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Evening Primrose Oil

John Montgomery6 min read

Evening Primrose Oil

Evening primrose oil (EPO) is pressed from the seeds of Oenothera biennis. It is rich in omega-6 fatty acids: a standard 1 g Efamol capsule holds about 0.62 g Linoleic Acid and 0.08 g Gamma-Linolenic Acid (GLA) (AAFP 2009). The theory behind it, popular from the early 1980s, was that people with Atopic Dermatitis convert linoleic acid to GLA poorly, so taking GLA directly would bypass the block, feed anti-inflammatory prostaglandin pathways and repair the Skin Barrier Dysfunction. The mechanism looked plausible, side effects seemed few, and a “natural” option appealed to families with Steroid Phobia (Bamford 2013; AAFP 2009). Native Americans used the plant’s stem and leaf juices as topical remedies, and it is still sold widely as a food supplement for eczema, premenstrual symptoms and breast pain (AAFP 2009). Borage Oil (starflower oil) is a related, GLA-richer seed oil sold for the same purpose.

Evening Primrose Oil [part-of] Herbal and Home Remedies for Eczema Evening Primrose Oil [relates] Gamma-Linolenic Acid Evening Primrose Oil [relates] Linoleic Acid Evening Primrose Oil [relates] Borage Oil Steroid Phobia [relates] Evening Primrose Oil

Strength of evidence: strong evidence of no benefit. The Cochrane review by Bamford et al. (2013) pooled 27 RCTs with 1,596 adults and children from 12 countries: 19 trials of EPO and 8 of borage oil, all against placebo. Neither beat placebo. On a 0–100 global symptom scale, the mean difference was −2.22 (95% CI −10.48 to 6.04) as rated by participants and −3.26 by doctors. Most trials had low risk of bias. Because the confidence intervals were narrow enough to rule out a useful effect, the authors said further trials “would be hard to justify”. The 2014 American Academy of Dermatology guideline found “inconsistent to no evidence” for EPO, borage oil or fish oil (NCCIH), and the AAP says EPO and borage oil do not improve eczema over placebo. Earlier, the 2000 UK health technology assessment had found a meta-analysis of nine trials suggesting a moderate benefit, but the two largest, best-documented trials showed no difference from placebo (Schäfer). A later meta-analysis that included unpublished, industry-sponsored trials found only a modest effect on itch after four to eight weeks (AAFP 2009).

Conflict: [Senapati et al., Indian J Dermatol Venereol Leprol, 2008, via Schäfer] says 500 mg EPO capsules beat 300 mg sunflower oil capsules over 5 months in a placebo-controlled RCT. [Bamford et al., Cochrane, 2013] says oral EPO and borage oil “are not effective treatments for eczema” across 27 RCTs. Unresolved — add to open_questions.

Cochrane [contradicts] Evening Primrose Oil American Academy of Dermatology [contradicts] Evening Primrose Oil Evening Primrose Oil [treats] Atopic Dermatitis

Regulatory history. In the UK, EPO was once a prescription medicine. Epogam was licensed “for the symptomatic relief of atopic eczema in children and adults”, and Efamast for breast pain. On 10 August 2002 the Medicines Control Agency (now the MHRA) announced that both licences would be withdrawn from 7 October 2002. After a review with the Committee on Safety of Medicines of “new studies and statistical analyses”, it found the data did not meet the efficacy standard needed for a medicine. The agency stressed there was “no safety issue”. EPO stayed on sale in health food shops, but as a supplement that may not make medicinal claims (MCA/MHRA news release, 2002, via Quackwatch). In responses to Hywel Williams’s 2003 BMJ editorial on EPO, Pfizer, which had taken over the licence holder Pharmacia, confirmed that the Medicines Commission found “insufficient evidence of efficacy” and suspended the licence in October 2002. A dissenting GP called the withdrawal “a mistake”. She argued that the trials never measured red-cell essential fatty acid levels, so they could have missed patients who were truly deficient. This minority view echoes a German subgroup finding in favour of borage oil among people whose blood dihomo-γ-linolenic acid rose (Henz 1999, via Schäfer). It has not been confirmed (BMJ rapid responses, 2003–05).

MHRA [regulates] Evening Primrose Oil MHRA [opposes] Evening Primrose Oil

Toddler safety. The Cochrane trials reported the same mild, short-lived side effects with EPO, borage oil and placebo: mainly upset stomach, diarrhoea and headache. EPO has a blood-thinning effect and can raise bleeding risk with warfarin (Cochrane 2013). Extensive but temporary bruising and pinpoint bleeding were reported in a newborn whose mother took 6.5 g in the week before birth (AAFP 2009). Two 1980s case reports involving five adults on phenothiazine antipsychotics raised the idea that EPO might lower the seizure threshold. The evidence is weak, but caution is still advised for anyone taking anticonvulsants (AAFP 2009). A case report also warned of possible inflammation, thrombosis and immune suppression with use beyond a year, and no trial has studied long-term safety. Few trials reported toddler-specific data: a UK borage oil trial (Takwale 2003, 140 patients including 69 children) and a German paediatric borage trial (Borrek 1997) found no benefit (Schäfer). For a 1–4-year-old, the result is cost and capsules with no benefit. They should not replace Emollient Therapy or prescribed Topical Corticosteroids.

Bleeding and seizure cautions

Evening primrose oil can thin the blood. Check with a doctor before giving it to a child with a bleeding disorder, before surgery, or alongside blood-thinning medicines. Old case reports linked it to seizures, so avoid it in children with epilepsy or on anticonvulsants. It has no proven benefit for eczema.

Evening Primrose Oil [relates] Emollient Therapy Evening Primrose Oil [relates] Topical Corticosteroids

What parents report (evidence: anecdotal). Reddit threads in r/eczema are mostly adults describing their own use. One poster said 1 g of oral EPO daily (100 mg GLA), bought for premenstrual symptoms, cleared 20 years of hand eczema within “a couple of weeks”, and that the eczema stayed mild after stopping. Others in the thread said it did nothing, or that the oil applied to the skin smelled “like a wet dog”. One commenter asked whether such posts were disguised marketing. In a borage oil thread, a user taking 3–4 capsules a day (about 240 mg GLA each) said it helped skin “hydration” but not the eczema, and gave the credit to a diet change. Another said fish oil seemed to make their skin drier. In a BMJ response, a woman with lifelong eczema said borage and EPO (about 1,200 mg) “worked and still does”, and argued that trials miss individual responders. None of the threads found described toddlers. These reports show the usual confounders: several changes at once, natural waxing and waning, and seasonal effects.

Evening Primrose Oil [relates] Elimination Diets

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