+Model YCTIM-1253; No. of Pages 6 ARTICLE IN PRESS Complementary Therapies in Medicine (2013) xxx, xxx—xxx Available online at www.sciencedirect.com ScienceDirect jour nal homepage: www.elsevierhealth.com/journals/ctim Efficacy and safety of topical Trikatu preparation in, relieving mosquito bite reactions: A randomized controlled trial a b,c,d,e,∗ Ratree Maenthaisong , Nathorn Chaiyakunapruk , f g Waree Tiyaboonchai , Apiwat Tawatsin , h g Archawin Rojanawiwat , Usavadee Thavara a Clinical Pharmacy Research Unit, Department of Clinical Pharmacy, Faculty of Pharmacy, Mahasarakham University, Mahasarakham, Thailand b Discipline of Pharmacy, Monash University Sunway Campus, Jalan Lagoon Selatan, Bandar Sunway 46150, Selangor, Malaysia c Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand d School of Pharmacy, University of Wisconsin, Madison, WI, USA e School of Population Health, University of Queensland, Brisbane, QLD, Australia f Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand g The National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand h Clinical Research Center, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand Received 6 June 2012 ; received in revised form 16 August 2013; accepted 20 August 2013 KEYWORDS Summary Introduction: Trikatu is composed of dried fruits of Piper nigrum L and Piper retrofractum Trikatu preparation; Vahl, and dried rhizomes of Zingiber officinale R. Although this preparation has been used to Mosquito bite; relieve pruritis, pain, and inflammation for a long time, there is no clinical evidence to confirm Papule size reduction; its efficacy and safety. Therefore, we performed a double-blind, within person-randomized controlled study of 30 healthy volunteers to determine efficacy and safety of topical Trikatu on Mosquito bite symptoms; mosquito bite reactions. Methods: All subjects were bitten by Aedes aegypti laboratory mosquitoes on their forearms Eucalyptus oil and they were randomly assigned arms to apply either Trikatu or reference product on the mosquito bite papule. The main outcome was the difference of papule size reduction at 30 min, measured by a caliper, between the Trikatu and reference arms. Pruritis, redness, pain, and patient satisfaction were assessed at 15, 30, 60, 180, and 360 min as secondary outcomes. ∗ Corresponding author. Tel.: +603 5514 4413; fax: +603 5514 63261. E-mail addresses: [email protected], [email protected] (N. Chaiyakunapruk). 0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ctim.2013.08.014 Please cite this article in press as: Maenthaisong R, et al. Efficacy and safety of topical Trikatu prepa- ration in, relieving mosquito bite reactions: A randomized controlled trial. Complement Ther Med (2013), http://dx.doi.org/10.1016/j.ctim.2013.08.014 +Model YCTIM-1253; No. of Pages 6 ARTICLE IN PRESS 2 R. Maenthaisong et al. Results: There were no significant differences between treatment and reference arms on any outcome at any time of measurement. Conclusion: Trikatu did not show additional effects for relieving mosquito bite reaction as com- pared with the reference product containing camphor, menthol, and eucalyptus. For further study, it is very important to consider a proper selection of subjects, comparator product, and concentration of extract when Trikatu preparation is investigated. © 2013 Elsevier Ltd. All rights reserved. Introduction of Medical Sciences, Thailand to compare the effects of a topical Trikatu product with a reference product. The study Trikatu is one of the popular Thai traditional preparations was conducted in compliance with the principles of the Good comprising of dried fruits of black pepper (Piper nigrum Clinical Practice, in accordance with Declaration of Helsinki Linn., family Piperaceae), long pepper (Piper retrofractum and approved by the Institutional Review Boards of Nare- Vahl., family Piperaceae) and dried rhizomes of ginger (Zin- suan University. Thirty subjects participated to the study and giber officinale Roscoe., family Zingiberaceae) in various all of them provided informed consent before study partic- ratio. The various formulas of Trikatu have been used to ipation. This study was supported by the National Research adjust patient’s element during rainy season for the treat- Council of Thailand (NRCT) which had no role in study design, 1,2 ment of illness due to fire, wind, and water, respectively. data collection and analysis, decision to publish, or prepa- Trikatu is also used as Ayurvedic in India for a wide range ration of the manuscript. of diseases and symptoms such as cold, asthma, pruri- 3,4 tis, pain, inflammation. Dried rizhomes of ginger are composed of various substances such as essential oils, 6- Subjects gingerol, 6-shogaol, 6-gingessulfonic acid, gingerglycolipids 5—8 A, B and C. Ethanol extract of ginger has antioxidant, Healthy person with age ≥18 years who had reactions to anti-edema, antipyretic, analgesic and anti-inflammatory mosquito bite (had papule and pruritis within 30 min after 8—13 effects. Dried fruits of black pepper are composed of mosquito bites) were enrolled. Subjects were excluded if piperine, chavicine, piperamine, piperidine, and volatile they took oral or apply antihistamine, corticosteroid, non- 14—16 oils. Ethanol extract and volatile oils of pepper have steroid anti-inflammatory (NSAIDs) within 2 weeks before 17—21 anti-inflammatory, and anti-edema effects. Dried fruits enrollment. In addition, drug abuse subjects, pregnant and of long pepper are composed of piperine, pipernon- breast-feeding women, as well as subjects who were known 15,22,23 aline, piperundecalidine, and dehydropipernonaline. allergy against product containing ginger, pepper, long pep- Its ethanol extract and volatile oils have anti-inflammatory, per, or other ingredients in study product or history of 14—26 and can decrease abdominal pain and peptic ulcer. anaphylactic reaction from mosquito bites or insect sting The main active ingredients of Trikatu are piperine from were excluded. All included subjects came to participate in black and long pepper dried fruits, and gingerol from the experiment get their outcomes measured at the Clinical 5,27 ginger dried rhizomes. Although the Trikatu capsule Research Unit on a date. (500 mg) is now available commercially in India and other preparations of Trikatu have been used in India and 1,2,4,5 Thailand for a long time in various conditions, the Randomization and interventions majority of research was on pharmacology and toxicity with- out any studies demonstrating clinical evidence of such We randomly assigned arms of each subject to apply either preparation.2,5,28—31 Trikatu product or reference product on the mosquito bite Mosquito bites frequently cause skin symptoms includ- papule. Randomized codes were generated by a computer ing pruritis, redness, and papules. These symptoms are using block size of 4. To conceal the researcher enrolling mediated by antisavila IgE antibodies and histamine reac- (AT) and assessing (AR) participants, random allocation 32,33 tion leading to induce inflammatory process. Current sequences and products were placed in sequentially num- therapeutic options for treating mosquito bite associated bered, opaque and sealed envelopes by a research assistant symptoms are oral antihistamines and topical steroids and (PS) who was not involved in patient enrollment, product antihistamine. Moreover, OTC products containing men- distribution, or data collection. The Trikatu and reference thol, eucalyptus have been used for relieving insect bite products were similar in appearance and odor. Dosage form 34—37 reactions. It was postulated that the Trikatu product of both products was stick. exerting anti-inflammatory effects may have efficacy for The treatment product was topical Trikatu preparation controlling symptoms of mosquito bites. This study was con- containing ethanol extract of Trikatu 1%, camphor 2%, men- ducted to determine the efficacy and safety of this product thol 2%, and eucalyptus oil 4%. The extract was obtained on mosquito bite reactions. from dried fruit of black and long pepper, and dried rhi- zomes of ginger. The final product composed of piperine Methods and gingerol of 0.074% and 0.046% w/w, respectively, as determined by HPLC method. The reference product was a stick preparation containing the same ingredients of the A double blinded, within person-randomized, controlled treatment product except Trikatu extract. trial was conducted at Clinical Research Unit, Department Please cite this article in press as: Maenthaisong R, et al. Efficacy and safety of topical Trikatu prepa- ration in, relieving mosquito bite reactions: A randomized controlled trial. Complement Ther Med (2013), http://dx.doi.org/10.1016/j.ctim.2013.08.014 +Model YCTIM-1253; No. of Pages 6 ARTICLE IN PRESS Efficacy and safety of topical Trikatu preparation in, relieving mosquito bite reactions: A randomized controlled trial 3 Mosquito exposure and measurement of bite Table 1 Baseline demographic and clinical characteristics reactions of subjects. Mosquito-bite reaction was induced by Aedes aegypti labora- Average age; years (SD): 33.17 (6.95) tory mosquitoes. One mosquito in a cage was allowed to bite Demographic characteristics on the right or left forearm for 5 min. The reactions including