REVIEW ARTICLE
Perioperative Homeopathic Arnica and Bromelain
Current Results and Future Directions
Rebecca Knackstedt, MD, PhD,* and James Gatherwright, MD†
Introduction: Arnica and bromelain, two of the most widely recommended ho-
meopathic medications to improve perioperative outcomes, have yet to be widely
adopted by allopathic practitioners. A significant barrier to utilization of herbal
medications by allopathic doctors is that the preparations and dosing regimens
are not widely known or understood. The goal of this review was to critically an-
alyze studies that have examined the perioperative efficacy of arnica and brome-
lain with a focus on treatment regimen and outcomes.
Methods: A triple database search was conducted with the keywords “arnica,”
“bromelain,” and “surgery.” References for each identified article were analyzed
for additional articles. Articles were analyzed for methodology, outcomes, and
conclusion. Articles were excluded if they did not involve human subjects, were
published before 1990, and if they were not available in English. Level of evi-
dence was determined based on methodology.
Results: A total of 29 articles met inclusion criteria, with 20 and 9 in the arnica
and bromelain treatment groups, respectively. There was marked heterogeneity
with regard to surgical procedure, dosing regimen, outcomes measured, and re-
sults. Arnica seems to have a mitigating effect on ecchymosis, most notably fol-
lowing rhinoplasty and facelifts/facial procedures. Bromelain is well supported
across numerous studies in reducing trismus, pain, and swelling following molar
extractions. However, there was no effect demonstrated when evaluating topical
arnica following blepharoplasty procedures.
Discussion: A systematic review of the literature demonstrates the potential for
arnica and bromelain to improve perioperative outcomes including edema, ecchy-
mosis, and pain control. Future studies are required to determine safety and efficacy
of dosing and interactions with other medications. We hope this article stimulates
surgeons to consider using these interventions to improve perioperative outcomes
in the context of well-done studies with an objective analysis of results.
Key Words: arnica, bromelain, edema, ecchymosis
(Ann Plast Surg 2019;00: 00–00)
A rnica and bromelain, two of the most widely recommended ho-
meopathic medications to improve perioperative outcomes, have
yet to be widely adopted by allopathic practitioners. Arnica montana
is a perennial of the family Asteraceae and is indigenous to Central
Europe and England. The flowers of its various species contain glyco-
sides, terpinoids, amines, coumarins, and volatile oils.1 It has been used
in varying formulations in homeopathic medicine to treat a variety of
ailments and is one of the widely used homeopathic medications.1–3
Bromelain, a protease isolated from pineapple stems, leaves, and fruit,
has shown utility in decreasing soft tissue inflammation via reduction
in neutrophil migration and cytokine activation.4–6 Although fresh pine-
apple is not a concentrated source of bromelain enzymes, eating whole
food can avoid the occasional adverse effects of nausea and emesis as-
sociated with bromelain.7–9
Received April 22, 2019, and accepted for publication, after revision June 7, 2019.
From the *Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio; and
†Division of Plastic Surgery, MetroHealth, Cleveland, Ohio.
Conflicts of interest and sources of funding: none declared.
Reprints: Rebecca Knackstedt, MD, PhD, Mail Code A 60, 2049 E 100th St, Cleveland,
OH 44195. E-mail: Knacksr@ccf.org.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/19/0000–0000
DOI: 10.1097/SAP.0000000000002043
Annals of Plastic Surgery • Volume 00, Number 00, Month 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A significant barrier to use of herbal medications by allopathic
doctors is that the preparations and dosing regimens are not widely
known or understood. Therefore, the goal of this review was to critically
analyze studies that have examined the perioperative efficacy of arnica
and bromelain, with a focus on treatment regimen and outcomes. By
highlighting the differences in dosing and objective postoperative mea-
surements, we hope to emphasize the inconsistencies in homeopathic
studies and encourage future studies to be performed with translatable
dosing regimens and outcome measures.
METHODS
A triple database search was conducted with the keywords “arnica,”
“bromelain,” and “surgery.” References for each identified article were an-
alyzed for additional articles. Articles were analyzed for methodology, out-
comes, and conclusion. Articles were excluded if they did not involve
human subjects, were published before 1990, and if they were not available
in English. Level of evidence was determined based on methodology.
RESULTS
A total of 29 articles met inclusion criteria, with 20 and 9 in the
arnica and bromelain treatment groups, respectively.
Arnica
Twenty studies were identified assessing the efficacy of using ar-
nica perioperatively to reduce edema, ecchymosis, and pain among
other metrics.3,10–28 Topical and oral interventions were used in a vari-
ety of dosing regimens. Procedures investigated ranged from head and
neck surgery to podiatry.
Three randomized control studies investigated perioperative use
of arnica in rhinoplasty patients compared to steroids, placebo, or mu-
copolysaccharides (MPS).11,14,15 The MPS study was a topical compar-
ison, while the other two were oral. While the dosage and treatment
algorithms varied, all three studies demonstrated decreased ecchymosis
associated with arnica use; however, topical arnica was not superior to
MPS. The efficacy of arnica at minimizing postoperative edema was
less clear.
Regarding facial aesthetics, there were blepharoplasty randomized
control studies,12,17 one facial cosmetic,13 and one facelift study.3 The
two randomized control trials evaluating blepharoplasty (one topical/
one oral) found no difference when arnica was compared to placebos.
The facial cosmetic study found “accelerated” healing across a hetero-
geneous group of patients, although most underwent blepharoplasty. In
the facelift study, oral arnica resulted in significant improvements in ec-
chymosis but no differences in color change compared to controls.
There were two randomized control studies that evaluated topical
arnica in patients undergoing either 585- or 595-nm laser.16,26 The 595-
nm study demonstrated less ecchymosis with topical arnica compared
to controls and similar results with topical vitamin K. However, the study
evaluating topical arnica versus placebo in pulse dyed laser patients
found no difference. The dosage and regimens were significantly differ-
ent between studies.
There were two randomized control carpal tunnel studies.19,22
One study used oral arnica alone, while the other used oral and topical
arnica. The study using oral arnica alone demonstrated no difference,
www.annalsplasticsurgery.com 1
 2
TABLE 1. Arnica in Surgical Clinical Trials

Type of Level of
Author Year Study Evidence Procedure/Surgery Application Dose Frequency Control Finding
13
Kang et al 2017 Review III Cosmetic face, Topical Arnica 50 M Pads worn for 6 days No treatment Arnica and Rhododendron
most blepharoplasty (10–100,000) 50% tomentosum solution resulted
in accelerated healing
Totonchi et al14 2007 RCT II Rhinoplasty Oral Unknown 1. TID for 4 days 2. No treatment or POD 2: no difference, controls
Knackstedt and Gatherwright

dexamethasone had more swelling

POD 8: more extent/intensity
of ecchymosis with steroid,
no difference in edema, more

www.annalsplasticsurgery.com
resolution of ecchymosis with
arnica between days 2 and 8
Simsek et al15 1997 RCT II Rhinoplasty Topical 75 g QID for 4 day Mucopolysaccharide 1. MPP cream and arnica
polysulfate (MPP) cream had less ecchymosis
cream or nothing and quicker edema regression
on day 1, 5, 7. No difference
between those groups.
Kotlus et al12 2010 RCT II Upper blepharoplasty Oral 500 mg TID for 4 days Placebo pill 2. No difference in ecchymosis
homeopathic or recovery
dilution
Chaiet et al11 2016 RCT II Rhinoplasty with osteotomy Oral 500 mg TID for 4 days Placebo pill 3. Arnica accelerated healing with
homeopathic quicker resolution of extent
dilution and intensity of ecchymosis
Seeley et al3 2006 RCT II Facelift Oral Unknown TID for 4 days Placebo pill 4. Patients taking arnica had
less ecchymosis on POD
1, 5, 7, and 10; sig on POD 1
and 7. No difference color change
Leu et al16 2010 RCT II 595 nm laser Topical 20% arnica Under occlusion Vitamin K 5% or 5. Improvement over controls
for 2 weeks 1%, 0.3% retinol in bruising; equivocal to
5% Vitamin K
Van Exsel et al17 2016 RCT II Upper blepharoplasty Topical 10% with 30 g Daily for 1 week Placebo cream 6. No difference in regards to
of arnica in edema, ecchymosis,
100 g lotion pain, satisfaction
Hart et al18 1997 RCT II Total abdominal hysterectomy Oral C30 BID prior to surgery Placebo pill No difference in pain and
one day, TID discomfort, pain meds
for 5 days used, operation details
Stevinson et al19 2003 RCT II Carpal tunnel surgery Oral 30C or 60C TID 7 days before Placebo pill No difference in pain meds,
and 14 days bruising, swelling, analgesia
after surgery
Robertson et al20 2007 RCT II Tonsillectomy Oral 60C 6x/day POD 1, Placebo pill Arnica provided a small
BID for 7 days decrease in pain score.

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
No difference, analgesia,
antibiotics, swallowing
function, visits to hospital
Ramelet et al21 2000 RCT II Saphenous vein stripping Oral Unknown One dose night Placebo pill No difference in hematomas
before and one after on POD 6
Cornu et al29 2009 RCT II Aortic valve surgery Oral 5CH 5 granules bid day Placebo pill No difference in post-op
before until POD 4 blood loss, CRP, pain,
temp, troponin

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2019
Annals of Plastic Surgery • Volume 00, Number 00, Month 2019 Perioperative Arnica and Bromelain

while combination therapy resulted in decreased pain at 2 weeks with

no difference in swelling or strength.

pre- or post-treatment regimen

the CLR trial. No difference
In two studies evaluating third molar extractions, both studies

No difference in bruising with

Arnica improved edema and
2 weeks, no difference in

demonstrated improvement in mouth opening but no difference in pain

less swelling. Significant

pain, analgesia, drainage

difference only found in
showed a trend towards

Arnica improved trismus,

No effect on morphine in

or swelling when comparing arnica to placebo controls.25,28

Arnica decreased pain at

analgesia, worse pain

In all three trials, arnica
swelling or strength

Equivalent for wound

An additional seven studies evaluated varying applications follow-
mouth opening, no

no changes in pain

irritation, mobility,
ing total abdominal hysterectomy, tonsillectomy, saphenous vein stripping,
effect on pain

first 24 hours

aortic valve surgery, Anterior Cruciate Ligament (ACL) surgery,

or swelling
arthroscopy, implant or cruciate ligament surgery, and hallux valgus
surgery.10,18,20,21,23,24,29 These studies varied in their findings. Studies
are summarized in Table 1.

Bromelain
Nine studies were identified assessing the efficacy of using bro-
Placebo cream
no intervention
Placebo pill

Placebo pill
Placebo pill

Diclofenac melain perioperatively to reduce edema, ecchymosis, and pain among

Placebo pill or

other metrics.30–38 Oral interventions were used with a variety of dilu-

and cream
Placebo pill

tions and dosing recommendations. Procedures investigated included

molar extraction and double jaw surgery.
Of the nine studies meeting inclusion criteria, eight were related
to dental extractions, most commonly impacted 3rd molars.31–38 Despite
surgery and for 3 days

various time intervals

heterogeneous study designs and dosing regimens, most of the studies

3 days prior to surgery

tended to support oral bromelain in decreasing pain, trismus, and to a

3 tablets started after
surgery then taper
Day of surgery until
TID and POD 1

lesser degree, swelling. Seven of the eight studies were randomized con-
before or after
BID two weeks
Evening before
D6 and 5% cream TID for 3 days

trol trials with one cohort study.

follow-up at

Finally, there was one randomized control study evaluating

orthognathic surgery patients undergoing Le Fort I osteotomy, bilateral
sagittal split osteotomy, and genioplasty.30 In this study, oral arnica was
TID

able to result in significantly decreased swelling compared to placebo.

Studies are summarized in Table 2.
1x tincture

DISCUSSION
6CH

5CH

D30
30x

D4

There has been an increased interest in optimizing perioperative

outcomes and satisfaction following all types of surgery. Improving
postoperative pain, swelling, discomfort, and return to activities are crit-
ical. While there are a multitude of pain intervention protocols, edema
and ecchymosis reduction are limited to pressure dressings, drains,
Topical
Oral

Oral
Oral

Oral

Oral
Oral

and steroids.39 However, steroids are associated with multiple potential

adverse effects, including skin changes, glucose dysregulation, adrenal
suppression, impaired wound healing, and weakened immunity. Thus,
if an intervention could be adopted that could result in decreased edema
cruciate ligament (CLR)

and ecchymosis postoperatively without an increased risk of hematoma,

Hallux valgus surgery
Carpal tunnel surgery

Impacted 3rd molars

Impacted 3rd molars

Arthroscopy, implant or

this would be desirable. Bromelain and arnica have been anecdotally

ACL surgery

585 nm laser

thought to address these issues and are two of the most widely used ho-
meopathic remedies. However, their application in perioperative proto-
cols has been limited. To that end, we have critically reviewed the
available literature and demonstrate support for their safety, with some
studies also suggesting improved postoperative outcomes.
Arnica seems to have a mitigating effect on ecchymosis, most
notably following rhinoplasty and facelifts/facial procedures. However,
there was no effect demonstrated when evaluating topical arnica follow-
ing blepharoplasty procedures. This could be due to a multitude of factors
II

II

II

II

II
II

II

including variations in formulations and regimens. Given its relative effi-

cacy in other facial procedures, it could also be attributed to the fact that
Brinkhaus et al24 2006 3 RCTs

significant differences in swelling/bruising following blepharoplasty

RCT

RCT

RCT

RCT
RCT

RCT

are too small to assess. While the data on arnica's effect postlaser treat-
ments is also equivocal, similar to the aforementioned studies, there
2002

2007
2005

1995

2002

2008

were differences in technique and application. The study that demon-

strated efficacy used a higher concentration of topical arnica and occlu-
sive dressing applications. Thus, either or both of these could have
Macedo et al28

Lokken et al25

Alonso et al26

resulted in the observed increased efficacy. Arnica's impact on postop-

Jeffrey et al22

Karow et al10
Paris et al23

erative outcomes following other surgeries is less clear. Additionally,

combination therapy of topical and oral arnica was only evaluated in
one study evaluating carpal tunnel surgery. This study did demonstrate
a reduction in postoperative pain with dual therapy and prompts the

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 4
TABLE 2. Bromelain in Surgical Clinical Trials

Type of Level of
Author Year Study Evidence Procedure/Surgery Application Dose Frequency Control Finding
Knackstedt and Gatherwright

30
Shetty and Mohan 2013 RCT II Le Fort I osteotomy, Oral 180 mg BID for 5 days Placebo pill Bromelain decreased soft
bilateral sagittal tissue, especially on days 5
split osteotomy, and 15, at most assessed points.

www.annalsplasticsurgery.com
and genioplasty
Inchingolo et al31 2010 RCT II Impacted 3rd molars Oral 40 mg 1. QID for 6 days2. Ketoprofen Similar reduction in pain and edema
Ghensi et al32 2017 RCT II Single mandible molar Oral 40 mg +/− 4 mg QID for 6 days Dexamethasone 1. POD 2: reduction in edema
dexamethasone pre-op or nothing with combination or
dexamethasone alone
2. POD 7: combination had
decrease in edema and pain meds
Singh et al33 2016 Cohort study III Impacted 3rd molars Oral 200 mg BID for 5 days None Bromelain was effective in 70%
of patients in reducing
edema and pain
Isola et al34 2018 RCT II impacted 3rd molars Oral 50 mg BID for 5 days Placebo pill Bromelain reduced pain at 12 and
or ibuprofen 24 hours. All interventions
improved pain and changes in
maximum mouth opening
and facial contours.
Majid and 2014 RCT II Impacted 3rd molars Oral 250 mg QID for 4 days Placebo pill Bromelain and diclofenac
Al-Mashhadani35 or diclofenac reduced pain. Diclofenac
reduced edema. Both treatment
groups improved QOL
measures. A nonsignificant
reduction in trismus occurred
in both treatment groups.
Bormann et al36 2016 RCT II Wisdom teeth extraction Oral 1000, 3000 or 4500 FIP Various sequences Pooled treatments had trend to
reduced edema. No difference
in pain, pain meds and swelling.
No superiority observed with
increased dosing.
del Carmen de la 2014 RCT II Impacted lower molars Oral 150 mg, 100 mg 150 mg qday Placebo pill 1. Bromelain had trend in producing
Barrera-Núñez37 for 3 days and less inflammation and improved
100 mg POD 4–7 oral aperture. No statistically
significant differences between
the treatment groups.

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Ordesi et al38 2014 RCT II Impacted 3rd molars Oral 50 mg BID for 12 days None Bromelain decreased inflammation,
edema, pain medication
utilization, erythema

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2019
Annals of Plastic Surgery • Volume 00, Number 00, Month 2019
question whether combination therapy may be more efficacious than
single modality treatments.
Bromelain is well supported across numerous studies in reducing
trismus, pain, and swelling following molar extractions. Although only
one study has been performed to date, it also seems to be advantageous
in orthognathic surgery. This is despite varying dosing and regimens.
Regardless of intervention, there were limited or no adverse ef-
fects reported in each study, demonstrating the safety of homeopathic
arnica or bromelain as a perioperative intervention.
Therefore, based on these studies, one may assume a positive ef-
fect by incorporating them into their perioperative care. However, this is
not commonly done. While this is likely multifactorial, a lack of knowl-
edge regarding homeopathic remedies and their dosing is probably at
the core. Homeopathic medications rely on ultradilute concentrations,
represented by “X' or “C” with the goal of using the lowest possible dose
to achieve the desired outcome. As this is not a commonly used dosing
mechanism, regimens and outcomes can be misguided and misinterpreted.
While herbal supplements hold promise for improving perioper-
ative outcomes, there are several limitations and unanswered questions.
Homeopathic medications are often toxic in nondiluted doses, making
superdilution critical to avoid toxicity. However, the dilution schematic
used in homeopathic medicine is not readily understood, making wide-
spread translation difficult. As homeopathic medicines often rely on
natural ingredients, for example, bromelain from pineapple or arnica
from perennial flowers, there is the option for whole food supplementa-
tion. However, while animal studies have attempted to differentiate effi-
cacy and dosing based on whole food or supplements, this has yet to be
translated into humans.40 While clinical trials investigating supple-
ments are controlled, supplements in general are not Food and Drug Ad-
ministration regulated and only certain brands are third-party validated.
Therefore, even if a patient agrees to supplement use, the actual type
and/or amount of supplement being consumed is often not clear. Thus,
both potential risk of additives and the potential benefit of the supple-
ment cannot always be accurately predicted and assessed.
In conclusion, a systematic review of the literature demonstrates
the potential for arnica and bromelain to improve perioperative out-
comes including edema, ecchymosis, and pain control. Future studies
are required to determine safety and efficacy of dosing and interactions
with other medications. We hope this article stimulates surgeons to con-
sider using these interventions to improve perioperative outcomes in the
context of well-done studies with an objective analysis of results.
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