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Background

Horse chestnut seed extract (HCSE) is widely used in Europe for chronic venous insufficiency (CVI), a syndrome that may include leg swelling, varicose veins, leg pain, itching, and skin ulcers. Although HCSE is traditionally recommended for a variety of medical conditions, CVI is the only condition for which there is strong supportive scientific evidence.

Side effects from HCSE have been similar to placebo in clinical trials. However, due to an increased risk of low blood sugar, caution is advised in children and people with diabetes.

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Synonyms

Aescin, aescine, Aesculaforce®, aescule, aesculetin, buckeye, bongay, chestnut, conkers, conquerors, coumarins, eschilo, escin, escina, escine, fatty acids, fish poison, flavonoids, graine de marronier d'Inde, fraxetin glucoside, fraxin, HCSC, H. vulgare Gaertnhestekastanje, Hippocastabi folium , Hippocastanaceae (family), Hippocastani semen , horsechestnut, horse chestnut seed extract, HCSE, linolenic acid, Marron Europeen, Marronier, NV-101, palmitic acid, quinines, Rokastaniensamen , rosskastanie, scopoletin glucoside, scopolin, Spanish chestnut, steric acid, sterols, tannins, Venastat®, Venoplant®, Venostasin®.

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Evidence

Uses based on scientific evidence	Grade*
Chronic venous insufficiency Chronic venous insufficiency (CVI) is a condition that is more commonly diagnosed in Europe than in the United States and may include leg swelling, varicose veins, leg pain, itching, and skin ulcers. There is evidence from laboratory, animal, and human research that horse chestnut seed extract (HCSE) may be beneficial to patients with this condition. Studies report significant decreases in leg size, leg pain, itchiness, fatigue, and "tenseness." There is preliminary evidence that HCSE may be as effective as compression stockings.	A

Key to grades
A Strong scientific evidence for this use
B Good scientific evidence for this use
C Unclear scientific evidence for this use
D Fair scientific evidence against this use (it may not work)
F Strong scientific evidence against this use (it likely does not work)

Grading rationale

Uses based on tradition or theory

Angiogenesis, benign prostatic hypertrophy (BPH or enlarged prostate), bladder disorders (incontinence, cystitis), bruising, cough, diarrhea, dizziness, fever, fluid in the lungs (pulmonary edema), gall bladder disease, gall bladder infection (cholecystitis), gall bladder pain (colic), gall bladder stones (cholelithiasis), hemorrhoids, kidney diseases, leg cramps, liver congestion, lung blood clots (pulmonary embolism), menstrual pain, nerve pain, osteoarthritis, pancreatitis, post-operative/post-traumatic soft tissue swelling, rectal complaints, rheumatoid arthritis, ringing in the ears (tinnitus), skin conditions, ulcers, varicose leg ulcers, varicose veins, vein clots (deep venous thrombosis), whooping cough.

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Dosing

Adults (18 years and older)

A dose of 300 milligrams every 12 hours, for up to 12 weeks (containing 50 to 75 milligrams of escin per dose), has been taken by mouth. A dose of 600 milligrams of chestnut seed extract per day has also been studied.

A gel preparation of horse chestnut containing 2% escin (applied to the skin 3-4 times daily) has been studied for bruising, without clear benefits.

Severe allergic reaction (anaphylactic shock) has been reported with intravenous use. Horse chestnut leaf has been associated with liver inflammation (hepatitis) after injection into muscle.

Children (younger than 18 years)

There is not enough scientific evidence to recommend use of horse chestnut in children. Deaths have been reported in children who ate raw horse chestnut seeds or tea made from horse chestnut leaves and twigs.

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Safety

Allergies

Horse chestnut seed extract (HCSE) may cause an allergic reaction in patients with known allergy to horse chestnuts, esculin, or any of its ingredients (flavonoids, biosides, trisides of quertins, and oligosacharides including 1-ketose and 2-ketose). Anaphylactic shock (severe allergic reaction) has been reported with intravenous (through the vein) use.

Allergic skin rashes (contact dermatitis) have been reported after use of a skin cream containing horse chestnut seed extract.

Side Effects and Warnings

Unprocessed horse chestnut seeds have been associated with significant toxicity and death. Symptoms associated with horse chestnut poisoning may include vomiting, diarrhea, headache, confusion, weakness, muscle twitching, poor coordination, coma, or paralysis. Horse chestnut seed extract (HCSE) standardized to escin content should not contain significant levels of esculin and should not have the same risks.

Standardized HCSE is generally considered to be safe in adults at recommended doses for short periods of time. Stomach upset, muscular (calf) spasm, headache, dizziness, nausea, and itching have been reported. Contact skin irritation (dermatitis) has been reported following application of HCSE to the skin.

Based on animal study, HCSE may cause lowered blood sugar. Caution is advised in patients with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a qualified healthcare provider, and medication adjustments may be necessary.

In theory, horse chestnut may increase the risk of bleeding. Caution is advised in patients with bleeding disorders or taking drugs that may increase the risk of bleeding. Monitoring is recommended and dosing adjustments may be necessary. Liver and kidney toxicity has been associated with horse chestnut. Aflatoxins, considered to be cancer-causing agents, have been identified in commercial skin products containing horse chestnut, but not in HCSE.

Several studies report the development of pseudolupus (a syndrome characterized by recurrent fever, muscle pain, and lung and heart muscle inflammation) in patients taking Venocuran or Venopyronum, which contains phenopyrazone, horse chestnut extract, and cardiac glycosides. Because these are combination products, these effects may not be accounted for by horse chestnut alone.

Pregnancy and Breastfeeding

There is not enough scientific research to recommend the safe use of horse chestnut or HCSE during pregnancy and breastfeeding.

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Methodology

This patient information is based on a professional level monograph edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Monograph methodology

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Selected references

1. Bassler D, Okpanyi S, Schrodter A, et al. Bioavailability of beta-aescin from horse chestnut seed extract: comparative clinical studies of two Galenic formulations. Adv Ther 2003 Sep-Oct;20(5):295-304.
2. Bielanski TE, Piotrowski ZH. Horse-chestnut seed extract for chronic venous insufficiency. J Fam Pract 1999 Mar;48(3):171-2.
3. Comaish JS, Kersey PJ. Contact dermatitis to extract of horse chestnut (esculin). Contact Dermatitis 1980 Jan;6(2):150-1.
4. Diehm C, Trampisch HJ, Lange S, et al. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet 2-3-1996;347(8997):292-294.
5. Diehm C, Vollbrecht D, Amendt K, et al. Medical edema protection--clinical benefit in patients with chronic deep vein incompetence. A placebo controlled double blind study. Vasa 1992;21(2):188-192.
6. Ernst E, Pittler MH, Stevinson C. Complementary/alternative medicine in dermatology: evidence-assessed efficacy of two diseases and two treatments. Am J Clin Dermatol 2002;3(5):341-8.
7. Koch R. Comparative study of Venostasin and Pycnogenol in chronic venous insufficiency. Phytother Res 2002;16 Suppl 1:S1-5.
8. Lange S, Freitag G, Trampisch HJ. Practical experience with the design and analysis of a three-armed equivalence study. Eur J Clin Pharmacol. 1998 Sep;54(7):535-40.
9. Ottillinger B, Greeske K. Rational therapy of chronic venous insufficiency--chances and limits of the therapeutic use of horse-chestnut seeds extract. BMC Cardiovasc Disord 2001;1(1):5.
10. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev 2006 Jan 25;(1):CD003230.
11. Popp W, Horak F, Jager S, et al. Horse chestnut (Aesculus hippocastanum) pollen: a frequent cause of allergic sensitization in urban children. Allergy 1992 Aug;47(4 Pt 2):380-3.
12. Rehn D, Unkauf M, Klein P, et al. Comparative clinical efficacy and tolerability of oxerutins and horse chestnut extract in patients with chronic venous insufficiency. Arzneimittelforschung 1996;46(5):483-487.
13. Siebert U, Brach M, Sroczynski G, et al. Efficacy, routine effectiveness, and safety of horsechestnut seed extract in the treatment of chronic venous insufficiency. A meta-analysis of randomized controlled trials and large observational studies. Int Angiol 2002;21(4):305-315.
14. Suter A, Bommer S, Rechner J. Treatment of patients with venous insufficiency with fresh plant horse chestnut seed extract: a review of 5 clinical studies. Adv Ther 2006 Jan-Feb;23(1):179-90.
15. Vayssairat M, Debure C, Maurel A, et al. Horse-chestnut seed extract for chronic venous insufficiency. Lancet 4-27-1996;347(9009):1182.

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