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information sheet deals with essential oils and aromatherapy preparations containing them. Key points for pharmacists dealt with in this information sheet Pharmacists who offer advice on aromatherapy should ensure that they have a sufficient level of knowledge to do so. Essential oils should not be applied in undiluted form to the skin. They are normally diluted in a carrier oil (such as almond or grapeseed oil) before use. Essential oils should not be taken orally without medical supervision. Essential oils should be stored out of the reach of children. Adverse reactions to essential oils have only rarely been reported. There are no formalised reporting procedures for suspected adverse reactions to essential oils. The use of essential oils in certain patient groups is not advisable. Pregnant women or those who are breast-feeding, and patients with epilepsy, should not use essential oils. Essential oils should be purchased only from reliable sources, and stored in a cool place and away from naked flames. Citrus oils have been reported to cause photo-sensitisation and should be avoided for a minimum of 24 hours before exposure to sunshine or other sources of UV light Some patients may wish to consult an aromatherapist. Patients should be encouraged to choose one who has undertaken relevant training, is registered with a recognised aromatherapy organisation (see below) and who has professional indemnity insurance. What is aromatherapy? Aromatherapy is the therapeutic use of aromatic substances - mainly essential oils extracted from plant material - and is becoming one of the most popular complementary therapies in the UK. It is often used for the treatment of stress and related conditions but is also promoted for use in minor ailments (such as flatulence, indigestion and headache) and for more serious conditions such as asthma, impotence, hypertension, psoriasis and depression. There is no clinical evidence for effectiveness. Aromatherapy is also used in palliative care, and in patients with severe learning disabilities. Administration The most common method of use is topical application with massage. The essential oil (or oils), diluted in a vegetable carrier or base oil, is applied during a full-body or a localised massage. Essential oils are also purchased by the public to add to bath-water (the water should be agitated vigorously to disperse the oil), inhale from dispersions in hot water and for use in burners. Some aromatherapists recommend oral administration of aromatherapy oils. However, essential oils (other than established medicinal products such as peppermint oil capsules) should never be taken orally without medical supervision. Vaginal and rectal administration can cause mucosal membrane irritation and should not be recommended. Self-treatment
Many users of essential oils do not consult an aromatherapist. Most use essential oils to aid relaxation. Some literature encourages the use of essential oils for a wide range of conditions, some of which may not be suitable for self-treatment. As essential oils are almost invariably unlicensed products, no medicinal claims can be made. Packaging and storage Essential oils should be labelled with the following information • specific instructions for use • a statement "keep away from children and from eyes" • a warning not to take internally or apply undiluted to the skin • the quantity supplied • name and address of the manufacturer or supplier. Essential oils should be stored in a cool place, in tightly closed, dark bottles, away from naked flames. Even when stored correctly, essential oils are likely to change in composition during storage through oxidation and loss of volatile components. Clinical research Essential oils may act by exerting pharmacological effects following topical absorption, or through effects of odour on emotion and mood, or both. There is evidence for absorption into the circulation after topical application by massage, and after inhalation, but the amounts are probably very small. Some studies reported psychological effects due to ambient odour, but it is probable that no simple relationship exists. Aromatherapists claim that the numerous constituents of essential oils work synergistically to improve efficacy and also that different constituents reduce the occurrence of adverse effects. The results from some animal studies support these claims for certain essential oils or constituents, but the relevance to use in humans is not clear. Whereas there is anecdotal evidence to support the use of aromatherapy, there is little clinical research. Generally, trials have not demonstrated that massage with essential oils is significantly better than massage with carrier oil alone. Quality A typical essential oil will contain more than 100 chemical constituents, many of which are volatile compounds present at concentrations below 1%. Some essential oils contain one or two major constituents and the properties of the oil can largely be attributed to those constituents. However, some constituents present at low concentrations can be important therapeutically or toxicologically. A gas chromatographic profile or "fingerprint" of the oil may be a useful aid to identification in a quality control laboratory, but will vary with source of the material. Adulteration and contamination are said to be prevalent. The composition of essential oils can be affected by several factors including plant growing conditions and extraction techniques. Safety There are currently few data on the safety of essential oils used in aromatherapy. Essential oils
are not formally included in the Committee on Safety of Medicines’ yellow card scheme for adverse-reaction reporting but any suspected major interaction should be reported. Safety data come from research with fragrances and from toxicological and pharmacological studies. There are several reports of accidental poisonings of children through swallowing of essential oils. The most common adverse effect associated with aromatherapy treatment is allergic contact dermatitis through prolonged use. Aromatherapists are exposed to the essential oils they use and may develop multiple sensitisations. Minor transient adverse effects, such as drowsiness, headache and nausea can occur after an aromatherapy treatment and customers should be warned not to drive if they feel disoriented. The use of essential oils during pregnancy and labour is of concern. Some essential oils may stimulate uterine bleeding, or have abortifacient, teratogenic or mutagenic effects (although many of these particular oils are not suitable for use in aromatherapy). Because of uncertainties about the safety of essential oils during pregnancy and in infants, it is prudent to advise that essential oils be avoided during pregnancy, especially during the first trimester, and while breast-feeding. Gentle massage with vegetable carrier oil alone could be considered as an alternative. Some essential oils used in patients with epilepsy can precipitate attacks. The extent to which essential oils interact with conventional medicines is not known. Massage of the feet or legs of patients with deep vein thrombosis is contraindicated. Generally, deep-tissue or heavy massage is contraindicated in patients with cancer, particularly at or close to tumour sites. Gentle massage of other areas is no more likely to lead to a spread of cancer than is gentle exercise or normal daily activities. The manufacturers and suppliers of products and aromatherapists must follow the Control of Substances Hazardous to Health (COSHH) and the Chemical Hazard Information and Packaging for Supply (CHIPS) regulations that apply to essential oils used in aromatherapy. Aromatherapy organisations The practice of aromatherapy is not currently regulated by statutory legislation. The governing body for aromatherapy in the UK is the Aromatherapy Organisations Council (AOC) which represents the majority of practising aromatherapists. The Aromatherapy Trades Council (ATC) is an independent, self-regulating body for the aromatherapy essential oil trade, representing about 75% of essential oil suppliers. The code of practice for members of the ATC includes statements on responsible marketing, the incorporation of single-drop dispensers in all bottles of essential oils on sale to the public, and guidelines for product labelling and packaging. Promotional literature should give clear guidelines as to how the aromatherapy products should be used. Aromatherapy Organisations Council PO Box 19834 London SE25 6WF Tel: 020 8251 7912 Aromatherapy Trades Council PO Box 52 Market Harborough Leicestershire LE16 8ZX
Tel: 01858 465731 Further reading Barnes J. Aromatherapy Pharm J 1998; 260: 862-7 Tisserand R and Balacs T. Essential Oil Safety: A Guide for Health Professionals. Edinburgh: Churchill Livingstone, 1995 Vickers A. Massage and Aromatherapy. A Guide for Health Professionals. London: Chapman & Hall, 1996 This information sheet was commissioned by the Royal Pharmaceutical Society of Great Britain. The authors are Joanne Barnes MRPharmS and Elizabeth M Williamson PhD MRPharmS, School of Pharmacy, London University Royal Pharmaceutical Society of Great Britain 1 Lambeth High Street, London SE1 7JN Copyright Royal Pharmaceutical Society September 2000