This is the Title

What do the Germans know that we don’t? If you looked into the first-aid kit of most soccer teams in Europe, you would find a tube of horse chestnut gel, ready to ease pain, bruising, and swelling from sprains and other contusions or sports ­injuries.

In the United States, you have to search a little harder to find topical horse chestnut products. For more than a decade, the ever-present tube of gel in my home medicine chest has come from Germany. This product (Reparil) contains the single most dramatic phytomedicine that my family has used. Whenever my children (or I) close a finger in a door, twist an ankle, drop something on a foot, or suffer other types of injuries that cause bruising or swelling, we head straight for the horse chestnut gel. It reduces pain and swelling almost immediately and prevents bruising.

In Germany, horse chestnut extracts are used for another purpose as well—to treat vascular problems. The extracts reduce phlebitis (vein inflammation) and increase vein tone in cases of chronic venous insufficiency (CVI). CVI is a condition characterized by leg tiredness, tension, and heaviness, as well as nocturnal cramping of calf muscles, itching, pain, and swelling. Horse chestnut extracts may also help improve symptoms of leg swelling and pain associated with varicose veins, which may be an early sign of CVI.

Clinical evidence

The clinical research on horse chestnut focuses on CVI. At least thirteen such studies—all placebo controlled and double-blind—have been published since 1973. Most used 600 mg of an extract (equivalent to 100 mg/day of aescin, the group of compounds thought to be biologically active) and showed positive results.

A recent review of these studies concluded that horse chestnut seed extract is safe and effective for decreasing symptoms of CVI, including reducing lower-leg volume ­(circumference at the calf and ankle), leg pain, itching, ­fatigue, and muscular tension in the legs. Five of these clinical trials compared horse chestnut extract against treatment with a standard drug. The reviewers concluded that horse chestnut extract was superior to placebo and just as effective as the standard (European) treatment. Another trial suggested that horse chestnut extract is as effective as compression stockings.

Finding horse chestnut

So how can you find this herb in the United States? Well, it’s not always easy. In the rest of the world, topical horse chestnut extract products are usually sold as over-the-counter drugs. In the United States, they’re primarily found as cosmetics because of labeling restrictions. Oral horse chestnut forms are becoming increasingly common and can be found in health-food stores and even some grocery stores. These products are intended to reduce venous insufficiency and are marketed to help reduce varicose veins. A few pharmacological studies show that horse chestnut may both prevent and treat varicose veins. However, treatment for varicose veins with horse chestnut has not been adequately addressed in human clinical studies.

Here are some tips for selecting good horse chestnut ­products.

Start with standardization. Horse chestnut seed extracts, used in both oral and topical forms, are complex phytomedicine. Extracts  are made through an exacting process that can’t be duplicated by consumers in the kitchen or by backyard herbalists.

The extract is made from the seeds of the European horse chestnut (Aesculus hippocastanum). It is then calibrated to contain 16 to 20 percent of a group of compounds called triterpene glycosides. This group of compounds is collectively known as aescin (also spelled escin), which is the term you want to look for on the label.

Tablets and capsules. An average therapeutic dose of horse chestnut should contain 100 mg of aescin, according to the German Commission E monograph on horse chestnut. This amount of aescin is commonly found in formulations of 250 to 312 mg and is usually split into two doses per day. The extract usually comes in timed-release tablets.

Gels, creams, and balms. Topical products containing aescin act by diminishing the number or diameter of tiny openings in capillary walls, helping to “seal” the outflow of fluid surrounding tissue, hence thwarting swelling and bruising. This unique mechanism of action makes it very useful for the topical treatment of bruises, sprains, and contusions. Look for aescin on the label. If it’s not there, you don’t know how much you’re getting.

Tinctures. In both the European and American markets, product forms such as liquid extracts that differ from those stated in the German regulatory text are formulated to deliver an equivalent amount of aescin. Research has focused on standardized extract forms, but non-standardized tinctures are also made in the United States. Follow label instructions on any product you use.

How aescin works

The “cement” between cells can be broken down by lysosomal enzymes, which in turn leads to increased capillary permeability and edema (collection of fluids in tissue). Aescin has been shown in various pharmacological studies to inhibit these enzymes, shrinking the size and quantity of tiny pores in capillary walls that regulate the flow of fluids. German and Italian researchers also suggest that, in cases of CVI, the lysosomal enzymes increase the number of white blood cells in the blood, a condition similarly reduced by aescin.

In addition, horse chestnut extract improves vein tone by helping to increase the contraction of elastin fibers in the vein walls. This activity, called a venotonic effect, counteracts a relaxation of vein tissue that can lead to varicose veins.

Safety

CVI is a serious health problem that requires medical attention. Horse chestnut seed extracts are scientifically based herbal medicines that, in proper formulas and controlled dosages, have proven effective and safe. Don’t combine horse chestnut with warfarin (Coumadin) unless you are supervised by a knowledgeable health-care provider, and don’t use it during pregnancy or nursing. In rare instances, oral forms may cause stomach upset, nausea, or itching. Timed-release tablets reduce the chance of stomach upset.

Caution: Unprocessed horse chestnut (including bark, leaves, or seeds) potentially can be toxic, and fatalities have been reported from eating relatively small amounts of the raw seeds. Use standardized, manufactured preparations only. Avoid homemade horse chestnut preparations.

References

Blumenthal, M., et al., eds. Translated by S. Klein. German Commission E Therapeutic Monographs on Medicinal Herbs for Human Use. Austin, Texas: American Botanical Council, 1998.

Bombardelli, E., and P. Morazzoni. “Aesculus hippocastanum L.” Fitoterapia 1996, 67 (6):483–511.

Calabrese, C., and P. Preston. “Reports of the results of a double-blind, randomized, single-dose trial of a topical 2% escin gel versus placebo in the acute treatment of experimentally induced hematoma in volunteers.” Planta Medica 1993, 59:394–397.

Pittler, M. H., and E. Ernst. “Horse chestnut seed extract for chronic venous insufficiency.” Archives of Dermatology November, 1998, 134:1356–1360.

Shah, D., et al. “Aesculaforce in chronic venous insufficiency: Placebo-controlled double-blind study to demonstrate the efficacy and tolerability of a plant remedy.” Schweizerische Zeitschrift fur Ganzheitsmedizin 1997, 9 (2):86–91.  

{Blurb}This powerful, safe herb can ease summer’s bumps, bruises, and sprains—and it may help  swelling and pain associated with varicose veins.

What’s so great about herbs used in Germany?

Before herbs such as echinacea, garlic, ginkgo, St. John’s wort, and saw palmetto were best-sellers in the American market, they had been sold for years, sometimes decades, in Germany. There, herbal medicines are not considered “complementary” or “alternative” medicine; they’re simply another aspect of conventional medical treatment. This trend is ever so slowly beginning to emerge in the United States as well.

All the best-selling herbs in Germany are covered by therapeutic monographs. These monographs, called the German Commission E monographs, serve as the basis for labeling and regulating herb products.

Until recently, however, the Commission E monographs were published only in German, making them inaccessible to a broad North American readership. In 1998, the American Botanical Council published an English translation of the German regulatory monographs: The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Now, more Commission E–approved herbs are beginning to get attention in the U.S.  market.

Herbs to watch for? Hawthorn (Crataegus spp.) for heart conditions, stinging nettle root (Urtica dioica) for benign prostatic hyperplasia, and ivy (Hedera helix), whose extracts are used for respiratory irritations.

To order the monographs

The Commission E monographs are available in bookstores or through the American Botanical Council, (512) 926-4900, www. herbalgram.org.

The Complete German Commission E
Monographs: Therapeutic Guide to Herbal Medicines

Mark Blumenthal, ed., et al.

Integrative Medicine Communications, 1998

Hardcover, 685 pages, $165

CD-ROM, $99

Book and CD-ROM, $199

Includes 380 monographs on herbs and herb combinations approved for therapeutic use and a glossary of medical, pharmaceutical, and technical terms.

Herbal Medicine:
Expanded Commission E Monographs

Mark Blumenthal, ed., Alicia Goldberg,

and Josef Brinckmann

Integrative Medicine Communications, 2000

Hardcover, 519 pages, $49.95

CD-ROM, $49.95

Includes an in-depth overview on 107 monographs, with clinical research and expanded sections on chemistry, pharmacology, dosage, and administration.

Did you know?

Injectable forms of horse chestnut seed extracts are used in German trauma centers for the treatment of acute head injuries or brain trauma.