HCSE is chiefly used in chronic pathological conditions of the veins where there is increased activity of lysosomal enzymes resulting in damage to and hyperpermeability of vascularwalls. Numerous pharmacological and clinical trials have confirmed the efficacy of HCSE (horse chestnut standardised extract) in stabilising the walls of the venous system and improving conditions such as chronic venous insufficiency.
CHRONIC VENOUS INSUFFICIENCY
There is strong evidence that HCSE is an effective treatment for chronic venous insufficiency (CVI). A recent Cochrane review that assessed 17 RCT of HCSE capsules (standardised to escin) concluded that signs and symptoms of CVI improve with HCSE as compared with placebo. Six of seven placebo-controlled trials reported a significant reduction in leg pain for horse chestnut standardised extract compared with placebo, another study reported a statistically significant improvement compared with baseline and one study reported that HCSE may be as effective as treatment with compression stockings. Pruritus was assessed in eight placebo-controlled trials. Four trials (n = 407) showed a statistically significant reduction compared with placebo and two trials showed a statistically significant difference in favour of horse chestnut standardised extract compared with baseline, whereas one trial found no significant differences for a score including the symptom pruritus compared with compression. Meta-analysis of six trials (n = 502) suggested a reduction in leg volume compared with placebo, as did the studies in which the circumference at calf and ankle was assessed overall. Adverse events were usually mild and infrequent.
An earlier meta-analysis of 13 RCT(n = 051) and 3 observational studies (n = 10,725) found that HCSE reduced leg volume by 46.4 mL (95% Cl, 11.3-81.4 mL) and increased the likelihood of improvement in leg pain 4.1 -fold (95% Cl, 0.98-16.8), oedema 1.5-fold (95% Cl, 1.2-1.9) and pruritis 1.7-fold (95% Cl, 0.01-3.0). Observational studies reported significant improvements in pain, oedema, and leg fatigue/heaviness.
A case observational study involving more than 800 general practitioners and more than 5,000 patients with CVI (chronic venous insufficiency) taking HCSE (horse chestnut standardised extract) reported that symptoms of pain, tiredness, tension and swelling in the leg, as well as pruritis and tendency to oedema, all improved markedly or disappeared completely, with the additional advantage of better compliance than compression therapy. In an open study carried out to assess the safety and tolerability of A. hippocastanum, 91 subjects received a tablet (equiv. 50 mg escin) twice daily for 8 consecutive weeks. At the end of the study the majority of patients rated horse chestnut to be good or very good for Widmer stage I and II CVI.
In patients suffering from CVI, oedema can give rise to trophic skin changes, inflammatory lesions, and an increase in blood coagulability with the associated risk of thrombosis development. Therapy should therefore be aimed at providing protection against oedema at the earliest possible stage of venous disease to prevent complications. As HCSE therapy appears to provide more significant benefits in the earlier stages (less so with the advancement of the condition) it would appear prudent to initiate HCSE (horse chestnut standardised extract) therapy early in order to prevent or delay the need for compression therapy, which is associated with discomfort and poor patient compliance. In the later stages combined treatment with compression stockings and HCSE may provide added benefit.
Although the standard dose used in clinical trials appears to be equivalent to 50 mg escin twice daily, one study observed that reducing the dose to 50 mg escin once daily at 8 weeks appeared to maintain similar benefits to the twice daily routine at the end of the 16-week observation period.
VENOUS LEG ULCERATION
Chronic venous leg ulceration (VLU) is a common recurrent problem in the elderly population and may result in immobility, with 45% of patients being housebound. As a result, individuals with VLU frequently experience depression, anxiety, social isolation, sleeplessness and reduced working capacity. CVI (chronic venous insufficiency), which is characterised by an increase in capillary permeability, inflammatory reactions, decreased lymphatic reabsorption, oedema and malnutrition of tissues, is a precursor to venous leg ulceration. As HCSE increases venous tone while reducing venous fragility and capillary permeability and possesses anti-oedematous and anti-inflammatory properties, it has been speculated that by improving microcirculation, ulceration may be delayed or prevented.
A preliminary 12-week triple-blind, randomised, placebo-controlled trial of 42 participants with active VLU (venous leg ulceration) suggested a potential role for HCSE (horse chestnut standardised extract); however, further large scale trials are required to fully elucidate the potential use in practice. The second stage of this trial was a descriptive survey exploring current opinion and usage of such therapies. The author concluded that positive results from clinical trials may facilitate the incorporation of the extract into clinical practice, although the integration into mainstream medicine may be ‘constrained by medical and organizational gate keeping’.
Horse chestnut is also used both orally and topically for the treatment of haemorrhoids. Although it has not been investigated for this indication, escin has been shown to significantly improve signs and symptoms according to a placebo-controlled double-blind study of 72 volunteers with haemorrhoids. Symptom relief was experienced by 82% of subjects compared with 32% for placebo, and swelling improved in 87% compared with 38% for placebo (Sirtori 2001). Symptom improvement required at least 6 days of treatment to become established and the dose used was 40 mg escin three times daily.
Traditionally the seeds are used to treat conditions affecting the veins, including haemorrhoids, phlebitis and varicose veins; bruising, diarrhea, fever, enlarged prostate, eczema, menstrual pain, painful injuries, sprains, swelling, and spinal problems. The leaf is used for soft tissue swelling from bone fracture and sprains, complaints after concussion, cough, arthritis, and rheumatism, and the bark for malaria and dysentery, and topically for SLE and skin ulcers (NMCD 2006, PDRHealth 2006).
There is some evidence to support its use for preventing post-operative oedema and the antioxidant, vascular toning and anti-inflammatory effects of A. hippocastanum, as well as the presence of flavonoids and other active constituents, may support some of the other traditional uses.