10.5826/dpc.1203a115
Introduction: Epidermolysis bullosa (EB) is a rare inherited genetic skin disorder with severe skin itching and recurrent blisters and erosion. There is no effective and specific therapy for all types of EB.
Objective: The aim of this study was to evaluate a topical formulation of henna (Lawsonia inermis L.) in the management of wounds and the itching sensation in patients with EB.
Methods: This is a pilot single-arm clinical trial. Nine patients with recessive dystrophic EB (RDEB), with the age range of 5 to 32 years old were enrolled in the study. The patients were instructed to apply the topical 1% henna ointment once daily on two erosions and on also two sites with moderate to a severe itching sensation. The total duration of the intervention was four weeks with weekly follow-up visits. Patient global impression of improvement (PGI-I), visual analog scale (VAS), and clinical global impression of improvement (CGI-I) were used for assessing the wound healing process and itching discomfort.
Results: There was a significant improvement in the skin symptoms of epidermolysis bullosa including skin redness, itching, burning, and local warmness (p-value&lt;0.05). Local pain decreased during the study period, but this was not statistically significant (p-value&lt;0. 0.19). One patient reported moderate xerosis of skin after continuous usage.
Conclusion: It seems that the topical formulation of henna may be effective in the management of itching, burning, stringing, and cutaneous warmness sensation in patients with EB. Further controlled studies with larger sample sizes are recommended to better evaluate this formulation.
text/xml
2160-9381
2020
en
Mojtaba  Heydari
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
complementary therapies
Efficacy of a topical formulation of Henna (Lawsonia inermis) on the itch and wound healing in patients with epidermolysis bullosa: A pilot single-arm clinical trial
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-09-08
2022-07-28
2022-11-23
e2022115
Dermatol Pract Concept
Introduction: Epidermolysis bullosa (EB) is a rare inherited genetic skin disorder with severe skin itching and recurrent blisters and erosion. There is no effective and specific therapy for all types of EB.
Objective: The aim of this study was to evaluate a topical formulation of henna (Lawsonia inermis L.) in the management of wounds and the itching sensation in patients with EB.
Methods: This is a pilot single-arm clinical trial. Nine patients with recessive dystrophic EB (RDEB), with the age range of 5 to 32 years old were enrolled in the study. The patients were instructed to apply the topical 1% henna ointment once daily on two erosions and on also two sites with moderate to a severe itching sensation. The total duration of the intervention was four weeks with weekly follow-up visits. Patient global impression of improvement (PGI-I), visual analog scale (VAS), and clinical global impression of improvement (CGI-I) were used for assessing the wound healing process and itching discomfort.
Results: There was a significant improvement in the skin symptoms of epidermolysis bullosa including skin redness, itching, burning, and local warmness (p-value&lt;0.05). Local pain decreased during the study period, but this was not statistically significant (p-value&lt;0. 0.19). One patient reported moderate xerosis of skin after continuous usage.
Conclusion: It seems that the topical formulation of henna may be effective in the management of itching, burning, stringing, and cutaneous warmness sensation in patients with EB. Further controlled studies with larger sample sizes are recommended to better evaluate this formulation.
Mojtaba  Heydari
2022/07/28
10.5826/dpc.1203a115
e2022115
Research Center for Traditional Medicine and History of Medicine, Department of Persian Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
2160-9381
complementary therapies
en
e2022115
Efficacy of a topical formulation of Henna (Lawsonia inermis) on the itch and wound healing in patients with epidermolysis bullosa: A pilot single-arm clinical trial
https://dpcj.org/index.php/dpc/article/download/2020/1665
    Efficacy of a Topical Formulation of Henna
(Lawsonia Inermis Linnaeus) on the Itch and Wound
  Healing in Patients With Epidermolysis Bullosa:
          a Pilot Single-arm Clinical Trial
             Mehdi Niazi1, Mohammad Mahdi Parvizi2,3,4, Nasrin Saki5, Zahra Parvizi6,
                            Mehrzad Mehrbani1,7, Mojtaba Heydari3,,4


1 Department of Traditional Medicine, Faculty of Traditional Medicine, Kerman University of Medical Sciences, Kerman, Iran.
2 Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
3 Research Center for Traditional Medicine and History of Medicine, Department of Persian Medicine, School of Medicine, Shiraz University
  of Medical Sciences, Shiraz, Iran.
4 Persian Medicine Network (PMN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
5 Molecular Dermatology Research Center, Department of Dermatology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
6 Health System Research, Vice Chancellor of Treatment, Shiraz University of Medical Sciences, Shiraz, Iran.
7 Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran.



Key words: epidermolysis bullosa, Lawsonia plant, wound healing, pruritus, complementary therapies
Citation: Niazi M, Parvizi MM, Saki N, Parvizi Z, Mehrbani M, Heydari M. Efficacy of a topical formulation of henna (Lawsonia inermis
L.) on the itch and wound healing in patients with epidermolysis bullosa: A pilot single-arm clinical trial. Dermatol Pract Concept.
2022;12(3):e2022115. DOI: https://doi.org/10.5826/dpc.1203a115
Accepted: November 22, 2021; Published: July 2022
Copyright: ©2022 Niazi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: This study was supported by Vice Chancellor of Research, Shiraz University of Medical Sciences, Shiraz, Iran (Grant No:
98-01-65-19435).
Competing interests: The authors declare that there is conflict of interest, in the way that two individuals listed in authors’ list, MMP and
ZP, suffer from DEB and they participated in this clinical trial, but they did not have any role in response evaluation of the drug.
Authorship: Conception and design of the work: MN, MMP, MH, NS, MM, ZP; data collection: MN, NS, MM; analysis and interpretation
of the data: MN, MH, MM, NS; statistical analysis: MMP, MM; drafting the manuscript: MN, MMP, NS, MM, ZP; critical revision of the
manuscript: MMP, MM, NS, MH, Final approval: MN, MMP, MH, NS, MM, ZP
Corresponding author: Mohammad Mahdi Parvizi, MD, MPH, PhD, Assistant professor of Persian Medicine, Molecular Dermatology
Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Zand Avenue, Shahid Faghihi Hospital, Shiraz, Iran, 7134844119.
Telephone: 00989173237031. E-mail: mmparvizi@gmail.com




  ABSTRACT              Introduction: Epidermolysis bullosa (EB) is a rare inherited genetic skin disorder with severe skin
                        itching and recurrent blisters and erosion. There is no effective and specific therapy for all types of EB.
                        Objectives: The aim of this study was to evaluate a topical formulation of henna (Lawsonia inermis
                        Linnaeus) in the management of wounds and the itching sensation in patients with EB.
                        Methods: This is a pilot single-arm clinical trial. Nine patients with recessive dystrophic EB, with the
                        age range of 5 to 32 years were enrolled in the study. The patients were instructed to apply the topical




Original Article | Dermatol Pract Concept. 2022;12(3):e2022115                                                                                  1
                     1% henna ointment once daily on two erosions and on also two sites with moderate to a severe itching
                     sensation. The total duration of the intervention was 4 weeks with weekly follow-up visits. Patient
                     global impression of improvement, visual analog scale, and clinical global impression of improvement
                     were used for assessing the wound healing process and itching discomfort.
                     Results: There was a significant improvement in the skin symptoms of epidermolysis bullosa including
                     skin redness, itching, burning, and local warmness (P < 0.05). Local pain decreased during the study
                     period, but this was not statistically significant (P < 0.19). One patient reported moderate xerosis of
                     skin after continuous usage.
                     Conclusions: It seems that the topical formulation of henna may be effective in the management of
                     itching, burning, stringing, and cutaneous warmness sensation in patients with EB. Further controlled
                     studies with larger sample sizes are recommended to better evaluate this formulation.




Introduction                                                      Objectives
Inherited epidermolysis bullosa (EB) is a rare genetic skin       To the best of our knowledge, there are no studies on the
disorder that can affect many extracutaneous organs includ-       efficacy of henna in the management of wounds and itch in
ing the gastrointestinal and genitourinary system, eye and        patients with RDEB. The aim of this study was to evaluate
etc [1,2]. There are four major types of inherited epidermol-     the efficacy of henna in the wound healing process and itch-
ysis bullosa; epidermolytic (EB simplex [EBS]), lucidolytic       ing complaints in patients with RDEB.
(junctional EB [JEB]), dermolytic (dystrophic EB [DEB]),
and Kindler syndrome [3]. The common characteristics of           Methods
all subtypes of EB are recurrent blistering and erosions (after
even minor trauma or traction) of skin and the organs cov-        Study Design
ered by mucous membrane [4].                                      This study was designed as a single-arm, uncontrolled clini-
    The pathogenesis of EB is the mutation of the genes           cal trial. This study was in compliance with the Declaration of
which is caused due to dysfunction of collagen type VII           ­Helsinki (1989 revision) [17], and also approved and monitored
that is the main component of the anchoring fibrils located       by the Ethics Committee of Shiraz University of Medical Sci-
below the lamina densa layer of the epidermal basement            ences (License number: IR.SUMS.REC.1398.761). Moreover,
membrane zone [2]. EB patients, especially patients with re-      the enrolled patients were informed completely about the pro-
cessive dystrophic EB (RDEB), suffer from severe skin itch-       tocol of the study and signed the written informed consent. The
ing and also recurrent blisters and erosion [2,5]. There is       patients were permitted to withdraw from the study at any time
no specific therapy for all types of EB, therefore supportive     of the study. This clinical trial was registered at the Iranian Reg-
care including wound care, control of infection and itching       istry of Clinical Trials (IRCT) by IRCT20150825023753N14
are very important [6]. Using topical and systemic antibi-        code (http://www.irct.ir/trial/41647).
otics, analgesics, antihistamines are very popular in these
patients.                                                         Sample Size and Study Population
    Henna (Lawsonia Inermis Linnaeus) is one of the most          Patients with RDEB were recruited from Faghihi Derma-
commonly used medicinal plants in traditional Persian             tology Clinic, Shiraz University of Medical Sciences, Shiraz,
medicine as a treatment for dermatological conditions and         Iran. Given the rarity of RDEB, the researchers decided to
improving wound healing [7,8]. There are several studies          enroll at least seven patients in this pilot study.
demonstrating the efficacy of henna on skin disorders such            Inclusion criteria were patients with RDEB, who signed
as dermatitis including diaper dermatitis, bedsore, itch, and     the written informed consent (themselves or their parents if
et. [9-12]. It has been shown that henna can improve the          less than 15 years old) to participate in the study. The exclu-
wound healing process and also has antipruritic effects           sion criteria were a positive history of allergic reaction to
[13,14]. In addition, some investigations revealed the antimi-    henna, or glucose-6-phosphate dehydrogenase (G6PD) defi-
crobial and antifungal properties of henna. These effects are     ciency, and any other systemic diseases.
considered to be due to high concentrations of some compo-
nents in this plant including carbohydrates, anthraquinones,      Drug Preparation
naphthoquinone derivatives, flavonoid, and phenolic com-          Henna (Lawsonia inermis Linnaeus) leaves were gathered
ponents. [15,16].                                                 from Shahdad fields (Kerman, Iran) and dried. A botanist




2                                                                      Original Article | Dermatol Pract Concept. 2022;12(3):e2022115
at Kerman University of Medical Sciences authenticated the       at a specified interval, 1 ml volume of PBS solution was sam-
plant and recorded it with a specified voucher number (No:       pled and replaced with the same volume of PBS. The samples
KF-1408). The maceration method five times was conducted         were analyzed by UV spectrophotometer and repeated three
to prepare the hydro-ethanolic extraction (30:70). The gath-     times and the amount of active ingredient release was calcu-
ered extract was purified through filtration and concentrated    lated according to the standard curve.
by a vacuum rotary evaporator and dried in an oven 40°C. The
                                                                 Microbial Control
ointment containing 1% henna was prepared by dissolving a
                                                                 The microbial and fungal control tests of the product were
one-gram fine powder of dried henna extract in the minimum
                                                                 performed by Barij Essence® Pharmaceutical company (­serial
volume of ethanol 40%, then it was dispersed in 99 grams
                                                                 number:1521M98; batch number: 9805101) for aerobic mi-
of Eucerin through geometric dilution. The prepared ointment
                                                                 croorganisms, Pseudomonas aeruginosa, Staphylococcus au-
was packed in 50-gram containers for delivery to the patients.
                                                                 reus, modals, and yeasts enumeration.

Pharmaceutical Properties of the Ointment                        Intervention and Follow-up of the Patients
The quality control of the prepared ointment was performed       The patients were instructed to use a fingertip of henna oint-
according to WHO guideline [18]. Pharmaceutical char-            ment once a day on two erosions and also on two sites with
acterizations of henna ointment were evaluated as follows        moderate to severe itching for 4 weeks with first, second,
[19-23]:                                                         and fourth week follow-up visits. Patient global impression

Determination of pH                                              of improvement (PGI-I), visual analog scale (VAS), and clin-
                                                                 ical global impression of improvement (CGI-I) were used to
Some ointment was heated up to the melting point and di-
                                                                 assess the wound healing process and itching discomfort.
luted with a 1:9 dilution ratio (1 unit of drug and 9 units of
                                                                 Furthermore, photographs were taken of all of the patients.
water) and measured with a pH meter. This procedure was
                                                                    Furthermore, wound improvement response was defined
repeated three times and its mean and standard deviation
                                                                 as excellent (90% improvement), good (50%-90% improve-
were recorded.
                                                                 ment), mild (20%-50% improvement), and fair (less than
Homogeneity                                                      20% or worse) according to general appearance.
Homogeneity of the herbal ointment was evaluated for any            At the end of the study, patients or their parents (for
aggregation by the skin test. In this study, 12 healthy volun-   children participants) were asked to express their opinions
teers tested some of the product on the back of their hands      about the efficacy of henna ointment in comparison to other
and were asked to express their satisfaction with the particle   used medications.
being present in the ointment.
                                                                 Statistical Analysis
Total Polyphenolic Content
                                                                 Statistical Package for Social Sciences, SPSS version 18 (SPSS
The total phenolic content of the extract and ointment were
                                                                 Inc.), was used for data analysis. According to the low sam-
measured based on the Folin-Ciocalteu method.
                                                                 ple size, Freedman test was used for assessment of the ef-
Rheological Behavior                                             fects of henna ointment on the variables of the study. P value
Cone and Plate Brookfield rheometer (Brookfield Engineer-        equal to or less than 0.05 was considered significant.
ing Laboratories) at 25°C was performed to evaluate the rhe-
ological behavior of ointment for triplicate.
                                                                 Results
Spreadability Test
                                                                 Pharmaceutical Characterization
Two horizontal glass plates (10 cm × 10 cm) were conducted
                                                                 The measured pH of ointment was 6.4 ± 0.3. This ointment
to assess the spreadability of the prepared ointment. The
                                                                 displayed rheological thixotropic behavior. The results of
spreading diameter of one gram of sample between plates
                                                                 the spreadability test showed that the mean diameter for
was measured under 25 grams standard weight shear appli-
                                                                 henna ointment was 9 ± 0.8 cm. Folin-Ciocalteu method
cation three times.
                                                                 was used to determine total phenolic contents in terms of
In Vitro Drug Release                                            Gallic acid equivalent (GAE) in mg/g of the extract. Based
Two grams of henna ointment were poured into a 10-kDa            on the equation of the calibration curve (y = 0.007x+0.006,
semi-permeable dialysis membrane bag. After dispersing, it       R2 = 0.999), the total phenolic content of the extract and
was immersed in 50 ml of 25 mM phosphate buffer solution         ointment were 129.6 ± 1.1 and 0.98 ± 0.18 mg/g of extract,
(PBS) at 37 ± 0.5 ° C and rotated at 100 rpm. For 24 hours,      respectively.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022115                                                               3
     The rate of drug substance release is presented in ­Table 1.         on PGI-I, 6 patients reported “very much better” and 1
As shown in Figure 1, the release of active ingredients of henna          reported “much better” in itching discomfort after using
                                                        A
ointment follows the Weibull equation (Q=1-exp -t ) with                  henna ointment. According to CGI-I, the physician con-
                                                      K
R2=0.97 so that k (time constant) is equal to 6.92 and A (shape           cluded that all the patients were “much better” and “very
parameter) is equal to 1.03. The prepared product releases half           much better” after using henna ointment. There was a sig-
of its active ingredient content up to 4 hours and about 90% of           nificant improvement in the skin symptoms of epidermolysis
its active ingredient content releases up to 12 hours after appli-        bullosa including skin redness, itching, burning, and local
cation. This release kinetic is consistent with topical products          warmness sensation (P < 0.05). Local pain decreased during
containing ointment-based hydroalcoholic extracts.                        the study period, but this was not statistically significant
                                                                          (P < 0.19) (Table 2). Moreover, Figure 3 shows the photos
Participants Enrollment and Basic Characteristics                         of 3 patients with RDEB before the treatment and after four
A detailed description of the patients enrolment and analysis             weeks of receiving topical 1% henna ointment.
is given in Figure 2. Nine patients were enrolled in the study.
Two patients were lost to follow-up. Finally, 7 out of 9 pa-              Qualitative Evaluation of Patients Opinion About
tients including 3 boys and 4 girls completed the study. The              Topical Henna Ointment
age range of the patients was 5-32 years.                                 Five out of 7 patients who participated in the study reported
                                                                          henna as the most effective ointment for their pruritus in
Efficacy Outcomes                                                         comparison to other medications, including corticosteroids,
The average drug satisfaction rate was reported 74% (min = 50%,           Vaseline, and repair creams. In addition, most patients had a
and max = 90%) by the patients. For more details, based                   good experience in wound healing effect while using henna
                                                                          ointment, at least as well as conventional medicine such as
            Table 1. Mean percentage of release                           Mupirocin, MEBO® and BIAFINE® topical emulsion.
                     of henna ointment
                                                                          Side Effects Evaluation
     Time
    (hours)      Cumulative % Qa                   Standard deviation     No serious adverse effect was observed. One patient re-

      0.5                 8.3                              2.1            ported moderate xerosis of skin after continuous application
                                                                          of henna after 4 weeks so that he needed to apply larger
       1                11.4                               1.2
                                                                          amounts of emollient medicines.
       2                17.9                               2.1
                                                                             Conclusions This study showed that the 1% henna oint-
       4                50.1                               2.5
                                                                          ment could improve skin redness, itching, burning, and local
       6                70.5                               3.1
                                                                          warmness. But it should be considered that it was a pilot
      12                89.3                               2.4
                                                                          study and further studies with a higher number of cases are
      24                95.2                               5.3            necessary to approve these results. Although EB patients suf-
a. cumulative amount released                                             fer from several severe complications related to their disease,


                                         100


                                          80
                         CUMULATIVE %Q




                                          60


                                          40


                                          20


                                           0
                                               0       4         8        12         16          20         24
                                                                        TIME (HR)

                         Figure 1. In vitro release of total phenolic compounds from henna ointment performed
                         according to the Folin-Ciocalteau method (mean ± standard deviation, N=3).



4                                                                             Original Article | Dermatol Pract Concept. 2022;12(3):e2022115
                 ENROLLMENT                       ASSESSED FOR ELIGIBILITY (N=12)


                                                                             EXCLUDED (3)

                                                                                NOT MEETING INCLUSION CRITERIA (N=3)



                                                      NOT RANDOMIZED (N=9)




                                          ALLOCATED TO INTERVENTION (N=9)
                  ALLOCATION
                                            RECEIVED ALLOCATED INTERVENTION (N=9)




                                          LOST TO FOLLOW-UP (2 LEAVING CITY)(N=2)
                  FOLLOW-UP
                                          DISCONTINUED INTERVENTION (N=0)




                                          ANALYSED (N=7)
                    ANALYSIS
                                            EXCLUDED FROM ANALYSIS (N=0)


          Figure 2. TREND flow chart of efficacy of a topical formulation of henna (Lawsonia inermis Linnaeus) on the itch
          and wound healing in patients with epidermolysis bullosa.




           Table 2. Mean of dermatological complaints scores from baseline to weeks 1, 2 and 4
               in patients with epidermolysis bullosa who treated with local henna ointment

                                                                               Weeks
           Outcome measures                        Week 0            Week 1             Week 2             Week 4             Pa
 Skin redness (mean ± SDb)                       6.28 ± 1.26       6.14 ± 1.10        3.57 ± 0.68        2.42 ± 0.48         0.003
 Itching sensation (mean ± SD)                   8.57 ± 0.71       4.71 ± 0.47        3.42 ± 0.86        2.00 ± 0.43         0.001
 Skin burning (mean ± SD)                        3.57 ± 1.21       2.28 ± 0.77        1.57 ± 0.61        1.00 ± 0.436        0.003
 Local warmness sensation (mean ± SD)            5.14 ± 0.98       4.00 ± 0.92        3.14 ± 0.93        2.00 ± 0.75         0.001
 Local pain (mean ± SD)                          4.71 ± 1.45        4.14 ±1.29        3.57 ± 1.19        2.71 ± 0.74         0.197
a. P-value; b. SD = standard deviation




there are not enough randomized clinical trials for novel             care providers try to administer multiple topical medications
drugs that can manage their complications.                            including natural and herbal remedies to manage or relieve
    EB is a non-curable hereditary condition with several             these symptoms [27].
cutaneous and extracutaneous manifestations. Skin redness                 Henna is one of the herbal medications that is used com-
(dermatitis), pruritus, burning sensation in the skin, local          monly in both traditional and folk medicine for the treatment
warmness sensation, repeated ulceration, and pain are the             of skin, hair, and nail diseases, as well as cosmetic problems
most common cutaneous manifestations and complaints of                [7,28,29]. Niazi et al demonstrated that henna ointment
patients with EB [24]. These manifestations could affect the          could improve the symptoms of contact dermatitis including
quality of life in patients with EB and their families [25,26].       skin edema, itching, sweating, skin thinning and pain which
Therefore, most of the time patients, their parents, and health       is consistent with our study [12]. However, unlike our study,



Original Article | Dermatol Pract Concept. 2022;12(3):e2022115                                                                       5
Figure 3. This image shows the patients with recessive dystrophic epidermolysis bullosa(RDEB) who were enrolled in the study before the
treatment (A-C) and after four weeks of receiving topical 1% henna ointment (D-F). (A and D) The right knee of a 6-year-old boy with RDEB.
(B and E) The left forearm of a 32-year-old girl with RDEB. (C and F) The back of a 10-year-old boy with RDEB.



skin redness increased due to the use of henna ointment,                   The mechanisms of wound healing of topical henna are
which may be due to the method of measuring erythema [30].             unclear till now, but one recent study suggests that these
    Keshavarz et al showed that henna had a significant effect         mechanisms may include reduction of tissue inflammation
in comparison to hydrocortisone ointment in the improve-               and increasing cellular glucose uptake, which was mediated
ment of diaper rash [10]. Ansari et al revealed that topical           by up-regulating the expression of glucose transporter-1 and
      ®
Alpha ointment (containing natural henna) had a signifi-               insulin-like growth factor I. Furthermore, this study showed
cant therapeutic effect on the healing of radiation-induced            that topical henna could shorten the inflammatory phase of
dermatitis in breast cancer patients [31]. Another study               the wound healing process, accelerate cellular proliferation,
conducted by Yucel et al. showed that topical henna had                raise wound contraction ratio, and caused improvement of
significant effects in the treatment of capecitabine-induced           revascularization, collagen deposition, and re-epithelializa-
hand-foot syndrome. The authors of this study suggested                tion rate, and promotion of intracytoplasmic carbohydrate
that these therapeutic effects could be related to anti-inflam-        storage [34]. According to the knowledge of TPM, “­Ghabz”,
matory, antipyretic and analgesic effects of henna [32].               with nearly meaning of “contraction” in conventional med-
    The present study showed that 1% of henna ointment had             icine, is the common feature of drugs that are effective in
an acceptable effect on skin characteristics in patients with EB.      wound healing [35,36], as well as henna [29,37], that is in
In fact, all the selected wounds of these patients were improved       line with the finding of conventional medicine.
clinically during to first two weeks of the study. Mourad et al            The findings of our study showed that topical henna
demonstrated that the henna gel had a significant effect on            ointment did not relieve pain sensation of the patients with
wound healing in in-vivo model. The results of this study were         EB. This result may be referred to stimulate pain receptors
confirmed by histological stain assessments [13]. The study of         of the selected sites by pain signals coming from contiguous
Shiravi et al revealed that henna had anti-inflammatory and            wounds. This finding was not in line with the other stud-
anti-bacterial effects in Wistar rats. According to this study,        ies. The study of Nesa et al showed remarkable analgesic,
reduction of inflammation, edema, bleeding, and increased              anti-inflammatory, and central nervous system (CNS) de-
collagen formation resulted in acceleration of wound healing,          pressant effects of henna [38]. Hasan Imam et al suggested
angiogenesis, and vasodilatation in these rats [33].                   that the analgesic effect of henna was resulted from alpha



6                                                                           Original Article | Dermatol Pract Concept. 2022;12(3):e2022115
amylase enzyme inhibitory and Anti-inﬂammatory effects of         References
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                                                                      PMC4110526.
study investigating the efficacy of herbal medicine in the
                                                                   7. Aghili Khorasani MH. Makhzan al-Advieh. Tehran: Tehran Uni-
management of EB complications. Therefore, it was impos-
                                                                      versity of Medical Sciences. 2009:341.
sible to compare this product with other herbal remedies in        8. Arzani MA. Teb-e-Akbari. Qom, Iran: Jalaledin Publication.
EB. But there is a great piece of evidence showing the effi-          2008;
cacy of topical usages in dermatological conditions, such as       9. Rafiei Z, Mazaheri M, Eghbali-Babadi M, Yazdannik A. The Ef-
wound, androgenic alopecia, and prevention and treatment              fect of Henna (Lawsonia Inermis) on Preventing the Development
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of pressure ulcers, dermatitis, and much more [9,11,45-47].
                                                                      J Prev Med. 2019;10:26. DOI: 10.4103/ijpvm.IJPVM_286_17.
    There were several limitations in this study. First, this
                                                                      PMID: 30967912. PMCID: PMC6413520.
was a non-controlled single-arm clinical trial; therefore, the    10. Keshavarz A, Zeinaloo AA, Mahram M, Mohammadi N, Sade-
results of this study had not been compared with placebo              ghpour O, Maleki MR. Efficacy of Traditional Medicine Prod-
or other medications. We did not administer a second arm              uct Henna and Hydrocortisone on Diaper Dermatitis in Infants.
for this trial because there is not any standard and defined          Iranian Red Crescent medical journal. May 2016;18(5):e24809.
                                                                      DOI:10.5812/ircmj.24809.       PMID:      27478628.     PMCID:
treatment for EB ulcers and patients usually apply different
                                                                      PMC4948373.
or multiple medications for controlling the itching sensation
                                                                  11. Rekik DM, Ben Khedir S, Daoud A, Ksouda Moalla K, Re-
and wound healing with different responses. Second, we                bai T, Sahnoun Z. Wound Healing Effect of Lawsonia in-
used a researcher-made checklist for evaluating the patients.         ermis. Skin Pharmacol Physiol. 2019;32(6):295-306. DOI:
Although the face validity and content validity of this ques-         10.1159/000501730. PMID: 31466077.
tionnaire were acceptable, we could not evaluate the internal     12. Niazi M, Mehrabani M, Namazi MR, et al. Efficacy of a top-
                                                                      ical formulation of henna (Lawsonia inermis L.) in contact
validity of the questioner because of a low sample size of the
                                                                      dermatitis in patients using prosthesis: A double-blind ran-
study. Next, because of the rarity of the disease, the sample
                                                                      domized placebo-controlled clinical trial. Complement Ther
size of the study was low. Finally, the age range of the pa-          Med. 2020:102316. DOI: 10.1016/j.ctim.2020.102316. PMID:
tients was wide (5-32 years); therefore, the parents evaluated        32147071.
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ble confounding factor.                                               of cuttlefish gelatin gels and films enriched by henna (Lawso-
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                                                                      2017;512:71-79. DOI: 10.1016/j.colsurfa.2016.10.014.
formulation of henna may be effective in the management
                                                                  14. Negahdari S, Galehdari H, Kesmati M, Rezaie A, Shariati G.
of wound, itching, burning, stringing, and cutaneous warm-            Wound healing activity of extracts and formulations of aloe
ness sensation in patients with EB. In this regard, we suggest        vera, henna, adiantum capillus-veneris, and myrrh on mouse
further controlled clinical trials with larger sample sizes and       dermal fibroblast cells. Int J Prev Med. 2017;8:18. DOI:
longer duration of follow-up to evaluate the efficacy of this         10.4103/ijpvm.IJPVM_338_16. PMID: 28382194. PMCID:
                                                                      PMC5364744.
herbal medication.



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Original Article | Dermatol Pract Concept. 2022;12(3):e2022115                                                                      9
