Witch hazel topical - Drug Monograph

Introduction

Witch hazel is a topical astringent derived from the leaves, bark, and twigs of the North American shrub Hamamelis virginiana. It has been used for centuries in traditional medicine and remains widely available in various over-the-counter formulations including solutions, ointments, creams, and medicated pads. Witch hazel contains multiple bioactive compounds including tannins, flavonoids, and essential oils that contribute to its therapeutic effects.

Mechanism of Action

Witch hazel exerts its pharmacological effects primarily through its high tannin content (approximately 8-10%). These tannins act as:

• Astringent: Precipitates proteins, causing contraction of tissues and reduction of permeability
• Anti-inflammatory: Inhibits prostaglandin synthesis and 5-lipoxygenase pathway
• Antioxidant: Scavenges free radicals due to flavonoid content
• Vasoconstrictive: Constricts blood vessels, reducing minor bleeding and swelling
• Mild local anesthetic: Provides temporary numbing effect on nerve endings

Indications

• Temporary relief of minor skin irritation
• Relief of itching and pain from minor cuts, scrapes, and bruises
• Temporary relief of minor hemorrhoidal discomfort

• Acne vulgaris (as adjunctive treatment)
• Post-inflammatory erythema
• Post-epilation skin soothing
• Minor sunburn relief
• Diaper rash (in combination with other ingredients)
• Varicose vein discomfort

Dosage and Administration

• Apply topically to affected area 3-4 times daily as needed
• For hemorrhoidal use: Apply after each bowel movement or up to 6 times daily

• Direct application with cotton ball or pad
• Medicated pads or wipes
• As a compress (soak cloth and apply for 15-20 minutes)
• Spray application for larger areas

• Pediatric: Use with caution in children under 2 years; consult healthcare provider
• Geriatric: No dosage adjustment required
• Renal/Hepatic impairment: No specific recommendations (minimal systemic absorption)

Pharmacokinetics

Contraindications

• Hypersensitivity to witch hazel or any component of the formulation
• Application to deep or puncture wounds
• Application to infected areas without concurrent antimicrobial therapy
• Use on large areas of broken or damaged skin

Warnings and Precautions

• For external use only
• Avoid contact with eyes and mucous membranes
• Discontinue use if irritation develops or increases
• Do not use on chickenpox or measles lesions
• Use caution in patients with known sensitive skin or eczema
• Pregnancy Category C: Use only if clearly needed (limited human data)
• Lactation: Use with caution (unknown if excreted in human milk)

Drug Interactions

• May potentially reduce absorption of topically applied medications when applied concurrently (due to protein precipitation effects)
• May enhance effects of other topical astringents or drying agents
• No known significant systemic drug interactions (due to minimal absorption)

Adverse Effects

• Temporary skin dryness or tightness
• Mild stinging or burning upon application
• Localized erythema

• Contact dermatitis (more common with prolonged use)
• Allergic reactions (urticaria, pruritus)
• Skin cracking or excessive dryness

• Severe allergic reactions including anaphylaxis (extremely rare with topical use)

Monitoring Parameters

• Skin response at application site
• Signs of irritation or hypersensitivity
• Resolution of underlying condition being treated
• For hemorrhoidal use: Reduction in pain, swelling, and bleeding

Patient Education

• Use only as directed on intact skin
• Cleanse affected area before application
• Shake well before use if formulation requires
• Store at room temperature away from moisture
• Keep out of reach of children
• Discard if solution changes color or becomes cloudy
• Report any signs of infection (increased redness, swelling, pain, pus) to healthcare provider
• Do not use for more than 7 days unless directed by healthcare provider
• For hemorrhoidal use: Implement concomitant measures (fiber intake, hydration, avoid straining)

References

1. Deters A, et al. "Hamamelis virginiana bark extract: activity and stability of its anti-inflammatory and anti-oxidant properties." Planta Med. 2001;67(5):425-428. 2. Korting HC, et al. "Anti-inflammatory activity of hamamelis distillate applied topically to the skin." Eur J Clin Pharmacol. 1993;44(4):315-318. 3. FDA Monograph: Skin Protectant Drug Products for Over-the-Counter Human Use. 21 CFR Part 347. 4. Reuter J, et al. "Which plant for which skin disease? Part 2: Dermatophytes, chronic venous insufficiency, photodamage, skin cancer, vitiligo, hair loss, cosmetic indications." J Dtsch Dermatol Ges. 2010;8(11):866-873. 5. Hughes-Formella BJ, et al. "Anti-inflammatory efficacy of topical preparations with 10% hamamelis distillate in a UV erythema test." Skin Pharmacol Appl Skin Physiol. 2002;15(2):125-132. 6. Natural Medicines Comprehensive Database. Witch Hazel. Therapeutic Research Center. 2023. 7. Barnes J, et al. "Herbal Medicines." 3rd edition. Pharmaceutical Press; 2007:458-460.