Should you recommend bromelain to cosmetic surgery patients? | Plastic Surgery Practice June 2014
The stems and fruit of pineapple contain bromelain, a natural compound believed to reduce inflammation, bruising, and swelling, and improve wound healing. Ayuverdic specialists have used it for centuries for this very reason—with strong anecdotal support. But does bromelain belong in your conventional plastic surgery practice?
THE CHEMISTRY OF BROMELAIN
Bromelain is really a combination of at least two protease enzymes. Some experts may refer to a combination of those enzymes along with other compounds produced naturally in the extract.
The protein-digesting enzymes are sulfhydryl proteases; characterized by a free sulfhydryl group of a cysteine side-chain. The other substances typically include peroxidase (an important detox enzyme), acid phosphatase, protease inhibitors, and calcium.
Bromelain was first introduced in medical research in 1957, where it was theorized that it could reduce inflammation by degrading pro-inflammatory cytokine metabolites when applied topically.
In addition to its cytokine-degradation properties, preliminary research also indicates that bromelain may affect migration of neutrophils to sites of acute inflammation. In effect, bromelain can help regulate tissue repair and swelling by effectively degrading inflammatory cytokines, inhibiting neutrophil migration, and removing cell surface inflammatory molecules.1
Now with a little understanding of bromelain’s biochemical properties, could it be used to reduce inflammation, pain, and swelling following minor cosmetic surgery?
THE ANTI-INFLAMMATORY PROOF OF BROMELAIN
As we all know, growing evidence of the cardiovascular and gastrointestinal risks associated with non-steroidal anti-inflammatory (NSAID) drugs has left many people seeking safe, effective strategies for relieving pain and inflammation, especially for arthritis and after minor surgeries.
In clinical trials, bromelain-based formulations were more effective than an NSAID drug in relieving inflammation and arthritis pain. Supplementing with bromelain-based formulations after injury or surgery also speeds healing and
In a recent blinded study from Germany, researchers divided 90 patients with painful osteoarthritis of the hip into two groups. One group received an oral enzyme preparation containing bromelain for 6 weeks, while the other group received the anti-inflammatory drug diclofenac.
They found that the bromelain preparation was as effective as diclofenac in standard scales of pain, stiffness, and physical function, and was better tolerated than the drug comparator. The researchers concluded, “The bromelain preparation may well be recommended for the treatment of patients with osteoarthritis of the hip with signs of inflammation as indicated by a high pain level.”2
Another study comparing a standardized commercial enzyme preparation
containing bromelain with diclofenac reached the same conclusion. The study reported that the supplement containing bromelain was as effective as diclofenac in improving the symptoms of osteoarthritis of the knee.
Patients reported comparable reductions in joint tenderness, pain, and swelling, and improvement in range of motion at the end of the study. The investigators found bromelain was as good as diclofenac on a standard pain assessment scale and was better than the drug in reducing pain at rest, improving restricted function, being rated by more patients in improving symptoms, and being evaluated by more physicians as having good efficacy.3
IMPROVED SOFT-TISSUE HEALING
So there is substantial proof that bromelain is an anti-inflammatory. But what about bromelain’s potential in healing soft tissues?
The first study looked at preoperative and postoperative outcomes with impacted molars. It was a prospective, placebo-controlled, double-blind study in 34 patients. The preoperative and postoperative outcomes included inflammation, pain, and oral aperture, as well as the need for analgesics.
One group received 150 mg of bromelain per day for the first 3 days and 100 mg on days 4 to 7. The other group received placebo in the same dosage. Although there were no statistically significant differences between the treatment groups, a trend toward less inflammation and improved oral aperture was observed in the group that received bromelain.4
A second study looked at re-epithelialization following burns. A bromelain-based solution was applied, and the mean time to complete re-epithelialization was faster for bromelain-treated burns than control-treated burns. The authors concluded that treatment of mid-dermal porcine burns with a single topical application of bromelain-based solutions results in earlier wound re-epithelialization.5
HOW TO USE BROMELAIN IN YOUR PRACTICE
A quality bromelain product has to be enteric-coated so that it will not be activated in the stomach and used as a digestive enzyme. Enteric-coated bromelain tablets pass into the small intestine, where they are absorbed into the bloodstream to provide systemic benefits.
The suggested dose is 500 to 1,000 mg of bromelain proteolytic enzyme extract taken on an empty stomach. The enzyme activity for bromelain is measured in GDUs, or Gelatin digesting units. The target is 1,200 to 2,400 GDUs per 500 and 1,000 mg of bromelain, respectively.
Caution: Bromelain supplements, when taken with other medications like antibiotics, anticoagulants, and antiplatelet drugs, may increase the risk of tachycardia, blood clotting, and bleeding postsurgery.
Michael A. Smith, MD, is author of The Supplement Pyramid—How to Build Your Personalized Nutritional Regimen (www.MySupplementPyramid.com). He is also host of Healthy Talk on www.RadioMD.com/show/healthy-talk. He is a graduate of the University of Texas, Southwestern Medical Center in Dallas. He can be reached at PSPeditor@allied360.com.
1. Fitzhugh DJ, Shan S, Dewhirst MW, Hale LP. Bromelain treatment decreases neutrophil migration to sites of inflammation Clin Immunol. 128(1):66-74.
2. Klein G, Kullich W, Schnitker J, Schwann H. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomised study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol. 2006;24(1):25-30.
3. Akhtar NM, Naseer R, Farooqi AZ, Aziz W, Nazir M. Oral enzyme combination versus diclofenac in the treatment of osteoarthritis of the knee—a double-blind prospective randomized study. Clin Rheumatol. 2004;23(5):410-415.
4. de la Barrera-Núñez MC, Yáñez-Vico RM, Batista-Cruzado A, et al. Prospective double-blind clinical trial evaluating the effectiveness of bromelain in the third molar extraction postoperative period. Med Oral Patol Oral Cir Bucal. 2014;19(2):e157-162.
5. Singer AJ, Taira BR, Anderson R, McClain SA, Rosenberg L. Re-epithelialization of mid-dermal porcine burns after rapid enzymatic debridement with Debrase®. J Burn Care Res. 2011;32(6):647-653.
Original citation for this article: Smith, M. A., Pineapple power: Should you recommend bromelain to cosmetic surgery patients?. Plastic Surgery Practice. 2014; June, 26-27.