Efficacy and Safety of 4% Hibiscus rosa-sinensis Leaf Extract Ointment as an Adjunct Treatment to Compression Stockings on the Closure of Venous Leg Ulcers: A Pilot Study

Introduction. Venous leg ulcers (VLUs), the most common leg ulceration worldwide, are caused by venous hypertension due to venous reflux, the failure of the calf muscle to pump, and venous flow obstruction. They are associated with a reduced quality of life, particularly in relation to pain and physical function. Hibiscus rosa-sinensis is commonly employed because of its many medicinal properties, and studies have shown Hibiscus contains phytochemicals that have antimicrobial, antioxidant, and anti-inflammatory properties that promote wound healing. Objective. The authors evaluate the efficacy and safety of 4% gumamela leaf extract ointment in the closure of VLUs among patients seen in a dermatology outpatient department in the Philippines. Materials and Methods. The study included male or female patients with leg ulcers confirmed by duplex scan to be venous in origin and willing to have elastic compression therapy. Patients were instructed to clean the wound with normal saline solution and to apply the extract twice daily. The study was conducted for 12 weeks or until wound closure. Wounds were evaluated and photographed at baseline and every subsequent 2 weeks. Efficacy of therapy was evaluated based on ulcer area size using planimetry method at each visit. Safety was assessed using a 4-point grading system to monitor possible adverse reactions, namely pruritus, rash, burning, and urticaria. Results. Twelve patients were included in the study; 5 patients had an initial ulcer area of > 10 cm² and 7 had an initial ulcer area of ≤ 10 cm². By the end of the study, 10 patients (83.3%) achieved complete ulcer closure in < 12 weeks, 1 patient (8.3%) had a decrease in ulcer area > 50% by week 12, and 1 patient (8.3%) had < 50% decrease in ulcer area at the end of the study. Conclusions. Data showed compression stockings with 4% gumamela leaf extract ointment application could close VLUs in < 12 weeks. Applied with compression stockings, the ointment shows potential use in VLU management.

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The most common cause of chronic lower extremity ulceration is venous insufficiency, with about 600 000 new venous leg ulcers (VLUs) developing annually.¹ It accounts for nearly 80%^2-4 of all lower extremity ulcers, with an overall prevalence of 1% to 2%.² Venous leg ulcers are caused by venous hypertension due to venous reflux, failure of the calf muscle to pump, and venous flow obstruction. It is considered a chronic wound since the normal process of wound healing does not occur.⁵ Instead, it goes through repairs but without restoring a functional skin barrier.

Currently, VLU management poses a significant burden on patients, their families, and the health care system.⁴ Chronic venous insufficiency is associated with a reduced quality of life,⁵ depression,⁶ and social isolation.⁶ In a population study conducted in the United Kingdom,⁷ the median duration of ulceration was 9 months. The study also noted 20% of ulcers will not heal within 2 years and 66% of patients will have an ulcer lasting more than 5 years.⁷ Venous ulcers have caused the loss of 2 million working days per year⁸ and are estimated to account for 1% to 3% of the total health care budget in countries with a developed health care system.^6,9 Treating VLUs costs between $2.5 to $3.5 billion in the United States¹⁰ and £1298 to £1526 in the United Kingdom annually.^11,12 

Venous ulcers of the lower extremity are a chronic, long-term problem and recurrence rates are as high as 70%.³ The mainstay in the treatment of VLUs involves the use of compression therapy to reduce venous hypertension,^13,14 and multilayer compression bandaging is considered the gold standard of treatment.^15,16 However, only 30% of patients with VLUs will heal within 1 year with compression stockings alone.¹⁷ Clinicians should consider other treatment modalities for unresponsive or noncomplaint patients, but there is no concensus on what second-line therapy is recommended. Although considered only as second-line treatment, wound dressings containing antiseptics, antimicrobials, cleansing agents, or autolytic debriding agents heal wounds by regulating or moisturizing the wound surface by moisture retention or exudate absorption protecting the wound base and periwound tissue.^1,7,18 

Traditionally, plant materials have been used to treat and heal wounds for thousands of years. ¹⁹ Among the plants that are known to have medicinal use, Hibiscus rosa-sinensis is one of those that are commonly employed because of its many medicinal properties. Wound healing is one of the reasons why it is commonly used all over the world. In a review conducted on various medicinal plants in India, animals treated with the ethanolic extract of the flowers of H rosa-sinensis exhibited an 86% reduction in the wound area compared with controls, who exhibited a 75% reduction.¹⁹H rosa-sinensis belongs to the family Malvacea and is commonly known as tropical hibiscus or Queen of the Tropics. In the Philippines, it is called gumamela. Its petals and leaves are crushed to create a paste that is applied on the wound twice daily until healed.^20,21 Studies have shown H rosa-sinensis contains phytochemicals that promote wound healing²² and has anti-inflammatory, antioxidant, and antimicrobial properties that heal chronic wounds.²³

The general objective of the present study is to determine the efficacy and safety of 4% gumamela leaf extract ointment in the closure of VLUs among patients seen in a dermatology outpatient department. The specific objectives were to determine (1) the proportion of patients who had a healed ulcer, (2) at what week complete healing of ulcer will occur with 4% gumamela leaf extract, (3) the adverse effects of 4% gumamela leaf extract ointment, and (4) the proportion of patients who had an adverse effect with 4% gumamela leaf extract.

Patients and study design
This is a quasi-experimental trial conducted at the Dermatology Outpatient Department, José R. Reyes Memorial Medical Center, in Manila, Philippines. Approval from the Institutional Review Board of the hospital was obtained prior to commencement of the trial. All eligible patients were required to provide written, informed consent prior to study inclusion.

Included in the trial were men and women between 18 and 85 years old, with at least 1 ulcer open for at least 3 months’ duration and confirmed by duplex scan to be venous in etiology. Included patients also had to be willing to have elastic compression therapy. 

Excluded from the trial were patients with known hypersensitivity to any of the test medications or with acute/chronic dermatoses. Patients with infection of deeper skin structures or with intensive involvement requiring systemic antibiotics also were excluded. Those who received oral/topical antibiotics within 2 weeks of study initiation were not allowed to participate. Lastly, patients with peripheral arterial occlusive disease that might have interfered with the study were not included.

Materials
Gumamela leaves were collected in Lopez, Quezon, Philippines, to avoid contamination of impurities from the environment. The 4% gumamela leaf extract ointment was prepared by an industrial pharmacy (Department of Industrial Pharmacy, College of Pharmacy, University of the Philippines, Manila, Philippines). 

Study intervention
Patients also were instructed to clean the wound with normal saline solution using gauze prior to the application of the ointment. They were asked to apply the ointment twice daily and apply saline-moistened gauze to ensure the ointment was not removed. This procedure was repeated for a maximum of 12 weeks^19,20 or until the wound closed. Patients also were advised to wear compression stockings daily and remove the stockings at night before sleeping. 

Clinical assessment
Wounds were evaluated at baseline and every subsequent 2 weeks using manual planimetry measurements. Photographs of the ulcer were taken at baseline and every 2 weeks of treatment to document and evaluate ulcer size. Nikon Coolpix P310 (Nikon, Tokyo, Japan) was used to capture the pictures under standardized lighting and positioning of the patient.

Efficacy of the therapy was evaluated based on the surface area of the ulcer at each visit using manual planimetry method²⁰ in which the ulcer was traced on acetate with grid. The surface area of the ulcer was measured by counting the number of grids found within the traced circumference and multiplying by area in square centimeters. All partial grids divided by the traced circumference by ≥ 50% were included as well.

Safety parameter was evaluated based on the following skin reaction parameters: erythema, edema, vesiculation, pruritus, and scaling. These parameters were measured using a 4-point grading system (0 = none, not noticed by the physician or patient; 1 = mild, noticed by the physician and/or patient but not disturbing to the patient; 2 = moderate, definitely present and disturbing to the patient and interferes with some activity or sleep; and 3 = severe, very marked and disturbing, interfering with most activities and sleep). The scores of each parameter were added. A clinical scoring of mild (total score: 1–6), moderate (total score: 7–12), and severe (total score: 13–18) were used.

The primary endpoint of the study was defined as complete closure of the ulcer or ≥ 50% reduction in percent change of surface area. The secondary endpoint was defined as the number of weeks at which reduction in surface area was observed. 

Treatment halting guidelines
The trial was stopped on patients who experienced a moderate reaction on 2 consecutive visits or severe reaction as determined by the safety parameter of the study. These patients were considered as a withdrawal from the study. Those who failed to comply wth the treatment, or those who use other topical medications other than the one provided, also were withdrawn. Dropouts were defined as those who did not follow-up within 2 weeks and whose outcome was unknown by the end of the study period.

Sample size
Due to a small population of patients with VLUs and a lack of previous study focus on gumamela, a sample size of 12 was used.  

Data processing and analysis
Descriptive statistics were performed using the means for each characteristic. Analysis of variance (ANOVA) of repeated measure was used to determine whether H rosa-sinensis flower extract is effective in reducing ulcer area. The mean and standard deviation (SD) for the outcome variables were calculated and compared. A paired t test was performed to determine if gumamela extract was effective in reducing the mean ulcer area per 2-week follow-up.

Twelve patients (12 ulcers) were evaluated for eligibility between January 2014 and June 2014. The baseline characteristics of the study population are summarized in Table 1. Of these patients, there were 10 (83.3%) women and 2 (16.7%) men. The mean age for all 12 patients was 56 years (range, 40–73 years). All female patients worked as a vendor and all male patients worked as a security guard. The mean VLU duration was 29 months (range, 12–108 months), with 5 (41.7%) patients with an initial ulcer area > 10 cm² (mean area, 193.86 cm²; range, 20 cm²–902 cm²]) and 7 (58.3%) patients with an initial ulcer area of ≤ 10 cm² (mean area, 6.67 cm²; range, 5 cm²–7.5 cm²). Table 2 shows the proportion of patients with ulcers ≤ or > 10 cm² with their respective mean area. No adverse effects were noted in the study. Figure 1 and Figure 2 demonstrate 2 representative cases from this study.

Clinical effect and statistical analysis
The changes in ulcer area from each patient's follow-up is documented in Table 3. All 7 patients with an ulcer area  ≤ 10 cm² had complete closure. Patients with an ulcer area > 10 cm² had only 3 complete closures, 1 had an area decrease > 50% and 1 had an area decrease < 50%. By the end of the study, 10 (83.3%) patients achieved complete ulcer closure in < 12 weeks, 1 (8.3%) patient had a decrease in ulcer area > 50% by week 12, and 1 (8.3%) with < 50% decrease in ulcer area at the end of the study. The patient who had the least percentage decrease also had the largest ulcer area. Results are summarized in Table 4.

Table 5 shows the gradual decrease in ulcer area every 2 weeks. In addition, ANOVA of repeated measures showed a significant decrease in the size of the ulcer in between weeks (P < .0001). Since there was a significant difference in the size of the ulcer from pretreatment to posttreatment, a post hoc comparison test was performed to assess at which week wound closure was most significant. The pairwise comparison test (Tukey) results are reported in Table 6 and Table 7. It showed a significant difference in decrease of ulcer size as early as 4 weeks posttreatment (P = .031). Furthermore, comparing week 2 to weeks 10 and 12 showed a significant decrease in the size of ulcer (P = .036; P = .015, respectively). This shows the gumamela extract still promotes significant wound healing even at treatment weeks 10 and 12. 

In this study, 4% H rosa-sinensis extract ointment applied in conjunction with compression stockings showed potential in the treatment of VLUs. Of the 12 patients enrolled in the study, 10 patients had complete area closure in < 12 weeks. Although compression therapy, with various levels of compression and different degrees of elasticity, is still the mainstay treatment for VLUs, there is considerable uncertainty as to the most effective therapy.²⁴ A Cochrane review²⁵ was performed on different types of compression stockings and bandages and concluded that multicomponent systems (bandages or stockings), such as the 4-layer bandage, produced complete healing at 3 months, 6 months, or 1 year. Another study comparing the efficacy of 3-layer paste bandaging with 4-layer banadaging regimen on VLUs indicated that median times to complete healing were 12 weeks for the paste bandages and 16 weeks for the 4-layer group (P = .04), but significant differences occurred after only 32 weeks.²⁶ One large trial and 3 small trials reported multilayer high-compression systems healed ulcers at 24 weeks.²⁷ In the present study, data showed compression stockings with 4% gumamela extract ointment application can heal or close VLUs in < 12 weeks, which is faster than compression stockings alone. 

As early as 6 weeks posttreatment, 3 patients had achieved wound closure and by the end of week 10, there were 10 (83.3%)patients with complete wound closure. This observation is significant enough to recommend the addition of 4% gumamela leaf extract in the treatment of VLUs. If researchers were to compare the results of this study with data presented for multilayer compression stocking use, the use of single-layer compression stockings and gumamela extract showed a faster healing time with decreased ulcer area noted as early as 2 weeks posttreatment and complete closure as early as 6 weeks posttreatment.

Based on phytochemical screenings of the ethanol extract of the leaves, H rosa-sinensis contain polyphenols, triterpenoids, tannins, saponins, flavonoids, alkaloids, carboxylic acids, and steroids.^19,28 The ethanol extracts of the flowers and leaves of the red cultivar H rosa-sinensis contain flavanoids, saponins, and steroids that exhibit anti-inflammatory activity.^14,29 One documented anti-inflammatory mechanism of the gumamela metabolites is its cyclooxygenase-2 inhibition, which leads to the inhibition of neutrophil chemotaxis via prostaglandin F2-alpha inhibition.¹⁹ This mechanism also explains why patients enrolled in this study noted decreased erythema and ulcer pain after 2 weeks of treatment with 4% gumamela extract. Furthermore, the plant is a potential source of natural antioxidant that can facilitate wound healing.¹⁷ A study conducted by Patel et al²³ demonstrated the leaves and stems of H rosa-sinensis contain moderate to abundant levels of phenol, glycosides, flavanoids, saponins, terpenoids, and tannins²⁹ that promote wound healing^17,29 through their antimicrobial^18,29 and antioxidant properties.^18,30 Flavonoids are an effective antimicrobial agent due to their ability to make a complex with extracellular and soluble proteins and the bacterial cell wall. They also act as an antioxidant by interacting and scavenging free radicals, which damage cell membranes and biological molecules.¹⁷ In addition, H rosa-sinensis aids in wound healing due to the existence of tannins and terpenoids, which plays an important role in promoting wound healing.²² Tannins isolated from plants possess toxic activity against bacteria.³⁰ They promote wound healing through chelation of free radicals and reactive oxygen species promoting contraction of the wound and increasing the formation of capillary vessels and fibroblast.^17,29

Studies^23,31 comparing the radical scavenging activity and reducing power of the different H rosa-sinensis cultivars showed all cultivars possess good scavenging activity and antioxidant activity. Using spectrophotometric method with Folin-Ciocalteu reagent, colorimetric method, and HPLC-DPPH method, the study demonstrated that among the 4 cultivars, the red cultivar is the most superior as far as total phenolic content, total flavanoid content, and antioxidant activity are concerned.^23,31 The red cultivar also has the highest total antioxidant capacity, which explains its wound healing ability. This is why the present authors chose to determine the wound healing potential of the red gumamela plant for this study. 

One limitation of this study is the small sample size due to the small number of patients with VLUs in the study department. In addition, the researchers did not compare compression stockings with 4% gumamela extract to compression stockings with placebo, which would further substantiate the results of this study. A randomized, controlled trial should be conducted with a larger sample size to strengthen the claims of this study. It also would be more beneficial if researchers explored the wound healing properties of gumamela by using it as a monotherapy on other forms of ulcers (eg, neuropathic ulcer secondary to leprosy or diabetes) or postoperative wounds.

In this study, 4% H rosa-sinensis extract ointment applied with the use of compression stockings showed potential in the treatment of VLUs. The data showed an ulcer area ≤ 10 cm² can have complete closure in < 12 weeks, which is faster than previous research using only a single-layer compression stocking.

Authors: Martha Joy Maralit Bruan, MD; and Elizabeth Amelia Tianco, MD

Affiliation: José R. Reyes Memorial Medical Center, Manila, Philippines

Correspondence: Martha Joy Maralit Bruan, MD, Medical Officer, José R. Reyes Memorial Medical Center, Dermatology, Rizal Avenue, Sta Cruz, Manila, Metro Manila 1012 Philippines; marthajoyb@gmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.