Effectiveness of Topical Onion Extract Gel in the Cosmetic Appearance of Blepharoplasty Scar

J Clin Aesthet Dermatol. 2018;11(10):31–35

by Naser Owji, MD; Behzad Khademi, MD; and Mohammadreza Khalili, MD 

Drs. Owji, Khademi, and Khalili are with the Poostchi Ophthalmology Research Center at the Shiraz University of Medical Sciences in Shiraz, Iran.

FUNDING: This study was funded by Shiraz University of Medical Sciences (funding code #92-01-01-5783).

DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

ABSTRACT: Objectives.Topical onion extract gel is commonly used in commercial anti-scar medications. The purpose of this study was to evaluate the effectiveness of topical onion extract gel on the appearance of blepharoplasty scars and to compare the results of its use to those of petroleum jelly.

Design. The participants enrolled in this prospective, double-blind study were randomly treated with either topical onion extract gel or petroleum jelly. The products were applied twice daily for two months following suture removal. Patients were evaluated objectively using the Manchester Scar Scale at the end of treatment. Six months after surgery, a follow-up phone interview was conducted.

Setting.The study was carried out in the Khalili and Dastghaib Hospitals in Shiraz, Iran.

Participants.Out of 43 participants who had upper blepharoplasty, 26 patients completed the follow up.

Measurements.The Manchester Scar Scale evaluates five different characteristics of scar: color (score: 1–4), distortion (score: 1–4), contour (score: 1–4), texture (score: 1–4), and transparency (score: 1–2). A visual analogue scale (VAS) was also used to quantify the overall scar appearance on a range of 0 to 10 (with the highest number indicating the worst appearance). The scores for the five different parameters and the VAS were calculated and compared.

Results. There was no statistically signi?cant di?erence in overall cosmetic appearance objectively and/or subjectively between the two sides (p value: 0.25).

Conclusion. Topical onion extract gel was ineffective in improving overall blepharoplasty scar appearance when compared with a petroleum-based ointment.

KEYWORDS: Blepharoplasty, Contractubex, scar, petroleum jelly

Introduction

Blepharoplasty is one of the most common aesthetic surgeries in the world.¹ Hypertrophic scars and keloids seldom occur around the eyelids.² Since scars at the incision sites can present functional and aesthetic dilemmas and cause psychological stress in the patient, scar prevention is a concern for cosmetic surgeons.

According to a survey conducted in 2009, topical onion extract gel is commonly used in commercial antiscar medications.³ Its active component, Allium cepa, demonstrates anti-inflammatory, antiproliferative, antibacterial, and fibrinolytic properties.^4,5

In this study, we compared the effectiveness of a topical onion extract gel (Contractubex; Merz Pharmaceuticals, Frankfurt, Germany) with petroleum jelly for the improvement of blepharoplasty scars. To the best of our knowledge, this is the first study to investigate the efficacy of topical onion extract for the improvement of blepharoplasty scars.  

Methods

We designed a prospective, interventional, comparative, double-blind case series involving patients who underwent upper blepharoplasty. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

Of the 43 subjects who were included in the study, 26 patients completed the follow-up. All of them were Iranian women. The ages of the patients ranged from 39 to 65 years, with an average age of 51.5 years.

The exclusion criteria of our study included the following: 

• Diseases that impair wound healing, such as diabetes mellitus and connective tissue diseases
• Previous upper eyelid surgery or trauma 
• Skin disease
• Significant postoperative hematoma
• Retinoid use within three months berfore the surgery. 

Blepharoplasty was done by an oculoplastic surgeon under standby anesthesia (lidocaine 2% with 1/100,000 epinephrine), and incisions were closed with continuous 6/0 nylon sutures. Sutures were removed on the seventh postoperative day. Patients were instructed to apply a cold compress for 20 minutes every two hours for 48 hours post-surgery. Patients also applied topical erythromycin eye ointment twice daily until suture removal at one-week post-surgery. Following removal of the suture, each side was randomly treated with either topical onion extract or petroleum jelly. Each participant was given two opaque drug canisters in accordance with the allocated group and instructed to apply one medication to the right eyelid and the other medication to the left eyelid two times a day for two months in combination with wound line massage. Patients and observers were blind to which medications were applied.

All patients were evaluated at one-week post-surgery, concurrent with suture removal, and again in the fourth postoperative week to assess side effects and complete any required drug refills. All patients had additional follow-up appointments in the eighth postoperative week and were evaluated objectively by two observers: an oculoplastic surgeon and an ophthalmologist, who were blind to the type of medications. The observers used the Manchester Scar Scale (MSS).⁶ The MSS evaluates the following five characteristics of scar: color (score: 1–4), distortion (score: 1–4), contour (score: 1–4), texture (score: 1–4), and transparency (score: 1–2) (Table 1). A visual analogue scale (VAS) was also used, which scores the overall scar appearance on a scale of 0 to 10, where 10 denotes the worst appearance. The scores for the five different parameters and the VAS were calculated and compared with each other.

The final follow-up took place by phone in the sixth postoperative month. All patients were questioned about redness and the subjective appearance of scar between the two eyelids.

We used the Statistical Package for the Social Sciences version 15 software (IBM Corp., Armonk, New York) and the Mann-Whitney U test for the analysis of data. A P value greater than 0.05 was considered significant.

Results

Seven subjects did not complete the study due to incomplete follow-up. Ten patients left the study due to intolerance of topical onion extract gel. We compared the scores of the two observers, which showed no significant difference (p-value: 0.719), and used the average for the final comparison. All parameters of the MSS mentioned were scored for each eyelid and compared between sides. The mean MSS scores were was 10.076 for the side of the face that received the topical onion extract gel and 10.038 for the side that received petroleum jelly. There was no statistically significant difference between two sides (p-value: 0.25). There was neither a statistically significant difference in any of the scar characteristics (color, translucence, contour, distortion, and texture [all had p-value <0.05]) nor in the sum of the scores.

During the sixth-month phone follow-up, our patients were asked about their satisfaction levels when comparing their two eyelids and whether they perceived a difference in the appearance between the two eyelids. The results revealed no significant disparities between the two scar sites on the basis of subjectivity (p-value: 0.763). Patients were also questioned about any difference in scar redness between the two lids; the results showed no difference (p-value: 0.793).

Discussion

Blepharoplasty is among the three most common types of cosmetic surgeries performed in the United States.¹ A prominent scar at the site of operation presents cosmetic concerns and can impact patient satisfaction. 

Wound healing involves four different phases that overlap with each other: hemostasis, inflammation, proliferation, and maturation/remodeling.⁷ Disruption of the normal healing process leads to abnormal wound healing and scar formation.⁷ 

The topical onion extract gel used in the study is a top-selling over-the-counter antiscar agent.³ According to a literature review, there have been a few randomized, controlled trials conducted on the potential benefits of this topical onion extract gel product;⁸ however, to our knowledge, our investigation is the first randomized, prospective, double-blinded study to evaluate the effectiveness of this topical agent for the improvement of scarring after blepharoplasty.

Onion extract gel is available in both Europe and the United States. Mederma®, the American formulation of topical onion extract gel (Merz North America, Raleigh, North Carolina) contains 10% aqueous onion extract and 1% allantoin. The European formulation used in this study ((Contractubex®) contains Allium cepa, allantoin, and heparin, the latter of which is thought to inhibit fibroblast proliferation.⁹  The manufacturers of these onion extract agents have claimed their products cosmetically improve surgical scarring,¹⁰ but the clinical efficacy in scar improvement has not been shown.⁸

The exact mechanism of onion extract in the wound healing process is unknown. Perhaps its role occurs through its antibacterial, anti-inflammatory, antiproliferative, and collagen downregulatory properties. These actions are conducted by its effect on fibroblasts and mast cells.^9,11,12

Wound hydration is one of the most important factors that reinforce wound healing. A moist environment is considered essential in wound healing, especially in chronic cases.¹³ A humidified setting accelerates cutaneous wound healing and prevents scars, which could be achieved by petroleum jelly.^14,15

 According to our results obtained using the MSS, the onion extract gel was equally effective as petroleum jelly in improving scar cosmesis following upper eyelid blepharoplasty.

Our results agree with previous studies. Jackson et al¹⁶ evaluated the effects of onion extract and petroleum jelly in patients with scars from Mohs surgery and found no significant effect of onion extract on color and itching of the scar, though a significant reduction in redness was noted in the petroleum group. Hosnuter et al¹⁷ demonstrated no significant influence of onion extract gel on the height, itching, or color of hypertrophic and keloid scars. Saulis et al¹⁸ found that onion extract gel was ineffective in the reduction of redness and scar hypertrophy in an induced rabbit ear wound. Additionally, Clarke et al¹⁹ found no difference in physician assessment of scar improvement between placebo and onion extract gel, while Chung et al²⁰ evaluated the effects of onion extract gel in 24 subjects with new surgical wounds compared with petroleum ointment and found no statistically signi?cant di?erence in terms of scar symptoms, erythema, hypertrophy, and overall cosmetic improvement. 

A few studies comparing the effects of onion extract gel (e.g., Erasé® gel [Zenta Healthcare, New Delhi, India] and Contractubex®) on the incision site from caesarean section found onion extract to be effective for scar reduction.^21,22 Onion extract gel was also useful in scar treatment after thoracic surgery.²³

This discrepancy in results between studies might be due to diversity of the study population, different causes of scar formation, and the use of different scales for scoring and assessing scars. The risk of abnormal scar tissue formation is higher in some parts of the body following a surgical wound (e.g., the shoulder, scapula, anterior chest, lower abdomen, earlobe, and all cutaneous tissues on bony prominences).²⁴ In the studies that showed reduced scar formation after using onion extract gel following caesarean section and thoracic surgery, the results might be due to the higher potential for abnormal scar formation in the studied surgical sites than in our studied surgical site, the eyelid, which has a lower risk for this type of scar. This might explain the discrepancies between the results of our study and these studies. 

From the pathological aspect, fibroblast proliferation, collagen synthesis, and fibroplasia occur more vigorously during wound healing in regions with thicker dermis.²⁵ These processes occur in the eyelids, but with a lesser intensity, due to the thinner dermis present there. This suggests that onion extract gel might be effective for anatomical regions with a thickened dermis that are considered high-risk for scar formation. According to our study on eyelids, as the eyelids are a low-risk anatomical region for scar formation, onion extract gel is not superior to petroleum jelly as a preventive measure for improving scar appearance.

On the other hand, wound massage with physical manipulation of the scar at the earliest stage of wound remodeling (two weeks after wounding) can be beneficial.^26,27 In our cases, the combination of physical massage with petroleum jelly or onion extract gel might have been bene?cial in improving the appearance of scars. These two agents, in addition to their direct effects on wound healing, might have acted as a lubricant for massage therapy.

When we evaluated the safety profile of these medications, we enrolled all patients, including those who left the study. Of the patients who used onion extract gel (n=43), 11 patients (25.6%) reported significant local reaction (itching, burning, redness). One of these 11 patients completed the follow-up, and 10 cases left the study early because of intolerable symptoms. On the eyelid that received petroleum jelly, no local adverse reactions were reported. The observed side effects might be attributed to the constituting ingredients of onion extract gel and have been reported in other studies.^28,29 

Our study investigated two topical agents in a single patient simultaneously. A comparison of topical agents in the same individual eliminates intrinsic and extrinsic confounding factors that might affect scar formation. 

Limitations. Our study is limited by the small sample size. Future studies that include a larger number of patients are needed to support our findings.

Conclusion

Based on our results, we found no difference between onion extract gel and petroleum jelly regarding their effects on scar appearance on the eyelids following blepharoplasty. Petroleum jelly is considerably cheaper than onion extract gel, and localized irritation was rarely reported with petroleum jelly. These factors and the results of our study suggest petroleum jelly is a suitable option for post-blepharoplasty wound care. Further studies are needed to confirm our findings. 

References

1. Black EH NF, Gladstone G, Levine MR, Calvano CJ. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery. 3rd ed. New York, NY: Springer; 2012.
2. Cho IC. Revision upper blepharoplasty. Semin Plast Surg. 2015;29(3):201–208.
3. Morganroth P, Wilmot AC, Miller C. Over-the-counter scar products for postsurgical patients: disparities between online advertised benefits and evidence regarding efficacy. J Am Acad Dermatol. 2009;61(6):e31–e47.
4. Foo CW, Tristani-Firouzi P. Topical modalities for treatment and prevention of postsurgical hypertrophic scars. Facial Plast Surg Clin North Am. 2011;19(3):551–557.
5. Liu A, Moy RL, Ozog DM. Current methods employed in the prevention and minimization of surgical scars. Dermatol Surg. 2011;37(12):1740–1746.
6. Beausang E, Floyd H, Dunn KW, et al. A new quantitative scale for clinical scar assessment. Plast Reconstr Surg. 1998;102(6):1954–1961.
7. Gantwerker EA, Hom DB. Skin: histology and physiology of wound healing. Facial Plast Surg Clin North Am. 2011;19(3):441–453.
8. Khansa I, Harrison B, Janis JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr Surg. 2016;138(3 Suppl):165S–178S.
9. Augusti K. Therapeutic values of onion (Allium cepa L.) and garlic (Allium sativum L.). Indian J Exp Biol. 1996;34(7):634–640.
10.  Zurada JM, Kriegel D, Davis IC. Topical treatments for hypertrophic scars. J Am Acad Dermatol. 2006;55(6):1024–1031.
11. Cho JW, Cho SY, Lee SR, Lee KS. Onion extract and quercetin induce matrix metalloproteinase-1 in vitro and in vivo. Int J Mol Med. 2010;25(3):347–352.
12. Pawlikowska-Pawlega B, Gawron A. Effect of quercetin on the growth of mouse fibroblast cells in vitro. Pol J Pharmacol. 1995;47(6): 531–535.
13. Panuncialman J, Falanga V. The science of wound bed preparation. Surg Clin North Am. 2009;89(3):611–626.
14. Field CK, Kerstein MD. Overview of wound healing in a moist environment. Am J Surg. 1994;167(1):S2–S6.
15. Sawada Y, Sone K. Hydration and occlusion treatment for hypertrophic scars and keloids. Br J Plast Surg. 1992;45(8):599–603.
16. Jackson BA, Shelton AJ. Pilot study evaluating topical onion extract as treatment for postsurgical scars. Dermatol Surg. 1999;25(4):267–269.
17. Hosnuter M, Payasli C, Isikdemir A, Tekerekoglu B. The effects of onion extract on hypertrophic and keloid scars. J Wound Care. 2007;16(6): 251–254.
18. Saulis AS, Mogford JH, Mustoe TA. Effect of Mederma on hypertrophic scarring in the rabbit ear model. Plast Reconstr Surg. 2002;110(1):177–183; discussion 84–86.
19. Clarke LF, Baker B, Trahan C, et al. A prospective double-blinded study of Mederma skin care versus placebo for post-traumatic scar reduction. Cosmetic Dermatol. 1999;12(3):11.
20. Chung VQ, Kelley L, Marra D, Jiang SB. Onion extract gel versus petrolatum emollient on new surgical scars: prospective double-blinded study. Dermatol Surg. 2006;32(2):193–197.
21. Chanprapaph K, Tanrattanakorn S, Wattanakrai P, et al. Effectiveness of onion extract gel on surgical scars in asians. Dermatol Res Pract. 2012;2012:212945.
22. Ocampo-Candiani J, Vazquez-Martinez OT, Iglesias Benavides JL, et al. The prophylactic use of a topical scar gel containing extract of Allium cepae, allantoin, and heparin improves symptoms and appearance of cesarean-section scars compared with untreated scars. J Drugs Dermatol. 2014;13(2):176–182.
23. Willital G, Heine H. Efficacy of Contractubex gel in the treatment of fresh scars after thoracic surgery in children and adolescents. Int J Clin Pharmacol Res. 1994;14(5–6):193–202.
24. Ogawa R. Keloid and hypertrophic scarring may result from a mechanoreceptor or mechanosensitive nociceptor disorder. Med Hypotheses. 2008;71(4):493–500.
25. Kim S, Choi TH, Liu W, et al. Update on scar management: guidelines for treating Asian patients. Plast Reconstr Surg. 2013;132(6):1580–1589.
26. Draelos ZD. The ability of onion extract gel to improve the cosmetic appearance of postsurgical scars. J Cosmet Dermatol. 2008;7(2):101–104.
27. Roques C. Massage applied to scars. Wound repair and regeneration. 2002;10(2):126–128.
28. Beuth J, Hunzelmann N, Van Leendert R, et al. Safety and efficacy of local administration of contractubex to hypertrophic scars in comparison to corticosteroid treatment. Results of a multicenter, comparative epidemiological cohort study in Germany. In Vivo. 2006;20(2):277–283.
29. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg. 2006;32(7): 891–896.