Oral evening primrose oil and borage oil for eczema
Abstract
Background
Eczema is a chronic inflammatory skin condition, which usually develops in early childhood. Many children outgrow this disorder as they reach secondary school age, and although It may improve with age, there is no cure. Constant itch makes life uncomfortable for those with this condition, no matter what age they are, so it may have a significant effect on a person's quality of life. Its prevalence seems to be increasing as populations move from rural locations to cities. Some people, who do not see an adequate improvement or fear side‐effects of conventional medical products, try complementary alternatives to conventional treatment. This is a review of evening primrose oil (EPO) and borage oil (BO) taken orally (by mouth); these have been thought to be beneficial because of their gamma‐linolenic acid content.
Objectives
To assess the effects of oral evening primrose oil or borage oil for treating the symptoms of atopic eczema.
Search methods
We searched the following databases up to August 2012: Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 1946), EMBASE (from 1974), AMED (from 1985), and LILACS (from 1982). We also searched online trials registers and checked the bibliographies of included studies for further references to relevant trials. We corresponded with trial investigators and pharmaceutical companies to try to identify unpublished and ongoing trials. We performed a separate search for adverse effects of evening primrose oil and borage oil in November 2011.
Selection criteria
All randomised controlled, parallel, or cross‐over trials investigating oral intake of evening primrose oil or borage oil for eczema.
Data collection and analysis
Two review authors independently applied eligibility criteria, assessed risk of bias, and extracted data. We pooled dichotomous outcomes using risk ratios (RR), and continuous outcomes using the mean difference (MD). Where possible, we pooled study results using random‐effects meta‐analysis and tested statistical heterogeneity using both the Chi² test and the I² statistic test. We presented results using forest plots with 95% confidence intervals (CI).
Main results
A total of 27 studies (1596 participants) met the inclusion criteria: 19 studies assessed evening primrose oil, and 8 studies assessed borage oil. For EPO, a meta‐analysis of results from 7 studies showed that EPO failed to significantly increase improvement in global eczema symptoms as reported by participants on a visual analogue scale of 0 to 100 (MD ‐2.22, 95% CI ‐10.48 to 6.04, 176 participants, 7 trials) and a visual analogue scale of 0 to 100 for medical doctors (MD ‐3.26, 95% CI ‐6.96 to 0.45, 289 participants, 8 trials) compared to the placebo group.
Treatment with BO also failed to significantly improve global eczema symptoms compared to placebo treatment as reported by both participants and medical doctors, although we could not conduct a meta‐analysis as studies reported results in different ways. With regard to the risk of bias, the majority of studies were of low risk of bias; we judged 67% of the included studies as having low risk of bias for random sequence generation; 44%, for allocation concealment; 59%, for blinding; and 37%, for other biases.
Authors' conclusions
Implications for practice
Oral borage oil and evening primrose oil lack effect on eczema; improvement was similar to respective placebos used in trials. Oral BO and EPO are not effective treatments for eczema.
In these studies, along with the placebos, EPO and BO have the same, fairly common, mild, transient adverse effects, which are mainly gastrointestinal.
The short‐term studies included here do not examine possible adverse effects of long‐term use of EPO or BO. A case report warned that if EPO is taken for a prolonged period of time (more than one year), there is a potential risk of inflammation, thrombosis, and immunosuppression; another study found that EPO may increase bleeding for people on Coumadin® (warfarin) medication.
Implications for research
Noting that the confidence intervals between active and placebo treatment are narrow, to exclude the possibility of any clinically useful difference, we concluded that further studies on EPO or BO for eczema would be hard to justify.
This review does not provide information about long‐term use of these products.
Author(s)
Joel TM Bamford, Sujoy Ray, Alfred Musekiwa, Christel vanGool, Rosemary Humphreys, Edzard Ernst
Abstract
Plain language summary
Oral evening primrose oil and borage oil for eczema
Eczema is an itchy and red skin condition, which may affect 20% of people world wide at some time in their life. Though it may improve with age, there is no cure. Many children outgrow this disorder as they reach secondary school age. Constant itch makes life uncomfortable for those with this condition, no matter what age they are.
Conventional medical treatments make life better for people; however, some people who do not see an adequate improvement in their eczema or fear side‐effects of conventional medical products, turn to complementary alternatives to conventional medical treatment. This review is of two such products: evening primrose oil (EPO) and borage oil (BO) taken orally (by mouth), which have been thought to have benefits for eczema.
We included 27 studies, with 1596 adults and children from 12 countries. Of these, 19 studies compared EPO with a placebo (dummy) treatment, and 8 used BO compared with placebo. We looked for evidence of overall improvement in eczema and in quality of life. All 27 studies evaluated overall improvement of eczema, but only 2 studies of EPO measured improvement in quality of life. There was no statistically significant advantage demonstrated for either EPO or BO compared to placebo. In summary, we did not find evidence that eczema improved by taking these products any more than it did by taking placebo.
There was some evidence of mild and temporary side‐effects for participants with either product or placebo, which were mainly mild, and included temporary headache and upset stomach or diarrhoea. With EPO there is an anticoagulant (blood‐thinning) effect when taking these products. There is a warning with the blood thinner warfarin (Coumadin®) that taking EPO can increase bleeding. One report warns that if EPO is taken for a prolonged period of time (more than one year), there is a potential risk of inflammation, thrombosis, and immunosuppression due to slow accumulation of EPO in the tissues. Another reports a single case in which EPO was thought to have produced harms. We found no clinical evidence of such harm in these short‐term trials.
This systematic review found no evidence that either BO or EPO are effective in treatment of eczema. Both of these products and the placebos used in the studies had similar mild, temporary side‐effects, which were mainly gastrointestinal.
Author(s)
Joel TM Bamford, Sujoy Ray, Alfred Musekiwa, Christel vanGool, Rosemary Humphreys, Edzard Ernst
Reviewer's Conclusions
Authors' conclusions
Implications for practice
Oral borage oil and evening primrose oil appear to be equivalent in their lack of effect on eczema. They had the same effect on global ratings as the placebos used. They do not seem to add any benefit to eczema as measured in this systematic review.
They seem to have the same fairly common mild transient adverse effects, which are mainly gastrointestinal (ranging from 7% to 15% in‐house studies) (France 1988). There is evidence that EPO may increase bleeding for people on Coumadin® (warfarin) medication.
Over the years since the last study closed 10 years ago, there have been new developments in the use of systemic treatments for eczema: methotrexate for children, biologics, selective neuroepinephrine re‐uptake inhibitors, serotonin uptake inhibitors, μ‐ and κ‐opioid receptor agonists, and substance P antagonists, which are being evaluated (Patel 2011).
During the years since the protocol to this review was published, there have been changes in practice:
1. the term 'atopic eczema/dermatitis syndrome' (AEDS) to summarise all forms of eczema that have previously been called 'prurigo Besnier' or 'atopic dermatitis' (we did not find AEDS used in any included study); 2. the introduction of pseudo‐ceramide, immunomodulator and biologic agents which came to the market after all our included studies; 3. disclosure of authorship and sponsorship requirements; and 4. the preregistration of protocols and the possibility of public posting of results on web sites such as www.clinicaltrials.gov.
The latter two will bring greater transparency and reproducibility to clinical studies as well as helping to combine study data in meta‐analyses.
Implications for research
Noting that the confidence intervals between the active and placebo treatments are so narrow to exclude the possibility of any clinically useful difference, we conclude that further studies EPO or BO for eczema would be hard to justify.
In the future, as initial publication of trial protocols and early publication of detailed results become standard practice, all data will be available for evaluation by journal peer reviewers, readers, and researchers to those wishing to confirm or extend their investigations or carry out their own meta‐analyses.