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Table 13.1. Continued.
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406
Scientific name
(family)
Dracaena cinnabari
Balf.f.
(Asparagaceae)
Erysimum × cheiri (L.)
Crantz
(Brassicaceae)
Lawsonia inermis L.
(Lythraceae)
Olea europaea L.
(Oleaceae)
Common name
(English/Arabic)
Dragon’s
blood/Damm-
ol-akhwain
Common
wallflower/Kheiri
Henna/Hena Leaf
Olive/Zeitoon Oil (sitz bath of olive oil,
Part used in TPM
(administration method)
Resin
(compounded in other
formulations)
Flower
(dried powder as a
dressing/TPM wallflower
oil)
(topical cerate of henna
leaves and TPM damask
rose oil)
water, and an astringent
agent/enema of olive oil
and verjuice)
In vitro/in vivo/clinical studies,
extract, and effect
In vivo:
effect
In vitro:
• Resin: ↓ TNF-α, IL-6, nitrite production
In vivo:
• Resin: ↑ anti-inflammatory effect
In vitro:
↑ anti-inflammatory effect
Clinical:
inflammation
In vitro:
↑ anti-inflammatory effect
In vivo:
healing, epithelialization, and antiinflammatory eff ects; ↓ ROS-induced
damages
Clinical:
ulcer
pressure ulcer
In vitro:
eff ect; ↓ COX-2 and NO production
Reference
Sosa etal. (1993); Kimura etal.
(2001); Mencarelli etal. (2009)
Gupta etal. (2014)
Alwashli etal. (2012); Gupta etal.
(2014)
Mosleh etal. (2021a)
Mosleh etal. (2020)
Liou etal . (2013); Wiem etal. (201 4);
Bouhlali etal. (2016); Manuja etal.
(2021)
Nayak etal. (2007); Jridi etal.
(2017); Salih etal. (2017); Daemi
etal. (2019); Rekik etal . (2019); Ali
etal. (2021)
Hekmatpou etal. (2018b); Poursadra
etal. (2019); Rafiei etal. (2019)
Miles etal. (2005); Rosignoli etal.
(2013); Cardeno etal. (201 4);
Cárdeno etal . (2014); Takeda etal.
(2014); Abdallah etal. (201 8);
Yonezawa etal . (2018); Aparicio-
Soto etal. (2019); Elaasser etal.
(2020); Fernández-Prior etal. (2021)
Ghazaleh Mosleh etal.
Prunus armeniaca L.
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(Rosaceae)
Quercus infectoria
G. Olivier
(Fagaceae)
Common apr icot/
Meshmesh
Aleppo oak/Afs Gall (hydroalcoholic
Kernel oil (topical kernel
oil, either singly or in
combination with guggul
gum resin)
solution of powdered nut
galls suspended in a
mixture of wine and
water/decoction of galls
in concentrated grape
wine)
Clinical:
ulcers and dermatitis
In vitro:
• Seed: ↑ anti-inflammatory effect
In vivo:
inflammation, and colitis
In vitro:
• Gall: ↓ Set7, p65, NF-κB activity, IL-1β,
IL-6, CCL-2/MCP-1, CCL-7/MCP-3;
↑ caspase-3 activity; scavenging NO,
ameliorating LPS-stimulated PGE2,
PMA-stimulated superoxide pr oduction;
regulating Bcl-2, Bax, p53, pAkt
production
In vivo:
inflammatory eff ect; ↓ IL-1β, TNF-α
Clinical:
Amani etal. (2015); Nasiri etal.
(2015); Lupiañez-Perez etal.
(2015, 2017); Díaz-Valenzuela
etal. (2019); Miraj etal. (2020)
Chang etal. (2005)
Hwang etal. (2008); Minaiyan etal.
(2014); Karaboga etal. (2018)
Kaur etal . (2004); Yoon etal. (201 3);
Chokpaisarn etal. (2017b)
Jalalpure etal. (2002); Kaur etal.
(2004); Choudhar y (2007); Yousif
etal. (2011); Bonab and Farahpour
(2017); Chokpaisarn etal.
(2017a,b)
Chokpaisarn etal. (2020)
Medicinal Plants for Anal Fissure
Rosa × damascena
Herrm.
(Rosaceae)
Damask rose/Ward Fixed oil from petals
(topical TPM oil)
In vitro:
from r ose oil distillation: ↓ IL-1β, IL-6, IL-8,
RANTES, and MCP-1
In vivo:
↑ wound healing
Clinical:
inflammation
Wedler etal. (2016)
Mansouri etal. (2016)
Mosleh etal. (2020)
Continued
Table 13.1. Continued.
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408
Scientific name
(family)
Taraxacum camp ylodes
G.E. Haglund
(Asteraceae)
Vitex agnus-castus L.
(Lamiaceae)
NLRP3, nod-like receptor (NLR) family pyrin domain containing 3.
Common name Part used in TPM In vitro/in vivo/clinical studies,
(English/Arabic) (administration method) extract, and effect
Common
dandelion/
Khas-ol-h ema r
Lilac chaste/Athlaq All parts, especially the
All parts
(cerate of dandelion in
damask rose oil)
seeds (powder)
In vitro:
inflammatory eff ect; ↓ NO, TNF-α,
NLRP3, IL-1β
In vivo:
and anti-inflammatory eff ects; ↓ COX-2
expression, TNF-α, IL6
In vitro:
inflammatory effect
In vivo:
↑ anti-inflammatory effect
Reference
Koh etal. (2010); Park etal. (2010,
2011, 2014); Zhang etal. (201 2);
Jeon etal. (2017); Xue etal.
(2017); Lai etal . (2020); Yang etal.
(2021)
Jeon etal . (2008; Wang, etal. (2017);
Ding and Wen (2018); Razak etal.
(2020)
Choudhary etal . (2009); Ahmad
etal. (2010); Ibrahim etal. (2021)
Ramezani etal . (2010); Aboul-Enein
etal. (2017)
Ghazaleh Mosleh etal.
409 Medicinal Plants for Anal Fissure
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Aloe vera (L.) Burm.f.; basionym: Aloe per-
foliata var. vera L.
The phytochemical compounds in Aloe vera
such as acemannan, aloesin, β-sitosterol, and
aloin have in vitro anti-inflammatory and
wound healing activities through various
mechanisms of action (Zhang and Tizard,
1996; Moon et al., 1999; Yagi et al., 2002).
Aloe gel has increasing effects on cytokine
production in RAW 264.7 cells (Zhang and
Tizard, 1996). Also, it has shown wound healing effects in the monolayer of human keratinocytes, primary human epidermal keratinocytes (HPEKs), and EpiDerm-FT (Choi
etal., 2001; Moriyama et al., 2016). Aloe gel
increases basic fibroblast growth factor
(bFGF) and transforming growth factor-β1
(TGF-β1) in mouse embryonic fibroblasts
(Hormozi et al., 2017). Furthermore, it has
angiogenic effects on the chorioallantoic
membrane of chick embryos in vitro (Moon
et al., 1999). Besides, aloe leaf has shown
wound healing effects in HaCaT keratinocyte
cells (Fox etal., 2017). The peptide and polypeptide fraction of the plant showed
anti-inflammatory effects on RAW 264.7 cells
(Babu and Noor, 2019). Aloesin of A. vera increases interleukin (IL)-6 and TGF-β1 while
decreasing IL-1β and tumor necrosis factor-α
(TNF-α) in skin cell lines, RAW 264.7, and HaCaT cells (Wahedi et al., 2017). In addition,
aloin increased cell proliferation, epidermal
growth factor (EGF), and blood vessels in
endothelial cells (Li etal., 2017). Also, aloesin
derivatives reduced cyclooxygenase-2 (COX-
2) and thromboxane A2 synthase in vitro (Yag i
etal., 2002). On the other hand, accelerating
wound healing and anti-inflammatory activities of A. vera are reported in various in vivo
pharmacological studies. Aloe gel increased
fibroblast numbers, TGF-β gene expression,
and wound healing effects in square-shaped
wounds in rats (Takzaree etal., 2015, 2016).
The mannose-rich polysaccharides of aloe gel
increased matrix metalloproteinase-3 (MMP-
3), tissue inhibitor of metalloproteinase-2
(TIMP-2), and wound closure in full-thickness
skin wounds (Tabandeh etal., 2014), as well as
acemannan-stimulated keratinocyte growth
factor-1 (KGF-1), vascular endothelial growth
factor (VEGF), fibroblast proliferation, and
type I collagen expressions in rats (Jettanacheawchankit et al., 2009). Glucomannan
induced protective effects against colitis in
dextran sodium sulfate (DSS)-induced colitis
murine models (Zhang et al., 2019). Also, a
glycoprotein fraction G1G1M1DI2 accelerated wound healing and cell proliferation in
mouse models (Choi et al., 2001). Furthermore, aloin has shown wound healing effects
in rats (Li etal., 2017), and aloesin accelerated
wound closure while increasing Smad and mitogen-activated protein kinase (MAPK) signaling proteins (Wahedi et al., 2017). Aloe
extract accelerated epithelialization and
wound contraction in the full-thickness
wound in rats (Rezaie etal., 2012). The leafy
exudate decreased nitric oxide (NO) and inflammatory mediators in carrageenan/dextran-induced edema models in rats (Sarkar
et al., 2005). Peptides and polypeptide fractions of the plant decreased aspartate aminotransferase (AST), alanine aminotransferase (ALT), TNF-α, IL-6, and secretory
phospholipase A2 (sPLA2) in complete Freund’s adjuvant-induced paw edema models in
rats (Babu and Noor, 2019). On the other
hand, in a randomized, double-blind, placebo-controlled study, a cream formulation
containing aloe gel decreased the anal pain
and wound repair time in 49 patients via 28
days of treatment after hemorrhoidectomy
(Rahmani et al., 2014). Besides, aloe gel has
shown preventing effects on pressure ulcers
in a randomized, triple-blind study on 80 hospitalized patients after 10 days of treatment
(Hekmatpou etal., 2018b).
According to Avicenna’s opinion, a topical solution containing aloe juice dissolved in
sweet wine (the alcoholic extract) possesses
anti-inflammatory and wound healing properties in the AF site (Avicenna, 1038).
Astragalus gummifer Labill.
Tragacanth mucilage presented healing properties in full-thickness wound models in albino
rats and rabbits (Moghbel etal., 2005; Fayazzadeh etal., 2014). Furthermore, in a triple-blind
randomized clinical trial on 94 patients, pad
and foam formulations of tragacanth gel
410 Ghazaleh Mosleh etal.
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showed delaying effects on the onset of erythema and preventive effects on pressure ulcers in patients admitted to intensive care units
(ICUs) (Shakibamehr etal., 2019).
According to the Canon, mucilaginous
dressings made from gum tragacanth, either
singly or compounded with other medicaments, are recommended for the management of AF (Avicenna, 1038).
Commiphora mukul (Hook. ex Stocks)
Engl.; basionym: Balsamodendrum mukul
Hook. ex Stocks
Despite the lack of relevant clinical trials,
the active constituents of Commiphora
mukul have been studied in several experiments. Myrrhanone A of the gum resin
showed anti-inflammatory effects on phorbol-12-myristate-13-acetate (PMA)/lipopolysaccharide (LPS)-activated human monocyte
U937 cells (Madasu et al., 2017). Guggulsterone showed anti-inflammatory activities in vitro via decreasing nuclear factor-κB
(NF-κB) activation and COX-2 expression
(Ahn and Youn, 2008). Also, it showed
stimulatory effects on nuclear factor erythroid 2-related factor 2 (Nrf2) and heme
oxygenase-1 (HO-1) transcriptional activity, antioxidant response element (ARE)binding activity, and protein kinase B (Akt)
phosphorylation in MCF10A epithelial cell
line (Almazari et al., 2012). Additionally,
guggulsterone showed in vitro anti-inflammatory effects in CD4+ cells of the intestinal
lamina propria (Mencarelli etal., 2009). In vivo
studies on air-pouch granulomas models in
mice indicate anti-inflammatory potential
of myrrhanol A (Kimura etal., 2001). Also,
E-guggulsterone and Z-guggulsterone showed
anti-inflammatory effects in murine
models of inflammatory bowel disease and
croton oil-induced ear edema models in
mice (Sosa et al., 1993; Mencarelli et al.,
2009).
In the Canon the ointment made by
mixing C. mukul gum resin with tallow or
kernel oil is considered to be effective for the
treatment of AF (Avicenna, 1038).
Dracaena cinnabari Balf.f.
The alcoholic extract of dragon’s blood resin
containing 4′-hydroxy-7,8-methylenedioxy-
homoisoflavan as an active constituent has
shown in vitro pro-inflammatory activities
via reducing TNF-α, IL-6, and nitrite production in macrophages (Gupta etal., 2014).
Also, it has shown in vivo anti-inflammatory
effects in rat paw edema models (Alwashli
etal., 2012; Gupta etal., 2014).
Avicenna has introduced dragon’s blood
resin in his Canon as a good astringent substance in AF formulations (Avicenna, 1038).
Erysimum × cheiri (L.) Crantz; basionym:
Cheiranthus × cheiri L.
The hydroalcoholic extracts of wallflower
flowers, aerial parts, roots, and seeds
showed in vitro anti-inflammatory effects by
inhibiting egg albumin denaturation (Mosleh etal., 2021a). Noticing the several cardenolide compounds in different wallflower
organs, safety evaluations and dose adjustments of variouis extracts of this herb would
be necessary (Mosleh et al., 2021a,b).
Besides, in a randomized clinical trial on AF
patients, a traditional cerate formulation
containing wallflower oil exerted comparable healing effects to diltiazem 2% gel after
14 days of treatment in 64 patients (Mosleh
etal., 2020).
In the Canon, dried powder of wallflower flower is considered to be a useful
dressing for AF. Furthermore, wallflower oil
is reported to be a suitable topical medication for fissures induced by dry dystemperament of the anus (Avicenna, 1038).
Lawsonia inermis L.
Henna leaf extract showed anti-inflammator y
activities via membrane stabilization potential and inhibition of protein denaturation
in vitro (Bouhlali et al., 2016). Also, lawsochylin A, lawsonaphthoate A, luteolin,
apigenin, 4S-4-hydroxy-α-tetralone, and
Medicinal Plants for Anal Fissure 411
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2-butoxysuccinic acid available in leaf and
stem have presented in vitro anti-inflammatory effects (Liou et al., 2013). Different
henna extracts have shown in vivo antiinflammatory and wound healing properties
via various mechanisms of action. The aqueous extract of henna decreased damage induced by reactive oxygen species (ROS) and
ulcers in rat excision wound models (Jridi
et al., 2017). The oily extract presented
wound healing and full reepithelialization
properties in circular excision wound models
in rats (Rekik etal., 2019). The suspension
of henna with normal saline showed antiinflammatory and healing effects on fullthickness skin wounds in mice (Ali et al.,
2021). In a randomized clinical study on 108
patients, 7 days’ application of topical henna
oil made from leaves and stems of L. inermis
showed wound repairing effects on grade 1
pressure ulcers (Poursadra etal., 2019). Another randomized clinical trial indicated the
healing effects of the herb mixture on pressure ulcers in 72 patients after 7 days of
treatment (Rafiei etal., 2019). In a randomized clinical study on 80 patients in critical
care units, powdered henna leaves suspended in distilled water exerted preventive
effects on decubitus ulcers (Hekmatpou
etal., 2018b).
Avicenna introduced henna in the
Canon as an important plant for various
medial indications such as inflammations,
wounds, burns, bone fractures, and AF. In
this regard, the cerate made from henna
leaves and damask rose oil is recommended
for topical use on AF (Avicenna, 1038).
Olea europaea L.
Phenolic compounds including vanillic, p-cou-
maric, syringic, homovanillic and caffeic acids,
as well as kaempferol, oleuropein glycoside,
tyrosol, hydroxytyrosol, and an unsaponifiable fraction of the oil have shown in vitro
anti-inflammatory effects via various mechanisms of action such as increasing TNF-α and
reducing COX-2 and NO production (Miles
et al., 2005; Rosignoli et al., 2013; Cardeno
et al., 2014; Takeda et al., 2014; Yonezawa
etal., 2018). In addition, the beneficial effect
of topical olive oil (fixed oil) on wound healing
has been observed in several clinical studies.
Topical application of olive oil for 10 days
showed positive wound healing effects in a
randomized, controlled clinical trial on 90 patients (Amani et al., 2015). In a triple-blind,
parallel, multicenter, randomized clinical trial
on 831 patients, olive oil reduced pressure ulcers
after 112 days of treatment (Lupiañez-Perez
et al., 2015, 2017). Also, according to a
randomized controlled clinical trial on 173
patients, the indication of olive oil cream for
28 days decreased dermatitis successfully
(Kiechl-Kohlendorfer etal., 2008).
The Canon mentioned a mixture of olive
oil and water with an astringent ingredient
as a therapeutic sitz bath for AF. Moreover,
the enema made from olive oil and verjuice
is recommended for curing internal ulcers of
the anus (Avicenna, 1038).
Prunus armeniaca L.
In vitro studies of apricot kernels on mouse
BV2 microglial cells have demonstrated
anti-inflammatory properties (Chang etal.,
2005). Furthermore, apricot kernel oil (fixed
oil) has shown anti-inflammatory activities
in ethanol-induced gastric ulcers in rats
(Karaboğa etal., 2018). Kernel extract and
oil showed ameliorating effects on colitis in
trinitrobenzene sulfonic acid-induced colitis
in rats (Minaiyan et al., 2014). Besides,
amygdalin isolated from apricot kernels reduced inflammatory pain in an in vivo study
on rats via histological examination and RTPCR (Hwang etal., 2008).
According to Avicenna’s viewpoint in
the Canon, topical indication of kernel oil, either singly or in combination with C. mukul
gum resin, has been considered useful for
medical treatment of AF (Avicenna, 1038).
Quercus infectoria G. Olivier
As an active ingredient in gall nuts and oak
bark, gallic acid has shown potent proinflammatory activities in vitro. It increases
412 Ghazaleh Mosleh etal.
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caspase-3 activity, regulates Bcl2-associated-X protein (Bax), -cell lymphoma 2 (Bcl-2),
p53 protein, and phosphorylated Akt (pAkt)
production, and decreases IL-6, IL-1β,
chemokine ligand (CCL)-2/monocyte chemoattractant protein (MCP)-1, and CCL-7/MCP3 in fibroblast-like synoviocytes (Yoon etal.,
2013). Also, the gall presented inhibitory effects on NF-κB, Set7, and p65 activity in bone
marrow-derived macrophages (Chokpaisarn
et al., 2017b). In addition, the alcoholic extract of gall has shown scavenging effects on
NO, and ameliorating effects on LPS-stimulated prostaglandin E
stimulated superoxide production in a rat
(PGE2) and PMA-
2
peritoneal macrophage model, in vitro (Kaur
etal., 2004). On the other hand, the alcoholic
extract of gall presented anti-inflammatory
effects on PMA-induced ear edema in mice
(Kaur etal., 2004). The crude aqueous extract
of gall, as well as its ethanol extract, showed
wound healing properties in rats (Jalalpure
etal., 2002; Choudhary, 2007). The aqueous
extract of the internal layer of fruit containing polyphenolic compounds and tannins decreases NO and MDA, while increasing pH in
rat gastric ulcer induced by stress (Jafari
Barmak etal., 2018). The aqueous extract of
the external layer of oak fruit ameliorates the
biochemical alteration; it increases glutathione (GSH) and decreases malondialdehyde
(MDA) and NO in acetic acid-induced ulcerative colitis models in rats (Jafari etal., 2015).
Besides, in a multicenter randomized controlled trial on 51 diabetic patients with ulcers, a topical solution made from Quercus
infectoria galls showed accelerated wound
healing effects (Chokpaisarn etal., 2020).
In Avicenna’s Canon, powdered nut galls
suspended in a mixture of wine and water
(hydroalcoholic solution) is considered a useful topical suspension for healing of AF. Also,
decoction of galls in concentrated grape wine
is recommended for inflammation-induced
fissures in the anus (Avicenna, 1038).
Rosa × damascena Herrm.
According to an in vitro study, a polyphenol
fraction obtained from damask rose flowers
was found to modify the inflammatory target
gene expression via various mechanisms of
action, including decreased IL-6, IL-1β, IL-8,
RANTES (regulated on activation, normal T
cell expressed and secreted), and MCP-1 (Wedler etal., 2016). A topical lotion prepared
from a hydroalcoholic extract of damask rose
enhanced the healing process of full-thickness wounds in rat models (Mansouri etal.,
2016). A herbal cerate containing damask
rose oil and wallflower oil showed potential
healing effects on patients suffering from
acute AF (Mosleh etal., 2020). Furthermore,
damask rose oil has been commercialized for
the treatment of hemorrhoids in Iran (Afsari
Sardari etal., 2019).
In the Canon Avicenna has frequently
prescribed damask rose oil as a suitable oily
vehicle in various AF formulations. This
popular traditional essential oil has significant analgesic and wound healing properties
according to TPM (Avicenna, 1038; Afsari
Sardari etal., 2019).
Taraxacum campylodes G.E. Haglund
The leaf extract of dandelion containing luteolin and chicoric acid reduced inflammation
in LPS-stimulated RAW 264.7 cells (Park
etal., 2010). The crude extract of dandelion
has shown decreasing effects on NO and
TNF-α in RAW 264.7 cells (Park etal., 2014).
In addition, the methanol extract of the herb
with active constituents of protocatechuic
acid, chlorogenic acid, caffeic acid, p-coumaric
acid, and ferulic acid has led to anti-inflammatory effects in LPS-stimulated human umbilical vein endothelial cells (Jeon et al.,
2017). Also, the leaf and root containing
taraxinic acid β--glucopyranosyl ester have
induced anti-inflammatory effects in Huh7
cells (Esatbeyoglu etal., 2017). On the other
hand, the aqueous extract of dandelion root
has anticolitis and anti-inflammatory effects
in DSS-induced ulcerative colitis rats (Ding
and Wen, 2018). Besides, the alcoholic extract of aerial parts, as well as taraxasterol,
have shown in vivo anti-inflammatory effects
via various mechanisms of action, including
reduction of TNF-α, IL-6, and COX-2 expression
Medicinal Plants for Anal Fissure 413
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(Jeon et al., 2008; Wang et al., 2017; Razak
etal., 2020).
In the Canon, a cerate formulation containing dandelion in the vehicle of traditional damask rose oil is considered to be
useful in the healing of AF (Avicenna, 1038).
parts of Vitex agnus-castus showed in vitro
anti-inflammatory activities (Choudhary etal.,
2009; Ahmad et al., 2010; Ibrahim et al.,
2021). Additionally, the essential oil of seeds
and the hydroalcoholic extract of fruits have
shown anti-inflammatory effects in previous
in vivo studies (Ramezani etal., 2010; AboulEnein etal., 2017).
Vitex agnus-castus L.
According to Avicenna’s point of view
explained in the Canon, all parts of V. a g -
Aqueous alcoholic extracts obtained from
fruits and methanolic extracts from the aerial
nus-castus herb, and especially the seeds,
show healing effects on AF (Avicenna, 1038).
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