|Year : 2017 | Volume
| Issue : 1 | Page : 11-13
Saw palmetto extract: A dermatologist's perspective
Varshini Reddy, Aditya Kumar Bubna, Mahalakshmi Veeraraghavan, Sudha Rangarajan
Department of Dermatology, Sri Ramachandra University, Chennai, Tamil Nadu, India
|Date of Web Publication||27-Jun-2017|
No. 13/7, 7th Main Road, RA Puram, Chennai - 600 028, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Saw palmetto extract is believed to have antiandrogenic properties and has been used widely for the treatment of androgenic alopecia. It is claimed to have much less side effects as compared to finasteride. Along with its use for androgenic alopecia, it has also been tried for other conditions associated with increased androgen levels in dermatology. This article will review a dermatologist's perspective of this traditional herb.
Keywords: 5-alph reductase inhibitor, anti-androgen, serenoa repens
|How to cite this article:|
Reddy V, Bubna AK, Veeraraghavan M, Rangarajan S. Saw palmetto extract: A dermatologist's perspective. Indian J Drugs Dermatol 2017;3:11-3
|How to cite this URL:|
Reddy V, Bubna AK, Veeraraghavan M, Rangarajan S. Saw palmetto extract: A dermatologist's perspective. Indian J Drugs Dermatol [serial online] 2017 [cited 2017 Nov 19];3:11-3. Available from: http://www.ijdd.in/text.asp?2017/3/1/11/209042
| Introduction|| |
Saw palmetto or serenoa repens (SR) is a small palm tree native to eastern regions of the United States. Its extract is believed to be a highly effective antiandrogen as it contains phytoesterols and fatty acids as its major ingredient. SR is used in several forms of traditional herbal medicine. American Indians used the fruit for food and to treat a variety of urinary and reproductive system problems. The Mayans drank it as a tonic, and the Seminoles used the berries as an expectorant and antiseptic. Crude SR extract was used by the European and American medical practitioners for at least 200 years for various conditions, including asthenia, recovery from major illness and urogenital problems. SR is currently being commercially marketed for the treatment of benign prostatic hyperplasia. Of late SR has gained popularity as a magical remedy for androgenetic alopecia (AGA). Being a naturally occurring 5 alpha reductase inhibitor, it has also been used for other dermatologic indications. This article will review the dermatologic perspective of SR.
| Mechanism of Action|| |
Like finasteride, SR is believed to block the enzyme 5 alpha reductase. Whether SR inhibits 5 alpha reductase 1 or both the isoenzymes of 5 alpha reductase is not clear. This action thereby blocks the conversion of testosterone to dihydrotestosterone (DHT). This is its primary mode of action for most dermatologic conditions. Other mechanisms of therapeutic benefit by SR will be elaborated under the specific conditions of its usage in dermatology.
| Dermatologic Indications of Serenoa Repens|| |
There is no Food and Drug Administration (FDA) approved indications of SR in dermatology. All are off-label indications.
SR has proved to be effective in the management of AGA. Apart from the primary mechanism of action of 5 alpha-reductase blockade, SR is thought to decrease the uptake of DHT by the hair follicles  and decrease its binding to androgenic receptors. Another possible effect of SR in AGA seen with its liposterolic extract is suppression of lipopolysaccharide-activated gene expression of chemokines, including CCL 17, CXCL 6, and LT B 4 associated inflammatory and apoptotic pathways. Hence, its anti-inflammatory properties are of value in AGA. With SR growth of hair is prevalently seen over the frontal and temporal regions of the scalp.
The safety and efficacy of SR in treating hirsuitism have not been sufficiently investigated. Studies show that it inhibits 5 alpha reductase and as a result prevents the conversion of testosterone to DHT. Further SR strongly inhibits 3 ketosteroid reductase-mediated conversion of DHT to 5-alpha androstane-3 alpha and 17 beta-diol which may help as therapy for hirsuitism. A study done using a cream containing SR extract (Nela Depil) twice a day for 2 months in 31 women with idiopathic facial hirsuitism showed a 29% decline in hair counts 2 months posttreatment which is statistically significant (P < 0.0001). However, further studies maybe required to determine the effectiveness of SR extract for this condition.
As SR lowers DHT levels, it influences the production of sebum by reducing the excessive oils contributing to the development of acne. SR is a dual inhibitor of cyclooxygenase and 5-lipoxygenase pathways according to in vitro research. More recently, decreased expression of COX-2 has been identified providing a further explanation for the observed anti-inflammatory activity. Further studies would only help in elucidating the efficacy of SR both as monotherapy or as a combination therapy in acne.
Polycystic ovarian syndrome
In polycystic ovarian syndrome, there are increased levels of adrenal androgens. Furthermore, the peripheral tissues such as skin, liver, and adipose tissue also take part in androgen synthesis by converting the weaker androgens into, the more potent ones. Androgen receptor activation takes place only with circulating testosterone and DHT. Twenty-five percent of the circulating testosterone is produced individually by the ovaries and adrenals. The remaining 50% is by the peripheral conversion from androstenedione. SR helps as an antiandrogen and may also have anti-inflammatory effects. An ethanol extract of SR inhibited the lipid droplet accumulation by attenuation of protein expressions of C-EBP alpha and PPAR gamma. Phosphorylation of Erk 1/2 and Akt 1 were also decreased by SR ethanol extract. Hence, SR extracts could selectively affect the adipocyte differentiation through the modulation of several key factors that play a critical role in adipogenesis.
| Pharmacokinetics|| |
As yet, there is no data available on absorption, distribution, metabolism, and elimination for SR.
| Dosage|| |
The dosage of SR for dermatologic indications has not been clearly established. For benign prostatic hyperplasia 160 mg twice daily of an extract standardized to contain 85%–95% fatty acids or sterols is administered. Similarly, a single daily dose of 320 mg may just be effective in this condition., As with many other herbs the quality of SR products may vary widely, owing to which a standardized dosing may pose to be a serious problem.
| Adverse Effects|| |
Mild stomach discomfort is the most common side effect. It can be alleviated by taking the drug after food. Hepatic inflammation is another serious problem with SR. There have been two case reports showing this adverse reaction in patients taking the medication for benign prostatic hyperplasia.,
Pancreatitis has been reported with SR extract. In general, some potential mechanisms for drug-induced acute pancreatitis include pancreatic duct constriction, cytotoxic and metabolic effects, accumulation of a toxic metabolite or intermediary and hypersensitivity reactions. Another theory suggests that pancreatitis may occur due to SR stimulating the estrogenic receptors and induces a hypercoaguable state that leads to pancreatic necrosis. There is one report of SR apparently causing excessive bleeding during surgery. The significance of this isolated event is not clear, but it is probably prudent to avoid SR before and just after surgery.
| Drug Interactions|| |
Drugs such as warfarin, heparin, aspirin, clopidogrel, and ticlopidine should be avoided in patients taking SR, owing to an increased tendency for bleeding. The exact mechanism for the increased risk of hemorrhage while taking SR with the above-mentioned drugs requires further elucidation.
| Safety in Pregnant and Nursing Women|| |
It has not been established till date.
| Conclusion|| |
SR is an herbal drug which has found to be useful in the dermatologic indications mentioned above. It has been used as a topical formulation and also systemically. Despite the easy availability of saw palmetto extract and it being designated as a food product by the US FDA there still remains paucity on its regulations with regard to efficacy and safety. Moreover, we also need to be aware of the low quality of evidence about saw palmetto extract with regard to most dermatologic indications where it has been utilized. With there being a number of side effects with the systemic route the development of more topical formulations in the near future in the form of creams, lotions, and gels could help in getting a good therapeutic outcome with the risks minimized. Finally, all patients need to be adequately counseled regarding the paucity of literature with regard to the exact mode of action, safety, and long-term effects of SR and therefore its use should be limited in those patients where there is a contraindication in the usage of other conventional modalities of management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grant P, Ramasamy S. An update on plant derived anti-androgens. Int J Endocrinol Metab 2012;10:497-502.
Wilt TJ, Ishani A, Stark G, MacDonald R, Lau J, Mulrow C. Saw palmetto extracts for treatment of benign prostatic hyperplasia: A systematic review. JAMA 1998;280:1604-9.
Murugusundram S. Serenoa Repens: Does it have any role in the management of androgenetic alopecia? J Cutan Aesthet Surg 2009;2:31-2.
] [Full text]
Prager N, Bickett K, French N, Marcovici G. A randomized, double-blind, placebo-controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase in the treatment of androgenetic alopecia. J Altern Complement Med 2002;8:143-52.
Chittur S, Parr B, Marcovici G. Inhibition of inflammatory gene expression in keratinocytes using a composition containing carnitine, thioctic acid and saw palmetto extract. Evid Based Complement Alternat Med 2011;2011:985345.
Rossi A, Mari E, Scarno M, Garelli V, Maxia C, Scali E, et al.
Comparitive effectiveness of finasteride vs. Serenoa repens
in male androgenetic alopecia: A two-year study. Int J Immunopathol Pharmacol 2012;25:1167-73.
Fagelman E, Lowe FC. Saw Palmetto Berry as a Treatment for BPH. Rev Urol 2001;3:134-8.
Sultan C, Terraza A, Devillier C, Carilla E, Briley M, Loire C, et al.
Inhibition of androgen metabolism and binding by a liposterolic extract of “Serenoa repens
B” in human foreskin fibroblasts. J Steroid Biochem 1984;20:515-9.
Behrooz B. The effectiveness of the extract of Serenoa repens
in idiopathic facial hirsuitism. Iran J Dermatol 2009;12:139-40.
Dobrev H. Clinical and instrumental study of the efficacy of a new sebum control cream. J Cosmet Dermatol 2007;6:113-8.
Adashi EY. The climacteric ovary as a functional gonadotropin-driven androgen-producing gland. Fertil Steril 1994;62:20-7.
Villaverde N, Galvis A, Marcano A, Priestap HA, Bennett BC, Barbieri MA. Saw palmetto ethanol extract inhibits adipocyte differentiation. J Nat Med 2013;67:619-25.
Braeckman J, Bruhwyler J, Vandekerckhove K. Efficacy and safety of the extract of Serenoa repens
in the treatment of benign prostatic hyperplasia: Therapeutic equivalence between twice and once daily dosage forms. Phytother Res 1997;11:558-63.
Stepanov VN, Siniakova LA, Sarrazin B, Raynaud JP. Efficacy and tolerability of the lipidosterolic extract of Serenoa repens
(Permixon) in benign prostatic hyperplasia: A double-blind comparison of two dosage regimens. Adv Ther 1999;16:231-41.
Feifer AH, Fleshner NE, Klotz L. Analytical accuracy and reliability of commonly used nutritional supplements in prostate disease. J Urol 2002;168:150-4.
Singh YN, Devkota AK, Sneeden DC, Singh KK, Halaweish F. Hepatotoxicity potential of saw palmetto (Serenoa repens
) in rats. Phytomedicine 2007;14:204-8.
Jibrin I, Erinle A, Saidi A, Aliyu ZY. Saw palmetto-induced pancreatitis. South Med J 2006;99:611-2.
Underwood TW, Frye CB. Drug-induced pancreatitis. Clin Pharm 1993;12:440-8.
Kaurich T. Drug-induced acute pancreatitis. Proc (Bayl Univ Med Cent) 2008;21:77-81.
Cheema P, El-Mefty O, Jazieh AR. Intraoperative haemorrhage associated with the use of extract of saw palmetto herb: A case report and review of literature. J Intern Med 2001;250:167-9.
Avins AL, Bent S, Staccone S, Badua E, Padula A, Goldberg H, et al.
A detailed safety assessment of a saw palmetto extract. Complement Ther Med 2008;16:147-54.