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To cite this article: P R W Astana et al 2021 IOP Conf. Ser.: Earth Environ. Sci. 913 012097 - Ethnomedicine, phytochemical, and
toxicity activity of several alleged medicinal
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4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

Medicinal plants used by traditional healers for hemorrhoid

treatment in Borneo island: Ethnopharmacological study
RISTOJA

P R W Astana*, U Nisa, A Triyono, D Ardiyanto, U Fitriani, Z Zulkarnain, K P

Adwaita and F Novianto
Medicinal Plants and Traditional Medicine Research and Development Center, Jalan
Raya Lawu number 11, Tawangmangu, Central Java, Indonesia
*
Corresponding author: drwidhiastana@gmail.com

Abstract. Borneo is known as the third largest island in the world, which has enormous
biodiversity. For generations, the locals used to utilize surrounding plants to treat diseases and
maintain their health. Hemorrhoid is one of the diseases which is often treated using medicinal
plants. An ethnopharmacological study (RISTOJA) was conducted to find potential plants to be
developed in Borneo island by interviewing selected local traditional healers. Identification of
medicinal plants was performed, followed by descriptive and literature studies. The most
important medicinal plants were defined using the calculation of frequency of citation (FC), use
value (UV), and choice value (CV). In order to establish scientific evidence, a literature review
was conducted focused on the benefit and toxicity using electronic search engines Pubmed,
DOAJ, Scopus, and Google Scholar. The evidence was collected from empirical use to in-vitro,
animal, or clinical studies. There were 49 species under 31 families used in herbal formula for
hemorrhoids. Based on FC, UV, CV, and literature review, Curcuma longa L., Graptophyllum
pictum (L.) Griff., Melastoma malabathricum L., and Cocos nucifera were confirmed to have
enough scientific evidence regarding its safety and efficacy. Accordingly, those plants have the
potential to be further developed.

1. Introduction
Borneo island is known as the third biggest island in the world. Expanding along the equator, it has an
abundant diversity of flora and fauna. Therefore, traditional healers have many choices in using natural
resources for their practice. Until now, traditional healers still exist because they are considered essential
in ethnic societies [1]. The selection of medicinal plants is solely based on inherited knowledge and
customs within the community [2]. The ingredients of the herbal formula are often gathered by
traditional healers from the natural world, including the surrounding forest.
Hemorrhoids have been known since the time of the ancient Egyptians. In Indonesia, hemorrhoids were
estimated to affect 12.5 million people in 2015 (Basic Health Research). The prevalence of hemorrhoids
in Indonesia is believed to be only 5.7 percent [3]. However, there can be significant interference with
the patient’s daily life due to the condition caused by this disease [4]. Hemorrhoids have been treated in
the community since ancient times using traditional medications derived from plants and herbs. This
practice is still in existence now. They choose herbal medicine because they are uncomfortable with the
potential side effects of surgery.
The World Health Organization (WHO) encourages the development of herbal medicines based on
traditional knowledge [5]. However, to be approved by contemporary medicine in the modern period,

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4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

the use of medicinal plants must be supported by scientific data [6,7]. Center for Research and
Development of Medicinal Plants and Traditional Medicines (MPTMRDC) conducted an
ethnopharmacology study named RISTOJA in 2015 and 2017. On the island of Borneo, traditional
healers utilize a variety of herbal medicinal formulas to cure hemorrhoids. Each formula contains one
or more medicinal plants as an ingredient. In order to establish strong scientific evidence, it is required
to conduct a literature review and confirm the pharmacological and toxicological effects of medicinal
plants.

2. Methods

2.1. Description of the study area

Borneo is part of the Malay Archipelago’s Greater Sunda Islands group. The island is surrounded by the
South China Sea, Sulu Sea, Celebes Sea, and the Java Sea. On the Indonesian side, the island is divided
into five provinces: Central Kalimantan, East Kalimantan, North Kalimantan, South Kalimantan, and
West Kalimantan. Borneo is mountainous, with some flats. The Kapuas and Mahakam rivers run through
Kalimantan. The climate is equatorial, hot, and humid, with two distinct seasons: a rainy monsoonal
period from October to March and a dry, calmer summer the rest of the year. Borneo is covered in the
deep jungle, and its floral and faunal communities are very diverse.

2.2. Ethnopharmacology survey

In 2015 and 2017, ethnopharmacology research of RISTOJA was conducted in five provinces in Borneo.
The study focused on traditional healers in the ethnics. The ethnics in this study were chosen by a
purposeful sample technique based on several factors, including the minimum number of ethnic
population (1000), a long history of existence, and a wealth of local wisdom information. The informants
were chosen from traditional healers who were respected by the local community for their knowledge
and abilities. We used established guidelines to interview the informants to acquire data on the use of
plant species as hemorrhoids treatment. Local names, plant parts used, and how the plants were critical
points in the guideline [8]. After the interview, plant samples were collected from the location they
usually take.

2.3. Identification of medicinal plant species

Herbariums were made from plant samples that were acquired and used in traditional medical formulae.
Biology experts identified the specimens in terms of specifications and identity by comparing them to
herbarium exsiccated and literature. The specimens were kept in the Tawangmangu Ensis herbarium at
the Medicinal Plants and Traditional Medicines Research and Development Center.

2.4. Medicinal plants analysis

The medicinal plants were sorted according to the constituents in traditional hemorrhoid medicine
recipes. The frequency of citation (FC), use-value (UV), and choice value (CV) were calculated to
measure the importance and level of confidence of plants.
The citation frequency (FC) for each medicinal plant in this study was calculated using the formula:
FC = the number of times the medicinal plant was mentioned divided by the number
of medicinal plant species mentioned, multiplied by 100 [9].

The use-value (UV) is a quantitative measure for determining the importance of a species in a specific
area [10]. Use value interpreted population interaction with local plants to treat a particular disease. The
calculation uses the formula:
𝛴𝑈
𝑈𝑉 =
𝑛

‘U’ is the number of species mentioned by the informant/total number of interviewed informants.

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4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

The choice value (CV) is a valuable tool for measuring related plant species to treat hemorrhoids. The
CV was calculated as in the following equation:
𝑃𝑐𝑠
𝐶𝑉 𝑠𝑝𝑒𝑐𝑖𝑒𝑠 = × 100
𝑆𝑐

Pcs: the percentage of informants who mentioned certain plant species for hemorrhoid therapy.
Sc: the total number of species mentioned by all informants for disease therapy. Choice values range
from 0 to 100, with 100 signifying total preference and fewer possibilities.

2.5. Study of literature

The literature review was carried out in a methodical manner using scientific publications released
before May 2021. Pubmed, DOAJ, Scopus, and Google Scholar were among the electronic search
engines used. The study looked at medicinal plants' efficacy and safety which have a score of FC more
than 1.5 percent, UV more than 0.020, and CV more than 0.03. Folk hemorrhoids, ethnopharmacology
hemorrhoids, traditional technique hemorrhoids, effects and toxicity of each plant, and other terms
connected to medicinal plants were utilized as keywords.

3. Results and discussion

3.1. The demography of traditional healers

There were 25 traditional male healers recruited as informants, which was more than half compared with
females. The majority of the informants were between the ages of 41 and 60. The education levels of
the interviewees were diverse, with eight informants not accepting formal education, 18 informants
graduating from elementary to junior high school, and 16 informants graduating from senior high
schools or higher education institutions. According to the data, at least 18 of the 42 informants had been
in practice for 11 to 20 years. According to Table 1, the average number of patients seen in a month is
89.4 patients on average.

Table 1. Socio Demography related to the traditional healers.

Variable Number of traditional
healers
Gender
- Male 25
- Female 17
Experience (year)
- <5 5
- 5 – 10 11
- 11 – 20 18
- > 20 8
Average patients in one month 89.4
Education
- No formal education 8
- Elementary – Junior high school 18
- Senior high school 12
- University 4
Age (year old)
- < 40 10
- 41 – 60 20
- > 60 12

According to this study, most participants have been practicing for at least ten years before participating
in the study. How long a traditional healer has been practicing influences his capacity to diagnose and
treat diseases. It is clear from the number of patients seen in just a single month that those traditional
healers are highly respected. There will be a greater validity to ethnopharmacology study if the

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4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

traditional healers are of higher quality [1,2]. There is also a correlation between the age of traditional
healers and their experience and trustworthiness. The finding was also consistent in several studies [69].
The educational backgrounds of the majority of the informants were classified as low to moderate.
People living in Indonesia’s rural areas face many challenges when it comes to gaining access to
education. However, traditional healers are used to getting their traditional medicine knowledge from
their ethnic elders, who have a wealth of experience in the field. They were confident that the knowledge
they had gained would be enough to treat their patients. Therefore, higher education is undoubtedly out
of their priority.

3.2. Medicinal plants and herbal formulas used for hemorrhoids treatment
According to the information gathered by RISTOJA, not all informants in Borneo have a herbal formula
for hemorrhoids. Conversely, several informants reported having more than one remedy for
hemorrhoids. The data revealed that the informants utilized 45 different herbal medicine formulae. At
least 16 formulae contained at least two medical plants, while the remaining formulas contained only
one medicinal plant as a component. Herbal formulations utilized by the informants in Borneo were
defined in this study based on the relative importance of plant components, associated plants included
in the formula, production procedures, and administration routes.
Because hemorrhoids disease affects the skin’s surface area, there were two administration routes for
herbal formulas: oral preparations and topical preparations. According to the data, most informants gave
the herbs to the patients orally (83.3 percent). On the other hand, eleven formulae were given topical,
and only one formula was used orally and topically. It is estimated that up to 48% of the oral medicines
were produced by boiling the herbal mixture. Other oral preparations that are infrequently used include
squeezed, steamed, and eating straight. Fifteen topical formulae were created by withering the leaves in
the presence of a fire and then applying them to the rectum/anus. In contrast, over 36 percent of topical
formulations were created by mashing the ingredients using a grinder or grater before application.
Another ethnopharmacology investigation discovered the use of topical preparations in the treatment of
hemorrhoids. Collisions, oils, creams, bath therapy, and rattus are all common preparations. The
treatment is typically used for minor hemorrhoids. This finding is consistent with the physician’s
treatment guidelines for hemorrhoids. Grade I-II hemorrhoids can be managed with diet and medicine,
both oral and topical, whereas grade III-IV hemorrhoids require more advanced treatment, such as
surgery [94]. The main reason for using topical preparation is because they are absorbed immediately at
the lesion site rather than passing through the internal metabolic system. Accordingly, they have a lower
risk of side effects.

Table 2. Top 6 Medicinal plants used for hemorrhoids, taxonomic family groups, parts used, and the
value of each plant.

Plants name Family Part used Number FC UV CV

cited
Cordyline fruticosa (L.) A.Chev. Asparagaceae Leaves, Root, Trunk 3 4.55 0.048 0.09
Curcuma longa L. Zingiberaceae Rhizome 3 4.55 0.071 0.09
Graptophyllum pictum (L.) Griff. Acanthaceae Leaves, Root, Trunk 3 4.55 0.071 0.09
Melastoma malabathricum L. Melastomataceae Leaves, Root, Trunk 3 4.55 0.071 0.09
Areca catechu L. Arecaceae Root,Fruit 2 3.03 0.048 0.06
Cocos nucifera L. Arecaceae Fruit 2 3.03 0.048 0.06

The survey discovered 49 species of medicinal plants in 31 families that informants used in their
hemorrhoid treatment regimens. The Zingiberaceae, Arecaceae, Euphorbiaceae, Fabaceae, Lamiaceae,
Poaceae, and Vitaceae families were all named at least twice, with the Zingiberaceae being the most
frequently mentioned. The plants in these families were used in the development of 11 herbal
formulations. The most commonly used plants for hemorrhoids were determined by calculating the

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 4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

citation frequency of citation (FC), the use value (UV), and the choice value (CV). The greater the FC,
UV, and CV, the more frequent and significant that plant to be used by informants to treat hemorrhoids.
According to the calculations, six medicinal plants with FC more than 1.5, UV more than 0.050, and
CV more than 0.03. Curcuma longa L., Melastoma malabathricum L., and Graptophyllum pictum (L.)
Griff. were the most referenced plants (each receiving three citations), followed by Areca catechu L. and
Cocos nucifera L., which each received two citations. The leaves were the most frequently used
component in the formula (43.1 percent), followed by the rhizome (15.9), the root (10.5), the trunk (5.1
percent), and the fruit (4 percent ). The leaves are the most commonly used part of the plant in herbal
formulas by traditional healers. Their decision to use leaves is not dependent on the percentage of the
active ingredient in them. In general, leaves are chosen because they are easy to collect in large
quantities, regenerate quickly, are innocuous to plant life, and are simple to dry and determine the dose.
Rhizomes, on the other hand, are also commonly used in herbal formulae in Indonesia. In addition,
Herbs are utilized for shrub-type plants that are easy to grow in various climates [22].

3.3. Literature study of the most important plants

A review of the literature was carried out with a focus on the six most important medicinal herbs. Several
countries have reported the use of Curcuma longa L., Melastoma malabathricum L., Cocos nucifera L.,
and Graptophyllum pictum (L.) Griff. for hemorrhoids treatment (Table 3). These plants have been
widely used in Southeast Asia, South Asia, and Africa. Curcuma longa L. and Graptophyllum pictum
(L.) Griff. have specific proofs for their use for hemorrhoid therapy among these herbs. In addition, these
plants were also classified as the most often utilized plants for the treatment of hemorrhoids in Java
Island [11]. There have been no recorded harmful effects associated with the usage of all medicinal
herbs except Areca catechu L. Numerous investigations have proven that arecoline in Areca catechu L.
is a carcinogenic substance. Accordingly, the best recommendation to use it for hemorrhoids treatment
is for topical use.

Table 3. The result of literature study on the six most important medicinal plants

Species Traditional Use for hemorrhoids Efficacy evidence related to Toxicity and side effect evidence of
healers ID – treatment in other hemorrhoids treatment and other the plants according to the references
number of countries activities (in-vitro and in-vivo
formula (Ethnopharmacology studies)
studies)
Cordyline fruticosa 99 – 005 No evidence Anti-bacterial [12], analgesic, No aberrant behavior nor death were
(L.) A.Chev. anti-inflammation, anti-pyretic observed in mice receiving doses of
[13], anti-oxidant [14] up to 3200 mg/kg extract over a 14-
day period. [13].
Curcuma longa L. 82 – 005 India [15], Thailand [16] Anti-inflammation [17], Oral administration of curcumin of 1-
111 – 006 analgesic [18], anti-ulcer [19], 5 g/kg BW had no harmful effects in
119 – 024 vaso-relaxant [20], anti-bacterial rats. [21].
[17]
Graptophyllum 83 – 015 Philippines [22], India Anti-hemorrhoids [25], anti- Graptophylum pictum oral infusion
pictum (L.) Griff. 109 – 009 [23], Thailand [24] inflammation [26]. Increase doses of up to 800 mg/100 g BW of
120 – 009 elasticity of blood vessels, reduce rats given daily for six months showed
bleeding [25] no organ abnormalities[27].
Melastoma 94 – 010 Malaysia [28], Philipines Anti-inflammation [30], anti- Mice receiving 2000 mg/kg of leaf
malabathricum L. 121 – 012 [29] bacterial [31], anti-nociception extract showed neither death nor
122 – 006 [32], anti-oxidant [33] clinical symptoms of general
weakness [29].
Areca catechu L. 86 – 009 No evidence Anti-microbial [34], analgesic Arecoline affects the sperm of male
111 – 006 [35], Anti-inflammation [36], mice and induces chromosome
wound healing [37] abnormalities in mouse bone marrow
cells, destroys hepatocyte
ultrastructure, and elevates blood AST
and ALT levels [38].
Cocos nucifera L. 84 – 011 Nigeria [39] Anti-inflammation, analgesic, There have been no reports of toxicity
85 – 014 anti-bacterial [18], anti-ulcer associated with the use of crude,
[19], vaso-relaxant [20] endocarp, or mesocarp extract [40]

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4th International Conference on Bioscience and Biotechnology IOP Publishing
IOP Conf. Series: Earth and Environmental Science 913 (2021) 012097 doi:10.1088/1755-1315/913/1/012097

Areca catechu L. and Cordyline fruticosa (L.) A.Chev. did not have adequate evidence to support their
use as an empirical hemorrhoid treatment. However, The evidence of several activities that support the
treatment of hemorrhoids can be considered in preparing the herbal remedy. The anti-inflammation,
analgesic, antioxidant, anti-bacterial, anti-ulcer, vasorelaxant, wound healing, laxative, and bleeding
reduction properties of medicinal plants are beneficial in managing hemorrhoids symptoms and clinical
indications, as well as in the prevention of hemorrhoids [41].
The RISTOJA database contains a wealth of information that can be researched further to identify
possible medicinal plants for illness therapy. However, there was a data gap on hemorrhoids. According
to the study results, the informants could not specify the type of hemorrhoids they treated with their
herbal concoction. The primary clinical symptoms of the two types of hemorrhoids are pretty similar.
Accordingly, it is difficult for a non-medic person to distinguish the type of hemorrhoids [4]. The
informants’ incapacity to provide information regarding the type of hemorrhoids could be due to their
insufficient knowledge of medical science. Education is critical in this case, as the majority of
informants did not complete senior high school.

4. Conclusion
Curcuma longa L., Graptophyllum pictum (L.) Griff. Melastoma malabathricum L. and Cocos nucifera
L. according to the results, are the most potent medicinal herbs to be developed for hemorrhoids therapy.
Cordyline fruticosa (L.) A.Chev. is also considered potent because it has sufficient evidence to help
alleviate hemorrhoid symptoms. Due to the hazardous impact of Areca catechu L., it is not advised to
be used for oral preparation.

Funding statement
The National Institute of Health Research and Development (NIHRD) of the Republic of Indonesia
funded this research.

Conflict of interest
The authors declare no conflict of interest in this study

Acknowledgment
The authors are appreciative to the local communities and traditional healers for their contributions to
the study’s success. The RISTOJA 2015 and 2017 teams and the plant taxonomists that recognized the
specimens have all made significant contributions. Finally, the authors are grateful to the National
Institute of Health Research and Development’s Laboratory Data Management for providing the study’s
essential data subset.

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