Reviewed: Farahani AM, Aryanian Z, Memariani Z, Mozaffarpur SA, Shirafkan H. A comparison of the effect of topical preparation of Sambucus ebulus L. and hydrocortisone on hand eczema: A double-blind randomized controlled trial. J Altern Complement Med. April 2021;27(4):323-330. doi:10.1089/acm.2020.0343. 

Eczema is an inflammatory reaction of the skin and is characterized by redness, lesions, scaling, blisters, fissures, hyperkeratosis (thickened skin), itching, and pain. Moisturizers and topical corticosteroids often are used to treat hand eczema, but corticosteroids can produce adverse effects such as skin atrophy (thinning of the skin), rashes, acne, and changes in skin color. Dwarf elder (Sambucus ebulus, Viburnaceae) has been used to treat contact dermatitis, arthritis, and inflammation, among other conditions. The authors conducted a randomized, double-blind, controlled clinical trial to evaluate the efficacy of a topical dwarf elder preparation compared to hydrocortisone (a corticosteroid) for hand eczema.

The study was conducted in the dermatology clinic at Yahyanejad Hospital (associated with Babol University of Medical Sciences) in Babol, Iran, and at Baran Clinic in Arak, Iran, from June 2018 to November 2018. Included participants were between 18 and 60 years of age and clinically diagnosed with eczema on one or both hands. The authors excluded individuals who took corticosteroids or immunosuppressant medications four weeks before the study, were pregnant or lactating, or had a local infection of the hands, mental disorders that interfered with the study, kidney or liver disease, or diabetes, among other criteria.

Dwarf elder leaves were collected from Mazandaran Province in northern Iran and authenticated by a botanist. Phytochemical analysis of the prepared dry extract found 69.64 ± 6.13 mg/g (gallic acid equivalent) of total phenols and 116.79 ± 3.18 mg/g (rutin equivalent) of total flavonoids. Hydrocortisone (1%), purchased from a pharmacy, was used as the control. The dwarf elder leaf cream, containing 1% of the dry extract, was prepared in the pharmaceutical laboratory of the Babol University of Medical Sciences. Damask rose (Rosa damascena, Rosaceae) oil (0.01%) was added to both creams to help with blinding. Both creams were placed into similar 15-g tubes.

Participants applied 1 g of the dwarf elder cream (n = 43) or the hydrocortisone cream (n = 38) to the affected areas twice daily for four weeks. They were assessed at baseline and weeks 2 and 4 using the Dermatology Life Quality Index (DLQI) questionnaire and the Hand Eczema Severity Index (HECSI). During these visits, researchers also took photographs of participants’ hands to assess skin status. Study outcomes included the severity of hand eczema evaluated by HECSI score, which ranges from 0 (no eczema) to 360 (most severe eczema); changes in quality of life assessed by DLQI score; the rate of healing; the severity of itching; and any adverse effects.

HECSI scores decreased significantly after two and four weeks in both groups (P < 0.05 for both). The between-group differences in changes were not significant (P = 0.491). After four weeks, DLQI score improvements in the dwarf elder group were significantly greater than improvements in the hydrocortisone group (P = 0.029). The healing rate and itching score improved similarly in both groups.

No serious adverse effects were reported, although mild burning was reported by some participants in the dwarf elder group at the beginning of the study. All participants complied with the study protocol.

The authors did not use a patch test on the participants to assess potential allergic reactions to the substances, and they described this as a limitation of the study. The study also was limited by not establishing minimum clinically important differences (the smallest change in a treatment outcome that a participant would consider important) when assessing eczema severity. Further limitations are lack of a placebo group and lack of a group that received only rose oil (the blinding agent), which may have had pharmacological effects on its own.

The authors concluded that dwarf elder cream used topically “can be as effective as that of hydrocortisone when it comes to reducing the severity of hand eczema” while also providing better quality of life.