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Marshmallow

Scientific Name(s): Althaea officinalis L.
Common Name(s): Althea, Altheae radix, Mallards, Marshmallow, Mauls, Schloss tea, White mallow

Clinical Overview

Use

A. officinalis has been traditionally used for cough, inflammation of the mouth and stomach, and peptic ulcers. It appears to have antimicrobial and anti-inflammatory properties and may be used topically to increase epithelialization of wounds. However, there are no recent clinical trials to support these uses.

Dosing

Root: 6 g/day.

Leaf: 10 g/day.

Marshmallow syrup: 10 g/day.

Topical: 5 to 10 g in an ointment or cream base or 5% powdered marshmallow leaf applied 3 times daily.

Gargle: 2 g soaked in 240 mL of cold water for 2 hours then gargled. Hot water should not be used.

Contraindications

Contraindications have not been identified.

Pregnancy/Lactation

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

Interactions

Oral medications: When taken with other oral medications, marshmallow may delay the absorption of the other medications.

Oral hypoglycemic agents/Insulin: Due to potential additive hypoglycemic effects, marshmallow should be used cautiously in patients receiving oral hypoglycemic agents and insulin.

Topical corticosteroids: Marshmallow may enhance the effects of topical corticosteroids. Use caution.

Aminoglycosides: Use caution or avoid use of marshmallow in patients receiving aminoglycosides such as gentamicin.

Adverse Reactions

Anecdotal evidence suggests potential allergic reactions and hypoglycemia.

Toxicology

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

Botany

Marshmallow is a perennial plant that grows up to 1.5 m in height in salt marshes and moist regions throughout Europe, western and northern Asia, and the eastern United States. Its flowers are pink and the 3-lobed leaves are velvety due to a dense covering of hair. The plant blooms from July to September and resembles hollyhock (Althaea rosea). Marshmallow root is collected in the fall from a plant that is at least 2 years old, and is then peeled of its brown corky layer, dried, and used in commerce.

The Malvaceae family is known as the mallow family, and confusion may surround the common nomenclature and identification of plants in this group. A. officinalis should not be confused with confectionary marshmallows, which were once made from A. officinalis but currently consist mostly of sugar.1

History

Marshmallow root has traditionally been recognized as a source of mucilage, which has been used for more than 2 millennia to treat topical wounds and as a remedy for sore throats, cough, and stomach ailments. The first recorded therapeutic use of marshmallow was in the ninth century BC.2 The mucilage is incorporated into ointments to soothe chapped skin and is added to foods in small quantities (approximately 20 ppm) to provide bulk and texture.3 One report discusses althea-type plants at a Neanderthal gravesite in Iraq.4 Marshmallow has also been used ritualistically to treat impotence; seeds are harvested under a full moon and made into an oil that is applied to the genitalia.1

Chemistry

Marshmallow root and leaves contain mucilage polysaccharides (6.2% to 11.6% and 6% to 9%, respectively).2 The mucilage content varies considerably with the season and is highest in the winter. A purified mucilage is composed of L-rhamnose:D-galactose:D-galacturonic acid:D-glucuronic acid in a molar ratio of 3:2:3:3.3 Asparagine (2%), sugars, pectin, and a tannin have also been identified in the root.5, 6 Fatty oil of althea has been addressed.7 Flavonoid compounds of the leaves, flowers, and roots have also been described, including glucosidoesters and monoglucosides.8, 9 According to one study, flavonoid content of the white flowers of A. officinalis is higher than that of the pink and reddish-pink flowers. However, the reddish-pink flowers possess higher antioxidant activity than the white or pink flowers.10

Uses and Pharmacology

Dermatologic conditions

The mucilaginous properties of althea root allow for the formation of a protective film over inflamed areas to help minimize inflammation.11 Combinations of althea extracts with steroids have been used in the management of dermatologic conditions,12, 13 and the plant appears to possess anti-inflammatory activity that potentiates the effect of topical steroids.14

Animal and in vitro data

In an in vitro study, A. officinalis protected against ultraviolet A (UVA) light–induced oxidative stress in skin fibroblasts. However, no reduction in DNA damage was noted with ultraviolet B (UVB) light irradiation. Thus, marshmallow might be useful in skin preparations that protect against UVA.15 In a murine model of wound excision creation, A. officinalis extract promoted epithelialization at a faster rate than was observed in the group that received no treatment; there were no differences between the A. officinalis group and the group treated with zinc oxide.16 In another study, topical use of an ointment containing A. officinalis extract increased wound healing in rabbits.17

Clinical data

A clinical trial evaluated the effects of a topical product containing A. officinalis, A. rosea (hollyhock), and other herbals for the treatment of leishmania lesions. Among patients receiving the topical herbal extract (n=86), a complete cure occurred in 74.4%, a partial cure occurred in 11.6%, and treatment failure occurred in 14%. Among those receiving the standard treatment of meglumine antimoniate injection, 24.1% experienced complete cure, 14.1% experienced partial cure, and 58.8% experienced treatment failure.18

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.19

Animal and in vitro data

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).20 In another murine model, marshmallow did not impact the quantity of ulcers or the ulcer index following administration of indomethacin; however, it did increase histamine release.19

Clinical data

Research reveals no clinical data regarding the use of marshmallow for the treatment of ulcers.

Antitussive effects

The polysaccharides in A. officinalis are believed to exert antitussive effects via formation of a protective film on the oropharyngeal mucosa. A model of lozenges containing marshmallow has been evaluated.21

Animal and in vitro data

In a study of cats, an A. officinalis polysaccharide dose of 50 mg/kg exerted cough-suppressing effects. An extract of marshmallow was less effective than the polysaccharide.22 In a model of airway inflammation in guinea pigs, the polysaccharide rhamnogalacturonan from A. officinalis exerted cough-suppressing effects in a dose-dependent fashion.23 In another study of guinea pigs, it was theorized that rhamnogalacturonan's antitussive effects might be attributed to its association with 5-hydroxytryptamine 2 (5-HT2)receptors.24 In vitro, althea 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 activity.25

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.26

Diabetes

Animal and in vitro data

In a murine model, a polysaccharide from A. officinalis reduced blood glucose levels.27 This may be attributed to the high pectin content in althea.1

Clinical data

Research reveals no clinical data regarding the use of marshmallow in diabetes.

Antimicrobial effects

Animal and in vitro data

In a murine model of wound excision creation, A. officinalis extract demonstrated antibacterial activity against the gram-positive organism Staphylococcus aureus, but did not demonstrate activity against gram-negative organisms.16 In an in vitro study, A. officinalis exerted antimicrobial activity against numerous periodontopathic bacterial strains. In general, the methanolic extract exerted better antibacterial activity than the decoctions, suggesting a potential role in the management of patients with periodontitis.28 In another in vitro study, A. officinalis demonstrated antibacterial effects against methicillin-resistant S. aureus.29

Clinical data

Research reveals no clinical data regarding the use of marshmallow for its antimicrobial effects.

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.30

Clinical data

Research reveals no clinical data regarding the use of marshmallow for its neuroprotective effects.

Other uses

Effects of varying doses of A. officinalis on lipid parameters, platelet aggregation, inflammation, and gastric ulcers were assessed in rats. Following 1 month of administration, A. officinalis did not reduce total cholesterol, low-density lipoprotein cholesterol, or triacylglycerol concentrations; however, high-density lipoprotein cholesterol levels were improved with the 50 mg/kg dose. Time-dependent inhibition of platelet aggregation was demonstrated with A. officinalis. Improvements in inflammation were noted in both the acute and chronic inflammation models, with an apparent optimal dose of 250 mg/kg to exert these anti-inflammatory effects.20

Dosing

Root

6 g/day.1, 11

Leaf

10 g/day.1, 11

Marshmallow syrup

10 g/day.1, 11

Topical

5 to 10 g in ointment or cream base or 5% powdered marshmallow leaf applied 3 times daily.1, 11

Gargle

2 g soaked in 240 mL of cold water for 2 hours then gargled. Hot water should not be used.1, 11

Pregnancy / Lactation

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

Interactions

Oral medications

When taken with other oral medications, marshmallow may delay the absorption of the other medications.1, 2

Oral hypoglycemic agents/Insulin

Due to potential additive hypoglycemic effects, marshmallow should be used cautiously in patients receiving oral hypoglycemic agents and insulin.1

Topical corticosteroids

Marshmallow may enhance the effects of topical corticosteroids. Use caution.1

Aminoglycosides

Use caution or avoid use of marshmallow in individuals receiving aminoglycosides such as gentamicin. A. officinalis extract at varying doses did not exert renal protective effects against gentamicin-induced nephrotoxicity; higher doses of the extract actually worsened renal dysfunction.31

Adverse Reactions

Anecdotal evidence suggests potential allergic reactions and hypoglycemia.1

Toxicology

The acute LD50 of A. officinalis in mice was greater than 5,000 mg/kg.21

References

1. Basch E, Ulbricht C, Hammerness P, Vora M. Marshmallow (Althaea officinalis L.) monograph. J Herb Pharmacother. 2003;3(3):71-81.15277059
2. Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000.
3. Evans WC. Trease and Evans’ Pharmacognosy. 13th ed. London, England: Bailliére Tindall; 1989.
4. Lietava J. Medicinal plants in a Middle Paleolithic grave Shanidar IV? J Ethnopharmacol. 1992;35(3):263-266.1548898
5. Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. New York, NY: Wiley; 1980.1225566
6. Windholz M, Budavari S, Blumetti RF, Otterbein ES, eds. The Merck Index: An Encyclopedia of Chemicals, Drugs, and Biologicals. 10th ed. Rahway, NJ: Merck & Co; 1983.
7. Mishina AS, Kornievskii IuI, Shkurupii SM, Dolia VS. Fatty oil of Althea officinalis, stoloniferous valerian and golden wallflower [in Ukrainian]. Farm Zh. 1975;(5):92-93.
8. Gudej J. Flavonoid compounds of leaves of Althea officinalis L. (Malvaceae). Part 1. Glucosidoesters and monoglucosides. Acta Pol Pharm. 1985;42:192-198.
9. Gudej J. Determination of flavonoid in leaves, flowers, and roots of Althea officinalis L. Farmacja Polska. 1990;46:153-155.
10. Sadighara P, Gharibi S, Moghadam Jafari A, Jahed Khaniki G, Salari S. The antioxidant and flavonoids contents of Althaea officinalis. L. flowers based on their color. Avicenna J Phytomed. 2012;2(3):113-117.25050239
11. van Wyk BE, Wink M, eds. Medicinal Plants of the World. Portland, OR: Timber Press Inc; 2005.5745965
12. Piovano PB, Mazzocchi S. Clinical trial of a steroid derivative (9-alpha-fluoro-prednisolone-21-acetate) in association with aqueous extract of althea in the dermatological field [in Italian]. G Ital Dermatol Minerva Dermatol. 1970;45(4):279-286.5537593
13. Huriez C, Fagez C. On the association of althea and dexamethasone: Dexalta ointment [in French]. Lille Med. 1968;13(2)(suppl):121-123.5745965
14. Beaune A, Balea T. Anti-inflammatory experimental properties of marshmallow: its potentiating action on the local effects of corticoids [in French]. Therapie. 1966;21(2):341-347.5935643
15. Curnow A, Owen SJ. An evaluation of root phytochemicals derived from Althea officinalis (marshmallow) and Astragalus membranaceus as potential natural components of UV protecting dermatological formulations. Oxid Med Cell Longev. 2016;2016;7053897.2695314410.1155/2016/7053897
16. Rezaei M, Dadgar Z, Noori-Zadeh A, Mesbah-Namin SA, Pakzad I, Davodian E. Evaluation of the antibacterial activity of the Althaea officinalis L. leaf extract and its wound healing potency in the rat model of excision wound creation. Avicenna J Phytomed. 2015;5(2):105-112.25949951
17. Valizadeh R, Hemmati AA, Houshmand G, Bayat S, Bahadoram M. Wound healing potential of Althaea officinalis flower mucilage in rabbit full thickness wounds. Asian Pac J Trop Biomed. 2015;5(11):937-943.
18. Zerehsaz F, Salmanpour R, Handjani F, et al. A double-blind randomized clinical trial of a topical herbal extract (Z-HE) vs. systemic meglumine antimoniate for the treatment of cutaneous leishmaniasis in Iran. Int J Dermatol. 1999;38(8):610-612.10487453
19. Zaghlool SS, Shehata BA, Abso-Seif AA, Abd El-Latif AA. Protective effects of ginger and marshmallow extracts on indomethacin-induced peptic ulcer in rats. J Nat Sci Biol Med. 2015;6(2):421-428.26283843
20. Hage-Sleiman R, Mroueh M, Daher CF. Pharmacological evaluation of aqueous extract of Althaea officinalis flower grown in Lebanon. Pharm Biol. 2011;49(3):327-333.21281251
21. Benbassat N, Kostova B, Nikolova I, Rachev D. Development and evaluation of novel lozenges containing marshmallow root extract. Pak J Pharm Sci. 2013;26(6):1103-1107.24191313
22. Nosál'ova G, Strapková A, Kardosová A, Capek P, Zathurecký L, Bukovská E. Antitussive action of extracts and polysaccharides of marshmallow (Althea officinalis L., var. robusta) [in German]. Pharmazie. 1992;47(3):224-226.1615030
23. Sutovska M, Capek P, Franova S, et al. Antitussive activity of Althaea officinalis L. polysaccharide rhamnogalacturonan and its changes in guinea pigs with ovalbumine-induced airways inflammation. Bratisl Lek Listy. 2011;112(12):670-675.22372330
24. Sutovská M, Nosálová G, Sutovský J, Franová S, Prisenznáková L, Capek P. Possible mechanisms of dose-dependent cough suppressive effect of Althaea officinalis rhamnogalacturonan in guinea pigs test system. Int J Biol Macromol. 2009;45(1):27-32.19447256
25. Müller-Limmroth W, Fröhlich HH. Effect of various phytotherapeutic expectorants on mucociliary transport [in German]. Fortschr Med. 1980;98(3):95-101.7364365
26. Rouhi H, Ganji F. Effect of Althaea officinalis on cough associated with ACE inhibitors. Pak J Nutr. 2007;6(3):256-258.
27. Tomoda M, Shimizu N, Oshima Y, Takahashi M, Murakami M, Hikino H. Hypoglycemic activity of twenty plant mucilages and three modified products. Planta Med. 1987;53(1):8-12.3575513
28. Iauk L, Lo Bue AM, Milazzo I, Rapisarda A, Blandino G. Antibacterial activity of medicinal plant extracts against periodontopathic bacteria. Phytother Res. 2003;17(6):599-604.12820224
29. Mehreen A, Waheed M, Liaqat I, Arshad N. Phytochemical, antimicrobial, and toxicological evaluation of traditional herbs used to treat sore throat. Biomed Res Int. 2016;2016:8503426.2742998310.1155/2016/8503426
30. Rezaei M, Alirezaei M. Protective effects of Althaea officinalis L. extract in 6-hydroxydopamine-induced hemi-Parkinsonism model: behavioral, biochemical and histochemical evidence. J Physiol Sci. 2014;64(3):171-176.24464760
31. Talebi A, Karimi A, Ouguerram K, et al. Lack of nephroprotective efficacy of Althaea officinalis flower extract against gentamicin renal toxicity in male rats. Int J Prev Med. 2014;5(11):1360-1363.25538830

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