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The role of phytotherapy in the management of dermatological conditions: The case of the northern region in Morocco
Ilham Snoussi
1, Ouiame El Jouari1, Adil Gourinda2, Adil Najdi2, Salim Gallouj1
1Department of Dermatology and Venereology, Abdelmalek Essaadi University, CHU of Tangier, Morocco, 2Laboratory of Epidemiology and Public Health, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, CHU of Tangier, Morocco
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ABSTRACT
Background: Phytotherapy is currently gaining significant popularity among the North African and Moroccan population, particularly in the treatment of common dermatological conditions.
Material and Methods: This prospective, cross-sectional descriptive study, conducted over six months from June 2022 to December 2022, involved patients seen at the dermatology department of the University Hospital Center in Tangier. The study aimed to investigate the use of phytotherapy among Moroccans, particularly in the northern context. A questionnaire in Moroccan Arabic (Darija), comprising three parts related to the study’s objectives, socio-cultural profiles, and selected diseases, was administered to collect data. Data entry and analysis were performed using IBM SPSS software, version 25. The survey identified a significant number of plant species from versatile botanical families being used in aqueous maceration, infusion, and decoction. Common ailments treated with phytotherapy include alopecia, acne, and eczema, primarily among female patients.
Results: We recruited 215 patients suffering from various dermatoses, who had used phytotherapy for the past five years. There was a predominance of females, with a sex ratio of 3, and the average age was 32 years. Our survey identified 50 species of plants belonging to 26 botanical families used in the form of aqueous maceration (54.6%), infusion (37.4%), and decoction (11.8%). The level of satisfaction varied among the patients, with the majority (76%) reporting satisfaction with results ranging from a partial regression of lesions to complete whitening and complete hair regrowth for patients with alopecia. However, 24% of the patients were dissatisfied due to the lack of improvement or worsening of their dermatoses. Side effects encountered were infrequent to rare.
Conclusion: The findings of the study were consistent with previous research in Morocco, highlighting the growing popularity of phytotherapy as a medical alternative. Accordingly, the study concluded that phytotherapy is widely embraced in Morocco, offering a wide range of benefits due to the active biochemical and organic components in medicinal plants.
Key words: Dermatological pathologies, Phytotherapy, North of Morocco, Diversity and multiparity of medicinal plants
INTRODUCTION
Data from the World Health Organization (WHO) indicates that more than 80% of the global population relies on traditional medicines for their essential primary healthcare needs. The utilization of traditional medicines in Africa reflects a well-established history of human interactions with nature and the environment. Botanicals, employed in traditional medicine, encompass a wide range of compounds that may be utilized to address various skin-related conditions [1].
Practices in traditional medicine vary widely from country to country and region to region [2]. They are influenced by known factors such as culture, history, and personal philosophies. Natural products are highly valued as raw materials for various sectors, including cosmetics, pharmacy, agri-food, phytosanitary, and industry [1,2]. Consequently, there has been a recent and unprecedented surge in the interest in the use of herbal remedies. An increasing number of people are in search of “natural” medicines, and it seems that herbal-based cosmetics and household products are becoming more and more prevalent [1,2].
Similarly, within the Moroccan population, considering the diverse range of medicinal plants with potent therapeutic properties in Morocco, the use of herbal remedies is embraced for various health conditions [2]. Notably, there is a substantial focus on addressing dermatological issues. Dermatological diseases, which are numerous and prevalent, are regarded as a group of pathologies with their most visible symptoms manifested in target organs, particularly the skin, mucous membranes, and appendages. In the northern region, the reliance on traditional medicine is widely ubiquitous, with numerous herbal remedies, either used individually or in combination, being recommended for the treatment of dermatological conditions [2].
MATERIALS AND METHODS
The study is conducted in the region of Tangier, situated in northern Morocco. Tangier is a strategically located port city at the Strait of Gibraltar, facing Spain. This region is known for its cultural diversity, rich historical background, and significant geographical importance. Tangier serves as a major economic hub due to its bustling port. It is also recognized for its distinctive cultural influence, shaped by centuries of interactions between various civilizations. The northern region of Morocco, where Tangier is positioned, has a reputation for traditional medical practices, including the widespread use of traditional medicine and herbal remedies to address various health issues, including dermatological conditions. The study was conducted within this context, with the aim of exploring the utilization of phytotherapy in treating common dermatoses among the local population. This was a prospective, cross-sectional, descriptive study conducted over a six-month period from June 2022 to December 2022. The study included patients who attended consultations at the dermatology department of the University Hospital Center in Tangier. The survey utilized a questionnaire translated into Moroccan Arabic (Darija), comprising three parts: the first part provided information about the study’s objectives, the second part focused on socio-cultural profiles, and the third addressed specific diseases. Data collection, entry, and analysis were performed using the IBM SPSS software, version 25.
RESULTS
Patients Population
The 215 recruited patients suffered from various dermatoses and had used phytotherapy for the previous five years. Among those surveyed, women were the primary users of plants, accounting for 70%, compared to 30% in the case of men.
The age range of individuals varied between 13 and 70 years old. The age group between 19–30 years represented the highest percentage (44.8%) of individuals engaging in the use of medicinal plants. Additionally, 38.6% of individuals using plants fell within the age range of 31–50 years, and 7.6% of users were below 18 years of age.
Regarding the level of education, 67% of the individuals surveyed were not educated. The remaining 33% of the surveyed individuals were distributed between primary education (15.2%) and secondary education (18.6%) (Fig. 1).
As regards the most frequently reported pathologies by the respondents, alopecia topped the list with a percentage of 34.6%, followed by atopic dermatitis (eczema) with a percentage of 26.4%, acne with a percentage of 20%, and superficial mycoses with a percentage of 10% (Fig. 2).
The majority of the population (50%) accessed information from social media and the Google search engine. On the other hand, 45% of the population obtained information through personal experiences and those of others, while 5% of the patients utilized other sources. Our survey identified 50 species of plants belonging to 26 botanical families used in the form of aqueous maceration (54.6%), infusion (37.4%), and decoction (11.8%).
The most commonly treated conditions with phytotherapy were alopecia (34.6%), where Allium sativum (garlic) was the most frequently used plant (40%). Garlic was also frequently applied in the treatment of superficial mycoses (13.1% of the population). For acne (20.7%), the most frequently utilized plants were apple cider vinegar, green tea, and basil with percentages of 26.9%, 23.8%, and 21.7%, respectively. Eczema was the third most commonly treated condition with phytotherapy, accounting for 17% of the cases, with Lawsonia inermis being used in 36.1% of the treated cases.
We identified three plant species belonging to three families used against eczema. The most mentioned species are Lawsonia inermis, cited by 36% of the individuals, Trigonella foenum-graecum, Matricaria chamomilla, tar, and ground sulfur, reported respectively by 14.4%, 15,9%, 18.7%, and 22.2% of the patients (Tables 1 – 4).
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Table 1: List of medicinal plants used against acne, documented in the Northern region of Morocco. |
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Table 2: List of medicinal plants utilized for addressing alopecia, documented in the region of Tangier, Morocco. |
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Table 3: List of medicinal plants employed against Melasma, documented in Tangier region, Morocco. |
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Table 4: The list of medicinal plants used against superficial fungal infections. |
The degree of satisfaction varied from patient to patient, with the majority (76%) reporting satisfaction, with results ranging from partial regression of lesions to complete whitening, and complete hair regrowth for patients with alopecia. However, 24% of the patients were dissatisfied due to the lack of improvement or worsening of their dermatoses (Fig. 3).
Side effects encountered were infrequent to rare, with eczematization reported by 13 patients, 8 of whom used henna (Lawsonia inermis), and 5 used garlic (Allium sativum). Irritation was reported by 5 patients who used garlic (Allium sativum) and by 3 patients who applied tar, all of whom had associated superinfection. Additionally, two-thirds of the patients who used garlic (Allium sativum) reported tingling sensations during use. Six patients who made use of curcuma (Curcuma longa) to treat their melasma reported digestive symptoms such as bloating and nausea.
DISCUSSION
In Morocco, medicinal plants play a crucial role in traditional medicine and contribute significantly to the national economy (Bellakhdar, 1997). According to Scherrer et al., Morocco stands out among Mediterranean countries for its extensive medical tradition and traditional knowledge related to medicinal plants [3]. Nevertheless, although the sector of aromatic and medicinal plants is more advanced in Morocco when compared to other Maghreb countries, phytotherapy involves the use of medicinal plants for therapeutic purposes [1,3]. This practice dates back to antiquity, and throughout human history, various cultures have developed recipes based on their intelligence, ingenuity, cultural understanding of health and illness, and their relationship with the environment [4].
Phytotherapy in Acne
Reminder on acne
Acne is a chronic condition of the pilosebaceous follicle that typically develops during puberty. It affects 80% of individuals between the ages of 12 and 20, with severe forms representing only 15%. The comedones, in the form of a microcyst, are consistently present in “true” acne. Juvenile polymorphic acne is the most common form, yet there are numerous clinical variations [5].
Phytotherapy and acne
Green tea
The antibacterial and anti-inflammatory potential of natural compounds derived from plants has been reported in numerous studies. In vitro and in vivo studies have revealed that essential oil blends, oleoresin, flavonoids, alkaloids, phenolic compounds, tannins, xanthones and their derivatives, diterpene acids, phenylpropanoid glycosides, acteoside, and bisnaphthoquinone derivatives are effective in acne treatment thanks to their antimicrobial and anti-inflammatory activities [6,7]. Many plant-derived procedures involve the use of different plant extracts; for example, C. sinensis or green tea extracts have been associated with health benefits since antiquity [8]. The primary mediators of these biological effects are polyphenolic catechins and terpenes, which promote a reduction in the expression of genes associated with inflammation, an increase in the expression of antioxidant genes, and antimicrobial activity.
Basil (Ocimum basilicum L.)
Belonging to the Lamiaceae family, basil (Ocsimum basilicum L.) is a medicinal and aromatic plant cultivated worldwide. It has numerous oil glands that store essential oils. The basil essential oils (OBEO) extracted from the leaves and flowers of O. basilicum contain various biologically active compounds characterized by their antioxidant and antimicrobial activities [9].
In addition to the OBEO, basil also contains substantial amounts of phenolic compounds, including flavonoids, phenolic acids (such as caffeic, rosmarinic, and chicoric acids), and anthocyanins, which possess strong antioxidant effects [9].
Phytotherapy in Alopecia
Generalities
At birth, each individual has a genetically determined capital of hair follicles. This capital gradually diminishes over time due to two main factors: age and the influence of seasons. The seasonal hair loss is explained by the hormonal influence on the hair follicle cycle. Beyond physiological variations, there are numerous non-physiological causes, including psycho-affective shocks, pregnancy and postpartum, surgical interventions, strict dietary regimes, anemia, thyroid disorders, medication use, chemotherapy, radiotherapy, intoxication, certain diseases (alopecia, ringworm, acute systemic diseases), aggressive hair care practices, and the most common, hormonal influence responsible for androgenetic alopecia [10].
Phytotherapy and alopecia
Garlic
Allium sativum (Garlic) is used and recommended by the traditional Iranian medicine reference in the treatment of alopecia [11]. Known for its effect in promoting cutaneous microcirculation [12], a study showed that the use of Allium sativum gel in combination with topical betamethasone valerate had a significantly superior therapeutic effect compared to betamethasone valerate alone in the treatment of alopecia. This suggests that it may be an effective complementary topical therapy for alopecia [13].
Green tea (Camellia sinensis)
It is reported that epigallocatechin-3-gallate (EGCG), a major polyphenol in green tea with powerful anti-cancer and antioxidant properties [14,15], stimulates human hair growth through its proliferative and anti-apoptotic effects on dermal papilla cells [16].
Lawsonia inermis
Its extract has significant potential for hair growth development, and this effect may be due to its regulatory effects on cell growth and the expression of the growth factor gene [17].
Phytoterapy in Melasma
Overview of Melasma
The term melasma is derived from the Greek word “melas” and refers to an acquired hypermelanosis of the face that develops slowly and symmetrically, with shades ranging from light brown to dark brown. Melasma most commonly appears in women using oral contraception or during pregnancy. However, melasma may be observed outside of any hormonal influence in both women and men. Clinical examination allows for the identification of 4 clinical forms on the face based on the topography of hyperpigmentation [18–20]: centrofacial type: 63% of cases (involving the cheeks, forehead, chin, upper lip); malar type: 21% of cases (symmetrical involvement of the cheeks and nose); maxillary type: 8% of cases (involvement of the ascending branch of the maxilla); and labio-mentonnier type: 8% of cases (involvement of the upper lip and chin) [21–23].
Phytotherapy and melasma
Turmeric
Ponders have investigated the potential focal points of turmeric, curcumin (dynamic component in turmeric), and fragrant (ar)-turmerone (a normally happening turmeric oil) in overseeing hyperpigmentation clutters. Turmeric, deductively alluded to as Curcuma longa, capacities as both a flavor and a broadly recognized home-grown supplement known for its antioxidant, anti-inflammatory, antimicrobial, and antineoplastic properties. Swanson et al. conducted a double-blind, split-face study on non-melasma patients and found that a topical cream containing turmeric extricate viably decreased hyperpigmented spots. An examination by Stop et al. inspected the anti-melanogenic impact of ar -turmerone, uncovering its capacity to decrease the quality expression of tyrosinase-related proteins 1 and 2 and smother the tyrosinase action. In spite of the fact that ar-turmerone showed more prominent viability, curcumin essentially ruined the melanin union and tyrosinase action [24].
Boswellia (BAs)
These are pentacyclic triterpenes known for their potent anti-inflammatory properties. These compounds are extracted from the gum resins of the tropical tree Boswellia serrata, which is native to India and Africa. Traditionally, research on Boswellia has primarily focused on the immunomodulatory characteristics of the resin. Multiple clinical trials and studies conducted in vitro and in vivo have demonstrated that boswellic acids exhibit significant anti-inflammatory and pro-apoptotic effects [25]. While the precise mechanism of action in hyperpigmentation remains unclear, Boswellia is commonly incorporated into various cosmetic products.
Aloe vera extract
Research conducted on animals revealed that the leaf extract of Aloe vera and its active component, aloin, demonstrated potent, dose-dependent melanin aggregating effects with physiological significance, resulting in skin lightening through adrenergic receptor stimulation [26]. Aloe vera extract is utilized as an ingredient in various commercially available formulations.
Phytotherapy in Eczema
Generalities
Dermatitis, also known as eczema, is an itchy, inflammatory skin reaction that may present with a variety of histologic and clinical features. One dermatitis associated with the atopic state is atopic dermatitis. The patient has a history of dermatitis that is extremely itchy, especially on the flexures, and either a family or personal history of atopy (asthma, hay fever, urticaria, etc.).
Phytotherapy in eczema
Chamomile
Herbal remedies have long been utilized, either topically or orally, to treat skin conditions because of their anti-inflammatory and antipruritic properties. An overview of the principles of phytotherapy in dermatology has been provided by Bedi [27]. Regarding topical application, two randomized controlled trials that analyzed the safety and efficacy of a chamomile preparation and a St. John’s wort preparation, respectively, have been identified [28,29]. In a comparative trial involving 69 patients with atopic eczema, the commercial chamomile extract preparation (Kamillosan-Creme) was compared to a 0.5% hydrocortisone cream or a base cream without an active agent.
Regarding the most important clinical criteria such as itching, erythema, and desquamation, the chamomile preparation was slightly superior to the hydrocortisone preparation after two weeks. However, there was no difference between the chamomile preparation and the base cream. Unfortunately, the publication does not provide information on the results of statistical tests.
Fenugreek (Trigonella feonum-graecum L.)
It is a dicotyledon, annual, fodder crop frequently used as a herb and spice. Although it originated in an area that stretched from Iran to Northern India, it is currently grown in China, North and East Africa, Greece, and Ukraine. Fenugreek is referred to as “an old world” crop for the “new world” because it is one of the oldest known medicinal plants. When applied topically, fenugreek seed’s gelatinous texture may help calm sensitive skin caused by eczema or other ailments [30].
Phytotherapy in Superficial Mycoses
Overview of superficial mycoses
Cutaneous mycoses encompass infections that affect the skin on a superficial, semi-deep, or deep level, caused by microscopic fungi. Approximately ten classes of fungi contribute to most cutaneous mycoses. These microorganisms are categorized into three primary groups: filamentous fungi (dermatophytes), yeasts from the Candida and Malassezia sp. genera, and in exceptional cases, molds. This classification is crucial both from an epidemiological standpoint and therapeutic considerations, as antifungal agents exhibit varying degrees of efficacy against these three fungal groups [31]. Dermatophytoses include conditions such as ringworm, epidermophytosis (dermatophytic intertrigo affecting large and small folds, as well as circinate dermatophytosis), and onychomycosis caused by dermatophytes [32]. Candidiasis is a widespread condition caused by yeasts belonging to the Candida genus. These yeasts are responsible for superficial infections (mucosal and cutaneous) as well as deep or disseminated mycoses. Akin to dermatophytes, these yeasts cause cutaneous issues, including intertrigo in large or small folds, digital intertrigo (with digitoplantar intertrigo more commonly attributed to dermatophytes), and nail infections [32].
Pityriasis versicolor is a prevalent superficial mycosis that occurs in areas of the skin with high concentrations of sebaceous glands. The proliferation of Malassezia furfur is the underlying cause of this mycosis [32].
Phytotherapy for dermatomycoses
Allium sativum
Fungal infections, which are hard to eliminate using topical treatments, may require an extended course of systemic therapy. Additionally, the use of synthetic antifungals is associated with the risk of significant adverse effects. This often leads patients to explore alternative treatments, including phytotherapy. Consequently, numerous clinical trials are conducted to assess the antifungal efficacy of plant extracts. An in vitro study specifically examined the antifungal activity of aqueous extracts derived from Allium sativum (garlic) against Malassezia furfur (25 strains), Candida albicans (18 strains), and other Candida species (12 strains). The results indicate that garlic (Allium sativum) could be promising in the treatment of diseases associated with fungi from important pathogenic genera such as Candida, Malassezia, and dermatophytes [33].
Pelargonium graveolens
An investigation into the chemical composition, antifungal capabilities, and antioxidant properties of Pelargonium graveolens essential oil was presented in this study. The essential oil profile was identified through GC and GC-MS analysis, highlighting key compounds such as citronellol (24.54%), geraniol (15.33%), citronellyl formate (10.66%), and linalool (9.80%). Minimal inhibitory concentrations (MIC) and minimal fungicidal concentrations (MFC) were determined using microdilution and macrodilution methods, with the commercial antimycotic bifonazole used as a reference. Concentrations within the range of 0.25 to 2.5 mg/mL exhibited fungicidal effects [34].
Zingiber officinale
It is a perennial herbaceous plant belonging to the Zingiberaceae family, which has been utilized for over two centuries due to its medicinal and nutritional properties. It is regarded as a safe plant with negligible adverse effects. Numerous studies, both in vitro and in vivo, have substantiated the beneficial effects of Zingiber officinale, encompassing its roles as an anti-nausea, anti-inflammatory, antioxidant, antimicrobial, anticancer, antidiabetic, cardiovascular, and respiratory agent [35]. The aim of this study was to assess the specific biological activities of ginger essential oil, obtained through hydrodistillation from dried rhizomes. Notably, the study evaluated antibacterial and antifungal activities. The essential oil’s antibacterial and antifungal efficacy was tested against six bacterial strains: Escherichia coli, Salmonella typhi, Micrococcus luteus, Bacillus subtilis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and a yeast (Candida albicans), utilizing the agar diffusion method. The resultant essential oil displayed a yellow to brown color with a yield of 0.25%. Findings from the antibacterial and antifungal assessments revealed a notable inhibitory activity on nearly all tested strains, with growth inhibition varying across species [36].
CONCLUSION
Traditional herbal medicine remains widely practiced in Morocco, enjoying strong popular demand due to its perceived effectiveness. With the advent of communication tools, there has been an exchange of traditional medicines from other regions of the world, continually enriching this practice. A significant component of this medicine is dedicated to the treatment of dermatological conditions.
Medicinal plants offer extensive solutions to the complex problems of common dermatological diseases, serving as complementary therapeutic options to conventional treatments. Although the list of plants used for dermatological and cosmetic purposes is extensive, their use persists despite the absence of scientific studies justifying many of them. However, confirming the effects of certain plants and understanding their mode of action are hindered by various obstacles, including the lack of clinical trials evaluating their effectiveness and safety. Therefore, the implementation of a comprehensive research program is necessary to better understand these modulations.
Statement of Human and Animal Rights
All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the 2008 revision of the Declaration of Helsinki of 1975.
Statement of Informed Consent
Informed consent for participation in this study was obtained from all patients.
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