Aloe Vera

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Aloe Vera

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Aloe Vera

Common Names

  • Aloe gel
  • aloe leaf

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For Patients & Caregivers

How It Works

Aloe is safe for topical use. It is not an effective cancer treatment and is dangerous when given by injection.

Scientists think that compounds found in aloe inhibit molecules that play a role in inflammation. Studies in laboratory rats confirm this anti-inflammatory activity. Aloe is also thought to hinder the formation of thromboxane, a molecule that is detrimental to the healing of burn wounds. Aloe kills bacteria and fungi directly in laboratory studies. Aloe gel should not be confused with aloe juice or aloe latex, both of which contain potent laxative substances.

Purported Uses
  • To treat burns
    Scientific evidence supports the topical use of aloe for minor burns.
  • To prevent and treat redness, rash, and pruritus caused by radiation therapy
    Clinical trials have produced conflicting results in support of and against this use. Topical use of aloe is generally safe.
  • To prevent oral mucositis caused by chemotherapy
    There is evidence that aloe, when combined with chemotherapy, may prevent oral mucositis.
  • As a skin moisturizer
    No scientific evidence supports this use.
  • To treat inflammation associated with conditions such as cold sores, eczema, and pruritis
    Clinical evidence supports this use.
  • To treat cancer
    No scientific evidence supports this use. Cancer therapy using injections of acemannan, a substance found in aloe, resulted in death of several patients.
  • To treat diabetes
    Two non-randomized trials conducted by the same group suggest that blood glucose levels may be reduced by aloe vera. Further study is warranted.
  • To treat ulcerative colitis
    A small randomized, controlled trial shows weak support for this use. More research is needed.

 

Patient Warnings
  • Aloe gel should not be confused with aloe juice or aloe latex, both of which contain anthraquinone, a potent laxative.
  • Despite the use of some oral dosages in clinical trials of ulcerative colitis, there is not enough evidence at this time to support the use of aloe vera by mouth or by injection. The risk of serious adverse effects is high, and several cancer patients died from aloe vera injections that were used as a cancer therapy.
Do Not Take If
  • If you are taking drugs that are substrates of Cytochrome P450 3A4 and CYP2D6: Aloe vera juice may increase the risk of side effects of these drugs. Clinical relevance is not known.
  • If you are taking sevoflurane: A case report showed that additive antiplatelet effects with aloe resulting in excessive bleeding during surgery.
Side Effects
  • Certain dosages of aloe, when taken orally, can cause GI upset, nausea, vomiting, and rash.
  • Toxicity from ingestion of aloe includes seizures, dangerously low blood potassium levels, and electrolyte abnormalities.
  • A case of hypokalemia (low potassium levels) has been reported with use of aloe vera during chemotherapy.
  • Three cases of toxic hepatitis (liver inflammation) were reported following use of aloe preparations. Liver function was normalized after discontinuing aloe.
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For Healthcare Professionals

Scientific Name
Aloe vera, Aloe barbadensis, Aloe capensis
Clinical Summary

Aloe vera is a perennial, succulent plant that resembles a cactus and is used in traditional medicine throughout the world. The clear thick gel obtained from aloe leaves is used for wound healing, to treat burns, psoriasis, frostbite, ulcerative colitis, diabetes and to relieve constipation. Aloe demonstrated antioxidant and anti-inflammatory properties, in vitro (9).

In clinical studies, an Aloe vera cream was reported to be superior to silver sulfadiazine creams for the treatment of second-degree burns (21); an aloe gel was shown effective in skin graft donor-site healing (38); an aloe ointment improved symptoms of acute radiation proctitis in patients receiving radiotherapy (39); and an aloe cream improved postoperative pain and discomfort, and promoted healing following pilonidal sinus excision (45). A mouthwash containing aloe was shown to reduce plaque, gingivitis and S. mutans in the oral cavity in children, with the effects being comparable to chlorhexidine (46). Systematic reviews indicate aloe’s effectiveness against oral lichen planus, while not causing any adverse effects compared to corticosteroids (37); and for reducing pain/burning sensation and affecting clinical improvement in patients with oral submucous fibrosis (41). In addition, aloe gel complex was shown to affect reductions in body weight and insulin resistance in obese individuals with pre-diabetes or early untreated diabetes mellitus (29); to prevent pressure ulcers in hospitalized orthopedic patients at risk of developing such ulcers (42); to prevent traumatic oral ulceration in patients with fixed orthodontic appliances (47); and to accelerate split-thickness skin graft donor-site healing (43).

Data also suggest that constituents of aloe, such as acemannan, aloeride, and di(2-ethylhexyl)phthalate (DEHP) have immunomodulating and anticancer effects (5) (7) (8) (34) (35). Emodin from aloe inhibited cell proliferation and induced apoptosis in human liver cancer cell lines through p53- and p21-dependent pathways (4); along with enhancing the effects of radiation treatment (30). Concurrent administration of aloe with chemotherapy may prevent oral mucositis in patients receiving chemotherapy (23); along with benefitting those with metastatic cancers (20). However, findings of external use of aloe products to alleviate radiation-induced skin damage are inconsistent (1) (2) (3) (32) (36) (44).

Purported Uses
  • Burns
  • Side effects due to chemotherapy and radiotherapy
  • Dry skin
  • Inflammation
  • Cancer treatment
  • Diabetes
  • Ulcerative colitis
Mechanism of Action

Several studies have been conducted to explore the mechanisms of action of aloe.
Oligosaccharides isolated from aloe extracts were found to prevent ultraviolet radiation-induced suppression of delayed type hypersensitivity by reducing keratinocyte-derived immunosuppressive cytokines (25). Proposed mechanism underlying anti-psoriatic effect includes inhibition of tumor necrosis factor (TNF)‑alpha‑induced proliferation of keratinocytes and overactivation of the nuclear factor (NF‑kappa B signaling pathway, by an aloe polysaccharide (40). And a polymer fraction of aloe was shown to protect the gastric mucosa against ethanol-induced gastric damage by decreasing mRNA expression levels of inducible nitric oxide synthase (iNOS), neuronal nitric oxide synthase (nNOS), and matrix metalloproteinase (MMP-9). The three enzymes are critical biomarkers in gastric ulceration (26). Other findings suggest that the radio-protective effects of aloe polysaccharides are most likely due to inhibition of apoptosis (27).

Emodin, an extract of Aloe vera, was shown to inhibit cell proliferation and induce apoptosis in human liver cancer cell lines through p53- and p21-dependent pathways (4). Acemannan, a carbohydrate fraction derived from Aloe vera leaf, was found to stimulate cytokine production in mouse macrophage cell line (5). It also exhibited immunomodulating activity by inducing maturation of dendritic cells (6). And aloeride, a polysaccharide obtained from aloe vera juice, was reported to be a potent immunostimulator that acts by enhancing NF-kappa B activities (7). In addition, di(2-ethylhexyl)phthalate (DEHP), isolated from Aloe vera, inhibited leukemic cells, in vitro (8).

 

Warnings

Aloe gel should not be confused with aloe juice or aloe latex, both of which contain anthraquinone, a cathartic laxative. Aloe taken for internal use should be discouraged due to possible adverse effects and inconclusive clinical data. Aloe injections for cancer patients have resulted in several deaths.
The FDA rules that aloe is not safe as a stimulant laxative.
 (14)

Adverse Reactions
  • Topical administration of aloe gel is considered safe but oral consumption of aloe can cause gastrointestinal upset and electrolyte abnormalities.
  • Inappropriate use of aloe supplements has been linked to thyroid dysfunction (10), acute hepatitis (11), and perioperative bleeding (12).
  • A case of hypokalemia has been reported with use of aloe vera during chemotherapy (19).
  • Three cases of toxic hepatitis were reported following use of aloe preparations. Liver function was normalized after discontinuing aloe (22).
  • Long term exposure to Aloe vera can cause cancer in animals (28) .
  • Positive re-exposure tests have been reported with aloe, which highlight the herb’s potential for inducing liver injury (33).
Herb-Drug Interactions
  • Cytochrome P450 substrates: In vitro, aloe juice was found to inhibit CYP3A4 and CYP2D6 and can affect the intracellular concentration of drugs metabolized by these enzymes (24). Clinical relevance is not known.
  • Sevoflurane: A case report showed that additive antiplatelet effects with aloe resulting in excessive bleeding during surgery (12).
Dosage (OneMSK Only)
References

  1. Heggie S, Bryant GP, Tripcony L, Keller J, Rose P, Glendenning M, et al. A Phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nurs. 2002 Dec;25(6):442-51.

  2. Olsen DL, Raub W, Jr., Bradley C, Johnson M, Macias JL, Love V, et al. The effect of aloe vera gel/mild soap versus mild soap alone in preventing skin reactions in patients undergoing radiation therapy. Oncol Nurs Forum. 2001 Apr;28(3):543-7.

  3. Williams MS, Burk M, Loprinzi CL, Hill M, Schomberg PJ, Nearhood K, et al. Phase III double-blind evaluation of an aloe vera gel as a prophylactic agent for radiation-induced skin toxicity. Int J Radiat Oncol Biol Phys. 1996 Sep 1;36(2):345-9.

  6. Lee JK, Lee MK, Yun YP, Kim Y, Kim JS, Kim YS, et al. Acemannan purified from Aloe vera induces phenotypic and functional maturation of immature dendritic cells. Int Immunopharmacol. 2001 Jul;1(7):1275-84.

  8. Lee KH, Kim JH, Lim DS, Kim CH. Anti-leukaemic and anti-mutagenic effects of di(2-ethylhexyl)phthalate isolated from Aloe vera Linne. J Pharm Pharmacol. 2000 May;52(5):593-8.

  9. Yagi A, Kabash A, Okamura N, Haraguchi H, Moustafa SM, Khalifa TI. Antioxidant, free radical scavenging and anti-inflammatory effects of aloesin derivatives in Aloe vera. Planta medica. 2002 Nov;68(11):957-60.

  10. Pigatto PD, Guzzi G. Aloe linked to thyroid dysfunction. Archives of medical research. 2005 Sep-Oct;36(5):608.

  11. Rabe C, Musch A, Schirmacher P, Kruis W, Hoffmann R. Acute hepatitis induced by an Aloe vera preparation: a case report. World J Gastroenterol. 2005 Jan 14;11(2):303-4.

  12. Lee A, Chui PT, Aun CS, Gin T, Lau AS. Possible interaction between sevoflurane and Aloe vera. Ann Pharmacother. 2004 Oct;38(10):1651-4.

  13. Anon. License revoked for aloe vera use. Nat Med Law 1998;1:1-2.

  14. Food and Drug Administration, HHS. Status of Certain Additional Over-the-Counter Drug Category II and III Active Ingredients. Fed Regist 2002 May 9;67(90):31125-7.

  15. Brinker F. Herb Contraindications and Drug Interactions, 3rd ed. Sandy (OR): Eclectic Med; 2001.

  16. Robbers JE, et al. Pharmacognosy and pharmacobiotechnology. Baltimore: Williams & Wilkins; 1996.

  17. Foster S, et al. Tyler’s Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies. New York: Haworth Herbal Press; 1999.

  18. Tyler, V. Herbs of Choice, the Therapeutical Use of Phytomedicinals. Binghamton, New York: Pharmaceutical Press; 1994.

  19. Baretta Z, Ghiotto C, Marino D, Jirillo A. Aloe-induced hypokalemia in a patient with breast cancer during chemotherapy. Ann Oncol 2009 Aug;20(8):1445-6.

  21. Khorasani G, Hosseinimehr SJ, Azadbakht M, Zamani A, Mahdavi MR. Aloe versus silver sulfadiazine creams for second-degree burns: a randomized controlled study. Surg Today. 2009;39(7):587-91.

  22. Yang HN, Kim DJ, Kim YM, et al. Aloe-induced toxic hepatitis. J Korean Med Sci. 2010 Mar;25(3):492-5.

  23. Worthington HV, Clarkson JE, Bryan G, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD000978.

  24. Djuv A, Nilsen OG. Aloe Vera Juice: IC(50) and Dual Mechanistic Inhibition of CYP3A4 and CYP2D6. Phytother Res. 2011 Aug 15. doi: 10.1002/ptr.3564.

  25. Byeon SW, Pelley RP, Ullrich SE, et al. Aloe barbadensis extracts reduce the production of interleukin-10 after exposure to ultraviolet radiation. J Invest Dermatol. 1998 May;110(5):811-7.

  26. Park CH, Nam DY, Son HU, et al. Polymer fraction of Aloe vera exhibits a protective activity on ethanol-induced gastric lesions. Int J Mol Med. 2011 Apr;27(4):511-8.

  27. Wang ZW, Zhou JM, Huang ZS, et al. Aloe polysaccharides mediated radioprotective effect through the inhibition of apoptosis. J Radiat Res. 2004 Sep;45(3):447-54.

  28. Boudreau MD, Beland FA, Nichols JA, Pogribna M. Toxicology and Carcinogenesis Studies of a Nondecolorized Whole Leaf Extract of Aloe Barbadensis Miller (Aloe Vera) in F344/N Rats and B6C3F1 Mice  Natl Toxicol Program Tech Rep Ser. 2013 Aug;(577):1-266.

  31. Hamman JH. Composition and applications of Aloe vera leaf gel. Molecules. 2008 Aug 8;13(8):1599-616. Review.

  32. Hoopfer D, Holloway C, Gabos Z, et al. Three-Arm Randomized Phase III Trial: Quality Aloe and Placebo Cream Versus Powder as Skin Treatment During Breast Cancer Radiation Therapy. Clin Breast Cancer. 2014 Dec 24. pii: S1526-8209(14)00287-0.

  33. Teschke R, Genthner A, Wolff A, Frenzel C, Schulze J, Eickhoff A. Herbal hepatotoxicity: analysis of cases with initially reported positive re-exposure tests. Dig Liver Dis. 2014 Mar;46(3):264-9.

  35. Chang X, Zhao J, Tian F, et al. Aloe-emodin suppresses esophageal cancer cell TE1 proliferation by inhibiting AKT and ERK phosphorylation. Oncol Lett. 2016 Sep;12(3):2232-2238.

  36. Ferreira EB, Vasques CI, Gadia R, et al. Topical interventions to prevent acute radiation dermatitis in head and neck cancer patients: a systematic review. Support Care Cancer. 2016 Dec 12. [Epub ahead of print] Review.

  38. Burusapat C, Supawan M, Pruksapong C, Pitiseree A, Suwantemee C. Topical Aloe Vera Gel for Accelerated Wound Healing of Split-Thickness Skin Graft Donor Sites: A Double-Blind, Randomized, Controlled Trial and Systematic Review. Plast Reconstr Surg. 2018 Jul;142(1):217-226.

  39. Sahebnasagh A, Ghasemi A, Akbari J, et al. Successful Treatment of Acute Radiation Proctitis with Aloe Vera: A Preliminary Randomized Controlled Clinical Trial. J Altern Complement Med. 2017 Nov;23(11):858-865.

  41. Al-Maweri SA, Ashraf S, Lingam AS, et al. Aloe vera in treatment of oral submucous fibrosis: A systematic review and meta-analysis. J Oral Pathol Med. 2019 Feb;48(2):99-107.

  43. Burusapat C, Supawan M, Pruksapong C, Pitiseree A, Suwantemee C. Topical Aloe Vera Gel for Accelerated Wound Healing of Split-Thickness Skin Graft Donor Sites: A Double-Blind, Randomized, Controlled Trial and Systematic Review. Plast Reconstr Surg. 2018 Jul;142(1):217-226.

  44. Farrugia CE, Burke ES, Haley ME, Bedi KT, Gandhi MA. The use of aloe vera in cancer radiation: An updated comprehensive review. Complement Ther Clin Pract. 2019 May;35:126-130.

  45. SICCR PILONIDALIS STUDY GROUP, Giannini I, Andreoli R, Bianchi FP, et al. Effectiveness of topical use of Lietofix® in wound healing after pilonidalis sinus excision: a multicenter study by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol. 2019 Apr;23(4):373-378.

  46. Kamath NP, Tandon S, Nayak R, Naidu S, Anand PS, Kamath YS. The effect of aloe vera and tea tree oil mouthwashes on the oral health of school children. Eur Arch Paediatr Dent. 2020 Feb;21(1):61-66.
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