Inflammation is part of many common diseases. Herbalist Simon Mills explores herbal alternatives to anti-inflammatory drugs.
Inflammatory processes are the key disturbances in the majority of diseases. They define any condition ending in ‘-itis’ (e.g. arthritis, dermatitis – aka eczema – gastritis, cystitis, colitis, bronchitis, cellulitis, pericarditis, phlebitis, meningitis). However, inflammation is also central to chronic immunological diseases like rheumatism, Crohn’s disease, psoriasis and lupus, and is now understood as causative in diabetes, arteriosclerosis and cardiovascular diseases, and even cancer.
The modern approach to most inflammatory disturbances is to suppress them with anti-inflammatory drugs, mostly steroids like hydrocortisone or non-steroidal anti-inflammatories (NSAIDs). When steroidal drugs became widely available in the early 1950s, the transformation these made to the progress of arthritic, skin and other connective tissue diseases was dramatic. For decades any challenge to these drugs was dismissed. However, it then became apparent that both steroids and their non-steroidal counterparts (initially based on aspirin-like COX inhibitors and now extended to fenamate class of LOX inhibitors) were associated with a range of side-effects and diminishing benefits. There is again a demand for other approaches, especially in the case of those sufferers otherwise condemned to a lifetime of powerful and potentially dangerous drugs.
Healthy inflammation
Traditional herbal practices approached inflammatory problems in radically different ways. Although there is huge diversity of traditions and cultural variations these approaches were surprisingly consistent. Importantly they also accord with modern findings about the mechanisms of inflammatory and immunological diseases.
Inflammation starts as a healthy though robust response to an assault on the tissues. It is invoked when trouble cannot be cleared in the usual quiet ways. It is the body’s way of bringing reinforcements while also making clear that there is a threat that should be taken seriously. The initial stages we can all recognise were classically described in ancient Greece as rubor, calor, tumor and dolor: redness, heat, swelling and pain. They describe the activation at the site of the assault of chemical agents (cytokines) like histamine, TNF-alpha and the interleukins, leading to increased circulation (redness and heat), movement of defensive white blood cells and fluids out of the circulation into the tissues (swelling), and activation of pain fibres by cytokines (so that proper notice is taken of the injury). In the case of bacterial infections the inflammatory process can lead to accumulation of dead cells known as pus. When this extraordinary burst of activity has done its job the inflammation subsides and tissue resolution heals the damage.
All this is healthy and should not be suppressed, unless the defence is so robust that it risks damaging the body. Problems really start when the inflammation becomes chronic, in other words the initial healthy response does not finish the job. This may be because of repeated assaults, diminished vigour, or immunological complications. As we have seen the immediate medical response when this happens is to provide anti-inflammatories. By contrast the traditional medicine response is to ask: how can we support healthy inflammation so that it finishes the job? The term ‘anti-inflammatory’ does not fit well with traditional medicine.
So where can herbs act to help inflammation finish the job and move on?
Boost the inflammatory response
One of the oldest tricks in healthcare is to heat an inflamed area. This sounds counter-intuitive: ‘you are making the inflammation worse?!’ However, it is very simple. By increasing blood flow to an inflamed area you are doing what the inflammatory response has to do by invoking painful cytokines: to bring more circulation and white blood cells into the affected area, and then to flush it out. One very obvious benefit in supporting inflammation is that it also relieves the accompanying pain. Most people will know about the soothing effects of a hot water bottle or hot pack on a sore muscle or joint and many will also have applied heating liniments with similar benefits (1). The most dramatic effects however come from the careful use of dressings of mustard or chilli powder, particularly over arthritic joints. These can be applied as a poultice, spread onto a gauze of cloth dressing under a hot wet wrap (checking from time to time that the expected redness does not go too far towards blistering – although this used to be a more heroic version of the same principle). In the case of an affected hand or foot this could take the form of a mustard bath, in which mustard powder is dissolved into as small a quantity of water as possible, and the joint immersed in it (to keep the bath hot it is best to put the small container into a larger bowl of hot water). People who use this approach usually report not only immediate pain relief but longer-term reduction in the arthritis. In country districts there is another heroic tradition of beating the affected joints with stinging nettles – the ‘counter-irritation’ pain relief more than outweighs the nettle irritation. There is modern evidence that this works (2).
This approach can also be provided internally and there are many ‘heating’ remedies, usually spices, that have been used to reduce inflammatory conditions over many centuries. A classic example of this is our first alternative to anti-inflammatories.
Anti-inflammatory alternative 1: Ginger
Ginger has been perhaps the most valuable natural commodity in human history, valued for its dispersive heating effects across the body, as an antidote to all forms of symptoms exacerbated by cold and damp. There is increasing evidence that it also reduces inflammation in arthritis as well as more insidious forms associated with metabolic syndrome and diabetes (3,4,5).
Other systemic heating inflammatory modulators of this type include chilli/cayenne – containing the now standard pain-relieving constituent capsaicin – and turmeric.
Support the frontline
All inflammatory responses start in the same place: the endothelial lining of our blood vessels. When tissues come under attack from infection or damage they release chemical messengers (cytokines) which change the properties of the endothelial cells. It makes them ‘sticky’ (like viscose) to passing white blood cells and when these attach in turn transforms them too. Activated white blood cells start pushing their way between endothelial cells to move into the tissues behind (a process known as ‘extravasation’) and once there become totally transformed into prize fighters, including the ‘big eaters’ or macrophages.
In many long-term inflammatory problems endothelial dysfunction has been identified as a core factor exacerbating this initial response. This applies to overt inflammatory diseases like rheumatoid arthritis (6) as well as chronic metabolic and circulatory inflammations associated with cardiovascular disease (7), diabetes, dementia and neurological diseases (8). Endothelial dysfunction is increasingly implicated as a factor also in serious Covid-19 infections (9).
Most plants support endothelial integrity. Many do this through increased nitric oxide activity (10). Especially useful plants are spices and any with high polyphenol content, such as red or blue fruits, cocoa, hawthorn, and turmeric (see below). Our exemplar here is green tea.
Anti-inflammatory alternative 2: Green tea
This most popular drink in the world is also stacking up impressive research credentials in reducing inflammatory markers and signs associated insulin resistance, body weight, raised fat levels, type 2 diabetes and notably cognitive function. These are all chronic inflammatory states and the key role of green tea is to protect endothelial integrity in the face of such long-term stress (11,12,13).
Mobilise the fighters
In the Nativity story the three wise men bear gifts for the baby Jesus. Interestingly two of these most valuable commodities were resins: frankincense and myrrh, having in effect twice the heft of gold! These resins featured also in another Biblical story when King Solomon took the Queen of Sheba as his wife, so conveniently gaining access to the world’s centre of resin production in East Africa. Powdered myrrh (guggul) was history’s most powerful antiseptic, used in wound dressings and also to mummify (ie stop the putrefaction of) dead bodies. Frankincense (boswellia, olibanum) was used more for its powerful aroma, to be burnt in religious ceremonies, but was also used as a medicine, especially for the gut and lungs. Other popular resinous medicines were propolis (from bees), Balm of Gilead (another Biblical remedy), liquidamber, and from South America Tolu balsam. Most of these were used particularly in the mouth and throat.
Resins are insoluble in water and it was only with distillation of alcohol that liquid versions became available. However with the invention of glass their use fell into decline, especially by the analytical scientists arriving several hundred years ago, as resins notoriously coat glassware and can ruin expensive laboratory equipment. So from being the most valued commodities resins almost disappeared from attention. However herbal practitioners never lost their respect for these remedies. High-alcoholic resin extracts are perhaps the most powerful gum, mouth and throat remedies available. As well as having a direct antiseptic activity their most striking impression is that they mobilise local submucosal white blood cell defences. This is most noticeable in the throat and resinous solutions can transform throat inflammations, reducing pain, swelling and being ideal treatments when there are swollen lymphatic glands in the neck. This latter effect gives these remedies powerful benefits for a wide range of associated upper respiratory conditions. A practical point to note is that these resins are best combined with a strong licorice extract (see below) as this has the interesting property of helping the resins stay in solution when water is added; they also make the resinous taste more palatable.
Although resins are likely to be relatively easily denatured and dissipated further down the gut, one of them, frankincense/boswellia in relatively high doses is traditionally used here.
Anti-inflammatory alternative 3: Boswellia
Long used in Ayurvedic medicine in the treatment of arthritic and lung inflammatory conditions as well as in the gut, boswellia has attracted new research interest. There is growing evidence that this resinous remedy has appreciable effects in modulating inflammation through the body, including in relieving osteoarthritis (14). There are also laboratory studies that demonstrate that other constituents, boswellic acids, inhibit inflammatory enzyme 5-lipoxygenase (LOX): this makes them distinct from and safer than COX-inhibiting NSAIDs like iboprufen (15).
Chill out
In traditional medical language inflammation is a defence measure that involves the body heating up an area so as to eradicate an intrusion (often classified as ‘cold’). In other words it is a vital and essentially healthy response to a threat. Fever is understood in the same way.
So as indicated above, the traditional approach starts with supporting the inflammation and even adding more heat. However it was also easily understood that the healthy response could overshoot and the vital response could become harmful. Here ‘cooling’ remedies were considered. These have a dangerous edge to them as too much cooling was always seen as harmful (the ultimate cold body is the corpse) and many of the remedies used in extreme conditions were suppressants, or even poisonous in quantity. However one major group of cooling remedies were exalted for their non-suppressant qualities: the bitters.
Bitter remedies were universally classified around the world as ‘cooling and drying’, applied particularly to ‘hot/damp’ conditions. Translated this meant that they were particularly appropriate for infective or inflamed conditions affecting the digestive system and particularly the liver. Bitter remedies were therefore go-to treatments for hepatitis, food poisoning, gut infections, appendicitis etc. They were also standard fever management tools, cooling excessive temperatures, especially where the fevers were linked to the gut. Many of them have reputations for relieving inflammatory conditions throughout the body, such as the use of berberine-containing remedies like barberry, Oregon grape, coptis and golden seal internally in skin disease, urinary and respiratory conditions, and the widespread use of the wormwood (Artemisia) family for chronic infective and inflammatory conditions. Our choice here however is Andrographis.
Anti-inflammatory alternative 4: Andrographis
The Ayurvedic ‘king of bitters’ is renowned as expected for its digestive effects, being a classic bitter digestive stimulant. However it was also used for a much wider range of inflammatory conditions around the body, in the urinary tract, respiratory system and skin and joints. Recent evidence has focused on its benefits in managing upper respiratory infections (16).
Soothe
Probably the first use of plant remedies was as wound dressings, and plants often contain very useful soothing and healing constituents. Mucilages, gums and tannins all have direct physical effects on exposed tissues. Gums and mucilages add their own soothing mucus layers where a surface is dry and inflamed. Tannins actually knit the exposed proteins to form a leather-like seal. Any herbs with high levels of these constituents will be suitable to contain an inflammation on the skin, on accessible mucosal surfaces and also on the lining of the digestive tract. Classic mucilaginous remedies like slippery elm, aloe vera and gum Arabic, and the tannin-rich withhazel, meadowsweet, and for external use only, oak bark and galls and comfrey are all effective. Such effects are transient but except for the risks of heavy tannin consumption the repeated use of such remedies can help keep the relevant inflammation contained.
There is one soothing remedy that is not based on these constituents that however earns its star-rating in the soothing category.
Anti-inflammatory alternative 5: Licorice
One of the most widely used remedies in traditional medicine, the various species of licorice contain soothing saponins with interesting physical properties on mucosal surfaces (17), that includes reducing surface inflammation (18). A version of licorice was long used as a prescription medicine for peptic ulceration before the arrival of H2-blockers, again for its interaction with mucosal physiology (19), and there is new evidence for benefits there, possibly including in managing Helicobater pylori infections (20). The mucosal properties of licorice are also apparent remotely in its extraordinary reputation in inflammatory conditions of the respiratory tract, where it appears to act amphoterically to reduce both dry (including asthmatic symptoms) and congested bronchial conditions. Licorice has widespread application to other inflammatory problems, including liver disease (21), and potentially much more widely (22).
A bonus remedy
No review of alternatives to anti-inflammatories could be complete without turmeric and an introduction to the likely critical role of a healthy gut and microbiome. A healthy gut population is increasingly cited as key to healthy inflammatory responses around the body and in preventing against inflammatory diseases (23).
Anti-inflammatory alternative 6: Turmeric
Turmeric brings another important dimension into the work to reduce inflammatory damage: its effects in the gut. There is certainly evidence of wide ranging effects around the body (24). Much of the impact of turmeric and its curcuminoid constituents is in the gut, particularly given the poor absorption of curcumin. This includes importantly a likely reduction in the absorption through the gut wall of disease-causing inflammatory metabolites, lipopolysaccharides, from gut bacteria (25,26). Turmeric is also a significant prebiotic (27,28,29), not by providing food for healthy gut flora but apparently engaging in the crosstalk between gut wall, bile and the bacterial population (30). As well as having local benefits in managing inflammatory bowel disease (31), these effects in the gut are implicated in the systemic activity of turmeric and curcumin (32).
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