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.