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Mallows

Scientific Name(s): Alcea rosea L., Althaea officinalis L., Althaea rosea (L.) Cav., Malva neglecta Wallr., Malva officinalis (L.) K.F. Schimp. & Spenn., Malva parviflora, Malva sylvestris L.
Common Name(s): Antwerp hollyhock (A. rosea), Common mallow (M. neglecta, M. sylvestris), Common marshmallow (A. officinalis), High mallow (M. sylvestris), Hollyhock (Alcea spp.), Mallow (Malva spp.), Marshmallow (Althea spp.)

Medically reviewed by Drugs.com. Last updated on Jun 21, 2024.

Clinical Overview

Use

Limited clinical trial data primarily focus on use in the treatment of dermatologic and oral and pharyngeal mucosa conditions, due to the plant's anti-inflammatory activity. Despite a lack of clinical data, use of marshmallow (A. officinalis) for treatment of irritation of oral and pharyngeal mucosa and associated dry cough has been documented, according to the European Medicines Agency (EMA) and the Expanded Commission E Monographs.

Dosing

Commercial tea products are available. A. officinalis is indicated for dry, irritable cough and irritation of oral and pharyngeal mucosa by the EMA; however, robust clinical trial data are lacking.

Contraindications

Avoid use if allergic or hypersensitive to any components of the plant species.

Pregnancy/Lactation

Avoid use. Information regarding safety and efficacy in pregnancy and lactation is lacking.

Interactions

None well documented.

Adverse Reactions

Information regarding potential adverse reactions is lacking.

Toxicology

No data.

Scientific Family

Botany

The Malvaceae family, commonly known as mallows, is represented by almost 100 different genera, including Alcea, Althaea, Malva, and Lavatera.(ITIS 2021, Milin 2003, USDA 2021) Mallows are perennial plants native to Europe, North Africa, and southwestern Asia. The plants have been naturalized in North America and are cultivated from western Europe to Russia. They prefer damp areas, such as the ocean, salt marshes, meadows, sides of ditches, and banks of tidal rivers. They grow 1 to 2 m in height, and the leaves, flowers, and roots have been used for medicinal purposes. The flowers bloom in late spring, and the roots must be at least 2 years old before harvesting.(Chevallier 1996, USDA 2022)

Confusion may surround the scientific names, common nomenclature, and identification of plants in the mallow group. Althaea rosea (L.) Cav. is an accepted synonym for Alcea rosea L., while Malva officinalis (L.) K.F. Schimp. & Spenn is considered an accepted synonym for Althea officinalis L.(ITIS 2021, USDA 2021)

History

The mallow plants have a rich ethnomedicinal history and have been used since ancient Greek and Roman times. The leaves and shoots of common mallow have been used as food sources since the eighth century BC, whereas documented use of marshmallow root was first recorded in the ninth century BC, when it was used to treat sore throat, cough, stomach ailments, and as a topical wound treatment.(Blumenthal 2000, Chevallier 1996) One report discusses Althea-type plants at a Neanderthal gravesite in Iraq.(Lietava 1992) The aboveground portions of the plant have been used in pancakes and salads, cooked as greens, and used as stuffing.(Dogan 2004) The immature fruits may be consumed raw.(Tardio 2005)

Ethnomedicinal references document mallow plant efficacy as an anti-inflammatory for the respiratory tract, GI tract, and the skin.(Camejo-Rodrigues 2003, Guarrera 2005, Mousavi 2021, Novais 2004, Pieroni 2005, Pieroni 2004a, Pieroni 2004b) The plant can be used topically or in a bath to treat abscesses, bruises, burns, dermatitis, swelling, and varicose ulcers.(Camejo-Rodrigues 2003) A decoction may be chewed, gargled, or used as a wash to treat sore throat; mouth, throat, and gingival inflammation; and respiratory conditions, such as bronchitis and whooping cough.(Blumenthal 2000, Guarrera 2005, Pieroni 2004a, Pieroni 2004b) It may also be used as a compress on the stomach to relieve abdominal pains.(Pieroni 2005) M. sylvestri has been consumed as food to help with constipation or similar GI discomfort.(Guarrera 2005)

The mucilage compounds of A. officinalis are of commercial interest, particularly in dermatology and cosmetic preparations. Decoctions of the flowers and leaves of M. sylvestri have been used as an astringent and to treat acne.(Guarrera 2005, Hlavaty 1989, Mousavi 2021, Naseri 2021, Pieroni 2004b) Various other uses of the various species have been documented.(Mousavi 2021)

A. officinalis should not be confused with confectionary marshmallows, which were once made from A. officinalis but currently consist mostly of sugar.(Basch 2003)

Chemistry

The active components of the plant species are found in the leaves, flowers, and roots. Several studies document the mucilaginous polysaccharide content in the plant; the primary components are composed of rhamnose, galactose, galacturonic acid, and glucuronic acid.(Classen 2002, Gonda 1990a, Gonda 1990b, Karawya 1971, Tomoda 1989) Flavonoids, phenolic acids, tannins, and volatile oils have also been isolated.(Billeter 1991, Blumenthal 2000, Cutillo 2006, Proestos 2005) Malonated anthocyanins have been isolated from the flowers.(Mas 2000, Pourrat 1990, Takeda 1989)

Pharmaceutical-grade A. officinalis leaf must have a swelling index of at least 12 and pass macroscopic and microscopic authentication for botanical identification. The British Herbal Pharmacopoeia requires marshmallow leaf to be harvested before the flowering period and identified by thin-layer chromatography (TLC). The water-soluble extract must be at least 15%. Pharmaceutical-grade A. officinalis root also must pass macroscopic and microscopic authentication tests and have a swelling index of at least 10 (for the pulverized root). The British Herbal Pharmacopoeia requires botanical identification by TLC and additional quantitative standards for marshmallow root. A swelling index of at least 15 is required by The Swiss Pharmacopoeia.(Blumenthal 2000, EMA 2016, Rosik 1984, Ullmann 1990)

Uses and Pharmacology

Limited clinical trial data mainly focus on the anti-inflammatory properties of the plant for dermal, oral, and pharyngeal conditions. Despite a lack of clinical data, use of marshmallow (A. officinalis) for treatment of irritation of oral and pharyngeal mucosa and associated dry cough has been documented, according to the EMA and the Expanded Commission E Monographs.(EMA 2016, Silveira 2020)

Antibacterial activity

Animal and in vitro data

In contrast to in vitro antimicrobial activity of a methanolic extract of A. officinalis flowers and leaves,(Mehreen 2016) the extract did not show anti–methicillin-resistant Staphylococcus aureus (MRSA) efficacy in vivo. An S. aureus strain isolated from patients with sore throat was used to inoculate mice for an infection model; the strain was resistant to methicillin, cefixime, oxacillin, gentamicin, and penicillin. Administration of A. officinalis extract did not significantly reduce the bacterial load in the throat, joints, lung, heart, or blood compared with positive, untreated controls.(Arshad 2017) In a murine model of wound excision creation, A. officinalis extract demonstrated antibacterial activity against the gram-positive organism S. aureus, but did not demonstrate activity against gram-negative organisms.(Rezaei 2015)

A. officinalis has antibacterial activity that may be useful in periodontal prophylaxis.(de Souza 2004, Iauk 2003, Proestos 2005) In vitro, an ethanolic extract of A. officinalis roots and leaves was more effective against the dental caries strain Streptococcus mutans than Lactobacillus acidophilus in a dose- and time-dependent manner.(Haghgoo 2017)

Anti-inflammatory effects

Animal data

Improvements in inflammation were noted with A. officinalis in both acute and chronic inflammation rat models; the apparent optimal dose for exerting anti-inflammatory effects was determined to be 250 mg/kg.(Hage-Sleiman 2011)

Antioxidant activity

In vitro data

In vitro studies document antioxidant properties of the plant.(Ferreira 2006, Kardosová 2006, Mavi 2004)

Antitumor effects

In vitro data

In vitro analysis of a crude powder from Malva crispa L. showed antitumor activity.(Huang1998)

Antitussive activity

A. officinalis oral preparations demonstrate antitussive efficacy due to observed bioadhesive and anti-inflammatory properties, thereby acting to relieve mucosal irritation and hyposalivation.(Alani 2015, Benbassat 2013, Skrinjar 2015)

Animal data

A 100 mg/kg complex extract and 50 mg/kg polysaccharide isolated from the roots of A. officinalis were effective as antitussive agents in cats. The cough suppressant activity of the polysaccharide was more effective than prenoxdiazine but not dropropizine; marshmallow extract was less effective than the polysaccharide.(Nosal'ova 1992) Tracheobronchial smooth muscle contractility was inhibited by extracts of Althaea root in studies in rats, while in a model of airway inflammation in guinea pigs, the polysaccharide rhamnogalacturonan from A. officinalis exerted cough-suppressing effects in a dose-dependent manner, suggesting a potential role in the treatment of asthma.(Alani 2015, Sutovská 2009, Sutovska 2011) In vitro, Althaea reduced the transport velocity of isolated ciliated epithelium cells of the frog esophagus. Additionally, marshmallow may be useful in the management of cough and cold because of its ability to protect mucosal layers in the hypopharynx, and because of its spasmolytic, antisecretory, and bactericidal activities.(Müller-Limmroth 1980)

Clinical data

In a clinical study, 60 patients with angiotensin-converting enzyme inhibitor–induced cough were randomized to receive A. officinalis 40 mg (given as 20 drops) or placebo every 8 hours for 4 weeks. At the end of the study, patients receiving A. officinalis had significantly lower cough scores compared with baseline (P<0.05). No significant changes were noted in the placebo group. Eight patients in the A. officinalis arm experienced almost complete resolution of cough.(Rouhi 2007)

A. officinalis has been used for dry, irritable cough and irritation of oral and pharyngeal mucosa, according to the EMA. In an assessment of the benefits/risks of select herbal medicines traditionally used for respiratory diseases, clinical evidence regarding the safety and effectiveness of A. officinalis for use in cough, such as that associated with early COVID-19 symptoms, was rated as "high" based on a clinical decision-making framework; however, robust clinical data are lacking.(Silveira 2020)

Antiulcerogenic effects

Marshmallow is possibly beneficial in providing gastroprotection from ulcers due to its mucilaginous properties and flavonoid content, which offers coverage and protection of the GI tract.(Zaghlool 2015)

Animal and in vitro data

Histopathological results document that M. neglecta extracts protected rats from ethanol-induced gastric lesions.(Gürbüz 2005) Antiulcerogenic activity may be associated with the high mucilage content from the plant species. In a murine model, rats with ethanol-induced ulcers showed greater gastric protection with administration of A. officinalis 250 mg/kg than with control (cimetidine) (P<0.05).(Hage-Sleiman 2011) In another murine model, marshmallow did not impact the quantity of ulcers or the ulcer index following administration of indomethacin (to induce peptic ulcer); however, it did increase histamine release.(Zaghlool 2015)

Antiviral activity

In vitro data

In vitro, an aqueous extract of M. sylvestris had antiviral activity against HIV by reducing viral infectivity by 67% compared with 80% for the positive control, zidovudine, while the vehicle control showed no effect.(Benso 2021)

Dermatologic effects

The mucilaginous properties of Althea root allow for the formation of a protective film over inflamed areas to help minimize inflammation.(van Wyk 2005) Combinations of Althea extracts with steroids have been used in the management of dermatologic conditions,(Huriez 1968, Piovano 1970) and the plant appears to possess anti-inflammatory activity that potentiates the effect of topical steroids.(Beaune 1966)

Animal and in vitro data

Topical application of a hydroalcoholic extract of M. sylvestris significantly improved chronic skin inflammation in a psoriasis-like mouse model (P<0.001). Mean maximal reduction in edema was 64.7% for the extract and 79.9% for the positive control, dexamethasone, compared with controls and was observed on the first day of treatment application. Antiproliferative effects were confirmed in vitro.(Prudente 2017) Root extracts reduced ultraviolet A (UVA)-induced DNA damage in cultured human lung and skin fibroblasts.(Curnow 2016) In another study, topical use of an ointment containing A. officinalis extract increased wound healing in rabbits.(Valizadeh 2015) Wound healing benefit of a hydroalcoholic gel extract of A. officinalis has been documented in rats. Wound closure rates and fibroblast densities for both the 5% and 10% extract groups were significantly better than for controls.(Mohsenikia 2020)

In vitro, A. officinalis inhibited intracellular calcium mobilization in normal human melanocytes (NHMC) activated by endothelin-1 (ET-1). ET-1 expression increased in the epidermis after ultraviolet (light) B (UVB) irradiation, which is likely to contribute to UVB-induced pigmentation. ET-1 also is involved with inducing NHMC. The results of the study suggest the extracts from A. officinalis inhibit the physiological effect of ET-1 on NHMC after UVB irradiation and may be useful when used in combination with other preparations in treating hyperpigmentation conditions or disorders.(Kobayashi 2002)

Clinical data

In a double-blind, randomized, active-controlled pilot study conducted in 30 children 3 months to 12 years of age with atopic dermatitis, topical application of an A. officinalis flower ethanolic extract as a 1% ointment significantly improved dermatitis severity scores compared to hydrocortisone 1% ointment over the 4-week treatment period (P=0.015). Ointments (1.5 cc) were applied twice a day for 7 days, then 3 times per week for 3 weeks. No side effects were reported.(Naseri 2021)

Diabetes

Animal and in vitro data

In a murine model, a polysaccharide from A. officinalis reduced blood glucose levels.(Tomoda 1987) This may be attributed to the high pectin content in Althea.(Basch 2003)

Immune system effects

In vitro data

A carbohydrate in mallow has anticomplementary activity on the immune system. In vitro analysis of an acidic polysaccharide from the seeds of the related Malva species M. verticillata stimulated the reticuloendothelial system.(Gonda 1990a, Gonda 1990b)

Immune-stimulating effects have been demonstrated for A. rosea flower water extract via activation of MAPK and nuclear factor kappaB pathways and subsequent increased production of interleukin 6, tumor necrosis factor alpha, inducible nitric oxide synthase (iNOS), and cyclooxygenase 2. No cytotoxic effect on cell viability was observed.(Kim 2017)

Lipid effects

Animal data

One study in rats investigated the effects of anthocyanin from M. sylvestris on plasma lipids. Decreases in total cholesterol (20%) and triglycerides (34%) were found.(Wang 2005) In another rat study, A. officinalis administration for 1 month did not reduce total cholesterol, low-density lipoprotein cholesterol, or triacylglycerol concentrations; however, high-density lipoprotein cholesterol levels were improved with a 50 mg/kg dose.(Hage-Sleiman 2011)

Neuroprotective effects

Animal and in vitro data

In a study of rats with induced hemi-Parkinsonism, an A. officinalis 10 mg/kg extract exerted neuroprotective effects.(Rezaei 2014)

Platelet aggregation inhibitory effects

Animal data

Time-dependent inhibition of platelet aggregation has been demonstrated with A. officinalis in rats.(Hage-Sleiuman 2011)

Dosing

Commercial tea products are available.(Blumenthal 2000) A. officinalis has been used to manage dry, irritable cough and irritation of oral and pharyngeal mucosa, according to the EMA.(EMA 2016, Silveira 2020)

Cough

In a clinical study, A. officinalis 40 mg (given as 20 drops) every 8 hours for 4 weeks was evaluated in patients with angiotensin-converting enzyme inhibitor–induced cough.(Rouhi 2007, Silveira 2020)

Based on European Scientific Cooperative on Phytotherapy and traditional uses, A. officinalis has been dosed at 0.5 to 5 g in 150 mL of water as a macerate of roots and leaves, given 3 times daily. The syrup of the roots is commonly dosed at 2 to 8 mL/day.(Silveira 2020)

Atopic dermatitis

One study in children with atopic dermatitis evaluated an A. officinalis 1% ointment (made via maceration method using marshmallow dried flowers) topically applied 2 times per day for 7 days, then 3 times per week for 3 weeks.(Naseri 2021)

Pregnancy / Lactation

Avoid use. Information regarding safety and efficacy in pregnancy and lactation is lacking.

In Iran, where "hollyhock" (A. officinalis) is confirmed to be safe during lactation, the effect of topical application of A. officinalis leaf and stem powder combined with warm/cold compresses on breast engorgement was investigated in a randomized, controlled trial (N=47) in mothers breastfeeding every 2 to 3 hours. Neonates were full-term and of normal birth weight. The intervention was applied 3 times daily for 2 days. In addition to the warm/cold compress regimen, adjunctive application of 40 to 50 mL of leaf compress after breastfeeding significantly reduced breast engorgement severity scores compared to use of only the warm/cold compress regimen. Mean severity scores in the treatment group decreased from 9.15 at baseline to 0.2 by the end of day 2 compared with a reduction from 10.05 to 3.02 for controls (P<0.001).(Khosravan 2017)

Interactions

None well documented. The mucilage present in A. officinalis preparations may interfere with the absorption of other drugs. The EMA advises against taking A. officinalis 30 to 60 minutes before or after other drugs, minerals, or vitamins.(Silveira 2020)

Due to potential additive hypoglycemic effects, based on anecdotal and animal studies, marshmallow should be used cautiously in patients receiving oral hypoglycemic agents and insulin.(Basch 2003)

Adverse Reactions

No serious adverse reactions were reported in 2 clinical trials. Irritant contact dermatitis has been reported in 2 patients after topical application of M. sylvestris; bullous lesions and erythematous localized vesicular lesions developed 3 days and 12 hours later, respectively.(An 2019)

Anecdotal evidence suggests potential allergic reactions and hypoglycemia.(Basch 2003)

Toxicology

The acute median lethal dose (LD50) of A. officinalis in mice was greater than 5,000 mg/kg.(Benbassat 2013)

In a study evaluating M. parviflora growing in polluted soil, plant tissues showed accumulating concentrations of heavy metals, to an extent that could be hazardous to adults if consumed.(Galal 2019)

Index Terms

References

Disclaimer

This information relates to an herbal, vitamin, mineral or other dietary supplement. This product has not been reviewed by the FDA to determine whether it is safe or effective and is not subject to the quality standards and safety information collection standards that are applicable to most prescription drugs. This information should not be used to decide whether or not to take this product. This information does not endorse this product as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this product. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this product. This information is not specific medical advice and does not replace information you receive from your health care provider. You should talk with your health care provider for complete information about the risks and benefits of using this product.

This product may adversely interact with certain health and medical conditions, other prescription and over-the-counter drugs, foods, or other dietary supplements. This product may be unsafe when used before surgery or other medical procedures. It is important to fully inform your doctor about the herbal, vitamins, mineral or any other supplements you are taking before any kind of surgery or medical procedure. With the exception of certain products that are generally recognized as safe in normal quantities, including use of folic acid and prenatal vitamins during pregnancy, this product has not been sufficiently studied to determine whether it is safe to use during pregnancy or nursing or by persons younger than 2 years of age.

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