part, although it is usual for the whole flower to be used. Calendula is a member of the Asteraceae (formerly Compositae) family.

2 tetters, n, any of various skin diseases, such as eczema, psoriasis or herpes, characterized by eruptions and itching (Dictionary, 2012).

147 B1.5.1 Constituents Flavonoids, carotenoids (pro vitamin A), saponins, mucilage, essential oils, reins, sterols, potassium, bitter principles (including malic acid) and calendulin. Vitamins A and C and minerals, including phosphorus.

Figure 32: Calendula officinalis Figure 33: Calendula officinalis (Calendula/Marigold) (Calendula/Marigold)

Source: (Villis, 2003b) Source: (Scottish Rock Garden Club, 2016c)

B1.5.2 Therapeutic Actions Vulnerary, anti-inflammatory, antiseptic, astringent, anti-viral, anti-fungal, lymphatic stimulant, and immune supporter, menstrual regulator, and cholagogue. It is soothing to the digestive tract and can aid assimilation of nutrients, additionally; it assists to lower elevated blood pressure.

External Uses: Calendula can be utilised in a variety of applications; as a wash, compress, lotion, infused oil, essential oil, cream or ointment for most skin conditions, especially slow healing wounds, bruises, cuts, burns; including sunburn, eczema, fungal infections, cracked or sore nipples, oily skin or varicose veins.

Internal Uses: It is a useful treatment for liver and gall bladder dysfunction, stomach and digestive tract ulceration, menstrual dysfunction, candida and helps tone the circulatory

148 system. It stimulates the lymphatic and immune systems and is an aid to assist with lowering elevated blood pressure due to its vasodilatation effect.

Calendula infusions can also be used as a mouthwash for mouth ulcers and gum disease, or as a douche for vaginal infections or inflammations including candida. A modern application for vaginal thrush can be to dip a tampon into a strong infusion and insert it. Change regularly and leave one in overnight to assist (Ody, 1993); (Fisher & Painter, 1996); (Mills & Bone, 2000); (Khan & A., 2010); (Hilterman, 2019).

This herb certainly exhibits the necessary therapeutic activity that would indicate it as having potential for assessment as a possible treatment for AKs, preferably included in a formula with other herbs which have therapeutic actions to complement it for treating AKs, or other sun-induced skin damage.

 “The yellow leaves of the floures are dried and kept throughout Dutchland against the winter to put in broths...” (Gerard, 1998 (original work 1597)).  "Marigolds are very expulsive and little less effective in small-pox and measles than saffron" (Culpeper, 1981 (originally published 1653)).

B1.6 Echinacea purpurea L. Moench, and angustifolia DC. (Compositae) (Echinacea) The character of Echinacea is described as pungent, cool and dry (Ody, 2000).

B1.6.1 Constituents Including glycosides, amides, volatile oils, resins, polyacetylenes, isobutyl amides, caffeic acids esters, alkaloids, sesqueterpenes, inulin, phytosterols plus Vitamins A, C and E and minerals; potassium, iodine, iron, sulphur and copper.

B1.6.2 Therapeutic actions Immune stimulant, immune-modulator, antibiotic, anti-fungal, anti-viral, alterative, vulnerary, diaphoretic, anti-allergenic, anti-inflammatory, lymphatic tonic. The whole plant can be used but the roots are the most therapeutically active part (Mills & Bone, 2000).

Echinacea is in the Asteraceae (formerly Compositae) family. The most common member of this genus is Echinacea purpurea, commonly known as the purple cone flower. There are nine species of the Echinacea family: Echinacea angustifolia, the narrow leafed cone flower

149 is very useful medicinally but is not a vigorous grower. E. pallida has a pale flower is also used medicinally.

Figure 34: Echinacea purpurea Figure 35: Echinacea purpurea (Echinacea) (Echinacea)

Source: (Hilterman, 2003a) Source: (Scottish Rock Garden Club, 2016d)

The other Echinacea species are either not well-known or are an endangered species in the wild. The main commercial focus is on E. purpurea as it is much easier to grow and harvests more useable material. There is a long tradition of use of various Echinacea species by the natives of North America, where this genus originates.

Primary Uses: Infections and immune dysfunction. Echinacea is an immunomodulator; bringing balance to an either under-active or over-active immune system. It is as useful for AIDS (under-active immune system), as it is for Lupus or Rheumatoid Arthritis (over-active immune system). Due its excellent anti-inflammatory action, it assists with treating arthritic conditions. Basically, Echinacea is useful for any infection in any body system, internally or topically (Khan & A., 2010; Mills & Bone, 2000; Morgan & Bone, 2010; Ody, 1993).

 Echinacea: “It has proved a useful drug in improving the body’s own resistance in infectious conditions of all kinds” (Hilterman, 2019)

150 B1.7 Galium aparine (L.) (Rubiaceae) (Cleavers) The character of Cleavers is described as cold, salty and slightly dry (Ody, 2000).

B1.7.1 Constituents Cleavers contains flavonoids, coumarins, tannins, iridoid glycosides (including monotropein), phenolic acids, and three distinct acids, galantannic, citric and rubichloric acids, also chlorophyll, starch and volatile oils.

B1.7.2 Therapeutic actions Diuretic, lymphatic, alterative, tonic, mild astringent, anti-inflammatory and anti-neoplastic. (British Herbal Medicine Association, 1983); (British Herbal Medicine Association, 1992); (Fisher & Painter, 1996); (Mills & Bone, 2000); (British Herbal Medicine Association, 2003).

Figure 36: Galium aparine Figure 37: Galium aparine (Cleavers) (Cleavers)

Source: (Villis, 2003c) Source: (K. A. Hilterman, 2016b)

This herb belongs to the very large Rubiaceae family, with 13,000 known species. This herb has a long traditional history of medicinal uses in Europe, where it originates. It is the aerial parts which are used; the leaves, stems and flowers. It is closely related to Sweet Woodruff (Galium odoratum) and Ladies Bedstraw (Galium verum); also considered to be useful herbs. This herb is considered to be particularly helpful to human beings as a food and a medicine. It is described as a cleansing and purifying herb; assisting to rid blood and lymph of toxins and is excellent to use for cases involving swollen or enlarged glands, including tonsils and

151 adenoids. It is considered to be a ‘poorly researched herb’, considering both its traditional uses and therapeutic actions and health benefits (Fisher & Painter, 1996).

External Uses: For skin conditions; a strong infusion of Cleavers can be used externally for grazes, psoriasis and other skin inflammations or as a rinse for dandruff and other scalp problems. Additionally, it can be used as a wash for burns and scalds, including sunburn or freckles. The same infusion, taken internally, can be used to treat the body for the underlying causes of such skin conditions and support the healing function of the body (Fisher & Painter, 1996).

It is surprising that Cleavers has not been more thoroughly assessed with clinical research, considering its consistent use for lymphatic enlargements and skin diseases throughout history; however, it has been assessed for its therapeutic constituents, (Mills & Bone, 2005). In 1597, John Gerard said cleaver was:

 “a marvellous remedy for the bites of snakes, spiders and all venomous creatures … Women do usually make a pottage of clevers … to cause lankness and keepe them from fatness” (Gerard, 1998 (original work 1597)).

B1.8 Hypericum perforatum L. (Hypericaceae) (St John’s Wort)

The character of this herb is described as drying, cool and bitter sweet (Ody, 2000).

B1.8.1 Constituents Including volatile and essential oils, flavonoids; including hyperoside, quercitrin, quercetin, isoquercetin, I3,II8-biapigenin, miquelianin, rutin, epigallocatechin, astilbin and amentoflavone, melatonin, naphtodianthrones/glycosides; including hypericin, pseudohypericin, protohypericin, protopseudohypericin), xanthones; including 1,3,6,7- tetrahydroxyxanthone (XII) and kielcorin C, resins, tannins, phlorogucinols; including hyperflorin and adhyperforin, oligomeric procyanidins, phenolic acids (including cholorogenic, caffeic & 3-O-coumaroylquinic acids) and amino acids.

B1.8.2 Therapeutic actions Anti-depressant, sedative and tonic for the nervous system, anxiolytic antiviral (specifically antiretroviral and for enveloped viruses), antiseptic, anti-inflammatory, analgesic astringent

152 and relaxant. Topically; vulnerary, antiseptic and analgesic (Fisher & Painter, 1996); (Mills & Bone, 2000).

St John’s Wort belongs to the Clusiaceae (sometimes referred as Hypericaceae or Guttiferae) family; it originates from Europe—this particularly useful species has been transported to many lands. There are 370 recognised species in the Hypericum family; some quite similar to H. perforatum, which is considered to be a nuisance weed by many, including farmers, as there is some evidence that stock that graze on it may become photosensitised, making them more prone to sun-induced skin damage (Kacerovska et al., 2008). The part of this herb that is considered the most beneficial, medically, is the flowering tips.

Figure 38: Hypericum perforatum Figure 39: Hypericum perforatum (St John’s Wort) (St John’s Wort)

Source: (Scottish Rock Garden Club, 2016e) Source: (Ignaz, 1800)

“For chilblains, boild the roots of tutsan and pur upn curds. Pound with old lard and apply as a plaster…”  tutsan is a folk name for H. perforatum; this is a 13th Century remedy of the Physicians of Myddfai (Wales). Patočka (2003) suggests that this is a very well-known herb, which has an ancient history of use as a herbal medicine and despite the therapeutic constituents and actions of H. perforatum have been researched and analysed, there is still very little known and understood of their “molecular mode of action”. He concludes his report to say that “most of the compounds described in this report may be used for different

153 purposes in the near future” (p68) (Patočka, 2003). This indicates that there is still more to be learnt and understood about this remarkable herb. This herb does have a tradition of use back to antiquity in all lands of origin throughout Europe, and has created a lot of interest as a research subject. Much of this has been regarding the anti-depressant and photo-sensitising effect of H. perforatum. As mentioned in Chapter 4, St John’s Wort can have significant Herb-Drug interactions, particularly for internal use; this may not be as relevant for topical application. If this herb is to be considered for use, awareness of potential interactions must be at the foremost with the formulator and relevant labelling used (Steinhoff, 2012).

Of greater relevance to this thesis is the research of Hostanskaa et al., the in vivo research, which was published in 2003, where this study they assessed hyperforin [HP], hypericin [HY] and polyphenolic procyanidin B2 [PB-2]. They found that HP and PB-2 were able to inhibit the growth of the following: leukaemia K562 and U937 cells, brain glioblastoma cells LN229 and normal human astrocytes. Also discerned was that HP and HY has synergistic activity with their inhibitory effect on leukemic (K562, U937) cell growth. Additionally, it was discerned that apoptotic activity from HP and PB-2 caused cell death after 24 h treatment (Hostanskaa et al., 2003). Apoptosis is a therapeutic action that would greatly assist as an active in a treatment for AKs and for NMSCs.

 “St. Johns Wort with his floures and seed boyled and drunken, provoketh urine, and is right good against the stone in the bladder, and stoppeth the laske (diarrhoea) (Gerard, 1998 (original work 1597)).  “The leaves stamped are good to be layd upon burnings, scaldings, and all wounds; and also for rotten and filthy ulcers. The leaves, floures, and seeds stamped, and put into a glasse with oyle Olive, and set in the hot sunne for certain weeks together, and then strained from those herbs, and the like quantitie of new put in, and sunned in like manner, doth make an oyle of the colour of bloud, which is a most precious remedy for deepe wounds, and those that are thorow the body, for sinews that are prickt, or any wound made with a venomed weapon” (Gerard, 1998 (original work 1597)).

B1.9 Matricaria chamomilla (L.) (Compositae) (aka Matricaria recutita) (Chamomile)

The character is bitter, neutral, warm and moist (Ody, 2000).

154 B1.9.1 Constituents Volatile oils; including sesquiterpenoids, matricarin, matricin, and farnesol also chamazulene, farnesene, flavonoids; including apigenin, apigetrin, apiin, quercetin, quercimeritrin, luteolin, rutin and patuletin. Glycosides, tannins, phenols, coumarins; including aesculetin, scopoletin and umbelliferone. Plant acids; including anisic, caffeic, syringic and vinillic. Salicylates, polysaccharides and phytosterols; including campesterol, cholesterol, sitostanol, sitosterol, stigmasterol, taraxasterol. Minerals; calcium, iodine, magnesium, potassium, iron, manganese and zinc. Vitamins; A, niacin, riboflavin and C.

Figure 40: Matricaria chamomilla (chamomile)

Source: (Hilterman, 2012b)

B1.9.2 Therapeutic actions Anti-inflammatory, anti-spasmodic, antiseptic, vulnerary, anti-catarrhal, carminative, anti- allergic, digestive tonic, mild sedative, mild analgesic. This very useful herb is a member of the very large Asteraceae family (Fisher & Painter, 1996). As a herbal medicine, it is the flower of Chamomile which is the part used; it is a tiny daisy with a ring of white petals around a golden domed centre. The fragrance is described as somewhere between freshly cut hay and apples. The name is derived from Greek words for ground apple because of its scent. The flowers have a strong action on the nervous system and help reduce the effects of stress, tension and promoting peaceful sleep.

155 Internal Uses: Chamomile can assist with relieving headaches brought on by stress or over concentration and is considered to be one of the more effective remedies for nervous indigestion. It is also utilised for treating stomach cramps, colic, colitis, ulcers, gastritis, diverticulitis, irritable bowel, diarrhoea or constipation and other similar conditions, an excellent herb for treating gut conditions.

The mild analgesic action may help relieve pain, especially if the pain is of neuralgic origin or by damage to nerve function. Chamomile can slow down rapid heartbeats caused by fear and tension, additionally, it is useful to ease nausea in pregnancy and travel sickness.

This herb is considered to have a soothing gentle action, safe to use with babies and small children. It is useful for conditions such as colic, teething, measles, asthma or croup (with either infusion or inhalation), colds, earache, diarrhoea, sore eyes, conjunctivitis, fevers and eczema. In addition to herbalists, some medical doctors in Germany, France and Spain are in high regard the benefits of chamomile and it is considered as safe to prescribe it for babies and children (Fisher & Painter, 1996); (Ody, 2000); (Bone & Mills, 2013).

External Uses: An infusion is used as an eye-wash; use a strong infusion or decoction for haemorrhoids in a sitz bath (this same method may be used for genital candida), for heat rash, ulceration and wound healing (Ody, 2000).

 “To comfort the braine, smel to chamomill, eate sage…wash measurably, sleep reasonably, delight to heare melody and singing” (Ram’s Little Dodoen, 1606) (Dodoens & Ram, 1606).  “Chamomylle… is very agreeing unto the nature and man, and… is good against weariness…” (Turner, 1551).

B1.10 Phytolacca americana (L.) (Phytolaccaceae) (aka P. Decandra) (Poke Weed)

Has been assigned the character of cooling, slightly sweet and acrid (Ody, 2000).

B1.10.1 Constituents This herb has a highly complex chemical composition. Triterpenoid saponins; including phytolaccosides A-1, D2, and O. Alkaloids; including betalain–type, betanidine, betanine, isobetanine, isobetanidine, isoprebetanine, phytolaccine and prebetanine. Isoamericanin A, aglycones; including phytolaccagenin, lectins or glycoproteins, also known as known as

156 pokeweed mitogen, there are five glycoproteins Pa−1 to Pa−5), pokeweed antiviral protein, (aka PAP), α-spinasterol, acinosolic acid (a methyl ester), aesculentic acid, phytolaccic acid, phytolaccagenic acid, formic acid, oleanolic-acid, jaligonic acid, phytolaccatoxin monodesmosidic and bidesmosidic compounds, astragalin, gamma aminobutyric acid (aka GABA), resins, histamine, fatty oil, tannin, sugar, xylose, starch, Vitamins; A, B’s, C, D, E and K. Minerals; potassium, calcium, sodium, phosphate, potash, and silica.

Figure 41: Phytolacca americana Figure 42: Phytolacca americana (poke weed) (poke weed)

Source: (Scottish Rock Garden Club, 2016g) Source: (The American Cyclopaedia, 1873)

B1.10.2 Therapeutic actions Powerful immune and lymphatic stimulant, purgative, emetic, anti-inflammatory, antirheumatic, generally, a stimulant, including for the respiratory system, expectorant, deobstruent, resolvent, antisyphilitic, antiscorbutic, cathartic, alterative, mild anodyne, antifungal, anti-parasitic, and detergent (Fisher & Painter, 1996).

Internal Uses: This herb is primarily used to treat infections, infestations, under-active immune and lymphatic systems. The prophylactic use, to boost immune system prior to travel or stressful conditions is considered useful.

External Uses: Scabies, tinea, ringworm, acne, folliculitis, other infections or infestations and abscesses (including mammary abscesses) and mastitis (Ody, 1993); (Fisher & Painter, 1996); (Hilterman, 1998); (Mills & Bone, 2000); (Schar, 2010).

157 Poke Weed, belonging to the Phytolaccaceae family, it is indigenous to North America and was traditionally used as a medicine by the indigenous peoples. Quite rapidly it was accepted by the colonising peoples as a very useful medicine, though one to be used with caution. It became a favourite of The Eclectics, an American group of physicians, who were motivated by Samuel Thompson, the founder of Physiomedicalism in 1769. He was taught about healing with herbs, including indigenous herbs by a ‘herb wife’, known as Widow Benton. The physiomedicalists were renowned for ‘purging and poking’ their patients, by often using cathartic herbs, of which Poke Weed is one (Ody, 2000).

Dr Ellingwood, in his 1905 publication, writes of the usefulness of Poke Weed for:

 “inflammation of glandular structures, especially of the lymphatic glands. Pains of rheumatism, characterized by deficient catabolism, are relieved by it. It is directly indicated in irritation, inflammation, and ulceration in rheumatic subjects, sanious ulcers, scabies, tinea capitis, psoriasis, and all skin diseases. It is especially valuable in the squamous varieties of skin diseases” (Ellingwood, 1899).

It is primarily the root which is used medicinally, though traditionally, the new leaves in spring were harvested to make a cleansing, purifying tonic salad. With summarising the use of P. Americana, Schar (2010) writes “The Eclectics’ found P. americana effective in the most severe form of immune dysfunction, multi-system auto-immune disease (i.e. psoriatic arthritis, rheumatoid arthritis with systemic involvement, etc.)” Schar recommends that further investigation of this herb, by phytotherapists, is warranted, considering the indications of benefit for treating auto-immune dysfunctions (Schar, 2010).

Despite its record of use, as an effective treatment for a considerable number of medical conditions, there appears to have been no clinical research conducted using Poke Weed on humans for any dermatological conditions. This herb certainly warrants further exploration. It is prescribed as a ‘very low dose herb,’ (the recommended weekly dose of a 1:5 tincture is 1- 5mls per week) (Mediherb, 2018), this would suit it being included in a herbal formula for treating AKs, meaning less volume is required for a therapeutic dose.

 “In acute infection (so called blood-poisoning) characterized by the acutely swollen lymphatic glands, red cordy streaks, pyrexia, etc., incision at the point infected and the use of phytolacca and echinacea, both in full doses with the proper sedative, will reduce the entire train of symptoms in a most satisfying manner. It is a powerful eliminative agent and very potent in bringing about

158 destructive metabolism, making it a useful adjuvant in the various dyscrasias. It thus renders good service in so called scrofulous affections, in syphilitic troubles and in the different manifestations of chronic rheumatism. In rheumatic troubles it must be given in large doses. In chronic diseases in which the action of the skin is sluggish, the blood vitiated and the lymphatics inactive it is directly called for. In skin troubles calling for it, which are usually of a scaly variety, the cuticle is not hypersensitive though it may be inflamed” (Ellingwood, 1909).  “The uses of poke were handed down to European settlers by the American Indians who valued the plant as an emetic, and as a remedy in gonorrhoea and syphilitic rheumatism. Early American medicene used the root in oilments for the cure of many skin diseases, notably: psoriasis, eczema, capitis, and tinea cinata. A tincture of the berries was found to be cureative of syphilitic and gonorrhoeal rheumatism as well as not-specific forms of that disease. Also used as a stimulant vulnerary is syphilitic ulcers, and as a softening application in mastitis, as well as scrofulous swellings of the glands in general… It was expertimented with as a cure for cancer but its sucess in the cure of these maladies never became noticable” (Millspaugh, 1892).

B1.11 Prunella vulgaris (L.) (Lamiaceae) (Self Heal)

Has the character of slightly bitter, pungent, cold and astringent (Ody, 2000).

B1.11.1 Constituents Include flavonoids, rutin, hyperoside, anthocyanadins (including delphinidin), fatty acids, caffeic, triterpenes (including betulinic, rosmarinic, oleanolic and ursolic acids, D-camphor, 2α, 3α and 24-trihydroxyolean-12-en-28-oic acids) volatile oils, phenols, bitters, saponins, polysaccharides (including prunellin and prunelline), sterols, alkaloids and tannins. Vitamins A, B, C and K, Minerals manganese.

B1.11.2 Therapeutic actions Anti–bacterial, vulnerary, diuretic, astringent, and hypotensive. As an eye-wash, it is used for conjunctivitis or tired, itchy or strained eyes. For sore throats it is used as a gargle or mouthwash, also for mouth or gum infections and inflammations. Traditionally, it is used as a poultice or compress for clean wounds (Fisher & Painter, 1996).

Self Heal is a member of the Lamiaceae (formerly Labiatae) family. It originates from Europe and Asia and has found its way around the globe. Indeed, it is a most useful weed, quite a prolific grower in the garden but also an attractive ground cover. It is the aerial parts of P. vulgaris that are most commonly used in WHM, where as it is specifically the flowers of Self Heal that are used in Chinese Herbal Medicine, and they are known as Xia Ku Cao.

159 They are used as a liver stimulant, cooling, anti-bacterial and as an aid to lowering blood pressure and fevers. Traditionally, this herb has been used for treating cancers, boils and scrofula (Li 2009). There appears to be considerable interest in researching this herb within China, as most of the research papers have been published in the Chinese language, therefore have not been included, as the author cannot read and interpret them.

Figure 43: Prunella vulgaris Figure 44: Prunella vulgaris (Self Heal) (Self Heal)

Source: (Hilterman, 2003b) Source: (Szivos, 2010a)

Researchers from Kashmir, Rasool et al. (2010) published their assessment of the phytochemical constituents of P. vulgaris, a herb widely used in Unani traditional medicine, which is importance greatly respected medical tradition in Kashmir. They harvested and dried the plant material collected in the Naranag area of Kashmir, and then used a variety of extracting mediums to assess the bioactive constituents present. The results showed that on average there was present the following constituents; alkaloids—1120 mg %, saponins—350 mg %, phenolics—55.785 mg % and tannins (52.25 mg %). In addition, they discerned the plant material contained; carbohydrates—375 mg %, proteins—441.6 mg % and lipids— 2403.8 mg %. Their suggestions are that P. vulgaris be assessed phytochemically in other lands to compare levels, which may vary with climatic and growing conditions, to identify the highest levels for future pharmaceutical uses (Rasool, Ganai, Akbar, Kamili, & Akbar, 2010).

160 Czech researchers, Markova et al. (1997) assessed the activity of P. vulgaris as having high levels of rosmarinic acid, and with the immune-modulation effects of prunelline; a polysaccharide present in Self Heal, as well as other constituents with known antiviral activity (Marková, Sousek, & Ulrichová, 1997). Unfortunately, this paper is written in the Czech language, therefore only some content has been available to this author. They, too, see this herb as worthy of future pharmacological studies particularly since this herb, as used traditionally, appears to accelerate wound healing (Marková et al., 1997).

Xu, Lee, Lee, White and Blay (1999), assessed an anionic polysaccharide, extracted from an aqueous extract of P. vulgaris for antiviral activity against herpes simplex types I and II (HSV), including known acyclovir-resistant strains. The polysaccharide was able to inhibit the HSV strains, including the acyclovir-resistant strains, both at early and later stages of virus infection. The Prunella polysaccharide was not though effective at inhibiting other viruses it was tested on, which included human influenza virus types A and B, poliovirus type 1, cytomegalovirus or the vesicular stomatitis virus. Additionally, it did not exhibit any anticoagulant activity and was not cytotoxic to mammalian cells, even at the highest concentration it was tested at. Therefore they consider this herb has considerable potential as a specific HSV antiviral treatment (Xu, Lee, Lee, White, & Blay, 1999). In vitro research of three polysaccharides extracted from P. vulgaris conducted by Li et al. (2015) found that all three assessed, (PV-P1, PV-P2 and PV-P3), indicated efficacy as antioxidant and immunomodulatory agents, though there was variation in activity between them, they suggested that further research could be undertaken as these polysaccharides indicate potential as antioxidant and immunomodulatory agents as functional foods and CAM (C. Li et al., 2015).

In research published in 2011 to assess Prunella vulgaris as an antiviral agent, particularly for anti-lentivirus; as a potential inhibitor of HIV-1, Oh et al., used both water and ethanol extracts of P. vulgaris. Their findings were that water extraction had greater, more potent antiviral action against HIV-1, when compared to ethanol extraction. In addition, they stated that when analysed further it was exhibited that the extracts inhibited both virus/cell interactions and post-binding events. They stated that despite that there only being a 40% inhibition maximally achieved in their virus/cell interaction studies, the extract was effective in blocking post-binding events, when using similar concentrations to the ones that blocked the infection (Oh et al., 2011). They suggest the extract targets the later steps, which they

161 state is the most important for mediating inhibition of virus infectivity. They concluded that inhibition of the virus activity occurs by interfering with the virion binding, at both early and post binding stages (Oh et al., 2011). Considering that an aqueous extract has the ability to inhibit the early stages within the HIV life cycle, leads them to believe that Prunella vulgaris extracts and potentially purified extracts show promise as an antiviral, particularly for HIV1 and antimicrobial activity (Oh et al., 2011). Rosmarinic acid was the specific phenol, extracted from P. vulgaris, which was investigated by Psotova, Svobodovaa, Kolarovab and Walterovaa (2006). They assessed the photoprotective effects of rosmarinic acid against oxidative stress from changes to a human keratinocyte cell line caused by UVA exposure; Rosmarinic acid significantly reduced reactive oxidative stress and DNA damage, both of which can lead to the cellular dysfunctions that develop into AKs. They conclude that P. vulgaris could be useful for inclusion in skin care products and that it shows potential for protection against oxidative stress caused by UVA exposure and could provide benefit in skin formulations, which provide photo-protection (Psotova, Svobodovaa, Kolarovab, & Walterovaa, 2006).

Using an aqueous extract of P. vulgaris, Han et al. (2009) assessed the efficacy of P. vulgaris for its anti-tumour and immunostimulatory activity. It was found to increase the activity of phagocytes and macrophages and having cytostatic actions, it increases the production of the biological regulator nitric oxide, adding additional support to the health benefits of this common weed (Han et al., 2009). When analysing the active components and the anti-tumour activity of P. vulgaris, harvested from four different locations, specifically for the prevention and treatment of lung cancer, Feng et al. (2010) discerned similarity in peaks of actives with the HPLC analysis (caffeic acid, rosmarinic acid, rutin, quercetin, oleanolic acid and ursolic acid.), though the levels did vary from the various regions of harvest. They found that the anti-tumour activity was increased when using all the therapeutic constituents they assessed were in combination, as opposed to when used as isolated constituents—indicating synergistic activity. Additionally, the combination also significantly increased the TNF-α content and their results suggest that this herbs efficacy against lung cancer is due to the synergistic action of multiple components (Feng et al., 2010). An extract of P. vulgaris and a phenolic acid, rosmarinic acid, a component of it, were assessed by Vostálová et al., 2010, for anti-inflammatory and antioxidant activities and ability to suppress UVB damage to human keratinocytes (HaCaT or immortalised nontumorigenic human epidermal cells), using a solar simulator in vitro. Both substances significantly reduced ROS and Il-6 release. When

162 assessed together both substances were able to prevent UVB injury to the keratinocytes. The researchers’ state that this research requires to be conducted in vivo (Vostalova, Zdarilova, & Svobodova, 2010). With these positive research results, it indicates this is a herb that warrants further research investigation for a wide range of conditions.

 “There is not a better wound herbe…” (Gerard, 1998 (original work 1597)).  “Self-Heal whereby when you are hurt, you may heal yourself... it is an especial herb for inward or outward wounds. Take it inwardly in syrups for inward wounds, outwardly in unguents and plasters for outward” (Culpeper, 1981 (originally published 1653)).

B1.12 Stellaria media Stellaria media (L.) Vill. (Caryophyllaceae) (Chickweed)

The ascribed character of Chickweed is moist, cool and sweet (Ody, 2000).

B1.12.1 Constituents Active constituents are saponins, coumarins, hydroxycoumarins, triterpene glycosides, flavonoids (including rutin, apigenin hexosylapigenins, pentosylapigens, C-glycosylflavones, luteolin and genestein), saponins, fatty acids, galactolipids, carotenoids, linolenic acids, mucilage, caffeic, ferulic and trans-ferulic acids, vanillic, chlorogenic, carboxylic and oxalic acids and triterpenoids. Chickweed is considered to be a highly nutritious herb, containing Vitamins A, B1, B2, B12, C and D. Minerals; calcium, copper, calcium, potassium, phosphorus, sodium, iron, silica, zinc and some manganese.

B1.12.2 Therapeutic actions Nutritive, alterative, vulnerary, blood cleanser, cooling, demulcent, emollient, anti- inflammatory, anti–rheumatic, astringent and anti-pruritic (Mills & Bone, 2000).

“… In a word, it comforteth, digesteth, defendeth and suppurateth very notably” (Gerard, 1998 (original work 1597))

Stellaria media, an annual herb, which grows prolifically in the winter and spring, is considered by most as a weed. Indigenous to Europe, it has spread to grow in most temperate lands, it is related to the Carnation—both belong to the Caryophyllaceae family. This herb prefers cool, shady, damp places to grow in and if left to seed in these situations can grow for most of the year. A Chinese species, Stellaria dichotoma, with the common name of Yin Chai

163 Hu; it has similar nutritional and medical uses as Chickweed. For medicinal and nutritional uses, it is the aerial part which is used. An alterative, this herb assists with improving body function, its anti-inflammatory, vulnerary and demulcent actions can soothe digestive dysfunction and therefore is suited for treating such conditions as; gastric ulceration, constipation, colitis and other bowel disorders. The therapeutic actions which Chickweed has indicate it as well suited as a treatment for inflammatory skin disease, stings, burns and wounds. In 1530, Paracelsus3 when writing of chickweed described it as “the elixir of life… one of the supreme healers...” (Fisher & Painter, 1996).

Figure 45: Stellaria media Figure 46: Stellaria media (Chickweed) (Chickweed)

Source: (K. A. Hilterman, 2016) Source: (Villis, 2003d) .

In 1988, Green et al. published ‘Home Treatment of Skin Cancer and Solar Keratoses’, it was as a result from undertaking a survey of a Queensland community, where they asked local people about what they used “as home remedies for sun-induced skin lesions, including AKs”, Chickweed was one of the recorded home remedies (A. C. Green & Beardmore, 1988).  “a fine, soft, pleasing herb, under the dominion of the Moon”…“ The herb bruised, or the juice applied, with cloths or sponges dipped therein applied to the region of the liver, and as they dry to have fresh applied, doth wonderfully temper the heat of the liver, and is effectual for all impostumes and swellings whatsoever; for all redness of the face, wheals, pushes, itch or scabs,

3 Paracelsus aka Philippus Aureolus Theophrastus Bombastus von Hohenheim, 14931541, Swiss physician and botanist.

164 the juice being simply used, or boiled in hog’s grease” (Culpeper, 1981 (originally published 1653)). B1.13 Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae) (Dandelion)

The character of Dandelion is described as cold, bitter and sweet (Ody, 2000).

B1.13.1 Constituents The leaves contain glycosides, bitters, inulin, protein, fibre. Vitamins A, B, B2, B3, C, D, E, choline, folic acid, biotin, inositol, carotenoids and coumarins. Minerals; calcium, magnesium, potassium, selenium, zinc, manganese, aluminium, boron, chromium, iron, phosphorus, silicon, sodium and tin. The roots contain glycosides, bitters, inulin, protein, fibre, tannins, triterpenes, sterols, volatile oils, aspargin, inulin and phenols.

Vitamins A, B, B2, B3, C, D, E. choline, folic acid, biotin, inositol, carotenoids and coumarins. Minerals; calcium, magnesium, potassium, selenium, zinc, manganese, aluminium, boron, chromium, iron, phosphorus, silicon, sodium and tin.

Figure 47: Taraxacum officinale Figure 48: Taraxacum officinale (Dandelion) (Dandelion)

Source: (Szivos, 2010b) Source: (Villis, 2003e)

B1.13.2 Therapeutic actions Leaf: Nutritive, bitter tonic, alkaliser, digestive stimulant, cholagogue, alterative, diuretic, vulnerary, aperient, galactogogue and anodyne.

165 Root: Nutritive, hepatic, cholagogue, lithotropic, digestive stimulant, stomachic, laxative, diuretic, deobstruent, anti-bacteria, anti-fungal and astringent.

Flower: Emollient, anodyne, vulnerary, hepatic, calmative and cardio-tonic.

Sap: discutient, keratolytic, anodyne, anti-fungal and anti-bacterial.

Depurative activity, being one of Dandelion’s main actions is via its stimulation of the digestive system, the liver and kidneys, hence its detoxifying effect, which help such skin problems as eczema and acne. It has a modulatory effect to improve body functions. Anti- inflammatory and is most helpful for arthritis, rheumatism and other muscular skeletal problems and gout. It has also shown some anti-tumour action (Fisher & Painter, 1996).

Dandelion belongs to the Asteraceae (formerly Compositae) family and they originate from Europe and the Middle East and have been taken to many countries. The origin of the first part of the botanical name of this herb is from taraxos, which means disorder and akos, which means remedy, in the Greek language, when combined they form the genus name Taraxacum. There is a long recorded history of Dandelions being used as healing medicine, within the Middle Eastern medical tradition (Unani or Unani-Tibb Medicine sometimes presented as Yunani) and through Europe and the UK.

Flowers: as a skin wash to help sunburn, bites and stings, acne, oily skin and freckles, cardiac tonic and for headaches, Dandelion flower wine is both delicious and medicinal.

Sap: (external use only) Fresh sap on warts, corns, pimples, bee stings and calluses (Fisher & Painter, 1996).

 “It is colde, but drieth more and doth withal clense and open by reason of the bitternes which hath joined with it…” (Gerard, 1998 (original work 1597)).  “You see here what virtues this common herb hath, and that is the reason the French and Dutch so often eat them in the spring; and if you look a little farther, you can plainly see, without a pair of spectacles, that foreign physicians are not so selfish as ours, but more communicative of the virtues of plants to people” (Culpeper, 1981 (originally published 1653)).

166 B1.14 Trifolium pratense (L.) (Leguminosae) (Red Clover)

The character of Red Clover is slightly sweet and cool (Ody, 2000). Figure 49: Trifolium pratense (Red Clover)

Source: (K. A. Hilterman, 2016c)

B1.14.1 Constituents Flavonoids which act as antioxidants, isoflavones (including genestein, biochanin A, diadzen, isotrifolin, isorhamnetin, pratol, pratensol, trifolin and trifolirhizin), trifoliin, glycitein, calycosin, trifoside, pratensein, prunetin, pseudobaptigenin, phenolic glycosides, coumarins (including coumarin, coumestrol and medicagol), hentriacontane, heptacosane, myricyl alcohol, and b-sitosterol, isorhamnetin glucosides, cyanogenic glycosides, procyanidin polymers, cis-clovamide, trans-caffeic and cis-caffeic acids, phaselic acid, fats, galactoglucomannan, furfural, resins and mineral salts. Vitamins A, B complex, and P (when fresh), high in minerals, magnesium, calcium, copper, with some selenium, cobalt, nickel, manganese, sodium, tin, and iron.

B1.14.2 Therapeutic actions Anti-neoplastic, anti-inflammatory, dermatological healing agent, alterative, blood cleanser, mild anti-spasmodic, expectorant, mild, diuretic, mild sedative, assists with regulation of hormonal imbalances for women; its oestrogenic activity may assist to modulate function. Red Clover has traditionally been called a ‘blood cleanser’ (Mills & Bone, 2000). It belongs to the Fabaceae (or Leguminosae) family.

167 Medicinal Uses: Use of Red Clover is beneficial for treating skin conditions, which may include psoriasis, eczema, and other chronic problems. This herb is considered to be a ‘blood tonic’, tonifying and cleansing the body when taken internally. As the largest organ of elimination in your body, your skin assists in clearing out waste products, and if you are not processing wastes well via the digestive system and liver, your skin may develop rashes, itching and scaly patches. Red Clover assists with improving metabolic functions. Taken internally it is said to ‘soothe the nerves’ and promotes calm sleep. It is considered to be a useful adjunct with the treatment for infertility. T. pratense assists in soothing coughs, bronchitis and whooping cough; for this treatment the flowers are made into a syrup (Fisher & Painter, 1996). Wende, Krenn, Unterrieder & Lindequist (2004), assessed extracts of, with confirmed isoflavone content, to assess if they were able to stimulate osteoblastic osteosarcoma cells; their findings suggest that these isoflavonoids do have a stimulating effect on osteoblastic cell activity (Wende, Krenn, Unterrieder, & Lindequist, 2004). An isoflavonoid extract of Red Clover was trialled to on men with elevated prostate-specific antigen (PSA) levels; a daily dose of 60grams decreased the total PSA levels by >30%, was well tolerated and caused no side effects (Engelhardt & Riedl, 2008).

External Uses: Red Clover can be used topically; as a wash, compress, lotion or cream. Additionally, as a compress; for arthritic pains, gout and athlete’s foot. Topically the freshly crushed flowers can be used on stings and insect bites. Traditionally, Red Clover flowers have been used as a treatment for cancer, especially breast, ovarian and lymphatic; it has a long tradition of use in the lands from where it originates (Fisher & Painter, 1996). Therefore, its inclusion in cleansing and purifying formulations, such as Essiac, Hoxsey and Jason Winter’s is not surprising. Recent research is supporting the traditional uses for cancer—it appears that science is now validating folk traditions.  “Government and virtues. It is under the dominion of the Sun; and if it were used, it would be found as great a strengthener of the heart, and cherisher of the vital spirits as grows, relieving the body against fainting and swoonings, fortifying it against poison and pestilence, defending the heart against the noisome vapours of the spleen” (Culpeper, 1981 (originally published 1653)).  “…oxen and cattle do feed of the herb, and also calves and lambs. The flowers are acceptable to bees…” (Gerard, 1998 (original work 1597)).  “…Fomentations and poultices of the herb have been used as local applications to cancerous growths” (Culpeper, 1981 (originally published 1653)).

168 B1.15 Viola odorata (L.) (Violaceae) (Sweet Violet)

Violet’s character is considered to be moist, pungent, cold slightly bitter (Ody, 2000).

B1.15.1 Constituents Saponins, salicylates, alkaloids, flavonoids, rutin, quercetin and volatile oils (including. 3- hexenol, α-pinene, β-pinene, 2-hexenal, linalool, citronellal, 1,8-ocimene), aldehydes,( including undecanal, salicylaldehyde, 3-hexenol, 2-hexenal) terpenes and oils (including geraniol, dodecanol, spathulenol), cyclotides, (including varv A, varv F, and cycloviolacin O2), hydrocarbons (including heneicosane, hexadecane, tridecane, 1-octadecene), methyl esters (including hexadecanoic acid, 1-Hexadecene, 1-ecosene and butyl-2- ethylhexylphtalate), 5, 6, 7, 7 a-tetrahydro-4, 4 and 7 a-trimethyl-2(4 H)-benzofuranone. Vitamins A and C and minerals; potassium, phosphorus, calcium, magnesium and sulphur.

The roots contain violine, an alkaloid, which is similar to emetine, obtained from the South American herb, Ipecacuanha (Carapichea ipecacuanha), which is a powerful emetic. The flowers are mildly laxative and in the form of a tea or as a syrup are very useful for constipation especially for children.

B1.15.2 Therapeutic actions Anti-neoplastic, anti–inflammatory, alterative, emollient , stimulating expectorant, diuretic, nutritive, and anodyne (Fisher & Painter, 1996; Mills & Bone, 2000; Ody, 1993). Sweet Violet belongs to the Violaceae family and originates from Europe. Historically, this herb was used for the treatment for lung and breast cancers; this continued up to the 1930s. Topically, the leaves were used as poultices, in addition to taking this herb internally; these treatment methods were used for skin cancers. Clinical research is now beginning to validate the traditional uses of this herb. Nowadays, Violet leaf is used as a CAM cancer treatment, particularly post-surgery for cancer removal, to prevent the development of secondary tumours. Lindholm et al. (2002) trialled three specific cyclotides, varv A, varv F, and cycloviolacin O2 (cyO2), which naturally occur in Viola odorata and Viola arvensis, to assess the cytotoxic effects against 10 different human tumour cell lines. All three demonstrated strong cytotoxic activity; cycloviolacin O2 having the most significant actions (Lindholm et al., 2002). Gerlach et al. (2010) assessed the anti-tumour activity of cycloviolacin O2, a cyclotide, (referred to in the study as CyO2), from V. odorata, the research found that CyO2 initiated

169 apoptosis in tumour cells by membrane permeabilisation. Additional findings were that there was only insignificant disruption to membranes of human brain endothelial cells, indicating that “cyclotide specificity toward induced pore formation in highly proliferating tumor cells” (p617) (Gerlach et al., 2010). However, the use of Violet, as a valuable component of a cancer treatment protocol is yet to be clinically proven in humans, perhaps, with time, it will be.

Figure 50: Viola odorata Figure 51: Viola odorata (sweet violet) (sweet violet)

Source: (McNeely, 2002) Source: (Hilterman, 2003c)

In a further assessment of the therapeutic activity of cycloviolacin O2 derived from V. odorata, research by Pranting, Loov, Burman, Goransson & Andersson (2010) supports that it has potent bactericidal activity against Gram-negative bacteria. Another traditional use for this herb was for easing the symptoms of coughs, bronchitis and catarrh. Qasemzadeh et al. 2015, investigated the efficacy of V. odorata flower syrup to alleviate the coughs of children with asthma, when compared to placebo syrup. The efficacy of the Violet syrup to both reduce and suppress coughing was significant (P = .001 and P < .001, respectively) (Qasemzadeh et al., 2015). After inducing lung damage to rats by administering formalin via nebulisation Koochek, Pipelzadeh and Mardani (2003), compared the anti-inflammatory effects of an aqueous extract of V. odorata and hydrocortisone. In efficacy, Violet was equal to hydrocortisone for resolving the lung damage. They state that V. odorata is a safer alternative medicinal agent than corticosteroids are for the treatment of inflammatory lung conditions (Koochek, Pipelzadeh, & Mardani, 2003).

170 The leaves of V. odorata have been found to be high in flavonoids and vitamins, which act as antioxidants to fight free radicals in the body; free radicals having been indicated in the development or exacerbation of cancers. This can be as simple as adding fresh leaves to a salad. Free radicals have a deleterious effect on mammalian cells via causing oxidation to bio-molecules; this causes damage to cells and cell death. To assess the free radical scavenging activity of V. odorata, Stojković et al, 2011 used the flowers of V. odorata, harvested from two different sites and processed with water extraction to evaluate activity. The extract from both sites showed ability to scavenge free radicals, supporting the value of this herb to human health (Stojković et al., 2011).

As a treatment for bruises, Violets were used traditionally; usually in the form of a strong infusion, as a decoction or a poultice of fresh leaves; these methods are is still relevant for use nowadays. Cosmetically, Violets are still used as a fragrance. It is increasingly becoming chemically synthesised, due to the quantity of raw material needed to produce extracts. It takes over 100kg (220lb) of flowers to extract 60gm (2oz) of essence.

A Chinese species, Viola yedoensis, called Zi Hua Di Ding, is also used for treating skin conditions, also for breast abscesses, inflammations of the lymphatic system and snakebites (Fisher & Painter, 1996).

Hammami et al., 2011, investigated the antifungal effects of an essential oil of Viola odorata, for its potential as a bio-control of Botrytis cinerea. This mould causes considerable crop destruction, particularly in high humidity environments. The essential oil of V. odorata had strong antifungal activity on the pathogenic fungi for which was tested. They suggested that this very common and easily grown herb might be a potential source of sustainable eco- friendly botanical fungicides (Hammami, Kamoun, & Rebai, 2011).

To assess its anti-microbial properties, Akhbari et al., (2011) trialled extracts of V. odorata on 11 microorganisms. The results showed that an ethanol extract of V. odorata had considerable antimicrobial activity against some of the gram-positive and gram-negative microorganisms on which it was tested. When assessing antioxidant activity, they found that ethanol extraction obtained stronger levels than extraction using chloroform, and in addition was more effective as an anti-microbial agent. Their research contributes to the evidence for the therapeutic activity of this herb (Akhbari, Batoolib, & Kashia, 2011).

171 In further investigations of V. odorata, Orhan et al. (2015), assessed the antioxidant capabilities of this herb, via its flavonoid constituents, to inhibit tyrosinase [TYR] and cholinesterase. Ethanol extracts were successful with inhibiting tyrosinase but not cholinesterases, they did though have some nitrous oxide [NO] scavenging ability, and they suspect this is mostly due to vitexin, isovitexin, and kaempferol, as well as some ability to chelate heavy metals (Orhan et al., 2015).

Further research on cyclotides, conducted by Colgrave, Kotze, Ireland, Wang and Craik (2008), specifically of the natural variants cycloviolacin O2, cycloviolacin O3, cycloviolacin O8, cycloviolacin O13, cycloviolacin O14, cycloviolacin O15, and cycloviolacin O16 extracted from Viola odorata, to assess their anthelmintic activity against two intestinal parasites, Haemonchus contortus and Trichostrongylus colubriformis, found in sheep. Their findings indicate significant nematocidal activity of a number of natural variants of cyclotides, comparable to currently available commercial anthelmintics. They suggest that further research is required to confirm the safe dosage as an anthelmintic for animals (Colgrave, Kotze, Ireland, Wang, & Craik, 2008). The diversity of beneficial therapeutic activities indicates this herb has value for human and animal health and further research is recommended.

 “The lytynes… in substaunce is nobly rewarded in gretnesse of sauour and of virtue” (Bartholomaeus Anglicus, circa 1250) (Anglicus, Circa1250).  “It has power to ease inflammation, roughness of the throat and comforteth the heart, assuageth the pains of the head and causeth sleep” Gerard, 1597, (Gerard, 1998 (original work 1597)).

B1.16 Viola tricolor (L.) (Violaceae) (Heartsease)

The character of Heartsease is considered to be slightly bitter, moist, cold, and pungent; this indicates it is ideal for treating inflammatory conditions (Ody, 2000).

B1.16.1 Constituents In the aerial parts of the plant are found flavonoids (including violanthin, violaquercitrin, quercetin apigenin, chrysoeriol, isorhamnetin, kaempferol, luteolin and rutin; which may strengthen capillaries), β-carotene, methyl salicylate (aspirin like properties), alkaloids, volatile oils, mucilage gums (which soothe), resin, saponins. Vitamins; A and C. Minerals; potassium, phosphorus, calcium, magnesium and sulphur

172 . Figure 52: Viola tricolor (Heartsease) Figure 53: Viola tricolor (Heartsease)

Source: (Hilterman, 2012c) Source: Hilterman, 2003d

B1.16.2 Therapeutic actions Anti-inflammatory stabilises capillary membranes, anti-rheumatic, expectorant, diuretic and laxative.

External Uses: Historically Heartsease was used for ‘skin eruptions and irritations’, skin conditions, including cradle cap, and nappy rash for babies, eczema and tubercular skin lesions. With its anti-inflammatory actions, this herb is well suited for these disorder in addition to AKs and is still as relevant today (Ody, 1993); (Fisher & Painter, 1996; Mills & Bone, 2000).

This herb is another member of the Violaceae family; Heartsease originates from Europe, across to the Middle East, Central Asia and North America. It has a tradition of use back to antiquity; its use is recorded in the earliest remaining herbal texts, where one of its main uses was to treat skin conditions (Fisher & Painter, 1996).

Researchers based in Lithuania, Rimkienë, Ragazinskiene & Savickiene published in 2003 their assessment of V. tricolor (wild pansy); they concluded that the natural, wild habitats where this herb grows were rapidly reducing, both threatening its survival and thus

173 potentially reducing supplies of wild crafted herb for manufacturing herbal products. They were also concerned with the apparent altering of the climate. Increasing summer droughts reduce the growth of this and other endemic herbs. They suggested that this important herb requires further research and encouraged planting it as a cultivated crop, for species preservation and to ensure ongoing raw material for medicines (Rimkiene, Ragazinskiene, & Savickiene, 2003).

Vukics et al., have two publications from 2008, in which Heartsease was assessed specifically for its flavonoid components. They utilised a microLC-MSn approach to extract and assess the following phytochemicals, four flavonol O-glycosides, nine flavone-C-glycosides, and three flavone C, O-glycosides, which were defined in the ethanol extraction of V. tricolour. They discerned that these glycoconjugates which were present were derivatives of six aglycones: apigenin, chrysoeriol, isorhamnetin, kaempferol, luteolin, and quercetin (Vukics, Kery, Bonn, & Guttman, 2008); (Vukics, Ringer, Kery, Bonn, & Guttman, 2008).

It is surprising that there appears to have been so little research conducted on this herb, to evaluate its efficacy and safety, when considering its significant use historically and its chemical constituents. In support of its potential for commercial production, Heartsease is an annual, and is easy to grow (European Medicines Agency, 2010).

 “It is good as the later physicians write for such as are sick of ague, especially children and infants, whose convulsions and fits of the falling sickness it is thought to cure. It is commended against inflammation of the lungs and chest, and against scabs and itchings of the whole body and healeth ulcers” (Gerard, 1998 (original work 1597)).

B1.17 Zingiber officinale (Roscoe) (Zingiberaceae) (Ginger)

Its character is described as pungent, hot and dry (Ody, 2000).

B1.17.1 Constituents Contains volatile oils (including gingerol and shogaol), resins acrid resin, phenols, alkaloids bisabolene, borneal, borneol, camphene, choline, cineole, citral, inositol, PABA, phellandrene, sesquiterpenes, zingerone, zingiberene and mucilage. Vitamins A, B complex and C. Minerals: calcium, magnesium, phosphorus, potassium, sodium and iron.

174 B1.17.2 Therapeutic actions Anti-inflammatory, anti-spasmodic, anti–nausea, stimulant, vasodilator, circulatory stimulant, rubefacient and diaphoretic.

Research is providing evidence to suggest that Ginger can assist to inhibit prostaglandins, which have an inflammatory effect on the body, additionally; it can assist with lowering elevated cholesterol levels. Ginger is anti-platelet aggregating, which may reduce the risks and incidence of heart disease and stroke.

For topical use, Ginger rhizome, in either fresh or dried powder form, can be used; as a bath for feet, hands or the whole body, as it stimulates circulation and this can ease aching and painful joints. It can also be used as a compress, or poultice (Fisher & Painter, 1996; Ody, 1993). This herb could be a useful addition to a topical herbal formulation as a treatment for AKs; by stimulating the circulation as a rubefacient.

Figure 54: Zingiber officinale (Ginger)

Source: (Köhler, 1896)

Ginger belongs to the Zingiberaceae family, and originated in Asia, where it has an ancient history as both a medicine and a spice for cooking. It is the rhizome of Ginger that is most commonly used. Its use was spread via the Silk Road trading routes and this herb became an

175 integral part of culinary and medicinal life through the Middle East and then westward via Greece to Europe. Ginger was mentioned in the Roman cookbook, ‘De Re Coquinaria’, written by the Roman, Apicinus Caelius, in the third century. Ginger journeyed to the Americas and in the West Indies, taken there by the colonising Spaniards. Wherever Ginger grows well, it is usually commercialised and thus has spread across the globe, and it has become an important part of the economy for many tropical and sub-tropical countries.

This herb has been comparatively well researched, though much of it being either with in vitro or animal studies. Of greater significance to this thesis are some of the following publications: Ling, Yang, Tan, Chui and Chew (2010), with in vitro experiments, assessed the anti-invasive effects of a series of shogaols on MDA-MB-231 breast cancer cells using the matrigel invasion assay, further assessments were made specifically for the suppressive effects of 6-shogaol on phorbol 12-myristate 13-acetate [PMA]-induced matrix metalloproteinase-9 [MMP-9] gelatinolytic activity and nuclear factor-κB [NF-κB] activation. There was significant indications of efficacy, particularly from 6-shogaol. The results are as follows: Shogaols (6-, 8- and 10-shogaol) inhibited PMA-stimulated MDA-MB- 231 cell invasion with an accompanying decrease in MMP-9 secretion. 6-Shogaol was identified to display the greatest anti-invasive effect in association with a dose-dependent reduction in MMP-9 gene activation, protein expression and secretion. The NF-κB transcriptional activity was decreased by 6-shogaol; an effect mediated by inhibition of IκB phosphorylation and degradation that subsequently led to suppression of NF-κB p65 phosphorylation and nuclear translocation. Specifically, 6-shogaol was found to inhibit JNK activation without reducing the activator protein-1 transcriptional activity. By using specific inhibitors, it was demonstrated that ERK and NF-κB signalling, but not JNK and p38 signalling, were involved in PMA-stimulated MMP-9 activation. The researchers suggest that these specific molecules has potential as antimetastatic treatments for clinical use (Ling, Yang, Tan, Chui, & Chew, 2010).

Colon cancer is a disease affecting many people worldwide; when assessing Z. officinale for its efficacy against this disease, Marelli, Menichini and Conforti (2015), used two hydroalcoholic extracts of ginger peel and ginger pulp on colon cancer cell lines using MTT assays. The peel extract was more effective than the pulp with the cancer cells, though the pulp indicated higher antioxidant and anti-inflammatory activity. Each extract was found to have different constituent levels, including polyphenolic content and lipophilic composition.

176 From the peel extract, α-zingibirene was discerned to be a significant constituent. This study indicates that therapeutic efficacy for the peel for treating colorectal carcinoma (Marrelli, Menichini, & Conforti, 2015). Grzanna, Lindmark and Frondoza from their 2005 paper ‘Ginger—an herbal medicinal product with broad anti-inflammatory actions’ discuss the history of the anti-inflammatory activity of Z. officinalis and continues with current research findings that a specific extract, EV.EXT.77, which is derived from Z. officinale and Alpina galanga (both members of the Zingiberaceae family). It had an inhibitory effect on several genes, which are part of the inflammatory response; including encoding cytokines, chemokines and cyclooxygenase-2 (an inducible enzyme). This provides evidence that Z. officinale has modulatory activity on biochemical pathways which are activated in chronic inflammation (Grzanna, Lindmark, & Frondoza, 2005). This herb exhibits a number of therapeutic activities which indicate it as well suited to be included in treatments for AKs and other forms of sun-induced skin disease and other cancers.

 “…it is of an heating and digesting qualitie, and it is profitable for the stomacke” (Gerard, 1597, cited in (Gerard, 1998 (original work 1597)).

177 APPENDIX C

C1 Therapeutic Action Descriptions The following table provides descriptions for the therapeutic actions of herbs used throughout this document, in particular, elaborating on Table 6: Therapeutic Actions of Herbs— Considerations for Skin Treatments, from Chapter 3. It is these therapeutic actions which could be considered when choosing herbs for treating sun-induced skin damage and in addition for other medical conditions and diseases.

Table 22: Descriptions of Therapeutic Actions

Therapeutic Description Herbs With This Therapeutic Action Action Withania somnifera (L.) Dunal (Solanaceae), Agent that modulates Eleutherococcus senticosus, (Araliaceae), Glycyrrhiza glabra Adaptogen hormones var. glabra (Leguminosae), Schisandra chinensis (Turcz.) Baill. (Schisandraceae), Panax ginseng C.A.Mey. (Araliaceae) Corrects disordered body Echinacea spp, (Compositae), Galium aparine (L.) functions; acts as blood (Rubiaceae), Eupatorium cannabinum, Trifolium pratense L. cleanser, assists (Leguminosae), Rumex crispus L. (Polygonaceae), Urtica Alterative elimination or protection. dioica L. (Urticaceae), Arctium lappa (L.) (Compositae), Acts on metabolism to shift Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), it in a beneficial direction Iris versicolor, (L.) (Iridaceae) Salix alba L. (Salicaceae), Hypericum perforatum L. (Hypericaceae), Gaultheria procumbens (L.) (Ericaceae), Rosmarinus officinalis (L.) (Lamiaceae), Linum usitatissimum Analgesic Pain reliever (L.) (Linaceae), Harpagophytum procumbens (Pedaliaceae), Phytolacca americana (L.) (Phytolaccaceae), Anemone pulsatilla (L.) (Ranunculaceae), Populus alba (L.) (Salicaceae) Anti-allergy or Inhibits allergic reactions Matricaria chamomilla (L.) (Compositae), Albizia lebbeck (L.) anti-allergenic in the body, histamine Benth. (Leguminosae), Echinacea spp, (Compositae), Allium release and mast cell sativa (L.) (Amaryllidaceae), Melissa officinalis (L.) degranulation (Lamiaceae), Scutellaria baicalensis Georgi (Lamiaceae) Hypericum perforatum L. (Hypericaceae), Origanum vulgare (L.) (Lamiaceae), Berberis vulgaris (L.) (Berberidaceae Prunella vulgaris (L.) (Lamiaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Thymus vulgaris (L.) (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Echinacea spp, (Compositae), Rosmarinus officinalis (L.) (Lamiaceae Destroys bacterial Hydrastis canadensis (L.) (Ranunculaceae), Mahonia spp Anti-bacterial organisms and, or inhibits (Berberidaceae), Coptis chinensis Franch. (Ranunculaceae), their replication Vaccinium macrocarpon Aiton (Ericaceae), Sambucus nigra (L.) (Adoxaceae), Leptospermum scoparium J.R.Forst. & G.Forst. (Myrtaceae), Melaleuca alternifolia (Maiden & Betche) Cheel (Myrtaceae), Eucalyptus spp (Myrtaceae), Allium sativa (L.) (Amaryllidaceae), Usnea barbata (Parmeliaceae)

178 Solanum incanum (L.) (Solanaceae), Arctium lappa (L.) (Compositae), Berberis vulgaris (L.) (Berberidaceae), Echinacea spp, (Compositae), Hypericum perforatum L. (Hypericaceae), Berberis vulgaris (L.) (Berberidaceae), Prunella vulgaris (L.) (Lamiaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Thymus vulgaris (L.) A substance used to treat (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Echinacea infections caused by spp, (Compositae), Rosmarinus officinalis (L.) (Lamiaceae), Anti-biotic bacteria and other Hydrastis canadensis (L.) (Ranunculaceae), Mahonia spp microorganisms (Berberidaceae), Coptis chinensis Franch. (Ranunculaceae), Vaccinium macrocarpon Aiton (Ericaceae), Sambucus nigra (L.) (Adoxaceae), Leptospermum scoparium J.R.Forst. & G.Forst. (Myrtaceae), Melaleuca alternifolia (Maiden & Betche) Cheel (Myrtaceae), Eucalyptus spp (Myrtaceae), Allium sativa (L.) (Amaryllidaceae), Usnea barbata (Parmeiaceae), Origanum vulgare (L.) (Lamiaceae) Disables or inhibits Colchicum autumnale (L.) (Colchicaceae), Coptis chinensis Anti- pathogens or malignant Franch. (Ranunculaceae), Glycyrrhiza glabra var. glabra chemotactic cells from nutrition or (Leguminosae), Angelica dahurica (Hoffm.) Benth & Hook.f. replication ex Franch. & Sav. (Apiaceae) Anemone pulsatilla (L.) (Ranunculaceae), Berberis vulgaris (L.) (Berberidaceae), Hypericum perforatum L. Prevents or reduces the (Hypericaceae), Scutellaria lateriflora (L.) (Lamiaceae), Anti- severity of epileptic Ginkgo biloba (L.) (Ginkgoaceae), Centella asiatica (L.) Urb. convulsant seizures or other (Apiaceae), Caesalpinia pulcherrima (L.) Sw. (Leguminosae), convulsions Bacopa monnieri (L.) Wettst. (Plantaginaceae), Drosera burmanni Vahl (Droseraceae), Nelumbo nucifera Gaertn. (Nelumbonaceae), Piper methysticum G.Forst. (Piperaceae) Avena sativa (L.) (Poaceae), Hypericum perforatum L. (Hypericaceae), Eschscholzia californica Cham. Anti- Substance used to treat (Papaveraceae), Lavandula angustifolia Mill. (Lamiaceae), depressive or mood disorders and Melissa officinalis (L.) (Lamiaceae), Matricaria chamomilla Anti- depression depressant (L.) (Compositae), Ginkgo biloba (L.) (Ginkgoaceae), Piper methysticum G.Forst. (Piperaceae), (Passifloraceae), Crocus sativus (L.) (Iridaceae) Achillea millefolium (L.) (Compositae), Quercus spp (Fagaceae), Rosa chinensis Jacq. (Rosaceae), Maranta arundinacea (L.) (Marantaceae), Plantago ovata Forssk. Anti- Substance used to treat (Plantaginaceae), Mahonia aquifolium (Pursh) Nutt. diarrhoeal diarrhoea or prevent it (Berberidaceae), Agrimonia spp (Rosaceae), Stachys officinalis (L.) Trevis. (Lamiaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae) Zingiber officinale Roscoe (Zingiberaceae), Berberis vulgaris (L.) (Berberidaceae), Mentha spp (Lamiaceae), Foeniculum Inhibits the urge or reaction vulgare Mill. (Apiaceae), Mahonia spp (Berberidaceae), Anti-emetic to vomit or relieves nausea Anethum graveolens (L.) (Apiaceae), Rubus idaeus (L.) (Rosaceae), Cymbopogon citratus (DC.) Stapf (Poaceae), Garcinia gummi-gutta (L.) Roxb. (Clusiaceae)

179 Echinacea spp, (Compositae), Ginkgo biloba (L.) (Ginkgoaceae), Thymus vulgaris (L.) (Lamiaceae), Phytolacca americana (L.) (Phytolaccaceae), Leptospermum scoparium Anti-fungal Kills fungus infections J.R.Forst. & G.Forst. (Myrtaceae), Calendula officinalis (L.) (Compositae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae) Achillea millefolium (L.) (Compositae), Berberis vulgaris (L.) (Berberidaceae), Capsella bursa-pastoris (L.) Medik. (Brassicaceae), Sanguisorba minor Scop. (Rosaceae), Assists to stop or prevent Hamamelis virginiana (L.) (Hamamelidaceae), Ulmus fulva bleeding from a wound, Anti- Michx. (Ulmaceae), Galium spp (Rubiaceae), Prunella haemorrhagic either internally or topically vulgaris (L.) (Lamiaceae), Equisetum arvense (L.) (Equisetaceae), Quercus spp (Fagaceae), Capsicum annuum (L.) (Solanaceae), Plantago spp (Plantaginaceae), Rumex acetosella (L.) (Polygonaceae) Hypericum perforatum L. (Hypericaceae), Phytolacca americana (L.) (Phytolaccaceae), Curcuma longa (L.) (Zingiberaceae), Allium sativa (L.) (Amaryllidaceae), Ocimum basilicum (L.) (Lamiaceae), Viola odorata (L,) (Violaceae), Kills or inhibits the growth Aloe spp (Xanthorrhoeaceae), Piper nigrum (L.) (Piperaceae), of microorganisms in Matricaria chamomilla (L.) (Compositae), Eucalyptus Anti-microbial particular pathogenic globulus Labill. (Myrtaceae), Glycyrrhiza glabra var. glabra microorganisms (Leguminosae), Thymus vulgaris (L.) (Lamiaceae), Acorus calamus (L.) (Acoraceae), Cassia angustifolia M. Vahl (Fabaceae), Berberis vulgaris (L.) (Berberidaceae), Capsicum annuum (L.) (Solanaceae), Hydrastis canadensis (L.) (Ranunculaceae), Carica papaya (L.) (Caricaceae) Trifolium pratense L. (Leguminosae), Aesculus hippocastanum (L.) (Sapindaceae), Allium sativa (L.) Anti- Inhibits tumours and (Amaryllidaceae), Viscum album (L.) (Santalaceae), neoplastic tumour growth Phytolacca americana (L.) (Phytolaccaceae), Viola odorata (L,) (Violaceae), Sanguinaria canadensis (L.) (Papaveraceae), Bellis perennis (L.) (Compositae) Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Ziziphus jujuba Mill, (Rhamnaceae), Juniperus communis (L.) (Cupressaceae), The action of reducing or Solanum nigrum (L.) (Solanaceae), Papaver somniferum (L.) Anti- blocking the sensing pain (Papaveraceae), Capsicum spp (Solanaceae), Salix spp nociceptive or injury stimulus by (Salicaceae), Cannabis sativa (L.) (Cannabaceae), Acorus sensory neurons calamus (L.) (Acoraceae), Nigella sativa (L.) (Ranunculaceae), Paeonia x suffruticosa Andrews (Paeoniaceae) Viola odorata (L,) (Violaceae), Prunella vulgaris (L.) (Lamiaceae), Rosmarinus officinalis (L.) (Lamiaceae), Viola tricolor (L.) ((Violaceae), Thymus spp (Lamiaceae), Mentha Inhibits oxidation, removes spp (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Berberis potentially damaging free vulgaris (L.) (Berberidaceae), Pimenta dioica (L.) Merr. Antioxidant radicals, oxidizing agents (Myrtaceae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), in a living organism Trifolium pratense L. (Leguminosae), Cinnamomum spp (Lauraceae), Curcuma longa (L.) (Zingiberaceae), Origanum vulgare (L.) (Lamiaceae), Lycium spp (Solanaceae), Vaccinium spp (Ericaceae), Crocus sativus (L.) (Iridaceae)

180 Phytolacca americana (L.) (Phytolaccaceae), Artemisia spp (Compositae), Cinnamomum spp (Lauraceae), Curcuma longa (L.) (Zingiberaceae), Origanum vulgare (L.) (Lamiaceae), Thymus vulgaris (L.) (Lamiaceae), Berberis vulgaris (L.) Kills or inhibits the (Berberidaceae), Artemisia spp (Compositae), Salvia spp development and (Lamiaceae), Andrographis paniculata (Burm.f.) Nees reproduction of parasites Anti-parasitic (Acanthaceae), Valeriana officinalis (L.) (Caprifoliaceae), (human and animal) including amoeba and Hypericum perforatum L. (Hypericaceae), Silybum marianum worms (L.) Gaertn. (Compositae), Curcuma longa (L.) (Zingiberaceae), Berberis vulgaris (L.) (Berberidaceae), Juglans nigra (L.) (Juglandaceae), Uncaria tomentosa (Willd. ex Schult.) DC, (Rubiaceae), Tabebuia avellanedae Lorentz ex Griseb. (Bignoniaceae) Achillea millefolium (L.) (Compositae), Tilia spp (Malvaceae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Berberis vulgaris (L.) (Berberidaceae), Matricaria chamomilla (L.) (Compositae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Stellaria media (L.) Vill. (Caryophyllaceae), Echinacea spp, (Compositae), Sambucus nigra (L.) (Adoxaceae), Zingiber officinale Roscoe (Zingiberaceae), Viola tricolor (L.) ((Violaceae), Calendula officinalis (L.) Reduces fever and Antiphlogistic (Compositae), Trifolium pratense L. (Leguminosae), Rosa spp, inflammation Viola odorata (L,) (Violaceae), Tanacetum parthenium (L.) Sch. Bip. (Compositae), Dioscorea villosa (L.) (Dioscoreaceae), Plantago spp (Plantaginaceae), Zea mays (L.) (Poaceae), Elymus repens (L.) Gould (Poaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae), Salix spp (Salicaceae), Verbascum thapsus (L.) (Scrophulariaceae), Trigonella foenum-graecum (L.) (Leguminosae), Colchicum autumnale (L.) (Colchicaceae) Artemisia spp (Compositae), Salvia spp (Lamiaceae), Andrographis paniculata (Burm.f.) Nees (Acanthaceae), Valeriana officinalis (L.) (Caprifoliaceae), Can either exterminate Hypericum perforatum L. (Hypericaceae), Silybum marianum protozoa or inhibit their Anti-protozoal (L.) Gaertn. (Compositae), Curcuma longa (L.) growth and ability to reproduce. (Zingiberaceae), Berberis vulgaris (L.) (Berberidaceae), Juglans nigra (L.) (Juglandaceae), Uncaria tomentosa (Willd. ex Schult.) DC, (Rubiaceae), Tabebuia avellanedae Lorentz ex Griseb. (Bignoniaceae) Berberis vulgaris (L.) (Berberidaceae), Tilia cordata Mill. (Malvaceae), Sambucus nigra (L.) (Adoxaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae), Achillea millefolium (L.) An agent to prevent or (Compositae), Salix spp (Salicaceae), Zingiber officinale Anti-pyretic reduce fevers Roscoe (Zingiberaceae), Mentha spp (Lamiaceae), Viola odorata (L,) (Violaceae), Verbena officinalis (L.) (Verbenaceae), Gentiana lutea (L.) Gentianaceae), Thymus vulgaris (L.) (Lamiaceae), Origanum vulgare (L.) (Lamiaceae)

181 Viola tricolor (L.) ((Violaceae), Colchicum autumnale (L.) (Colchicaceae), Centella asiatica (L.) Urb. (Apiaceae), Petroselinum crispum (Mill.) Fuss (Apiaceae), Curcuma longa Substance which can (L.) (Zingiberaceae), Arnica montana (L.) (Compositae), prevent, ease or reduce Harpagophytum procumbens (Pedaliaceae), Dioscorea villosa Anti- symptoms associated with (L.) (Dioscoreaceae), Juniperus communis (L.) rheumatic joint pain, stiffness and inflammatory disorders (Cupressaceae), Phytolacca americana (L.) (Phytolaccaceae), such as rheumatoid arthritis Capsicum spp (Solanaceae), Achillea millefolium (L.) (Compositae), Sassafras albidum (Nutt.) Nees (Lauraceae), Boswellia thurifera Roxb.ex Fleming (Burseraceae), Salix alba (L.) (Salicaceae), Zingiber officinale Roscoe (Zingiberaceae) Phytolacca americana (L.) (Phytolaccaceae), Capsicum spp (Solanaceae), Brassica spp (Brassicaceae), Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Mentha spp (Lamiaceae), Rosmarinus officinalis (L.) (Lamiaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Plantago spp (Plantaginaceae), A substance utilised to Trifolium pratense (L.) (Leguminosae), Viola odorata (L,) Anti-scorbutic prevent or relieve scurvy; a (Violaceae), Matricaria chamomilla (L.) (Compositae), Viola vitamin C deficiency tricolor (L.) ((Violaceae), Centella asiatica (L.) Urb. (Apiaceae), Petroselinum crispum (Mill.) Fuss (Apiaceae), Melissa officinalis (L.) (Lamiaceae), Rosa spp (Rosaceae), Bacopa monnieri (L.) Wettst. (Plantaginaceae), Galium aparine (L.) (Rubiaceae), Stellaria media (L.) Vill. (Caryophyllaceae) Phytolacca americana (L.) (Phytolaccaceae), Lobelia siphilitica (L.) (Campanulaceae), Piper nigrum (L.) Treatment to destroy and inhibits the replications of (Piperaceae), Smilax ornata Lem. (Smilacaceae), Tinospora the bacterium Treponema cordifolia (Willd.) Miers (Menispermaceae), Commiphora Anti-syphilitic pallidum subspecies mukul (Hook. Ex Stocks) Engl. (Burseraceae), Juglans nigra pallidum, a sexually (L.) (Juglandaceae), Arctium lappa (L.) (Compositae), transmitted disease Commiphora myrrha (Nees) Engl. (Burseraceae), Hydrastis canadensis (L.) (Ranunculaceae), Quercus alba (Fagaceae) Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Echinacea spp (Compositae), Berberis vulgaris (L.) (Berberidaceae), Commiphora molmol (Engl.) Engl. ex Tschirch (Burseraceae), Humulus lupulus (L.) (Cannabaceae), Quercus robur (L.) (Fagaceae), Mentha spp (Lamiaceae), Rosmarinus officinalis (L.) (Lamiaceae Salvia officinalis (L.) (Lamiaceae), Thymus vulgaris (L.) Anti-septic Assists to clear infections (Lamiaceae), Allium sativa (L.) (Amaryllidaceae), Smilax spp (Smilacaceae), Sanguinaria canadensis (L.) (Papaveraceae), Piper methysticum G.Forst. (Piperaceae), Plantago spp (Plantaginaceae), Rumex crispus (L.) (Polygonaceae), Hydrastis canadensis (L.) (Ranunculaceae), Populus spp (Salicaceae), Euphrasia rostkoviana (L.) (Orobanchaceae) Rheum palmatum (L.) (Polygonaceae)

182 Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Inhibits the development Phytolacca americana (L.) (Phytolaccaceae), Trifolium and proliferation of pratense (L.) (Leguminosae), Viscum album (L.) Anti-tumour abnormal cell growth and (Santalaceae), Curcuma longa (L.) (Zingiberaceae), Viola tumours odorata (L,) (Violaceae), Vinca spp (Apocynaceae), Polyphenols Sonchus oleraceus (L.) (Compositae), Hypericum perforatum (L.) (Hypericaceae), Humulus lupulus (L.) (Cannabaceae), Ginkgo biloba (L.) (Ginkgoaceae), Melissa officinalis (L.) (Lamiaceae), Rhodiola rosea (L.) (Crassulaceae), Anxiolytic Anti-anxiety (Passifloraceae), Scutellaria lateriflora (L.) (Lamiaceae), Matricaria chamomilla (L.) (Compositae), Piper methysticum G.Forst. (Piperaceae), Valeriana officinalis (L.) (Caprifoliaceae) Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Plantago spp (Plantaginaceae), Rumex crispus (L.) (Polygonaceae), Bacopa monnieri (L.) Wettst. (Plantaginaceae), Sonchus oleraceus (L.) L. (Compositae), Hydrastis canadensis (L.) (Ranunculaceae), Tanacetum parthenium (L.) Sch. Bip. (Compositae), Rheum palmatum Aperient Gentle laxative (L.) (Polygonaceae), Berberis vulgaris (L.) (Berberidaceae), Silybum marianum (L.) Gaertn. (Compositae), Asclepias spp (Apocynaceae), Andrographis paniculata (Burm.f.) Nees (Acanthaceae), Piper nigrum (L.) (Piperaceae), Cichorium intybus (L.) (Compositae), Fumaria officinalis (L.) (Papaveraceae) Geranium maculatum (L.) (Geraniaceae), Salix alba (L.) (Salicaceae), Achillea millefolium (L.) (Compositae), Calendula officinalis (L.) (Compositae), Solidago spp (Compositae), Symphytum spp (Boraginaceae), Commiphora molmol (Engl.) Engl. ex Tschirch (Burseraceae), Viburnum spp (Adoxaceae), Hypericum perforatum (L.) (Hypericaceae), Equisetum hymale (L.) (Equisetaceae), Thuja occidentalis (L.) (Cupressaceae), Arctostaphylos urva-ursi (L.) Spreng. (Ericaceae), Vaccinium myrtillus (L.) (Ericaceae), Quercus robur (L.) (Fagaceae), Hamamelis virginiana (L.) Firms and tones Astringent (Hamamelidaceae), Aesculus hippocastanum (L.) discharging tissues (Sapindaceae), Glechoma hederacea (L.) (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Thymus vulgaris (L.) (Lamiaceae), Trillium erectum (L,) (Melanthiaceae), Myrica cerifera (L.) (Myricaceae), Hydrastis canadensis (L.) (Ranunculaceae), Agrimonia eupatoria (L.) (Rosaceae), Filipendula ulmaria (L.) Maxim. (Rosaceae), Rubus idaeus (L.) (Rosaceae), Galium aparine (L.) (Rubiaceae), Euphrasia rostkoviana (L.) (Orobanchaceae), Ficaria verna Huds. (Ranunculaceae) (Syn: Ranunculus ficaria), Rheum palmatum (L.) (Polygonaceae)

183 Hawthorn, Coleus forskohlii, Convallaria majalis Avena Substances which have a sativa (L.) (Poaceae), Taraxacum officinale (L.) Weber ex tonifying, or beneficial F.H.Wigg. (Compositae), Allium sativum, Leonurus cardiaca, Cardiac tonic effects on the heart and Capsicum annuum (L.) (Solanaceae), Achillea millefolium (L.) circulatory system (Compositae), Ginkgo biloba (L.) (Ginkgoaceae), Cytisus scoparius (L.) (Leguminosae), Tilia spp (Malvaceae) Capsicum annuum (L.) (Solanaceae), Matricaria chamomilla (L.) (Compositae), Lavandula angustifolia Mill. (Lamiaceae), Mentha spp (Lamiaceae), Rosmarinus officinalis (L.) (Lamiaceae), Thymus spp (Lamiaceae), Tanacetum Aids digestion and relieves Carminative parthenium (L.) Sch. Bip. (Compositae), Foeniculum vulgare flatulence Mill. (Apiaceae), Carum carvi (L.) (Apiaceae), Cuminum cyminum (L.) (Apiaceae), Anethum graveolens (L.) (Apiaceae), Armoracia rusticana P.Gaertn., B.Mey. & Scherb (Brassicaceae), Berberis vulgaris (L.) (Berberidaceae) Colchicum autumnale (L.) (Colchicaceae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Phytolacca americana (L.) Strongly stimulates Cathartic (Phytolaccaceae), Ricinus communis (L.) (Euphorbiaceae), evacuation of the bowels Rhamnus purshiana DC. (Rhamnaceae), Podophyllum peltatum (L.) (Berberidaceae), Asclepias spp (Apocynaceae) Stimulates bile production Berberis vulgaris (L.) (Berberidaceae), Aloe vera (L.) Burm.f. from the liver (Xanthorrhoeaceae), Silybum marianum (L.) Gaertn. (Compositae), Taraxacum officinale (L.) Weber ex F.H.Wigg. Cholagogue (Compositae), Allium sativa (L.) (Amaryllidaceae), Calendula officinalis (L.) (Compositae), Mentha spp (Lamiaceae), Rosa spp (Rosaceae), Cynara cardunculus var. scolymus (L.) Benth. (Compositae) Produces or stimulates the Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Avena sativa (L.) Collagenic production of collagen (Poaceae), Echinacea purpurea, (Compositae) Borago officinalis (L.) (Boraginaceae), Symphytum spp (Boraginaceae), Drosera rotundifolia (L.) (Droseraceae), Glycyrrhiza glabra var. glabra (Leguminosae), Trigonella foenum-graecum (L.) (Leguminosae), Linum usitatissimum (L.) (Linaceae), Althaea officinalis (L.) (Malvaceae), Fucus Demulcent Soothing versiculosus (L.) (Fucaceae), Elytrigia repens (L.) Nevski (Poaceae), Zea mays (L.) (Poaceae), Verbascum thapsus (L.) Scrophulariaceae), Ulmus rubra Muhl. (Ulmaceae), Avena sativa (L.) (Poaceae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae) Thymus spp (Lamiaceae), Achillea millefolium (L.) (Compositae), Myrica cerifera (L.) (Myricaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Agrimonia Removes obstructions from theeupatoria (L.) (Rosaceae), Berberis vulgaris (L.) Deobstruent body, thereby improving channels (Berberidaceae), Fucus versiculosus (L.) (Fucaceae), of elimination Hydrastis canadensis (L.) (Ranunculaceae), Salvia officinalis (L.) (Lamiaceae), Thuja occidentalis (L.) (Cupressaceae), Phytolacca americana (L.) (Phytolaccaceae) Scrophularia nodosa (L,) (Scrophulariaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Arctium Depurative Cleanses the body systems lappa (L.) (Compositae), Phytolacca americana (L.) (Phytolaccaceae), Galium aparine (L.) (Rubiaceae)

184 Sambucus nigra (L.) (Adoxaceae), Achillea millefolium (L.) Stimulates perspiration to (Compositae), Tilia spp (Malvaceae), Nepeta cataria (L.) increase elimination (Lamiaceae), Capsicum annuum (L.) (Solanaceae), Zingiber Diaphoretic through the skin and officinale Roscoe (Zingiberaceae), Eupatorium perfoliatum through this action can help reduce fevers (L.) (Compositae), Mentha spp (Lamiaceae), Hyssopus officinalis (L.) (Lamiaceae) Euphorbia peplus (L.) (Euphorbiaceae), Chelidonium majus Reduces or removes a Discutient (L.) (Papaveraceae), Avena sativa (L.) (Poaceae), Taraxacum lesion officinale (L.) Weber ex F.H.Wigg. (Compositae) Stimulates vomiting, Lobelia inflata (L.) (Campanulaceae), Phytolacca americana drastic but can be a (L.) (Phytolaccaceae), Scilla maritima (L.) Asparagaceae), necessary form of Cephaelis ipecacuahana (Brot.) A.Rich. (Rubiaceae), Emetic elimination sometimes Nicotiana tabacum (L.) (Solanaceae), Polygala senega (L.) (Polygalaceae), Tylophora indica (Burm. f.) Merr. (Apocynaceae), Myrica cerifera (L.) (Myricaceae) Stimulates blood flow in Petroselinum crispum (Mill.) Fuss (Apiaceae), Juniperus the pelvic area and uterus; communis (L.) (Cupressaceae), Ruta graveolens (L.) Emmenagogue stimulates menstruation (Rutaceae), Daucus carota (L.) (Apiaceae), Artemisia vulgaris (L.) (Compositae), Actaea racemosa (L.) (Ranunculaceae) Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Avena sativa (L.) (Poaceae), Symphytum spp (Boraginaceae), Trigonella foenum-graecum (L.) (Leguminosae), Linum usitatissimum Emollient Soothes and protects skin (L.) (Linaceae), Althaea officinalis (L.) (Malvaceae), Fucus versiculosus (L.) (Fucaceae), Plantago spp (Plantaginaceae), Galium aparine (L.) (Rubiaceae) Sanguinaria canadensis (L.) (Papaveraceae), Euphorbia Caustic, corroding or Escharotic peplus (L.) (Euphorbiaceae), Thuja occidentalis (L.) eroding (Cupressaceae), Chelidonium majus (L.) (Papaveraceae) Stimulates breast milk Trigonella foenum-graecum (L.) (Leguminosae), Urtica spp, production Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Cnicus benedictus (L.) (Asteraceae), Medicago sativa (L.) Galactagogue (Leguminosae), Pimpinella anisum (L.) (Apiaceae), Foeniculum vulgare Mill. (Apiaceae), Galega officinalis (L.) (Leguminosae), Humulus lupulus (L.) (Cannabaceae) Assists efficient liver Berberis vulgaris (L.) (Berberidaceae), Taraxacum officinale function (L.) Weber ex F.H.Wigg. (Compositae), Allium sativa (L.) Hepatic (Amaryllidaceae), Silybum marianum (L.) Gaertn. (Compositae), Bupleurum spp (Apiaceae), Schisandra chinensis (Turcz.) Baill. (Schisandraceae) Lowers blood pressure Berberis vulgaris (L.) (Berberidaceae Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Zingiber officinale Roscoe (Zingiberaceae), Allium sativa (L.) (Amaryllidaceae), Hypotensive Crataegus spp (Rosaceae), Calendula officinalis (L.) (Compositae), Prunella vulgaris (L.) (Lamiaceae), Tilia spp (Malvaceae), Olea spp (Oleaceae) Loosens and separates or Chelidonium majus (L,) (Papaveraceae), Euphorbia peplus Keratolytic sheds thickened calloused (L.) (Euphorbiaceae), Taraxacum officinale (L.) Weber ex skin F.H.Wigg. (Compositae)

185 Dissolves stones and Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), gravel, enabling their Hydrangea arborescens (L.) (Hydrangeaceae), Phyllanthus Lithotropic removal niruri (L.) (Phyllanthaceae), Eupatorium purpureum (L.) (Compositae) Stimulates the lymphatic Galium aparine (L.) (Rubiaceae), Phytolacca americana (L.) Lymphatic system (Phytolaccaceae), Echinacea spp, (Compositae), Calendula officinalis (L.) (Compositae) Colchicum autumnale (L.) (Colchicaceae), Taxus brevifolia Enables the blocking or Nutt. (Taxaceae), Catharanthus roseus (L.) G.Don Mitosis inhibiting of the (Apocynaceae), Podophyllum spp (Berberidaceae), inhibitor uncontrolled process of cell division Combretum caffrum (Eckl. & Zeyh,) Kuntze (Combretaceae), (Papaveraceae), Vinca spp (Apocynaceae) Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Avena sativa (L.) (Poaceae), Urtica dioica L. (Urticaceae), Stellaria media (L.) Vill. (Caryophyllaceae), Allium sativa (L.) (Amaryllidaceae), Nutritive Nourishes the body Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Plantago spp (Plantaginaceae), Fucus versiculosus (L.) (Fucaceae), Galium aparine (L.) (Rubiaceae), Rubus idaeus (L.) (Rosaceae) Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Rhamnus purshiana DC. (Rhamnaceae), Phytolacca americana (L.) Strongly stimulates (Phytolaccaceae), Chelidonium majus (L.) (Papaveraceae), Purgative elimination from the Azadirachta indica A.Juss. (Meliaceae), Saponaria officinalis digestive system (L.) (Caryophyllaceae), Rheum palmatum (L.) (Polygonaceae), Ricinus communis (L.) (Euphorbiaceae) Matricaria chamomilla (L.) (Compositae), Verbena officinalis (L.) (Verbenaceae), Melissa officinalis (L.) (Lamiaceae), Humulus lupulus (L.) (Cannabaceae), Withania somnifera (L.) Promotes relaxation and Relaxant Dunal (Solanaceae), Camellia sinensis (L.) Kuntze (Theaceae), assists to reduce tension Piper methysticum G.Forst. (Piperaceae), Eschscholzia californica Cham. (Papaveraceae), Scutellaria lateriflora (L.) (Lamiaceae) Disperses or absorbs Phytolacca americana (L.) (Phytolaccaceae), Galium aparine inflammatory products or (L.) (Rubiaceae), Nigella sativa (L.) (Ranunculaceae), Resolvent substances, reduces Curcuma longa (L.) (Zingiberaceae), Symphytum spp inflammation or swelling (Boraginaceae), Arnica spp (Compositae)

Stimulating circulation to Zingiber officinale Roscoe (Zingiberaceae), Capsicum annuum an area after external (L.) (Solanaceae), Allium sativa (L.) (Amaryllidaceae), Rubefacient application, a mild to Rosmarinus officinalis (L.) (Lamiaceae), Armoracia rusticana moderate irritant, causing P.Gaertn., B.Mey. & Scherb (Brassicaceae), Laurus nobilis skin redness (L.) (Lauraceae), Brassica and Sinapis spp (Brassicaceae) Calms nerves and relaxes Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Berberis vulgaris (L.) (Berberidaceae Lavandula spp (Lamiaceae), Melissa Sedative officinalis (L.) (Lamiaceae), Trifolium pratense L. (Leguminosae) Stimulates the body Capsicum annuum (L.) (Solanaceae), Zingiber officinale systems Roscoe (Zingiberaceae), Lavandula spp (Lamiaceae), Stimulant Rosmarinus officinalis (L.) (Lamiaceae), Armoracia rusticana P.Gaertn., B.Mey. & Scherb (Brassicaceae), Ginkgo biloba (L.) (Ginkgoaceae)

186 Mentha spp (Lamiaceae), Berberis vulgaris (L.) (Berberidaceae), Artemisia absinthium (L.) (Compositae), Capsicum annuum (L.) (Solanaceae), Zingiber officinale Roscoe (Zingiberaceae), Armoracia rusticana P.Gaertn., B.Mey. & Scherb (Brassicaceae), Agrimonia eupatoria (L.) Relieves stomach pain and Stomachic (Rosaceae), Inula helenium (L.) (Compositae), Rosmarinus inflammation officinalis (L.) (Lamiaceae), Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), Humulus lupulus (L.) (Cannabaceae), Origanum vulgare (L.) (Lamiaceae), Salvia officinalis (L.) (Lamiaceae), Thymus vulgaris (L.) (Lamiaceae) Tonifying to the nervous Rhodiola rosea (L.) (Crassulaceae), Avena sativa (L.) system, engenders (Poaceae), Hypericum perforatum L. (Hypericaceae), Humulus Thymoleptic improved sense of lupulus (L.) (Cannabaceae), Turnera diffusa Willd, ex Schult. wellbeing (Passifloraceae), Rosmarinus officinalis (L.) (Lamiaceae) Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Avena sativa (L.) Assists to improve body (Poaceae), Urtica dioica L. (Urticaceae), Stellaria media (L.) function by nourishing, Vill. (Caryophyllaceae), Trifolium pratense L. (Leguminosae), Tonic balancing, strengthens and Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), enlivens the whole or specific parts of the body Galium aparine (L.) (Rubiaceae), Humulus lupulus (L.) (Cannabaceae) Dilates blood vessels, Taraxacum officinale (L.) Weber ex F.H.Wigg. (Compositae), lowers blood pressure, Achillea millefolium (L.) (Compositae), Zingiber officinale Vasodilator assists improving Roscoe (Zingiberaceae), Ginkgo biloba (L.) (Ginkgoaceae), circulation Allium sativa (L.) (Amaryllidaceae) Kills & expels worms Artemisia absinthium (L.) (Compositae), Aloe vera (L.) Burm.f. (Xanthorrhoeaceae), Allium sativa (L.) Vermifuge (Amaryllidaceae), Rumex spp, (Polygonaceae), Thymus vulgaris (L.) (Lamiaceae), Tanacetum vulgare (L.) (Compositae) Calendula officinalis (L.) (Compositae), Echinacea spp, (Compositae), Matricaria chamomilla (L.) (Compositae), Wound healer by external Symphytum spp (Boraginaceae), Stellaria media (L.) Vill. application, protects (Caryophyllaceae), Hypericum perforatum L. (Hypericaceae), Vulnerary against infection& Equisetum hymale (L.) (Equisetaceae), Geranium maculatum stimulate cell growth (L.) (Geraniaceae), Althaea officinalis (L.) (Malvaceae), Verbascum thapsus (L.) (Scrophulariaceae), Ulmus rubra Muhl. (Ulmaceae)

Source: (Fisher & Painter, 1996).

187 APPENDIX D

D1 Differing Extraction Methods and Availability of Herbal Constituents The following appendix is an elaboration to the reference to this subject in Chapter 3— Differing Extraction Methods and Availability of Herbal Constituents. This knowledge is important when discerning herbal treatments.

D1.1 Water as an extracting medium Extractions using water are most commonly called infusions (also known as a herb tea or tisane). These are very simply herbs ‘infused’, or steeped in hot water, (cold water can be used, but infusion is a much slower process). Pour boiling water over herbs and then cover to avoid the loss of the volatile oils. Leave to infuse for up to 10 minutes, but allow a longer infusion time for thick leaves or bark. This method is best suited for leaves and flowers.

More concentrated water extractions are traditionally called decoctions. This is usually achieved by heating to reduce the water content, thereby concentrating the constituents. Decoctions are well suited to dried herbs, barks, roots, which take longer to extract than soft herbs.

This type of extraction requires further processing to preserve them: which may be by freezing, drying for tablet making or using alcohol as a fixative. Alcohol added at a minimum of 20 percent (%) by volume will act as a preservative (Painter, 1998).

Table 23: Water as an Extracting Medium

Water is a good solvent for: Advantages of water are: Disadvantages of water are:

Anthraquinones Readily available Doesn’t extract all constituents Enzymes Cheap Non-selective Glycosides Has a wide solvent action Has no preservative activity Allows growth of moulds and Gums Non toxic bacteria Promotes hydrolysis (causes Organic acids Non flammable breakdown to inactive compounds e.g. saponins & tannins Plant pigments Non-irritant on gastric tissue

188 Proteins

Saponins

Sugars

Tannins

Vitamins and Minerals

Source: Modified from A Herbalist’s Medicine-Making Workbook (Painter, 1998).

D1.2 Alcohol as an extracting medium Using alcohol as an extracting medium produces a liquid called a tincture. The preparation is made by either macerating (a method of extraction to obtain a herbal treatment by immersing the herb in an extracting medium, i.e. water, oil or ethanol) herbs in ethyl alcohol, or using a percolation method (slow flow of ethanol through the finely ground herb to extract the desired therapeutic constituents). Alcohol is suited for extraction of many plant constituents, though it does not extract minerals well. It acts as a preservative (Cowper, 1996); (Painter, 1998).

Most tinctures are made with alcohol between 25-45%, it is dependent on the required constituents for extraction to determine the percentage, though generally roots are at the lower end of alcohol percentage and plants with a high oil or resin content require a higher percentage to ‘dissolve’ the resins, for example, 90% alcohol is used in the extraction process for Calendula, Ginger, Guaiacum resin, Myrrh, Propolis, and Frankincense (Painter, 1998).

Tinctures are made using either dried or fresh plant material, though the majority of commercially available tinctures are from dried plant material. A fresh plant, because it contains water content, can be made in the same way as a dried herb tincture except the moisture content of the fresh herb must be taken into consideration if the tincture is to be of a specific strength (Cowper, 1996); (Painter, 1998).

189 Table 24: Alcohol as an Extracting Medium

Alcohol is a good Alcohol does Disadvantages of Alcohol The advantages of Alcohol are: solvent for: not extract: are:

Alkaloids Enzymes Extracts actives selectively Volatile & flammable Legally, only commercially Astringent & disinfectant Anthraquinones Fats available with a license, which properties has strict regulations Glycosides Fixed gums Preservative action Expensive without a license At strengths over 20% inhibits Organic acids Minerals Strong taste moulds & bacteria Avoid use for alcoholics,  (increases) bioavailability by babies, small children, or those Plant pigments Proteins blood flow & absorption with liver & kidney dysfunction Generally non-toxic at prescribed Resins Vitamins doses Some volatile oils Waxes Mixes well with water Neutral, so compatible with

many constituents Inactivates enzymes Controls hydrolysis Source: Modified from A Herbalist’s Medicine-Making Workbook (Painter, 1998).

D1.3 Acetic acid and vinegar as extracting mediums Extracts using acetic acid or vinegars are called acetracts; any type of vinegar, including cider, wine or other fruit vinegars, are effective for extracting. Vinegars are very good at extracting minerals from herbs: they keep longer than a decoction (herb vinegars last about one year), though not as long as a tincture (Painter, 1998).

Table 25: Acetic Acid and Vinegar as Extracting Mediums

Vinegar is a good The advantages of Vinegar are: Disadvantages of Vinegar are: solvent for: Minerals Allays thirst Strong taste Alkaloids  stomach acid Short shelf life Tannins Improves assimilation of minerals Not acceptable for children or alcoholics on aversion medication Mild diuretic Mild diaphoretic Useful for inhalations Preservative activity Solubilises alkaloids & tannins& keeps them in solutions Used externally vinegar is anti-

190 inflammatory & reduces swelling Source: Modified from A Herbalist’s Medicine-Making Workbook (Painter, 1998).

D1. 4 Glycerine as an extracting medium Extracts using glycerine are called glycetracts. They are best made from dried herbs. When used as external treatments, glycerine and glycetracts are used for their water-retaining and emollient actions, well-suited for addition to lotions, creams and poultices. To extend the shelf life of a glycetract, it is advised to add alcohol, at least 20% by volume (Painter, 1998).

Table 26: Glycerine as an Extracting Medium

Glycerine is a good The advantages of Glycerine are: Disadvantages of Glycerine are: solvent for: Mucilage Sweet taste, makes taking more Insoluble in fixed or volatile oils palatable Tannins Suitable for diabetics Not suitable for blending with oily or resinous substances Phlobotannins Can be diluted with either Preservative activity gives short shelf (phlobaphenes) water/alcohol without precipitation life to extracted products Miscible with alcohol & water Less stable than alcohol Has some preservative activity, at ratio Its viscosity can cause blending of 50% or more difficulties Mild laxative activity Can solidify at low temperatures Absorbed in intestines Non-alcoholic, better for children & alcoholics Source: Modified from A Herbalist’s Medicine-Making Workbook (Painter, 1998).

191 APPENDIX E

Included in this appendix are; the Ethics Committee ‘Approval Letter, to conduct the survey, the invitation to participate and the complete survey tool questionnaire and all the participant responses, which have not been edited, nor corrected (QUALTRICS, 2002).

E1 Ethics Committee Application Approval Letter

Following, is the approval letter from the Human Research Ethics Committee at RMIT University: Ethics number ASEHAPP08–15; dated 30th March 2015 and the amendment dated 3rd August 2015.

192

E2 Invitation to Herbalists to Participate in Survey

Survey of Herbalists Use of Herbal Medicine For Treating Actinic Keratoses December 15th 2016, 1:44 pm AEDT

QID31 - “Screening and Treatment of Actinic Keratoses by Herbalists” Participant Information and Consent Form

Background As a practicing herbalist you are cordially invited to participate in a research project being conducted by RMIT University. Australia has the highest rates of actinic keratoses in the world. These skin lesions are induced by

193 exposure to the sun, particularly in fair-skinned individuals. They are often regarded as harmless blemishes, but they have the potential over time to transform into non-melanoma skin cancers. Karina Hilterman is interested to learn about the experiences of other Australasian herbalists in the diagnosis and treatment of actinic keratoses. Professor Stephen Robinson is supervising Karina to undertake a research project towards a Master of Applied Science degree at RMIT University. They have prepared a brief web-based survey that will help to build a clearer understanding of herbalists’ experience regarding the treatment of actinic keratoses. The survey will not collect the personal details of participants, and the responses of participants will remain completely anonymous. The collated results of this survey will assist the profession to improve practice in the important area of screening and treatment of actinic keratoses. If you choose to participate in this survey, please read the Consent to participate and confidentiality section, then click on the AGREE button to proceed. The survey will take between 5-15 minutes to complete, depending on the amount of detail you choose to provide.

Participation/Consent Please read the following information carefully and if you choose to participate in this survey click on the AGREE button to proceed. This project will use an external site (Qualtrics) to create, collect and analyse data collected in a survey format. If you agree to participate in this survey, the responses you provide will be stored on a host server that is used by Qualtrics. No personal identifying information will be collected in the survey, so none will be stored as data. Once data collection has been completed, the data will be imported to an RMIT server where it will be stored securely for five (5) years. The data on the Qualtrics host server will then be deleted. Your information is assured of complete confidentiality. It will only be assessed by the researchers and the information you provide cannot be traced back to you. All data and analyses will be treated with the utmost confidentiality. At no point will the researchers have access to any of your personal information, and all data collected will remain anonymous. The collated outcomes from this survey may be published as part of an RMIT Masters thesis, and may also be published in academic journals or presented at conferences. By undertaking the survey you are agreeing to the following statements: I certify that I am a practicing herbalist, naturopath or other traditional herbal practitioner. I understand that my participation is voluntary and that I am free to withdraw from the survey at any time. The survey is for the purpose of research. It may not be of direct benefit to me. All answers that I provide will be anonymous. The security of the research data will be protected during and after completion of the study. The data collected during the study may be published. This survey has been approved by the Human Research Ethics Committee at RMIT University (Ethics number ASEHAPP08–15).

If I have any concerns with this study, I can contact Professor Stephen Robinson on the details listed below. Should I not wish to discuss concerns with the researchers, then I can contact:

Ethics Officer Research Integrity, Governance and Systems, RMIT University GPO Box 2476, VIC 3001. Tel: (03) 9925 2251 Email: [email protected]

194

Contact details of primary researcher: Professor Stephen Robinson Deputy Head, School of Health Sciences, RMIT University Telephone: 03 9925 7120 Email: [email protected]

E3 Data From the Survey of Herbalist’s Use of Herbal Medicine For Treating AKs

(NB: None of the responses have been edited; therefore any spelling or grammatical errors have been left as they were entered — verbatim).

By completing this survey I am consenting to take part in this research.

# Answer % Count

1 If you choose not to participate, click here to exit: 2.86% 1

2 If you agree to continue, click here: 97.14% 34

Total 100% 35

Std Bottom 3 Top 3 Field Minimum Maximum Mean Variance Count Deviation Box Box

1.00 2.00 1.97 0.17 0.03 35 100.00% 100.00%

195

Q1 - Number of years you have been in practice:

Number of years you have been in practice:

15years

8 years

28 years

Twenty- eight years

13 years

student-studying for four years

twenty five years

196 1.5

Q2 - Your professional training? Tick all relevant boxes:

# Answer % Count

1 Western Medical Herbalist 84.62% 22

2 Naturopath 53.85% 14

3 Traditional Chinese Medicine 0.00% 0

4 Ayurvedic Medicine 0.00% 0

5 Other 19.23% 5

Total 100% 26

Q3 - If you answered ‘Other’ please provide details here:

197 If you answered ‘Other’ please provide details here:

Pharmacist

registered nurse

Registered Nurse. MHSc

Nutritionist

student of Western Herbal Medicine since 2012-due to graduate May 2016

Q4 - If you live in Australasia, is your practice located: (This is to assess the effect of annual solar UV load, without compromising participant anonymity)

# Answer % Count

1 North of Sydney 5.88% 1

2 In Sydney or south of Sydney 94.12% 16

Total 100% 17

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box If you live in Australasia, is your practice located: (This is to assess the effect of annual 1.00 2.00 1.94 0.24 0.06 17 100.00% 100.00% solar UV load, without compromising participant anonymity)

198

Q5 - Approximate number of patients you have seen in the past year?

# Answer % Count

1 0 0.00% 0

2 1-10 16.00% 4

3 11-50 32.00% 8

4 51-200 24.00% 6

5 More than 200 28.00% 7

Total 100% 25

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Approximate number of patients you 2.00 5.00 3.64 1.05 1.11 25 48.00% 84.00% have seen in the past year?

199 Q6 - Approximate percentage of your patients with sun-damaged skin?

# Answer % Count

1 0-20% 45.83% 11

2 21-40% 37.50% 9

3 41-60% 8.33% 2

4 61-80% 8.33% 2

5 81-100% 0.00% 0

Total 100% 24

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Approximate percentage of your patients with 1.00 4.00 1.79 0.91 0.83 24 91.67% 16.67% sun- damaged skin?

Q7 - Approximate percentage of your patients with actinic keratoses?

# Answer % Count

1 0-20% 68.00% 17

200 2 21-40% 20.00% 5

3 41-60% 12.00% 3

4 61-80% 0.00% 0

5 81-100% 0.00% 0

Total 100% 25

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Approximate percentage of your 1.00 3.00 1.44 0.70 0.49 25 100.00% 12.00% patients with actinic keratoses?

Q8 - Can you confidently identify actinic keratoses? Tick one box:

# Answer % Count

1 Always 8.00% 2

2 Mostly 32.00% 8

3 Sometimes 28.00% 7

4 Occasionally 24.00% 6

5 Never 8.00% 2

201 Total 100% 25

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Can you confidently identify 1.00 5.00 2.92 1.09 1.19 25 68.00% 60.00% actinic keratoses? Tick one box

Q9 - Do you refer patients with actinic keratoses to a specialist or a GP? Tick one box:

# Answer % Count

1 Always 40.00% 10

2 Mostly 8.00% 2

3 Sometimes 20.00% 5

4 Occasionally 20.00% 5

5 Never 12.00% 3

Total 100% 25

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box

202 Do you refer patients with actinic keratoses to a 1.00 5.00 2.56 1.47 2.17 25 68.00% 52.00% specialist or a GP? Tick one box:

Q10 - In your experience, do patients with actinic keratoses request treatment for these lesions? Tick one box:

# Answer % Count

1 Always 4.17% 1

2 Mostly 8.33% 2

3 Sometimes 20.83% 5

4 Occasionally 20.83% 5

5 Never 45.83% 11

Total 100% 24

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box In your experience, do 1.00 5.00 3.96 1.17 1.37 24 33.33% 87.50% patients with

203 actinic keratoses request treatment for these lesions?

Q11 - Do you treat actinic keratoses? Tick one box:

# Answer % Count

1 Always 4.00% 1

2 Mostly 8.00% 2

3 Sometimes 12.00% 3

4 Occasionally 24.00% 6

5 Never 52.00% 13

Total 100% 25

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Do you treat 1.00 5.00 4.12 1.14 1.31 25 24.00% 88.00% actinic keratoses?

204

Q12 - Comments: If there is any information you would like to provide that is relevant to questions 1-11 please add it here:

Comments: If there is any information you would like to provide that is rel...

I do have several herbal approaches I'd be happy to recommend if a client requested a herbal treatment. So far I've not treated this - not that I'd not like to or anything - it's more that I've not had the opportunity so far - recently out of full time homeopathic training so I've kept seeing clients to a minimum to be able to handle life and study etc - only recently been taking on odd more clients in general I'm a fertility specialist so patients with skin lesions don't typically come to me

In NZ people seem to just accept these as 'ageing'

Usually someone will go to a doctor with AC and do not see us as the primary care provider for treatment

I would treat more if i had a reasonable protocol to use for these conditions.

I have not been asked to treat this condition. However I have probably noticed it in some of my elderly clients.

Older people almost all, have sun damaged skin in NZ If people request assistance with AK's then I will help. Most people I find just accept them and do nothing unless they notice changes to the lesion. I recommend to patients to get a mole map. if an area looks like AK I use a poultice we have developed and which typically resolves the issues within a 2-3 week period. If the area is unresponsive I refer to GP. In the past few years I have not had nay patients requsestng an appointment for skin lesions such as actinic keratoses. When they have been discussed in a consultation it is as a seocndary or minor concerns to their main reason for making an appointment. Often they will have been cleared by their doctor as being ' not cancer'. Occasionally I have noticed lesions and have asked further about the history of such lesions and taken their presence into account in their prescription. We have a visiting skin specialist that comes to our clinic to do skin screening once per month. questions 8-10 need a N/A option? Never had a patient with it.

I have never seen/treated this condition. Most patients accept that they will need to see a skin or skin/cancer specialist, because they believe that's the only way to resolve skin cancers.

205 I have DSAP and thought it was AK. My partner has AK. I became aware of Euphorbia peplus sap when researching AK 12 years ago. I know about Picato (prescribed to my partner, but also was aware of its development when researching AK). and am appalled at how much it cost $140!! My practice is an area of many retired people near the sea, most over 50 have sun damage to their skin

Q13 - If you never treat actinic keratosis then proceed to the end of the survey. (Need to add an EXIT...

# Answer % Count

1 EXIT Survey 45.83% 11

2 CONTINUE Survey 54.17% 13

Total 100% 24

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box

If you never treat actinic keratosis then proceed to the end of the 1.00 2.00 1.54 0.50 0.25 24 100.00% 100.00% survey. (Need to add an EXIT...

206 Q14 - Otherwise, please answer the following questions about treatments for actinic keratoses. What herbs would you consider using to treat actinic keratoses as internal treatments? Provide details here:

Otherwise, please answer the following questions about treatments for actin...

Green tea I work as a AK practtioner so I have to say that I do not treat the AC directly and everyone's internal treatment will be different. You have to find the environmental triggers, the skin signs are just a sign. So liver and other detox herbs may be relevant, gut rememdies often are useful. Treatment would not differ as from other conditions, treat the whole person. Red clover, dandelion, burdock, thuja

Centella, green tea

Viola, Trifolium, Rosemary, Tumeric, ( quite a number of herbs depending on the person)

I would use primarily minerals and vitamins, antioxidants

Calendula, Comfrey, Echinacea, Clivers, St Mary's Thistle, Thuja

I dont treat for this internally. Maybe suggest they have more oils in their diet or take a good quality fish oil.

Dong quai red clover poke root violet

Conifer pine needle concentrate, chaparral, maritime pine, various mushroom extracts, resveratrol

Trifolium pratense, Phytolacca decandra, Arctium lappa, Viola odorata, Glyceriza glabra

Q15 - What herbs would you consider using to treat actinic keratoses as external treatments?

What herbs would you consider using to treat actinic keratoses as external...

Own ointment Black slave is my first treatment, Kalonji oil, Vit E with calendula, hypericum, chamomile one or all of these. Mebo oil, Papaya cream. Red clover, calendula, gotu kola

Comfrey, centella, plantain. chickweed, kawakawa, chamomile, plus thyme essential oil Trifolium, Kumerahou, cinnamon, periwinkle, viola, plantain, chelidonium, any herb with good levels of salicylates i may include. Comfrey, myrhh but these are part of a poultice I make with debriding actions.

Yarrow, Comfrey, Chickweed. I tend to use a comfrey root decoction mixed in with a good quality vit E cream base, with a calendula oil, rose hip oil, wheat germ oil. I have a formulation that I have been using for years with a couple of clients and have found that this really helps.

207 Concentrated herbal extracts (essential oils) black salve paste bloodroot, graviola, chaparral, tumeric Trifolium pratense, Phytolacca decandra, Arctium lappa, Viola odorata, Calendula officinalis, Aloe vera, Hamamelis virginiana, essential oil of Lavendula angustifolia

Q16 - Do you make your own topical treatments? i.e. creams or salves?

# Answer % Count

1 Yes 83.33% 10

2 No 16.67% 2

Total 100% 12

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box Do you make your own topical 1.00 2.00 1.17 0.37 0.14 12 100.00% 100.00% treatments? i.e. creams or salves?

208 Q17 - If yes, please provide details of the herbs or herbal extracts included in the treatments here:

If yes, please provide details of the herbs or herbal extracts included in...

Comfrey root, kawa kawa, thyme, centella plus some essential oils Usually a tincture of any of the herbs above, gentle heating to extract the alcohol, and then added to Vit E water based cream. red clover, calendula, gotu kola

As above as above. If making a cream I will use infused herbal oils ie plantain oil mixed with red clover and kumerahou tincture, cinnamon e/o or other oils/ tinctures/ infusions/ essential oils of choice. I have added in salicylic acid to some creams. I am currently working on refining a cream for this very purpose. The above

As stated above. Essential oils or CO2 extracts of Calendula officinalis, Lavendula angustifolia, Helichrysum italicum, Daucus carota, Boswellia carterii Dried herbs bloodroot, graviola, chaparral and tumeric made up into a salve, with some other ingredients (non herbal). Trifolium pratense, Phytolacca decandra, Arctium lappa, Viola odorata, Calendula officinalis, Aloe vera, Zingiber officinalis, Hamamelis virginiana, essential oil of Lavendula angustifolia

Q18 - Do you use any commercially prepared products for treating actinic keratoses, such as Black Salve paste? If so, please provide details here:

Do you use any commercially prepared products for treating actinic keratose...

Bepanthen

Black salve, mebo

I have only used Black salve paste for BCC's not AK's

Occasionally bepanthen

I have quite extensive experience with black salve preparations but would not use these for AK's

Black salve, blood root

No. I have used salisylate acid before and this can work but is quite harsh. no black salve paste

Yes, I make my own and dispense it on a bona fide basis to my clients. No I don't

209 Q19 - In your experience, how successful are herbal treatments in clearing actinic keratoses? Tick one box:

# Answer % Count

1 Always 25.00% 3

2 Mostly 33.33% 4

3 Sometimes 25.00% 3

4 Occasionally 8.33% 1

5 Never 8.33% 1

Total 100% 12

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box In your experience, how successful are herbal 1.00 5.00 2.42 1.19 1.41 12 83.33% 41.67% treatments in clearing actinic keratosis?

Q20 - In your experience, what duration is usually needed to achieve clearance of an actinic keratosis using herbal treatments? Tick one box:

210 # Answer % Count

1 Less than 1 week 0.00% 0

2 1-4 weeks 33.33% 4

3 1-3 months 33.33% 4

4 More than 3 months 25.00% 3

5 Ineffective 8.33% 1

Total 100% 12

Std Bottom Top Field Minimum Maximum Mean Variance Count Deviation 3 Box 3 Box

In your experience, what duration is usually needed to achieve clearance of an 2.00 5.00 3.08 0.95 0.91 12 66.67% 66.67% actinic keratosis using herbal treatments?

Q21 - In your experience, what are the adverse effects associated with herbal treatment of actinic keratosis? Tick all relevant boxes:

211 # Answer % Count

1 Reddening of the skin 50.00% 4

2 Rash 12.50% 1

3 Blistering 37.50% 3

4 Sloughing 37.50% 3

5 Pain 25.00% 2

6 Infection 0.00% 0

7 Ulceration 12.50% 1

8 Skin pigment alterations 0.00% 0

9 Scarring 0.00% 0 Transformed into 10 0.00% 0 carcinoma 11 Other 75.00% 6

Total 100% 8

212 Q22 - If you answered 'Other' to the previous question, please provide any additional details here:

If you answered 'Other' to the previous question, please provide any additi...

No adverse effects You will be familiar as to how the Black Salve works. Sometimes needs to be repeated if there has not been a good enough response first time and smaller sites appear in the area. Nothing

None outside of a temporary reddening or discomfort if using my own poultice recipe.

No real problems with the cream it is just ongoing and takes time.

None On areas of skin where circulation is poor (eg. around the ankle or shin), the reddening is more pronounced and painful. The lesion, where the salve is applied, often appears to blister around the edges, and looks like it is infected with pus, but this dries into a scab, and when the scab sloughs away, the skin is generally good underneath. Very occasionally, if the keratosis returns in a smaller size, I recommend to apply the salve again and repeat the process. Mostly the creams I make up cause not averse effects, I have started to use some Ginger in the creams, to stimulate the circulation to the treatment area and this, being a rubefacient, can cause some initial reddening to the treatment area, it lasts for about 30 minutes, sometimes there is no reddening.

Q23 - If there is any information you would like to provide that is relevant to questions 14-22 please add it here:

If there is any information you would like to provide that is relevant to q...

A dermatologist suggested Bepanthen to me years ago so if people aren't keen on using a herbal ointment I've made myself then I suggest they use Bepanthen. not ver had any adverse effects with either my own ointment or with the Bepanthen Black Salve is illegal for us to use and so treatment needs to be specific for patients that you trust because in some instances a patient may go to the hospital when the ulceration phase occurs worried about infection. If your studies could legalize the salve for herbalists you would have achieved a great step forward in assisting many people with AC. The other think about the slave is that the skin does not change at all if cancer sell changes are not present. I would love more information on how to treat these conditions. Thanks

Not painful, doesn't scar, no side effects and about 80% clearance in 1-3 months I am in the process of making the poultice I use commercially available. I will be looking to run trials on it. This may be of interest to you. If so please contact me on (Respondent info removed to maintain anonymity) Sometimes patients become alarmed with the diagnosis and return to doctor who removes it thru the usual methods It is not always to evaluate long-term effect of a prescribed treatment, due to ongoing costs to client in having follow-up appointments. I've used this process (above) for patients who present with poorly healed scars from the medical removal process, and it works for complete healing of the lesion. I find that the herbs I use seem not to cause any negative reactions, apart from the initial reddening, which is caused by the Ginger. I have found that the people who use the creams I make come back for more and they tell their friends about it too. The most effective treatment I find is when patients take an internal formula in conjunction with using the topical treatment.

213 APPENDIX F

F.1 Series of Practice Case Studies Included here are a series of case note studies of patients from the author’s WHM clinical practice. These patients used the experimental herbal skin cream designed to treat sun- induced skin damage. The name given to the cream was the ‘Sunspot Cream’. This cream appears to be effective for treating sun-damaged skin, as indicated in the case studies below.

All these cases have been de-identified and permission to use, as such, was sought as each case was taken.

F1.1 Patient A Woman, late 40s, blonde hair, blue eyes, Fitzpatrick skin type II-III, fair skin that tans easily. She admitted to a lot of sun baking through adolescence and early adulthood. Age spots had appeared on the backs of hands, her forearms and forehead. Some of these spots had become itchy and scaly and she was to have them burnt off by a dermatologist. She used the cream regularly and within three months all signs of the sunspots had disappeared leaving normal healthy skin:

“I used the sunspot cream on some scaly sun-damaged spots on the backs of my hands. They have not only gone, there is NO sign of the spots returning in those areas. I am now working on some others. They are normally gone when using the cream in less than three weeks. I expected it would take three months and I was surprised that it took less.”

F1.2 Patient B Woman, late 60s, Fitzpatrick skin type II, has been very active in the outdoors all of her life, had been sunburnt a lot. She had developed a proliferation of sun-induced skin abnormalities, sunspots, actinic keratoses and a number of early stage basal and squamous cell carcinomas. She was having some of them removed monthly by cryotherapy, and by regularly using the cream; the abnormalities are disappearing, leaving normal, healthy skin. She continues to use the cream on any signs of new skin abnormalities that appear, much to the amazement of her dermatologist:  “Thank you for being so clever to produce something that helps people like me.”  “Your cream really helped my fair vulnerable skin!”  “There doesn’t appear to be anything like it.”

214 F1.3 Patient C Woman, mid 70s, Fitzpatrick skin type II, active outdoor life. She developed a proliferation of sun-induced skin abnormalities, including sunspots (age), actinic keratoses and she had some early stage basal cell carcinomas. Regularly, she had some of these lesions removed by cryotherapy, usually five or six each month. With regular and continued use of the cream, these abnormalities have disappeared and she has healthy skin in place. She too continued to use this on any sign of new spots appearing.

F1. 4 Patient D Male, mid 80s, Fitzpatrick skin type II with a histologically confirmed Melanoma on the side of his nose. He was to have it surgically removed within one month of seeing the herbal medicine practitioner, also having been told that the surgeon would have to remove most of his nose and a lot of the right side of his face. He was most reluctant to have this happen. He used the cream very regularly and after two weeks of application the melanoma shrivelled and dropped off, leaving healthy, normal skin in place. He did not have an operation and had no reoccurrence. (He died of unrelated causes in his 90s.)

(NB. The use of a treatment, such as this cream, is not recommended for a condition such as melanoma. This was an exceptional case, where the other alternative was radical and invasive surgery on an old man).

F1.5 Patient E Woman, early 40s, blonde hair, olive complexion, Fitzpatrick skin type II-III, very active outdoor life for most of life. Sunspots appeared on face and backs of both hands. After one month of regular treatment they disappeared leaving normal healthy skin. She uses the cream now when new spots appear:

“I am delighted with how well the cream has normalised any ‘funny spots’ that have appeared. I work outdoors and have considerable sun exposure but I have allergic reactions to most sunscreens. I do take care and am very glad this cream has been produced.”

215 F1.6 Patient F Male, late 60s, Fitzpatrick skin type II, outdoor rural life. He had multiple actinic keratoses. A rapidly changing keratosis on his nose was to be surgically excised. Within one month of treatment all traces had gone, leaving normal healthy skin and an amazed surgeon.

F1.7 Patient G Male, mid 50s, Fitzpatrick skin type I-II, worked outdoors all adult life. He had a 12-year clinical history of basal cell carcinomas, also 2 squamous cell carcinomas; these lesions were either surgically excised or burnt off. He had a lot of scarring and when the author first met him was undergoing a course of treatment that involved an escharotic cream directly on the cancers, which eroded them away. This is a very painful treatment. He was in a lot of pain and quite depressed. He used the cream successfully on other cancers that he had not used the escharotic cream on and also used an internal herbal formula. In combination these aided him to have a greater feeling of well-being, controlled his skin cancers and created a much improved emotional state.

F1.8 Patient H Female, 45, olive skin; Fitzpatrick skin type III. She developed a ‘warty type’ growth on her bottom eyelid, which annoyed her as it was ‘in her line of vision’. She used the cream twice daily and the size reduced considerably, quite quickly.

“I was amazed I saw results so quickly, it was one to two weeks when I noticed a change.” 

Considering this document is about seeking natural solutions, the final word of this appendix is given to Albert, both a scientist and deep respecter of Nature:

“Look deep into Nature and then you will understand everything better” Albert Einstein (18791955) German born physicist and Nobel Prize winner (Einstein, 1921).



216