Volume 37, Issue 1, Page 16 (January 2006)

LESLIE S. BAUMANN, M.D.

DR. BAUMANN is director of cosmetic dermatology at the University of Miami. To respond to this column, or to suggest topics for future columns, write to Dr. Baumann at our editorial offices via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

There are 15 known species of horse chestnut, which is found as both a tree and a shrub in the temperate regions of Europe, Asia, and North America. Believed to have originated in northern Greece and the Balkan region, the European horse chestnut (Aesculus hippocastanum) is the species most often used in medical applications. It is not known whether other horse chestnut species have been thoroughly evaluated for their potential medicinal value. The European horse chestnut is not related to the more familiar sweet chestnut (Castanea vesca).

Most of the aerial sections of the European horse chestnut tree—including the seeds, leaves, and bark—have been traditionally utilized in medical treatments. As early as the 1500s, nuts from the horse chestnut tree were used to treat persistent fever; later, they were used for hemorrhoids, varicose veins in the leg, and phlebitis.

Modern horse chestnut formulations are derived from seed extracts, which are high in the active component aescin (also known as escin). The seeds also contain hydroxycoumarins, flavonoids, tannins, sterols, saponins, and glycosides.

Today, oral administration of standardized horse chestnut seed extract (HCSE) is a well-established treatment for chronic venous insufficiency (CVI) and edema. CVI is characterized by enlarged veins near the skin surface, edema, and leg fatigue. The extract is also effective when used in a sitz bath for the treatment of hemorrhoids. In addition, HCSE is used as an astringent and an anti-inflammatory.

Horse chestnut is a common ingredient in lotions, creams, massage oils, and other skin care products, often in combination with other herbal ingredients. Most such topical products tout the capacity of horse chestnut to combat varicose veins, swelling, and water retention, but some of the newer products ascribe antioxidant potency to horse chestnut and purport to combat wrinkling.

Traditional Chinese medicine uses horse chestnut (Aesculus chinensis, known as tien shi li) as an astringent, anti-inflammatory, diuretic, and expectorant, as well as for a wide range of ailments, including circulatory problems and viral infections.

Mechanism of Action

It is speculated that HCSE may work by inhibiting leukocyte activation (Arch. Dermatol. 1998;134:1356–60). A natural bioflavonoid and saponin, aescin is believed to foster normal, healthy tone in vein walls by inhibiting enzymes that attack vein interiors (Arzneimittelforschung 1994;44:25–35). Aescin facilitates the contraction of elastic fibers in blood vessel walls, thereby elevating the flexibility of the vessels (Dtsch. Med. Wochenschr. 1986;111:1321–9; Lancet 1996;347:292–4; “The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines.” Philadelphia: Lippincott Williams & Wilkins, 1996).

Researchers also have shown that aescin inhibits elastase and hyaluronidase in vitro. Both enzymes have roles in the degradation of proteoglycans, an important element in the extravascular matrix and a component of endothelium. It is speculated that aescin alters the equilibrium between proteoglycan synthesis and degradation, resulting in the prevention of vascular leakage (Arch. Dermatol. 1998;134:1356–60).

Aescin is associated with the release of prostaglandin F2 from veins, an antagonism to histamine and 5-hydroxytryptamine, and a decreased catabolism of tissue mucopolysaccharides (Pharmacol. Res. 2001;44:183–93).

Rutin, which is believed to strengthen fragile capillaries, is another active ingredient in horse chestnut seeds. Many researchers in Europe claim that aescin and rutin work synergistically with other active components to enhance circulation and ease inflammation.

The leaves of the horse chestnut tree purportedly have antioxidant properties that may slow skin wrinkling; such claims, however, have not been confirmed by controlled clinical trials.

Chronic Venous Insufficiency

Copious, strong evidence supports the effectiveness of oral HCSE for the treatment of CVI. In a thorough review of placebo-controlled studies, researchers found that HCSE was superior to placebo in all cases. The reviewers noted reductions in lower-leg volume and in leg circumference at the calf and ankle, as well as improvement in symptoms such as leg pain, pruritus, fatigue, and tension, with only mild adverse reactions occurring rarely. The same study found equivalence between horse chestnut and O-(ß-hydroxyethyl)rutosides against a reference medication, as well as equivalence between horse chestnut and compression therapy (Am. J. Clin. Dermatol. 2002;3:341–8; Arch. Dermatol. 1998;134: 1356–60).

In a different literature review of six placebo-controlled trials assessing leg pain, investigators observed a significant improvement in the groups treated with HCSE compared with placebo. They concluded that horse chestnut is safe and effective for short-term CVI therapy, but that more rigorous, randomized, controlled trials are necessary to evaluate long-term efficacy (Cochrane Database Syst. Rev. 2002;1:CD003230).

Others have noted that oral horse chestnut therapy is adequate for treating the early phases of CVI as a result of its capacity to close venular endothelial gaps, but that compression therapy remains indicated for later stages (BMC Cardiovasc. Disord. 2001;1:5). Various authors note that compression therapy is associated with poor compliance because it is uncomfortable and sometimes painful, rendering an oral (and perhaps topical) treatment such as horse chestnut preferable. The sooner such treatment is initiated, the better the chance of avoiding compression therapy.

Another study, in which 5,000 patients with CVI were treated with standardized horse chestnut extract, showed clearing or improvement of all of the symptoms—discomfort, fatigue, tension, edema in the leg, and pruritus—that were investigated (Fortschr. Med. 1996;114:196–200).

In a 12-week, randomized, partially blinded, placebo-controlled parallel study of 240 patients, significant and equivalent reduction of edema resulted from horse chestnut and compression therapy compared with placebo; both therapies were well tolerated with no adverse side effects (Lancet 1996;347:292–4).

Usage and Indications

Topical and systemic HCSEs are popular in Europe for the treatment of CVI and related conditions, such as varicose veins, leg cramps, phlebitis, and hemorrhoids. Topical application of gels or creams containing 2% aescin, three or four times per day, is used in Europe for eliminating hemorrhoids, varicose veins, and skin ulcers, as well as for healing sports injuries such as bruises, acute sprains, and similar traumas. The aescin in HCSEs clearly possesses anti-inflammatory capacity and has been demonstrated to ease edema after trauma, especially following head and sports injury, and surgery (Arzneimittelforschung 1994;44:25–35; Planta Med. 1993;59:394–7).

Standardized HCSE has been approved by Commission E (a German panel of experts that is comparable to the U.S. Food and Drug Administration) for the treatment of pathologic conditions of the leg veins, including pruritus, edema, nocturnal cramping in the calves, and the sensation of heaviness, as well as varicose and spider veins.

There are claims that horse chestnut may even be effective for treating wrinkles, hair loss, cellulite, backache, and arthritis, but there is no reliable evidence in the literature to substantiate these claims. As an ingredient in facial creams and shaving products, horse chestnut is intended for sensitive skin.

Contraindications

Horse chestnut is contraindicated in patients who have bleeding disorders or who take anticoagulant drugs, such as warfarin, because the herb reduces blood clotting. Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly aspirin, potentially interact with herbal supplements known to contain coumarin, such as horse chestnut, thus increasing the risk of bleeding (J. Clin. Pharm. Ther. 2002;27:391–401).

Topical horse chestnut has been associated, in a few instances, with allergic skin reactions.

At the Store

Nature's Life Horse Chestnut Herbal Balm ($20 for 2 ounces) is a topical formulation standardized to include 2% aescin, and is intended to soothe the symptoms of varicose veins. Studies have shown that the topical application of standardized HCSE balm with 2% aescin supports healthy skin, blood vessels, and muscles, particularly in the legs and hemorrhoidal plexus (Planta Med. 1993;59:394–7; Clin. Ter. 1981;98:517–24; Clin. Ter. 1986;118:339–42). A double-blind study assessing the effectiveness of a topical standardized HCSE balm (2% aescin) for localized swelling and hematoma showed that the product significantly reduced tenderness in the affected area, compared with placebo (Planta Med. 1993;59:394–7).

Beauty Naturally's Rosacea Cleansing Lotion ($18 for 4 ounces) is an anti-inflammatory, antibacterial, nondetergent cleansing lotion formulated with horse chestnut, aloe, and chamomile. It is free of alcohol and oil, and therefore appropriate for sensitive skin. The manufacturer claims it is effective in controlling rosacea flare-ups and reducing erythema.

Beauty Naturally's Rosacea Moisturizing Cream ($33 for 2 ounces) contains horse chestnut. The product is intended to arrest inflammation and reduce erythema.

Conclusion

The usefulness of horse chestnut for treating CVI and other venous disorders has been borne out by randomized, controlled clinical trials. However, much research with topical horse chestnut is needed to support some of the more recent claims regarding efficacy in treating wrinkles and hair loss.

PII: S0037-6337(05)70954-2

doi:10.1016/S0037-6337(05)70954-2

© 2006 Elsevier Inc. All rights reserved.