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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5217_Библиотеки_им_академика_М_И_Перельмана.pdf
Table 9.1 (continued)
Chapter 9 Medicinal and aromatic plants used in burn treatment 343
No. Traditional
name
Abou khalsa Arnebia euchroma
Lebleb Convolvulus
Narjes Narcissus tazetta L. Amaryllidaceae Hot and dry Bulb Zemad (with
Nil Indigofera tinctoriaL.Leguminosae Hot and dry – Zemad (with
Zairnera Ocimum basilicumL.Lamiaceae Hot and dry Leaf Tela (with
Quessus Hedera helix L. Araliaceae Hot Flower/
Quash’a
zarirah
Scientific name Family Characteristics Part
used
Boraginaceae Hot and dry Root Marham, Qeiroot
(Royle)
I.M. Johnst./
Alkanna tinctoria
Tausch
Convolvulaceae Dry and hot/
arvensis L.
Acorus calamus L. Acoraceae Hot and dry – Zemad (with Dokar
cold
✶
Leaf Natool, Qeiroot,
leaf
Dosage form
(with olive oil), and
Tela (with Dokar el
ward)
and Zemad (with
Dokar el ward)
honey)
honey)
rosewater)
Qeiroot (with olive
oil)
el ward)
9.5 Formulation and application methods of herbal products
In burn treatment, medicinal and aromatic plants are used in various pharmaceutical
formulations suitable for topical application to accelerate wound healing, prevent infection, and reduce inflammation. While these formulations are designed to increase
the bioavailability and effectiveness of herbal ingredients, the application method
and dosage determinations are also critical for the success of the treatment. In addition, nanotechnological approaches offered by modern technologies further improve
the effectiveness of these products and offer innovative treatment options [35].
9.5.1 Pharmaceutical formulations
Herbal ingredients are applied by being converted into different pharmaceutical
forms for use in burn treatment. These forms provide advantages such as preserving
344 İlayda Bersu Kul et al.
the chemical stability of the ingredients, providing controlled release to target tissues
and ease of application:
1. Creams and ointments: Creams and ointments are generally formulated on an oilwater or water-oil emulsion basis and are the most common pharmaceutical
products in which herbal extracts are used as carrier systems. Creams based on
Aloe vera gel, Calendula extract, and Centella asiatica are used to support cell renewal and form a protective layer on the skin surface. Ointments, in particular,
prevent moisture loss due to their high oil content and accelerate the healing process by providing an occlusive effect on the wound [36].
2. Gels: Hydrophilic gels are applied directly to the wound and provide a moisturizing and cooling effect. Aloe vera in gel form is widely used in burn treatment and
supports epithelialization. In addition, gels stand out as an effective carrier system because they provide a homogeneous distribution of essential oils or herbal
extracts in high concentration [37].
3. Essential oils: Essential oils such as lavender oil, tea tree oil, and clove oil are
used in burn treatment due to their antimicrobial and anti-inflammatory properties. These oils are usually diluted with carrier oils (such as coconut oil or jojoba
oil) and applied directly to the wound or integrated into creams [38].
4. Tinctures and extracts: Herbal tinctures are concentrated plant extracts prepared
using alcohol-based solvents. For example, Hypericum perforatum (St. John’s
wort) tincture is used in burn treatment due to its antimicrobial and woundhealing effects. Considering the drying effect of alcohol, these products are usually applied diluted or with other carrier products [39].
5. Dressing materials: Herbal extracts can be used in dressing materials by integrating them with biomaterials applied to the wound. Modern dressing products with
increased antimicrobial and regenerative properties have been developed, especially by incorporating herbal components (e.g., Centella asiatica or Calendula)
into alginate- or collagen-based wound dressings [40].
9.5.2 Dosage and application methods
Appropriate dosage and application method are of great importance for herbal products
to provide effective treatment. The concentration, application frequency, and treatment
duration of the products used in burn treatment are determined depending on the pharmacokinetic and pharmacodynamic properties of the herbal components used [41]:
1. Concentration and application dose: Products with high bioactive content such as
essential oils are generally used in low concentrations (1–5%) to avoid potential
toxic effects. For example, a cream containing lavender oil can be safely used on
burns by formulating it at a concentration of 2–3%.
2. Application frequency: Topical products are usually applied 2–3 times a day to
ensure a continuous effect of the active ingredients on the tissue. However, this
Figure 9.4: Nanotechnological approaches.
Chapter 9 Medicinal and aromatic plants used in burn treatment 345
frequency can be increased or decreased depending on the degree of the burn,
the risk of infection, and individual patient characteristics.
3. Treatment duration: Herbal treatments applied in the acute phase are generally
used for 7–14 days. Chronic burn cases or treatments aimed at preventing scar
formation may require longer-term applications.
9.5.3 Nanotechnological approaches
In recent years, innovative approaches based on nanotechnology have been developed to increase the effectiveness of herbal extracts and optimize tissue penetration.
These methods provide specific delivery of active ingredients to target tissues while
minimizing systemic side effects [42]. A visual about nanotechnological approaches is
given in Figure 9.4:
1. Liposomal systems: Liposomes formed by coating herbal extracts with phospholipids increase tissue penetration and provide controlled release of active ingredients. Liposomal formulations of Aloe vera extract allow anti-inflammatory and
regenerative effects to last longer.
346 İlayda Bersu Kul et al.
2. Nanoparticle systems: Silver nanoparticles or polymeric nanoparticles are combined
with herbal ingredients to increase antibacterial effects. For example, silver nanoparticle formulations prepared with tea tree oil are used to reduce the risk of infection.
3. Hydrogel materials: Nanotechnological hydrogel structures support wound healing by providing a moisturizing environment and allow controlled release of
herbal extracts. These materials are an effective option especially for chronic
wounds and second-degree burns.
4. Nanofiber dressings: Integrating herbal extracts into nanofiber wound dressings
prepared by electrospinning supports both infection control and tissue regeneration. For example, nanofiber dressings containing Centella asiatica extract accelerate wound healing by increasing collagen synthesis.
9.5.4 Factors affecting chemical stability
The main factors affecting the stability of herbal products include temperature, light,
oxygen, and humidity. For example, photosensitizers such as flavonoids and phenolic
acids can undergo chemical degradation as a result of direct exposure to light. Similarly, terpenoids found in essential oils can lose their effectiveness by undergoing oxidation when exposed to high temperatures or oxygen. Especially in herbal products
with antioxidant or antimicrobial properties, such chemical changes can seriously reduce product effectiveness [43].
pH is also an important factor in stability. For example, acidic or basic environ-
ments can lead to isomerization, hydrolysis, or oxidation of bioactive compounds in
herbal products. Therefore, it is of great importance to keep the pH within an appropriate range in product formulation.
9.5.4.1 Stability enhancement methods
Various methods are used to maintain chemical stability. These include protective
packaging, addition of antioxidants, and the use of stabilizers in the formulation:
1. Packaging techniques: Dark glass bottles that block light or vacuum packaging
that reduces oxygen permeability can increase the stability of essential oils and
herbal extracts.
2. Use of stabilizers: The effect of free metal ions that can cause oxidation can be
reduced by adding stabilizers (e.g., chelating agents such as EDTA) to the formulation of herbal products.
3. Addition of antioxidants: Natural antioxidants such as vitamin E (tocopherol) or
ascorbic acid can help protect bioactive compounds in herbal products from oxidation.
Chapter 9 Medicinal and aromatic plants used in burn treatment 347
9.5.4.2 Importance of storage conditions
Storage conditions of herbal products directly affect product stability and efficacy.
Ideal storage conditions should include low temperature, a dark environment, and
low humidity [44].
Essential oils should generally be stored in a cool, dry environment. A constant
temperature between 15 and 25 °C reduces the risk of oxidation. Formulations containing water, such as creams and gels, should generally contain a preservative to
protect them against the risk of microbial contamination and should be consumed
shortly after opening. Powdered herbal extracts should be stored in packages that are
completely isolated from air to prevent moisture from affecting them.
9.5.4.3 Stability tests and quality control
Stability tests should be applied to ensure chemical stability and determine the shelf
life of the product. These tests are usually performed under accelerated conditions
(high temperature, high humidity, exposure to light) and the physicochemical properties of the product are analyzed at regular intervals. For example:
Changes in the concentrations of bioactive compounds are monitored with methods such as HPLC (high-performance liquid chromatography) or GC-MS (gas chromatography-mass spectrometry). Physical parameters such as color, odor, and viscosity
provide clues about the stability of the product.
9.6 Clinical research and evidence-based practices
The use of medicinal and aromatic plants in burn treatment forms the basis of evidence-based practices with a process extending from historical experiences to scientific research. Modern phytotherapy is based on clinical studies aimed at verifying
traditional knowledge with scientific methods. These studies guide clinical practice by
examining the effectiveness and safety of herbal treatments. In addition, the synthesis
of existing research using systematic methods such as meta-analysis and literature reviews enriches the knowledge in this field and supports clinical decision-making processes [45].
9.6.1 Clinical studies
Clinical studies conducted with medicinal and aromatic plants used in burn treatment
indicate that herbal products can be used effectively and safely. The results of these
348 İlayda Bersu Kul et al.
studies reveal that certain herbal components offer positive effects in reducing inflammation, preventing infection and accelerating wound healing:
1. Aloe vera (Aloe barbadensis Miller): A large number of clinical studies conducted
with aloe vera show that this plant is an effective option in burn treatment. In a
randomized controlled trial conducted especially on second-degree burns, it was
found that aloe vera gel application provided faster epithelialization and reduced
pain levels compared to conventional silver sulfadiazine cream. This effect is
thought to be related to the moisturizing effect of the polysaccharides contained
in aloe vera and the support of epithelial cell proliferation [46].
2. Calendula officinalis (Calendula): Clinical studies with Calendula extract have confirmed the antiseptic, anti-inflammatory, and wound-healing effects of this plant.
One study observed that a calendula-based ointment shortened the time to burn
wound closure and reduced scar formation. This effect was reported to be related
to the flavonoid and triterpene compounds contained in calendula increasing collagen synthesis [47].
3. Lavandula angustifolia (lavender): Lavender oil has been studied in the treatment
of burns for its antimicrobial and wound healing effects. A randomized clinical
trial evaluated the effects of a topical product containing lavender oil on mild
thermal burns. The study showed that lavender oil application reduced inflammation and accelerated wound closure. Active compounds such as linalool and
linalyl acetate in lavender oil are thought to provide these effects [48].
4. Melaleuca alternifolia (tea tree oil): Tea tree oil has been studied as a potential
agent for infection control in burns. A clinical study has shown that a topical formulation containing tea tree oil reduced the microbial load in infected burns and
accelerated wound healing. This effect was reported to be due to the antimicrobial effects of tea tree oil [49].
5. Centella asiatica (gotu kola): Centella asiatica, known for its collagen synthesis-
enhancing effects, has been found to be particularly effective in preventing hypertrophic scar formation. In a clinical study, application of a cream containing
Centella asiatica extract increased the elasticity of post-burn scar tissue and improved scar appearance [50].
9.6.2 Effectiveness of phytotherapeutic products compared
to conventional treatments
Herbal treatments have been shown to offer many advantages over conventional
pharmacological agents. For example, products containing Aloe vera or Calendula
have been shown to provide similar or better clinical results compared to commonly
used topical burn creams such as silver sulfadiazine, while also having fewer side effects. The high cost of traditional treatments and the sometimes adverse effects such
as toxicity have led to the emergence of phytotherapeutic products as complementary
Chapter 9 Medicinal and aromatic plants used in burn treatment 349
or alternative treatments. However, the effectiveness of phytotherapeutic products
depends on the standardization of herbal ingredients, correct dosage, and method of
application [51].
9.6.2.1 Meta-analyses and literature reviews
Meta-analyses and systematic literature reviews provide a wealth of information evaluating the effectiveness of herbal treatments in burn healing. Such studies combine
the results of individual clinical trials to provide an overall effect size and provide
strong evidence for clinical application [52]:
1. Effectiveness of Aloe vera: A meta-analysis on Aloe vera has shown that this plant
accelerates wound healing and reduces infection rates in the treatment
of second-degree burns. The studies included in the review highlighted Aloe
vera’s moisturizing effects and cell regeneration-promoting properties.
2. Calendula and lavender: A literature review of the effects of Calendula officinalis
and Lavandula angustifolia in burn treatment found that these plants were effective in reducing inflammation and accelerating wound healing. However, these
reviews also point to the need for larger, randomized controlled trials.
3. Comparison of phytotherapeutic products: Comparative meta-analyses of traditional and herbal treatments show that phytotherapeutic products are a strong
treatment option, especially in low and moderate burns. It has also been stated
that herbal treatments are safer in terms of side effects, but the lack of standard
dosage and formulation causes some difficulties.
The mechanisms of herbal compounds enable the customization and individualization
of treatment processes. For example, the molecular pathways underlying the antiinflammatory effects of plants may be related to the inhibition of pro-inflammatory cytokines and enzymes. This suggests that plants not only accelerate wound healing but
also control inflammatory responses caused by traumas such as burns. Therefore, the
identification of phytochemicals with anti-inflammatory properties may lead to the discovery of new agents to be included in treatment protocols [53].
However, the effectiveness of herbal treatments in wound healing depends on dif-
ferent biological processes occurring at the cellular level. For example, the presence
of phytochemical compounds that increase fibroblast proliferation and migration
may accelerate wound healing. Furthermore, knowing how processes such as angiogenesis and collagen synthesis can be modulated by herbal compounds will help us
understand the effectiveness of these treatments in more depth. In this context, more
molecular studies are needed on how plants such as Centella asiatica and Aloe vera
accelerate the healing process by increasing collagen synthesis and supporting the
formation of microvessels at the wound site. Such studies indicate that phytothera-
350 İlayda Bersu Kul et al.
peutic approaches are not only an alternative treatment method, but also an essential
component of the treatment process [54].
In addition to the efficacy of herbal treatments supported by clinical data, the
safety profiles of these treatments are also of great importance. One of the greatest
challenges in the use of phytotherapeutic treatments is that potential toxicity and side
effects of herbal compounds should be considered in addition to their efficacy. In particular, it has been reported that herbal products used in burn treatments may cause
adverse effects such as allergic reactions, dermal irritations, or phototoxicity when
applied to the skin. For this reason, herbal treatments should be compared with pharmaceutical products not only in terms of efficacy but also in terms of safety. Before
integrating herbal treatments into pharmaceutical treatments, extensive toxicity tests
and collection of clinical safety data can ensure the safe use of these treatments [55].
It is necessary to develop appropriate formulation techniques for herbal compounds
to cross the skin barrier. In this context, nanotechnology and nanomedicine applications
offer an important strategy to increase the bioavailability of herbal extracts and ensure
tissue penetration. Formulating herbal compounds with nanocarriers allows these compounds to be directed to the areas where they will have an effect, making the treatment
process more targeted. Such innovative approaches can increase the effectiveness of
phytotherapeutic treatments and provide faster results compared to traditional pharmaceutical treatments [56]. Studies conducted in different ethnic groups and age groups
can determine how herbal treatments interact with genetic, environmental, and biological differences and further improve treatment processes. For example, whether herbal
treatments differ in terms of safety and effectiveness between elderly patients and pediatric patients should be analyzed in more depth. Such studies will allow herbal treatment options to be applied effectively and safely to a wider population.
9.7 Safety and side effects
Although herbal treatments are an important part of traditional medicine, they can
pose some safety issues when used in medical applications. The safety of phytotherapeutic treatments depends not only on the effectiveness of the herbal compounds, but
also on the possible toxic effects of these compounds. The safety of herbal products
used in specific clinical situations such as burn treatment requires careful evaluation
of both therapeutic efficacy and potential risks. In this context, incorrect dosage or
inappropriate use of herbal treatments may cause toxic effects. Safety and side effects
are shown in Figure 9.5.
Figure 9.5: Safety and side effects.
Chapter 9 Medicinal and aromatic plants used in burn treatment 351
9.7.1 Toxicological risks
Toxicological evaluation of herbal products is of great importance in determining
both efficacy and potential harmful effects. Although herbal treatments are generally
considered natural and safe, compounds contained in plants have the potential to
cause unexpected or harmful effects on biological systems. Plants used in burn treatment may cause toxic effects when used in inappropriate dosages or with incorrect
application methods. These toxic effects may be due to adverse reactions of herbal
compounds on the skin and body. For example, excessive use of Aloe vera may cause
irritation in the digestive system or allergic reactions on the skin. In addition, highdose consumption or long-term use of some herbal compounds may adversely affect
liver and kidney functions. Therefore, each herbal product should be subjected to toxicological tests before use in the pharmaceutical field [57].
In addition, phototoxicity can occur as a significant side effect of herbal treatments. Phototoxicity is the harmful reaction that some herbal compounds cause on
the skin when exposed to ultraviolet rays. In particular, some plants such as St. John’s
wort (Hypericum perforatum) can show phototoxic reactions that can cause redness,
irritation, and burns on the skin when exposed to the sun. The use of herbal treatments in the treatment of burns, when combined with sun exposure, can negatively
affect the treatment process. Therefore, the phototoxic potential of herbal treatments
352 İlayda Bersu Kul et al.
should be considered and patients should be informed to avoid direct exposure to
sunlight during treatment. Another important toxicological risk factor of herbal treatments is drug interactions. Herbal products can interact with pharmaceutical drugs
and change their bioavailability, effectiveness, or metabolism. In particular, interactions between herbal treatments and prescription drugs used can negatively affect
the treatment process and the patient’s health status. For example, some plants can
increase the effectiveness of drugs that have a blood-thinning effect, while others can
accelerate the metabolism of drugs and weaken the therapeutic effect. Therefore, the
use of herbal treatments in clinical practice requires careful consideration of potential drug interactions [58].
9.7.2 Side effects and contraindications
The side effects of herbal treatments may vary depending on the type of herbal compound used, dosage, duration of use, and individual patient characteristics. Although
herbal products are generally considered safe, some situations may pose a risk for
potential side effects. These side effects are usually mild, such as skin reactions, gastrointestinal disorders, headache, or allergic reactions, but in some cases they can
have more serious consequences. For example, Aloe vera gel has moisturizing and
soothing effects on the skin, but it can cause itching or rashes in some patients. Similarly, plants such as Calendula officinalis can sometimes cause allergic skin reactions,
which can adversely affect the treatment [59].
Special health conditions, such as pregnancy, breastfeeding, or childhood, may
further complicate the use of herbal products. During pregnancy, some herbal compounds have been reported to cause uterine contractions or adverse effects on the
fetus. For example, some plants may increase the risk of premature birth by stimulating the uterus. In addition, it is thought that some herbal products may pass to babies
through milk and cause toxic effects for breastfeeding mothers. For this reason, the
use of herbal treatments for women who are pregnant and breastfeeding should be
carefully evaluated [60]. Children also constitute a special group in the use of herbal
treatments. Since children have different skin structure and immune systems than
adults, the use of some herbal products may have adverse effects. The use of herbal
treatment methods in children is especially important in terms of determining ageappropriate dosages and carefully monitoring potential allergic reactions. In children,
some herbs, such as essential oils such as tea tree oil, may cause skin irritation or
more serious allergic reactions [61].
The use of herbal treatments in individuals with chronic diseases should also be
considered carefully. In particular, conditions such as diabetes, hypertension, or liver/
kidney diseases may affect the metabolism and effectiveness of herbal products. Herbal
products may interact with drugs used in the treatment of these diseases and affect the
treatment process. For example, some herbal treatments may affect blood sugar levels