Extracts of St. John's wort (Hypericum perforatum) are used in treatment of depression. They contain various substances with the naphthodianthrones
hypericin and
pseudohypericin as characteristic ingredients. These compounds were shown to cause
phototoxicity in cell culture and in animals. A placebo-controlled randomized clinical trial with monitoring of
hypericin and
pseudohypericin plasma concentration was performed to evaluate the increase in dermal photosensitivity in humans after application of high dose hypericum extracts. The study was divided into a single dose and a multiple dose part. In the single dose period, each of 13 volunteers received in a double blind fourfold complete crossover design, either placebo, or 900, 1800 or 3600 mg of a standardized
hypericum extract (LI 160) containing zero, 2.81, 5.62 and 11.25 mg of total
hypericin (total
hypericin is the sum of
hypericin and
pseudohypericin). Maximum total
hypericin plasma concentrations were observed about 4 h after dosage and were 0, 0.028, 0.061 and 0.159 mg/L, respectively. Before and 4 h after
drug intake, the subjects were exposed at small areas of their back to increasing doses of solar simulated irradiation (SSI, with combined ultraviolet A, UV-A, and UV-B light) and another part was exposed to selective UV-A light irradiation. Minimal
erythema dose was determined 5, 20 and 68 h after irradiation. Comparison of SSI sensitivity without and with hypericum extract did not show and difference and there was no dose-related trend in
light sensitivity. Sensitivity to selective UV-A light was increased only after the highest dose from a minimal tanning dose of 10.8 J/ cm2 (mean) after placebo to 8.7 J/cm2 after 3600 mg extract with marginal statistical significance (p = 0.03 by one sided paired t-test). There was no correlation between total
hypericin plasma concentrations and photosensitivity. In the multiple dose part, 50 volunteers received 600 mg hypericum extract t.i.d. with a daily dose of 5.6 mg of total
hypericin. Comparison of UV light sensitivity before dosing with day 15 of treatment showed a slightly increased SSI sensitivity expressed by decrease of the MED from 0.17 to 0.16 J/cm2 (p = 0.005 by Wilcoxon test), and similarly, sensitivity to UV-A light increased (the mean tanning dose decreased from 9.9 to 7.8 J/cm2, p < 0.0001). This increase in cutaneous
light sensitivity could be compensated by reducing irradiation time by 21%. Doses used in this study were higher than typical doses in current commercial preparations. In spite of these high doses in the double blind single dose part, frequency of side effects was equal to placebo medication and UV light sensitivity was not or only marginally increased. The study does not, however, exclude phototoxic reactions with doses above 11.25 mg of total
hypericin and plasma levels above 100 micrograms/L. Furthermore,
phototoxicity may be different after application of pure
hypericin, since some constituents in the
plant extract may exhibit protective effects.