Introduction

Frankincense is a resinous, evergreen tree that grows to 15 feet tall with papery, peeling bark.¹ Five-petaled, creamy-white flowers appear in the spring followed by 3 to 5 angled, red-brown seed capsules. While approximately 25 species of Boswellia are found in the tropical regions of Africa, Asia, and the Arabian Peninsula, B. sacra is native to northern Somalia, Ethiopia, south Yemen, and Oman,² and B. serrata (Indian frankincense) is commonly found growing in dry forests from Punjab to West Bengal and in peninsular India.^3,4 Exudate of Indian frankincense is used in the Ayurvedic, Siddha, and Unani systems of traditional medicine. The oleo-gum-resin is collected from wild trees by making incisions in the bark of the trunks and thick branches. The gum resin exudes from the incision point and solidifies into an irregular mass as a result of exposure to open air.⁵ The oleo-gum-resin is collected all year and used fresh or dried.¹

History and Cultural Significance

Boswellia sacra arrived in the Eastern Mediterranean region now composed of Israel, the Palestinian territories, Lebanon, and Jordan via the Incense Trail—the oldest caravan route in the world, which connected the aromatic growing regions with the ancient empires that valued these substances.^6,7 A 3,000-year-old ball of frankincense was found in the tomb of the Egyptian King Tutankhamun (ca. 1341-1323 BCE).⁷ Two millennia ago, frankincense was as valuable as gold, hence the Bible story of its presentation to the baby Jesus by the 3 wise men.⁶ It may be that the resins of as many as 24 species of Boswellia are used in the production of frankincense, but B. sacra is the main source in some countries.⁷ The main species for frankincense gum-resin production in Ethiopia and in the Sudan is B. papyrifera.⁸ Mediterranean and Middle Eastern peoples valued frankincense in religious rituals for its fragrant, white smoke which was thought to appease the gods. It was used as a ceremonial incense in Persia, Babylon, and Assyria, and by both Jews and Romans.⁹ According to ancient records, 2.5 tons of frankincense were burned in a Babylonian temple in 1 year.⁶ Currently, the Catholic Church is thought to be the major consumer of frankincense for use in ceremonies.⁷

Both B. sacra and B. serrata have been used in cosmetics since the ancient times.¹ A black powder, kohl, was made of charred frankincense and used by the Egyptian women to paint their eyelids.⁹ Kohl was also used in an eye wash for soothing sore eyes.⁷ Boswellia sacra has also been used by the Egyptians for rejuvenating the skin via facial masks.⁹ Frankincense has been melted to make hair-removal creams,¹⁰ and used as a paste to perfume the hands,⁹ clothes, hair, and home.⁴ Modern skin care products contain frankincense for the treatment of blemishes, dry and mature complexions, and wrinkles, scars, and wounds.

The early Islamic physician and philosopher Ibn Sina (aka Avicenna, ca. 980-1037 CE) recommended frankincense for dysentery, fevers, and tumors, ulcers, and vomiting.¹⁰ Other Middle Eastern uses include the stimulation of digestion and strengthening of teeth, as a diuretic and purgative, to enhance memory, and for emotional and psychological problems.⁷

In India, different parts of the B. serrata tree are used traditionally in Ayurvedic medicine for asthma, blood purification, bronchial conditions, dysentery, rheumatism, skin ailments, and wound treatment.⁴ Therapeutic uses of the oleo-gum-resin of B. serrata in the Ayurvedic system of medicine include treatment of fever, excessive vaginal discharge, asthma, conjunctivitis, spermatorrhea, pain in testicles, and disease of the mouth.³ Boswellia sacra is used in India for nervous disorders and rheumatism.⁷

Traditional Chinese Medicine (TCM) uses B. sacra internally to invigorate blood circulation, control bleeding, relax the muscles, relieve menstrual disorders, and control pain.^11,12 Called ru xiang, it is also used externally for lesions, particularly to reduce swelling, relieve pain, and to promote generation of flesh.¹²

In various African countries, frankincense is used as a tonic, diuretic, and to treat syphilis and bilharzia (schistosomiasis), a disease caused by parasitic worms.⁷

Frankincense is also utilized externally in aromatherapy for asthma, bronchitis, coughs, laryngitis, inflammation, colds, flu, stressrelated conditions, anxiety, nervous tension, and painful menstruation.⁹

In North America, for the purpose of pre-marketing authorization and product licensing in Canada, the Natural Health Products Directorate (NHPD) has published 3 Frankincense monographs (for buccal, oral, and topical applications).¹³ The following indications are permitted for the oral use of the dried gum resin: traditionally used as an astringent; traditionally used as a diuretic; traditionally used to relieve nervous problems; traditionally used in TCM to promote circulation of qi; traditionally used in TCM to relieve urinary disorders; and traditionally used in TCM to dispel wind-dampness.¹³ Permitted uses for frankincense topical application medicines are: traditionally used in TCM to promote healing of carbuncles; traditionally used in TCM to promote tissue regeneration; traditionally used in TCM to promote healing of injuries; traditionally used in TCM to relieve gum, mouth, and throat complaints; traditionally used in TCM to relieve pain; traditionally applied to treat ringworm; traditionally used in TCM to promote healing of sores; and traditionally used in TCM to reduce swelling.¹⁴

In the United States, quality standards monographs were issued for “Boswellia Serrata” oleo-gum-resin and “Boswellia Serrata Extract” for use as dietary ingredients in June 2010 and will become official in the 2nd Supplement to the United States Pharmacopeia 33rd Revision – National Formulary 28th edition (USP 33 NF 28) on December 1, 2010.¹⁵ Olibanum Oil, the volatile oil distilled from gum obtained from B. carteri and other Boswellia species, is regulated as a food additive permitted for direct addition to food for human consumption.¹⁶ For its use as a flavoring agent in food products, a quality standards monograph has been published in the Food Chemicals Codex.¹⁷

For Indian frankincense gum-resin exudate that will be used as an active ingredient of registered herbal medicinal products in the European Community, an official quality standards monograph has been published in the European Pharmacopoeia (PhEur) for test and release of the active substance.¹⁸ It must contain minimum 1.0% 11-keto-beta-boswellic acid and a minimum of 1.0% acetyl-11keto-beta-boswellic acid (dried drug).

Modern Research

While both B. sacra and B. serrata have been used medicinally, B. serrata is the species currently most used in herbal medicine and upon which all the modern clinical research has been done. Its main known pharmacologically-active constituents include α and β boswellic acid and other pentacyclic triterpenic acids shown in laboratory studies to inhibit inflammatory processes.¹⁹ Boswellic acids in proprietary formulations (e.g., 5-Loxin^®) have demonstrated a high safety profile.²⁰

A 2010 randomized, double-blind, split-face, comparative study was done to assess the efficacy, tolerability, and safety of a base cream containing 0.5% boswellic acids (BAs) (manufacturer unspecified) and the same cream without the BAs with regard to its use in treating photoaging of facial skin.²¹ Fifteen female volunteers applied the creams once daily for 30 days. The treatment was well tolerated and significant improvement occurred in tactile roughness and fine lines in the side of the face treated with the cream with BAs.

In 2008, a double-blind, randomized, placebo-controlled study examined 5-Loxin (30% 3-O-acetyl-11-keto-beta-boswellic acid [AKBA], P.L. Thomas and Co., Morristown, NJ) for treatment of osteoarthritis (OA) of the knee.22 For 90 days, 75 patients received either 100 mg or 25 mg daily of 5-Loxin or placebo. Each patient was evaluated at baseline and at days 7, 30, 60, and 90. At the end of the study, both doses of 5-Loxin showed clinically and statistically significant improvements in pain and physical function scores.

A DBRPC multicenter clinical trial in 2007 studied Boswellia Serrata Extract (BSE) (80% boswellic acid prepared by a local pharmacist in Western Germany who is associated with a naturopathic hospital) for the treatment of collagenous colitis.²³ Patients with chronic diarrhea and histologically proven collagenous colitis (n=31) were randomized to receive either 400 mg of BSE orally 3 times per day or placebo for 6 weeks. Proportion of patients in clinical remission at the end of the trial was higher in the BSE group than in the placebo group (63.6 % vs 26.7%), but the authors stated that large trials are necessary to establish the clinical efficacy of BSE.

In a 2007 randomized, prospective, open-label, comparative study, the efficacy, safety, and tolerability of BSE (333mg BSE, WokVel™, Pharmanza Pvt Ltd., Khambat, Gujarat, India) was compared to valdecoxib (Bextra^®, GD Searle, Peapack, NJ), a selective COX-2 inhibitor.²⁴ For 6 months, 66 patients ages 40-70 years old with OA of the knee received either WokVel 3 times per day or 10 mg valdecoxib (Tab Valdone, Cadila Pharmaceuticals Ltd, Ahmedabad, Gujarat, India) once daily. Following 2 months of therapy the BSE group showed statistically significant improvement in pain, stiffness, and level of difficulty in performing daily activities, with the improvements lasting a month after the therapy ended. The onset of the effect of the BSE was slower than that of valdecoxib but lasted longer.²⁴ [Note: Valdecoxib was subsequently taken off the market in India where the study was performed and voluntarily taken off the market in the U.S. due to adverse cardiac events.]²⁵

Another RDBPC crossover study in 2003 examined the efficacy, safety, and tolerability of BSE in 30 patients with OA of the knee.²⁶ Each group of 15 patients took either WokVel or a placebo 3 times per day. In the group that took the BSE, all patients reported decreased knee pain, increased knee flexion, increased walking distance, improvement in capacity of climbing stairs, and better ability in kneeling, crossed-legged sitting, and squatting. Range of knee movement was improved and frequency of swelling in the knee was decreased.

An additional open, uncontrolled study on 12 healthy men was conducted wherein the volunteers took one oral single dose of WokVel to determine optimal dosing and safety.²⁷ The authors determined that BSE is safe and well tolerated and needs to be given at the interval of 6 hours in the treatment of inflammatory diseases.

In 2002, orphan drug designation was granted by the European Commission to Pharmasan GmbH (Freiburg, Germany) for its B. serrata resin extract for the treatment of peritumoral edema derived from brain tumors.²⁸ Orphan designation is not a marketing authorization and still requires demonstration of quality, safety, and efficacy before an orphan product can be granted marketing authorization. The product was withdrawn in 2005 on request of the sponsor.

In addition, clinical trials using boswellic acids have demonstrated activity in patients with bronchial asthma,²⁹ ulcerative colitis,³⁰ Crohn’s disease,³¹ and malignant gliomas.³²

Future Outlook

Accurate, current statistics for the frankincense trade are difficult to find, primarily because the figures are usually combined with other gums, resins, and balsams. However, India does report its export trade data for frankincense oleo-gum-resin. For the agricultural year of April 2009 through March 2010, India’s exports of frankincense were valued at $0.55 million US dollars, an increase of 81.13% over the previous year’s total of $0.3 million (Apr 2008-Mar 2009).³³ Additionally, the name “frankincense” can refer to any of a number of species and it may not be possible to determine which species’ production is being reported. Nevertheless, in the latter part of the 20th century, an estimated 1,000 tons of frankincense were produced per year and current estimates of the amount imported to the United States is anywhere from 5 to 20 tons annually.⁷

In late 2006, there was a rash of popular press articles warning about the overharvesting of frankincense. This was based on an article in the August 2006 issue of the Journal of Applied Ecology that addressed only B. papyrifera.³⁴ Currently, a sustainability study is being conducted on B. papyrifera in Ethiopia.³⁵ Sustainability research on other species is sadly lacking.

—Gayle Engels

References

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