What is the dermatologic preoperative evaluation and management of St. John's wort?

Answer

A number of clinical trials have reported efficacy in the short-term treatment of mild-to-moderate depression. The most recent multicenter clinical trial concluded that St. John's wort is not effective in treating major depression. Nonetheless, St. John’s wort is widely used by many patients. The compounds believed to be responsible for pharmacologic activity are hypericin and hyperforin. Commercial preparations are often standardized to a fixed hypericin content of 0.3%.

St. John's wort exerts its effects by inhibiting serotonin, norepinephrine, and dopamine reuptake by neurons. Concomitant use of this herb with or without serotonin reuptake inhibitors may create a syndrome of central serotonin excess. Contradictory studies report that St. John's wort is comparable in effectiveness to most antidepressant agents. In 13 studies comparing the herbal remedy with placebo, 55.1% of St. John's wort–treated depressed patients showed significant improvement, versus 22.3% with placebo. The use of St. John's wort can significantly increase the metabolism of many concomitantly administered drugs, some of which are vital to the perioperative care of certain patients.

Single-dose and steady-state pharmacokinetics of hypericin, pseudohypericin, and hyperforin have been determined. After oral administration, peak plasma levels of hypericin and hyperforin were obtained at 6 hours and at 3.5 hours, and their median elimination half-lives were 43.1 hours and 9 hours, respectively. The long half-life and alterations in the metabolism of many drugs make concomitant use of St. John's wort particularly risky in the perioperative setting. The pharmacokinetic data suggest that patients taking this herbal medication should discontinue wort use at least 5 days prior to surgery. This discontinuation is especially important for patients waiting for organ transplantation or for those who may require oral anticoagulation postoperatively. St. John's wort also affects digoxin pharmacokinetics, possibly by inducing the P-glycoprotein transporter. Patients should be counseled to avoid taking St. John's wort postoperatively.

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Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Bejon T Maneckshana, MD Consulting Surgeon, Department of General Surgery, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Gregory E Rauscher, MD, FACS Chairman Emeritus, Hackensack Medical Center; Professor, Department of Plastic Surgery, Rutgers New Jersey Medical School

Gregory E Rauscher, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Laser Medicine and Surgery, International College of Surgeons, Medical Society of New Jersey, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Todd J Mekles Emory University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Desiree Ratner, MD Clinical Professor of Dermatology, NYU Langone Health

Desiree Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, New York Dermatological Society, Phi Beta Kappa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Regeneron; Canfield<br/>Serve(d) as a speaker or a member of a speakers bureau for: Genentech, Castle<br/>Received income in an amount equal to or greater than $250 from: Genentech; Regeneron.

Acknowledgements

Mary Farley, MD Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center

Disclosure: Nothing to disclose.

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