Discussion
IGM is a recurrent benign disease usually affects women of child-bearing
age, and other predisposing factors are lactation, inflammatory
diseases, diabetes, smoking habit and antidepressant or oral
contraceptive use. It usually presents with a tender, firm mass, and is
often associated with inflammation of the skin. Secondary infection is
common, and treatment is abscess drainage (if present), and empiric
antibiotics.6,9 Although most of the masses respond
well to the corticosteroids, and get smaller or disappear, skin lesions
may still persist, especially in patients with persistent or recurrent
disease. In the present series, the predisposing factors were not
statistically significant (p>0.05, each), except being in
the reproductive age and having a history of lactation (90% and 76%,
respectively). Hyperemia (100%), scaling (61%), induration (52%) and
ulcer (28%) were the predominant skin lesions, since abscesses over
2-cm and intractable skin fistulas were surgically managed with simple
interventions at the outpatient clinic. Since we could not find any
similar study, reporting the effects of topical SJW application on
intractable skin lesions of IGM disease, we will not be able to compare
our results.
Topical SJW applications have been used in some dermatologic disorders,
such as egzema, psoriasis, burns etc., and promising results were
reported.10,11 Furthermore, its use as a remedy for
wounds, bruises and skin ulcers has been well-documented in the
English-written literature.12-14 Of the constituents,
flavonoids, hypericin and hyperforin have antimicrobial, antioxidant,
anti-inflammatory and anticancer activities.1Hyperforin also stimulates growth and differentiation of keratinocytes,
and hypericin is a photosensitizer which can be used for selective
treatment of skin cancer.3 Menichini et
al.15 have suggested that SJW induces inhibition of
free radicals and enhanced phototoxicity in human melanoma cells under
ultraviolet (UV) light. Hypericin was able to suppress proliferation of
human malignant melanoma cells, and the extract together with UV
irradiation enhanced phototoxicity. This biological activity of
antioxidant effects was combined with inhibition of nitric oxide
production. It has also been suggested that other mechanism involves
induction of apoptosis (programmed cell death) through the activation of
caspases, which are cysteine proteases that trigger a cascade of
proteolytic cleavage occurrences in mammalian cells. In an another
study, Mansouri et al.16 showed that SJW ointment can
help decrease the clinical flares of psoriasis. The authors suggested
that its efficacy is probably related to its effect on lowering
cytokines including tumor necrosis factor alpha (TNFα).
Yadollah-Damavand et al.17 have shown that topical
hypericum perforatum improves tissue regeneration in full-thickness
excisional wounds in diabetic rat model.
There are not many studies published on the properties of SJW, how it
helps the wound healing process in detail. However, its
anti-inflammatory, antioxidant and antimicrobial activities were already
reported as well as fibroblast proliferation inducing
effect.18-20 SJW includes many more biologically
active substances, although hypericin and hyperforin have the greatest
medical activity. Other compounds, including the flavonoids, quercetin
and kaempferol, also appear to have medical use. Ozturk et
al.21 studied the wound healing activity of SJW on
experimental embryonic fibroblasts. According to their findings,
fibroblast density, collagen synthesis, and epithelial cell
proliferation rate were increased in the presence of flavonoids and
xanthones, which are among the constituents of SJW. In addition,
flavonoids are known to reduce lipid peroxidation by preventing or
slowing the onset of cell necrosis and improving
vascularity.17 A novel study of Suntar et al
demonstrated wound healing and antimicrobial activity of a topical
formulation containing olive oil extract of SJW.22
In the present series, although high-dose oral corticosteroid treatment
is very effective in reducing the mass, our previous experience with
steroid pomads was disappointing. Since IGM usually presents with skin
lesions, and some of them become persistent or intractable, we started
to recommend topical SJW oil extracts from 2016. In the beginning,
physical examination revealed hyperemia/erythema (100%), scaling
(61%), induration (52%) and fissure/ulcer (28%). Distributions of the
lesions according to the degree of severity were graded as mild,
moderate and severe, and seen in 35%, 41% and 23% of the patients,
respectively. When compared with pre-treatment severity scores, there
were very significant regression (clear: 76.4%, mild: 17.6%, moderate:
3.9%, severe: 1.9%; p<0.001 for each). The overall success
rate (total clearance plus mild signs) of treatment was 94%, and all
patients were satisfied with the treatment (100%).
Previous studies including SJW use in depressive patients have shown
that SJW is generally considered safe when used orally in appropriate
doses.23 The most common adverse effects are
gastrointestinal symptoms, allergic reactions, dizziness, restlessness,
headache and dryness of the mouth, but these effects are generally mild
and transient. Certain drug interactions with barbiturates, warfarin,
statins, immunosuppressive drugs and chemotherapeutic agents have also
been reported, depending on its effect on the liver P450 enzyme
isotypes.23-25 However, there is not enough
information about the safety of using SJW topically. In the present
study, we just encountered mild burning sensations in two of the
patients, but they tolerated well and continued using the drug to the
end of sixth weeks.
In conclusion, SJW oil massage seems to be effective and promising in
patients with persistent IGM-related skin lesions. However, further
studies with higher volume of patients are needed to make a final
decision.