Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial.

The short version

This randomized clinical trial with 199 adults at an Italian university proctology clinic compared two plant-based venotonic products, called phlebotonics, with routine care for hemorrhoidal disease (swollen anal cushions that cause bleeding, itching or irritation, and pain) and for recovery after hemorrhoid surgery. One product was a flavonoid preparation containing rutin, borage, horse chestnut and witch hazel. The other was a Centella asiatica (gotu kola) preparation containing triterpenic acids, asiaticoside, arnica and aloe. Flavonoids are plant antioxidants reported to improve venous tone and reduce inflammation, while Centella is reported to stimulate collagen and repair connective tissue. Participants aged 18 to 85 were randomized to three groups. Group A (73 people) took 300 mg flavonoid tablets twice daily for 15 days and applied a 3 g ointment inside the anus once daily. Group B (66 people) took 60 mg Centella tablets twice daily for 15 days and used a 3 g Centella-based ointment. Group C (60 people) received routine care only. Everyone followed a water- and vegetable-rich diet and used a medicated soap for 42 days. Time until bleeding stopped was tracked, and irritation or pain was rated on a visual analogue scale. Among 130 people with hemorrhoidal disease, bleeding stopped after a median of 2 weeks with flavonoids and 3 weeks with Centella or routine care (flavonoids versus routine care p < 0.001, meaning a clear difference; Centella versus routine care p = 0.152, meaning no significant difference). Irritation scores were lower than routine care for both products (flavonoids p = 0.007; Centella p = 0.041), and the two products did not differ (p = 0.782). After hemorrhoidectomy (31 people), bleeding time did not differ significantly between groups, and pain differed only for flavonoids versus routine care (p = 0.045). In 34 people with thrombosed hemorrhoids, pain fell faster with either product (all p < 0.001). Tissue examination linked flavonoids to fibrosis, a fibrous tissue change in the excised piles (p = 0.008). No adverse reactions were reported except burning from the Centella ointment in one person, which led to suspension of that ointment. The authors interpret the results as favouring flavonoids for bleeding and irritation, with Centella comparable on irritation. Limitations are stated plainly: a single centre, only 42 days of follow-up, small surgical and thrombosis subgroups added after the original protocol, no described blinding of participants, and multi-ingredient products that prevent attributing effects to individual plants. A medicated soap containing Centella was also given to every group. The authors suggest longer trials to test whether the benefits last.

Key findings

• In a randomized trial of 199 people with hemorrhoidal disease or hemorrhoid surgery, a flavonoid-based product (plant compounds that support vein tone) shortened the median time until bleeding stopped to 2 weeks, compared with 3 weeks for a Centella-based product or usual care alone (p < 0.001 versus usual care).
• Both the flavonoid product and the Centella product lowered anal irritation scores compared with usual care alone (p = 0.007 and p = 0.041), with no difference between the two products (p = 0.782).
• The Centella product did not shorten bleeding time significantly compared with usual care (p = 0.152) in people with grade II-IV hemorrhoidal disease.
• Among 34 people with thrombosed hemorrhoids (hemorrhoids containing a blood clot), pain fell faster with either product than with usual care (all p < 0.001), although this subgroup was small and was added after the original protocol.
• No adverse reactions were reported except burning from the Centella ointment in one patient, but the trial was single-centre, lasted only 42 days, and used multi-ingredient products, so effects cannot be traced to single plants.

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