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Herbal Wisdom for Topical Skin Preparation with Denis Stewart

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Herbal Wisdom for Topical Skin Preparations with Denis Stewart

Affectionately known as The Godfather of Australian HerbalismDenis Stewart is a herbal medicine luminary. Ahead of his last-ever educational program offering the Professional Extension Diploma of Herbal Medicine, we are honoured to have him join us on FX Medicine today, as we pick his brain about one of the most tricky areas of clinical practice: chronic, itchy skin conditions.

Denis shares his insights from over 40 years in practice on how he approaches these cases and, in particular, how he prepares topical preparations to provide his patients with fast-acting, soothing relief. What are his go-to herbs and why? Tune in to find out.

Covered in this episode

[01:04] Welcoming Denis Stewart
[02:38] The art of herbalism
[04:53] Looking beyond the 'active constituents'
[08:53] The alchemy of herbal manufacture
[14:26] Respecting the historical origins of a herbal medicine
[21:00] How Denis came to be a herbalist
[25:03] Herbal medicine heroes
[27:06] Tackling skin conditions with herbal medicine
[35:40] Hallmark herbs for topical itchy skin conditions
[47:17] Prioritising medical vs. natural interventions in psoriasis

    


]Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Denis Stewart, a clinical, medical herbalist and naturopath who's been in continuous practice for over forty years and currently conducts busy practices in both Newcastle and Cessnock, New South Wales, Australia. 

Referred to as the godfather of Australian herbalism Denis spearheaded a renaissance in Australian herbal medicine in the early 1970s. He established first, and taught, at the New South Wales College of Naturopathic Sciences and in the late 1970s founded the Southern Cross Herbal School and was a conjoint associate professor at the University of Newcastle from 2002 to 2007. 

He constructed professional examinations, course studies and curriculum for herbal training and education with the National Herbalists Association of Australia and he's a fellow and a life member of the NHAA and also inducted into the Australian Traditional Medicine Society Hall of Fame in 2012.

Now, Dennis will offer his final postgraduate program called Professional Extension in Herbal Medicine, a diploma, over six bi-monthly weekends on the central coast of New South Wales commencing in November, 2019 and I warmly welcome you to FX Medicine. How are you, Denis?

Denis: I'm very well, Andrew. And how are you?

Andrew: I'm very, very well. Thank you.

Denis: Good, good.

Andrew: More so for your teachings, thank you.

Denis: Well, you're very flattering.

Andrew: I've said this to you and I've given you homage about this, but I've also mentioned it in many podcasts when we're referring to herbal medicine, and particularly, standardisation and the conundrums of that. We'd like to have a repeatable medicine, but the danger is that we can, you know, look too far into one chemical thinking it's an active rather than a marker compound. And you have this beautiful sentence which I repeat saying that, “a glass of good red wine is not determined by how much resveratrol is in it ,” so...

Denis: Well, that's exactly right.

Andrew: I continually thank you for that.

Denis: Well, the fruit of divine after all is the product of a herb.

Andrew: And their skill in the manufacturing of it as well.

Denis: Correct, correct, correct. No, look, I stand by those strong principles that the preparations that herbalists have historically used have been referred to as galenical preparations and unfortunately, that term is not well understood today. It's a term that was well understood within pharmacy a couple of generations ago, when pharmacy in particular, had galenical preparations. But galenical preparations whether they be used by pharmacists or herbalists are essentially herbal medicine preparations that are based on the entire herb, without any secondary processes that seeks to accelerate the individual chemistry of any one entity within the herb. 

So it's best to define herbalism certainly as I've defined it and practiced it, as an art, a science, a practice that is based on using an entity called the herb which is a complex, multifaceted entity. And can be interfered with by manipulating one or more of its chemical constituents and giving them an accelerated level of importance. 

I think there's a great danger in that. Some would say that there's beneficial aspect in it. I've never found it in my 40 years, that one needs to depart from the traditional interpretation of the galenical preparation.

Andrew: Let's discuss this before we get into our topic for the day, because I think it's important.

Denis: Of course, of course. 

Andrew: You know, it's important to prevent adulteration, for instance, so we need certainly marker compounds to say, “That is the herb.” 

Denis: Correct. 

Andrew: Then we get into quality indicators and this is a far greyer area. So, what's your thoughts on that?

Denis: Well, look, I think we have to be very, very aware of the fact that the application of modern science and chemistry is not something alien to the modern interpretation, definition and usage of the herb. 

I see nothing wrong with some of the testing that's done to confirm the identify of a herb. And I see nothing wrong, in fact, in seeking to locate in the herb that you're using, markers if you like, that are important for the application or the action of the herb. We need to be cautious here however that we don't see these marker entities being the only entities that are responsible for the action of the herb. They are important constituents but bring with them a lot of other substances which attenuate, which synergise, which work with, which accelerate or even modify the action of these so-called ‘necessary markers’.

Andrew: Indeed, we've been led down the garden path, particularly with one herb, St. John's Wort. 

Denis: Yes. 

Andrew: Originally, it was just the herb. 

Denis: Yes. 

Andrew: Then of course we thought it was hypericin, then it was hypericins.

Denis: Yes. 

Andrew: Then it was hyperforin. 

Denis: Yes. 

Andrew: Now there's good research showing that the high hyperforin containing phytopharmaceuticals don't work and that it's the low hyperforin ones that appear to work. Particularly the evidence-based one of course, the ZE117 extract.

Denis: Yep. 

Andrew: And that it may indeed be inclusive of the flavanoids which are part of the herb. So, where do we go from here?

Denis: Well, it's coming around back to the original understanding of the galenical. But we lose sight of the concept of the galenical. The herb in its entity with no single active principle, or no single chemical, being responsible for the activity of the herb. The herb is an entity. 

The American...some of the Americans in their writings, refer to herbs as medicinal foods. Now I warm to that, to a degree. Because it then takes the herb out of this area of just seeing it as a phytopharmaceutical and puts it back to where it belongs. 

Andrew: Yeah. 

Denis: Really, it's a food with a medicinal property or activity and just as we don't dissect our foods to explain their efficacy or their benefits and extol the virtues of individual constituents in foods. So in my opinion we shouldn't do that with our herbs. Which in a sense are just an extension of this food concept. In a sense, they are a medicinal food.

Andrew: I love what you're saying that part of a chef's skill is how to choose high quality foods, but it gets harder though when we are preparing a herb for medicinal application though.

Denis: Well, remember the liquid representation of the herb, particularly in the preparation known as the fluid extract, purports to be nothing more than a preparation which embodies, in a liquid form, all or as many constituents from the original crude herb as possible. It's nothing more or nothing less. And this is why I've always emphasised the one-to-one fluid extract is essentially a preparation which purports to represent all that was in the original quality of the dried starting material.

Andrew: What are the lessons that we need to learn about the care and the preparation of herbs? The marc, the decoction, you know, all of the processes involved in manufacturing?

Denis: Well, again here, it's not as sophisticated as many people think. For years, I taught to my students a subject called ‘manufacturing and prescribing of herbal medicines,’ and we did two-day seminars where we took the dried herb and we took it through all the steps necessary to convert it into particularly the one-to-one liquid extract. And it's not rocket science. It's very simple and basic technology. All that one has to be aware of is the appropriate menstruum or solvent that is made to best extract the herb. The techniques associated with extraction i.e. maceration, which is essentially the soaking of a dried herb in a non-specific amount of menstruum for a period of time. Then the placing of that substance into a percolator and the allowing of further menstruum to go through the column of the macerated herb. And to be at the end concentrated, if necessary concentrated to give you that one-to-one relationship. 

And a lot of people tend to think that in the manufacture of the fluid extract that… and particularly the one-to-one fluid extract, that it's a problem because heat is applied to it. Well, we need to realise that in the actual percolation, the extraction process historically used to produce the one-to-one fluid extract, in fact, a disproportionate amount of the final liquid extract has never ever been subjected to heat. And the small amount that is concentrated to bring it up to the one to one strength is usually these days done under vacuum. 

Andrew: Right. 

Denis: So in fact, no active is lost and if any active is lost, it's so insignificant that in the context of things, in my opinion, it's not worthwhile worrying about.

So what needs to be done by a lot of younger practitioners today and even manufacturers, is to get back to the basic principles of extraction which are still available, in good literature, and see that it's not that sophisticated. Get back to basic simples. 

And the good thing about it is...and you've heard me talk on this before. "The British Herbal Pharmacopoeia" of 1983...now people say, "Why 1983?" Because, it was a landmark text that was produced by doctors, herbalists, pharmacists and pharmacologists. And what that text did was bring herbal medicine into a standardised pharmacopoeial form. And the good thing in that text is, in the monographs for the herbs that are called up in that text, which embody most of what we use today, the actual solvent was strength of the menstruum is called up as the solvable menstruum to extract that particular herb. 

Andrew: Right. 

Denis: So if one is extracting say something like...oh, say heartsease. The pharmacopoeia would tell you that it's one in one in 25%. Now that means it's a one-in-one fluid extract that has been extracted using a solvent appropriate to the simple chemistry of the herb, which is basically 25% which is essentially an aqueous solvent. A small amount of ethanol being used primarily for preservative purposes. There's no rocket science in this.

Andrew: Right. What about the use of different amounts of alcohol to extract different actives if you like, or different components of the herb? Like for instance, calendula, the more resinous components come out with a higher alcohol, yeah.

Denis: Correct. This was why historically some herbs have been shown to be better extracted in particular ways using differing solvents or menstruum depending upon our understanding of their basic chemistry. 

So if one is using herbs that are essentially alkaloidal in nature, one tends to move up the ladder as far as ethanol is concerned because we know that in herbs like hydrastis or goldenseal and other alkaloidal herbs that the alkaloids which in that...in a small section of herbs, are predominantly the active components, that they are better extracted and in fact, only extracted, if one uses a matching solvent that drags out if you'd like those chemistries and takes them into solution. If one were to extract them just with water one would get probably a very diminished level of the chemistry of the herb. 

So, our knowledge of plant chemistry is...it does not run against all that we're saying about the galenical. What it does, in fact, is give us greater knowledge to be able to harness the historic action of that galenical and put it into a liquid form that best represents the historic benefits of the herb.

Andrew: You know, I keep hearing you say the word historical and it's something that I revere. And it's something that I think we need to really think about. Our herbal medicines came from history.

Denis: Of course.

Andrew: We didn't have modern manufacturing techniques back then. The physicians of the day knew how to choose and manufacture a good herb. Therefore, it got its standing, its use and there are very few changes in that apart from things like, you know, for instance the leaf of ginkgo. This is where one of the things that I just admire and applaud you, is remembering our history. But I've got to ask the question. How do we remember and appreciate, revere, this rich herbal history?

Denis: Well, I think there's a good answer to that and that is our teaching institutions need to balance what I considered to be an overemphasis on chemical, phytochemical, if you like, that sort of interpretation of the herb at the expense of giving credibility to the tradition. In my opinion, there has been an overemphasis on trying to get students to appreciate the science behind the action of the herb, at the expense of looking at the way in which that herb has been used historically.

Now there's a very, very good support for what I'm trying to say here. I frequently mention in my talks and lectures the classic addition of Doctor Rudolf Weiss's book.

Andrew: Yes. 

Denis: "Herbal Medicine." It is an incredible work. I'm not sure that it is appreciated amongst us and amongst teaching institutions as it should be. But in the first chapter of Weiss's work it gives a great defence of herbal medicine by saying that it is based on two pillars. One of them is certainly the modern phytochemical interpretation of the herb wherever possible. But the other pillar is just as necessary. And that is the pillar of tradition, which is the empirical observation associated with the action of the herb. And that one is deficient if it's not supported by the other. 

So the moment we lose sight of the way in which an herb developed its momentum over the centuries, over the millennia, we're in grave danger of reducing the herb down to a phytochemical entity understood purely on the one or two perhaps active substances that can be found within its tissues. And that is the reason why I contend today we are producing...and this is an opinion. We are producing or may be producing graduates who, in my opinion again, and I have to be cautious in what I say here because it is an opinion based on my observation. We're producing graduates which, in my opinion, are deficient in understanding the rich history behind the action of an herb and very, very frequently, the action of an herb still defies a modern scientific dissection. 

And so we are very dependant in some situations on looking at its history, looking at its replicated benefit and seeing that that is sufficient to explain why say a vial of tricolor heartsease is so useful in addressing eczema conditions. Yet to try to explain the benefit of vial of tricolor in treating say atopic eczema on the basis of any outstanding chemical entity would be futile. We must bring with us the tradition, otherwise, we're going to have a whole heap of herbs that no one has an understanding of as to why we're using them for particular conditions.

Andrew: I guess, the concern is that we can over concentrate these herbs so that we eventually end up with something that almost resembles a pharmaceutical drug?

Denis: I would say that that is already happening. Because some would say, for instance, that when one is using a concentrate of an herb sometimes after a 50 to 1 strength, whether we are in fact using the herb at all? And there's a good argument for saying that you are basically using a phytochemical entity. And this worries me. I talk a lot about this at length. That many of the solid forms of herbal preparations we are producing some of which may have 8 or 9 or 10 herbal constituents, they're essentially based on very concentrated extracts of the herb. Sometimes 10 to 1, sometimes 8 to 1. Do they really represent...this is a question that go through my mind, I think about it a lot, do they really represent the herb or are they something different? It's a question that needs to be asked.

Andrew: Yeah. I gather you'll be discussing this at length in your upcoming course in herbal medicine?

Denis: Yes, look, I'm looking forward to conducting this final program and it will be my final program. People keep saying, "Oh, I remember Denis saying this was the last course he was going to do 20 years ago." 

Well, Denis is getting increasingly old. I hate to say that. And this will definitely be the last time that I will teach what's called the professional extension diploma course in herbal medicine. Which is a course that I have conducted for many, many years and subsequently, Southern Cross conducted it on its own and it became known as the professional extension diploma. It's open to all healthcare professionals and in this, to answer your question, very, very early in the piece, I go through some of these questions. What is a herb? When does it cease to become an herb? Are all extracts good renditions of herbs? Because at the end of the day the benefit in...or one of the benefits in practice is based on having preparations that reliably represent the activity of the herb and the traditional use of the herb. I'll be touching on that when I start my program in November this year. You bet.

Andrew: Yeah. Dennis, I wanted to go back into your history. 

Denis: Oh yes.

Andrew: Because you didn't start out as a herbalist. Indeed, you were an engineer. 

Denis: No, I was an engineer. 

Andrew: So what was the draw? What was the draw that took you away from becoming...you know, a budding career in engineering to become an herbalist and naturopath?

Denis: This is a difficult question in some ways to answer and not difficult in other ways. 

Now, I don't want to turn this into some sort of spiritual discussion or or a Damascus road-type of experience, but I genuinely believe that… how can I call it? That, I was called. Now, I know that sounds very, very spiritual and very theological. What, I guess, I'm saying was that there's always something there in my genes that was interested in plant life, in herbs and healing and that was a starting base. 

But the real issue came when I, as a young man, moved to Sydney from Newcastle to further my engineering studies trying to live on my own and feed myself and do most of my study at night, saw a real breakdown in my health and what emerged was a very, very serious level of eczema.

Andrew: Right. 

Denis: That really debilitated me and despite all the applications of steroids and other topical things most of which I couldn't handle, I wasn't getting anywhere until I was fortunate enough to be able to live with people who knew something about the application of herbal medicine and I discovered a topical application which gave me great benefit, which took the role...or took over from using steroid preparations. So that helped, if you like, at a topical level get the condition under control even while I was studying engineering. And I was fortunate enough also after seeing the benefit of a non-standard or unusual herbal topical application clear up my eczema, I was also fortunate enough to be in Sydney at the time when alternative or complementary medicine, call it what you like, was in renaissance. And all over Sydney, there were small teaching institutions popping up. And I was there amongst it. And did acupuncture studies and studies with whomever you could get close to. And I used to meet with the Herbalist Association, their regular meetings in King Street and learn from some of the older herbalists and eventually qualified doing their examination to become an herbalist and still belong to that association.

And also in Sydney at that stage, there were some very, very interesting book shops that I frequented. I can assure you, I still have many of them. And most of those book shops had very fascinating works on herbal medicine in particular. And I began to gather around me very interesting texts that furthered this real latent interest that I always had, until I became very, very conversant with herbalism and felt that there was something in this that was more important than designing bridges and things like that.

So eventually, I decided to take the plunge and decided to teach in it at first and then carry out what I call field excursions where I took students into the field. And then as opportunity arose on the central coast a practitioner, a good practitioner who passed away, her practice became open and I took up the challenge and left engineering and the rest is history from there on. And I practiced herbal medicine.

Andrew: I want to ask a quick question. You were mentioning your lecturers. Who were your heroes that you learned from regarding herbal medicine?

Denis: Well, look, this might sound, again, a little bit unusual, but most of the lecturers if you want to call them that, or it's better to use the teachers, because you have to realise that in Sydney even in the stage of renaissance that was beginning to occur, there were not a lot of formal teachers. There certainly...I think the New South Wales College of Naturopathic Sciences was one of the first to get off the ground. And it was one that I subsequently was associated with and did a lot of lecturing for. 

But the people that gave me most help interestingly were some of the greats whose writings I collected. For instance, sitting in front of me here, and I didn't plan this. Is a remarkable text written by the great English herbalist Arthur Barker. Now this book was written in 1938, "The Herbal Pocket Prescriber." I still use it. Barker, Eric Powell, William Smith, the people that helped me most apart from those that taught within the auspices of the National Herbalist Association of Australia, the ones that helped me most were those whose writings I collected and collected in great gusto and they came from that remarkable tradition of English herbalism that I still subscribe to, the herbalism that these men developed and practiced and made their living around. 

So they're basically, the men...Smith, Powell, Barker, the...what you might call those great herbalists in England that developed herbal medicine and saw it supported and planted in places like Australia.

Andrew: And you also mentioned a non-standard herbal preparation, you said?

Denis: Yes. 

Andrew: So how did you come across that and what was it?

Denis: It was non-standard in the sense that it was not being popularly used. It came about as result of my living next… in Ashfield, living next door to a nursing couple, both fairly elderly ladies who worked in a world known children's hospital. They knew that I was battling with eczema and they said, "Look. We have a topical application, a cream made up particularly for eczema and it works very well." I said, "Well, where can I get it?" And they said, "Well, there's a pharmacy in Dymocks arcade, they make the ointment." And I said, "Well, what's the name of it?" They said, "The name of the ointment is Zema ointment." Z-E-M-A. It took me years to realise that was just meant to be eczema ointment. 

But I made the beeline and got a hold of this preparation. And it had a distinct odour which later on I realised that it was based on a small percentage of pine tar, Pinus pinea.

Andrew: Yep.

Denis: Now Pinus pinea is still used a bit within dermatology. Pine tar preparations are still used a little bit but with the advent of steroid topicals they're sort of underused or not well known, nonconventional preparation, you know, so it's not used as much today. 

But it broke the back topically of my eczema. It was so successful that my eczema for a while would go into retreat as a result of applying it. A simple ointment in a zinc and aqueous-based cream with a very small percentage of Pinus pinea, or pine tar. And I still have preparations of my own today which incorporate that emphasis on using a non-conventional substance like pine tar extract as a useful antipruritic and anti-inflammatory agent particularly useful in eczema.

Andrew: Now discussing skin conditions, you know, I would gather that you've got a bit of a name for treating these in your community. What are some of the common ones which you've encountered over your, I'm going to say it, decades of experience in your clinic? 

Denis: Yes. 

Andrew: And I've got to...I just want to ask do you think the presentation has changed over the years? You know, with greater stress and, you know, more refined foods, things like that?

Denis: Oooh, that's a question that is difficult to answer. Because I still see the same sort of skin conditions that I saw 40 years ago and I think we've got to be cautious that we don't over-emphasise the stress and the dietary factors. They're all contributing factors. But I feel at times that they might be a little bit over-emphasized. 

At the end of my professional life and career, I'm more convinced than ever that an attempt to always explain disease and particularly chronic disease along simple lines is fraught with problems. 

Andrew: Right. 

Denis: That I see disease being based on multifactorial things that...and particularly with the skin. It is so dependent for its activity, or its problems, on not only stress but genetics for instance, environmental factors, personal factors. I think a lot about it. But at the end of the day I really am much more pragmatic and when it comes to treating the skin, I don't frequently look to try to find the sorts of things that many might be looking at and I would think that's a little bit disproportionately, though many a naturopaths and herbalists might be likely to say that. But I'm more pragmatic. 

If someone comes to me say with an eczema condition and I see as much eczema today as I saw 40 years ago. Probably, no more, no less. If someone comes to me today with an eczema condition, there might be one or two basic dietary factors I might raise, but my treatment protocol essentially is based on a pragmatic application of appropriate herbs reinforced by reputable and well known and well proven supportive supplements.

Andrew: Do you think this might be something to do with "being a country folk" if you like? I've interviewed Pat Collins. I'm sure you know her.

Denis: Yes, I know Pat, yes.

Andrew: And there's just...there's this pragmatism for complementary medicine practitioners who practice in a rural setting. And I think it might have to do with also the patient's demands. They haven't got time to waste around. They need to be well.

Denis: Correct. Look, I think you hit it on the head. I had the privilege of being able to practice in Sydney for many years at Wahroonga in a very busy practice and saw, how can you call it? The typical urban presentations... And some might say, "Why did you retreat back to your homeland in Newcastle?" Well, I won't go into that. 

But country people, although Newcastle is becoming less countrified than what it was. But your point is valid. Country people and working class people, if I use that terminology, are very pragmatic. You know for instance if you say to them, "Look, I want you to, you know, to eat this particular food and take these sorts of things and stop doing this and stop doing that." You know that they're not going to do it. A lot of naturopaths and herbalists will say, "Oh, that's very pessimistic." Well, they can have that opinion if they want. But they need to come into the countryside or into down and out working-class areas to understand what we're trying to say here. You have to bring a more pragmatic approach. Country people, working class people, can't afford the multitude of supplements that are doled out say, in the metropolitan areas of the country. At great expense I might say.

And so, we have to be more pragmatic. We have to say, "What is the best that can be given to this person to give the most likely best outcome?" And not always are our outcomes good. Sometimes we fail. And there's nothing wrong with admitting that a treatment may not work. With experience it's good to say that your treatments become more successful and you're more disappointment if you don't achieve the benefit. But it will be wrong to say that the approach, any approach, will always give the outcome you desire. 

But getting back to your point, the pragmatic aspect of prescribing is not just...how can you call it? A country-type of thing or a working class-type of thing. Such as, my practice here in Cessnock is obviously dominated by working-class people. They're different, their expectations are different and they come because they want you to give them an herb and preferably, not too many other things to tidy up their condition. And very frequently that does the job. And if you know your herbs you don't have to spend a long period of time dragging out from patients all this information that you think is important, that at the end of the day may not be important. It may be thought by the person sitting in front of you to be a bit of a bore. 

So if someone comes with an eczema condition my approach is always to treat the eczema and to treat it in a way that has previously shown to be beneficial for many, many patients.

Andrew: Let's go through some of these treatments. Some of the more common ones...I know that, you know, there's an expanse and that you personalise each prescription. I get that. But how would you favour internal versus topical..

Denis: Okay. 

Andrew: And, you know, how...what are your favourites? Let's word it that way.

Denis: That's a very sensible question. Because here again the purists out there might be offended when I say that I place a lot of emphasis on topical applications. When many purists might say, "Oh, that's suppressing the condition." Well, I don't agree with that. And the point about it is, if a topical application can give relief to someone, who’s scratching themselves to death so to speak. They can't sleep because of the itch condition. If you've got a topical preparation that gives relief, forget about the ideology, if you can give that person relief with natural things, go for it. And I found that topical applications are very effective in most of my treatments would incorporate a topical application.

For instance, if I were to be managing an inflammatory condition, say dermatitis or an eczema, I would think of pine tar preparations. I would think of...as a topical application, I would think of topical applications based on glycyrrhizinic acid. Glycyrrhizinic acid is the active principle from licorice which has been shown to have sort of steroidal characteristics that allow you frequently to prescribe it to patients that have hitherto been dependent on steroid applications. So I use a GA cream with a 2% glycyrrhizinic acid. I use a GA complex cream which incorporates the glycyrrhizinic acid but a small amount of pine tar for dry, chronic eczema conditions and particularly psoriasis. 

I use chickweed. I started with chickweed. I still use chickweed. Chickweed oil, chickweed ointment, chickweed cream to address both eczema and psoriasis conditions. And I would also use calendula. Particularly calendula where you have lesions that are slow to heal, that are reluctant to heal and frequently are characterised by infection. I would use calendula topical applications say, in conjunction, with my honey ointment in addressing skin conditions such as varicose ulcers popularly or popularly, unfortunately, popularly seen in many diabetic patients. 

So my ointment preparations are very, very important and in some skin conditions, it is the ointment that I think gives the treatment the outcome that patients are looking for. That is particularly so when one is addressing something like varicose eczema or varicose ulcer. The use of topicals there that I've mentioned, were outstanding, and have led to resolutions that have puzzled and surprised many medical cynics.

So, the topicals are important, but there again, if one is treating particularly a chronic skin condition then my belief is that this is where we shine in dealing with recurring or chronic situations. Essentially, the herbs that I structure or build my treatment around for eczema and dermatitis are well known herbs from "The British Herbal Pharmacopoeia." And they would be heartsease, or Viola tricolor as it's botanically named. Stinging nettle as it's botanically named. Most of my eczema or dermatitis formulae would incorporate those two herbs at least and then usually build around them. 

Other herbs that are also indicated, maybe less so for those conditions, herbs that we all know, old herbs like the burdoch and the clivers and the yellow dock. On the other hand, if I'm treating something like psoriasis, the two main herbs that I've built my formula around is the specific herb called up in "The British Herbal Pharmacopoeia" and that is the herb Sarsaparilla, botanically known as Smilax. And I prescribe it in conjunction with a lesser-known herb, which is a very important herb and that is the herb bittersweet. Solanum dulcamara. A very small low dose herb with a great reputation. Again, again very well presented in Doctor Weiss's book, "Herbal Medicine" where he puts it forth as being one of the major remedies used in Europe to address that condition. 

So in eczema, Viola tricolor and nettle. In psoriasis, which is see a lot of, the sarsaparilla and the bittersweet supported again by other herbs from "The British Herbal Pharmacopoeia" that have an indication perhaps not as specific but an indication also for psoriasis.

Andrew: I can still remember one of my sons having a reaction to a mango tree and thankfully this was in summer so a lovely cool bath with pine tar. There was nothing that gave him greater relief. 

Denis: Yes. I’ve experienced that. 

Andrew: And this was a rash that...yeah, lasted days. And it was...this was the thing that gave him the greatest relief. Not the antihistamines.

Denis: I frequently say to my patients that's presenting with very serious pruritic conditions, I will say, "Look, you really need..." And I'll frequently say, "Go to your pharmacy and pick it up if you can’t get it anywhere else." I will frequently recommend that they get a preparation that incorporates...a solution that is that incorporates pine tar and menthol. And that has in many cases changed the experience of many of my patients, eczemas and dermatitis conditions. 

Because again a lot of practitioners aren't aware that menthol with its cooling and numbing effect blended with the anti-inflammatory and antipruritic effect of the pine tar or the juniper tar well, that is sometimes more efficacious than even a steroid in getting rid of acute itch conditions. I emphasise that incredibly in my practice. And I'll encourage fellow practitioners to do a little bit of reading around two of these older preparations, topical applications, of menthol blended with say a pine tar. Hard to beat when it's applied topically.

Andrew: What are your thoughts about the traditional application of oatmeal for itch? And also, we mentioned chickweed before. Do you prefer the succus?

Denis: Okay. With chickweed, a lot of people probably don't know that was Robin Kirby, one of my first graduates, she and I produced the first chickweed ointment in this country. And it was always based on Priest's formula. 

Priest wrote a book with his daughter called "Herbal Medications." Great work. In that book, part of its greatness is associated with the presentation of a number of methods of making various creams. And in Priest's book, "Herbal Medications," there is a way of making the chickweed ointment or the chickweed cream and both the cream and the ointment are based on the juice, which is known as the succus, and also fresh plant tincture. Both of those constituents are used in stipulated proportions to give a preparation that, in my opinion, represents the best that one can get from that terribly underrated herb to be used in both eczema and dermatitis and also psoriasis. 

In fact, some of the older writers, I think it was William Smith in his book, "Wonders in Weeds"...and I'll...let me just say something on that. A lot of people might smirk at the name of that book, "Wonders in Weeds." If one is able to get a hold of it, as one still can, by William Smith, it's a remarkable text, written by a remarkable herbalist, on the way in which simple herbs, used in simple forms, including chickweed, can work and work so wonderfully. And in that text I'm sure it was Smith, who said anything less than using the fresh chickweed would only...would not work as well. There'd be a diminished benefit. And that sometimes is associated with herbs. The fresh herb brings with it constituents which can dissipate or fade in the drying process. That's not always the case. Sometimes the fresh herb is undesirable. But in some situations, particularly with chickweed, the literature and our experience has been well, it's better to use those preparations which extract the fresh herb that is the succus or the tincture.

Andrew: You mentioned glycyrrhizinic acid, which of course is an isolated constituent or active. Why do we use this approach instead of the whole herb?

Denis: You are isolating an active and in this situation one could say that that is a justifiable thing to do. For instance, we also isolate say, the oil from peppermint.

Andrew: Got you.

Denis: We use peppermint oil. So what we're talking about here is not...again, it comes back to this pragmatic concept. How do we get the best result from a herb? And in this case it means that this is not applied to all herbs but to a few herbs. In this case, there's an acknowledgement that there's an overwhelming dominating chemistry in the herb without which the herb would be useless. There is an understanding, there is a dominating single chemical constituent which has remarkable properties and in this case it justifies the isolation of it and the harnessing of it. 

One could still get arguably a benefit from using say liquorice extract. But one would have to use a lot more of the licorice extract to bring the bear the amount of glycyrrhizinic acid that's needed to bring about this benefit that it has on the skin.

Put it this way, there are always contradictions to the rule. This doesn't undo all that we spoke about earlier. It means that the pragmatism associated with herbalism, and that is using the herb in the best and most economical way to get a result, it is that pragmatic emphasis that perhaps lessens the seeming contradiction.

Andrew: Just a quick question on psoriasis, Denis. 

Denis: Yes. 

Andrew: And that is, how do you prioritise a natural treatment approach versus or alongside drug therapy?

Denis: Okay. There are some situations in any condition that we treat that must be acknowledged as requiring if you like, with some of potential problems that it brings with it, an initial medical approach. 

If you have a patient, for instance, that is very, very seriously afflicted with psoriasis and is in a desperate state, that is a condition that I would say requires initially to be managed by a dermatologist. Even a GP would not treat sort of level of psoriasis that can sometimes present to a patient. In fact, frequently, the best thing you could say to that patient would be, "Look, you really need to see a dermatologist. Your condition is out of control and it can lead to serious complications." Which it can.

Now the treatment for psoriasis at that level unfortunately involves the application or the prescribing of well-known immunosuppressant-type medications and usually steroid preparations. I don't retreat from that when it's necessary. I see our role, not in addressing a patient at that level, but in perhaps helping that patient whose psoriasis is under control to remain in a state of control or in a state of remission. 

What we try to do I would argue is to keep autoimmune condition in a state of subsidence. It has been, if you like, momentarily controlled by the application of modern dermatological preparations. But in my opinion, we have a role to play in working a treatment that works against the reassertion of it by addressing the underlying autoimmune activity. So where you've got that level of severity, I see as perhaps backing off and waiting for the condition to improve and at that point, to come in with herbs that we frequently prescribe known as the alteratives.  

On the other hand, if we are presented with patients that have a very limited experience of psoriasis on the typical areas where it occurs, the elbows, the knees and the scalp. I feel comfortable there in these conditions, particularly where the patient presents after many, many years of having had these lesions, I feel very comfortable of treating that condition with oral herbs and particularly the ones that I've mentioned. In this situation, I'm happy to prescribe because the patient's psoriasis is at a level that is amenable to our treatment and likely to respond to it reasonably quickly. And I also see our treatment as being something that works against, or can work against, the reassertion of a controlled psoriasis.

So in practice these days, I'm less ideological. I frequently will say to a patient particularly with skin conditions, "Look. You need steroid. You need some Prednisone to get this under control both orally and you need a steroid topical application. You need to get it under control and then let's look at how we can keep it at a level of subsidence by using a more natural approach." Many might find that offensive. I find it again very pragmatic. And at the end of the day many patients will bless me for giving them that advice.

Andrew: Indeed. It's got to do with helping your patients.

Denis: Correct. 

Andrew: And I wish that I had days right now to talk to you and draw all of that expertise out of your brain, Denis, but unfortunately, we're out of time. 

But I would like to sincerely and deeply thank you for your dedication to both your patients and indeed our professions. And, you know, not just in education but all that you have given to herbal and naturopathic medicine over the decades of your practice and your teachings. And I would just like to give you that, not just my personal thanks but also those from your previous students. Thank you so much for sharing just a little inkling of your expertise today on FX Medicine. 

And I would also just give a last final thing about this graduate program. If you wish to have professional extension I would urge all healthcare professions interested in herbal medicine to undertake this course. It's given over a weekend, each two months, and it's seven hours a day, right?

Denis: Big course. Big course.

Andrew: Big course.

Denis: But I've always enjoyed teaching it and I can tell you now I'm really fired up about teaching this final course. None of my courses are ever the same. And this course will bring together my 40 years of experience and give my last thoughts on treating the body systems with herbs. 

Andrew, thank you so much for the interview. It's been a very nice time with you. Thank you for your kind remarks. I hope I haven't been perhaps too provocative and controversial? That's part of perhaps my nature. But it's great to think about our profession, look at our roots, traditions, where we've come from, the direction in which we're going. We're here to stay. But to take with us the science and the tradition together. Thank you, Andrew.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.



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Denis Stewart

Clinical herbalist and Naturopath, Denis Stewart has been in continuous practice for over 40 years and currently conducts busy practices in Newcastle and Cessnock. Referred to as the Godfather of Australian herbalism, Denis spearheaded a Renaissance in Australian herbal medicine in the early 1970’s. At the NSW College of Naturopathic Sciences Denis established and taught the first 3-year full-time program in herbal medicine in Australia. For the National Herbalists’ Association of Australia, Denis constructed professional examinations, course studies and curriculum for herbal training and education. In the late 1970’s, Denis founded the Southern Cross Herbal School, offering undergraduate and post-graduate programs. From 2002-2007, Denis was a Conjoint Associate Professor at the University of Newcastle and helped construct the Bachelor of Herbal Therapies program at the Ourimbah campus. In addition to being a member of the Australian Traditional Medicine Society, Denis is also a fellow and life member of the National Herbalists’ Association of Australia, Denis was inducted into the Australian Medicine Society Hall of Fame in 2012. In addition to maintaining clinical practices, Denis broadcasts a weekly podcast on 2NurFM and offers online herbal training.