Marshmallow

Marshmallow (Althaea officinalis L.): A Comprehensive Reference

1. Identity, Botanical Classification, and Common Forms

Botanical and Chemical Identity

Althaea officinalis L. is a prominent medicinal plant in the Malvaceae family, with native habitats in Europe, Western Asia, and Northwest Africa. The species is a flowering plant indigenous to those regions, used in herbalism and as an ornamental plant. It is universally known by its common name, marshmallow, and also by the synonym althea root or, in pharmacopoeial contexts, Althaeae radix (marshmallow root) and Althaeae folium (marshmallow leaf).

The genus name Althaea is derived from the Greek word althainein (ἀλθαίνειν), meaning "to heal." The Latin specific epithet officinalis indicates a plant with culinary or medicinal value — specifically, that it was officially stocked in the pharmacy (officina).

Plant Description

This herbaceous perennial grows to 180 cm (6 ft) tall and puts out only a few lateral branches; the whole plant is softly stellate-hairy, especially the leaves, which are broadly triangular to oval, often with 3–5 shallow lobes, irregularly toothed, with cordate to cuneate bases. The plant grows up to 1.5 metres tall, with thick, fleshy stems covered in fine, downy hairs, large soft leaves, and delicate pale pink or white flowers that bloom in late summer. The plant is now commonly grown in many parts of the world including Asia (e.g., Iran, Iraq, Turkey, Uzbekistan, Tajikistan, Afghanistan, Turkmenistan, China, and Russia), Europe (e.g., Belgium, Denmark, Germany, Italy, France, Romania, Netherlands, Spain, Ireland, Ukraine, and Hungary), and North America and Canada.

Plant Parts Used and Common Preparations

The leaves, flowers, and root of A. officinalis have all been used in traditional herbal medicine. It is the root, harvested in autumn from two- to three-year-old plants, that is prized in herbalism for its extraordinarily high mucilage content. The root can be supplied in a peeled or unpeeled form and whole or sliced according to the British Pharmacopoeia (BP).

The dried leaves and roots are used in teas and alcoholic extracts (tinctures), and the roots are used in ointments and creams, cough syrups, or powdered in capsules. Herbal medicines containing marshmallow root preparations are usually available as herbal tea to be drunk, or in solid or liquid forms to be taken by mouth or applied in the mouth. The EMA/HMPC assessment covers preparations obtained by comminuting the roots or by macerating them to prepare a syrup, as well as dry and liquid extracts.

Sugary, mucilaginous material in the root of Althaea officinalis was the original source of the eponymous confection (marshmallows). The roots can be peeled, sliced, boiled, and sweetened to make candy.

2. Traditional and Historical Use

Ancient Civilizations

Marshmallow has reportedly been used in traditional European medicine for over 2,000 years. Its therapeutic use was first recorded in the 9th century BCE, and it was used widely in Greek medicine. Its genus name Althaea comes from the Greek altho, meaning "to cure," and its family name Malvaceae is derived from the Greek malake, meaning soft.

Hippocrates recommended decoction from the root as a wound remedy, while Dioscorides prescribed it in anuria, diarrhoea, lithiasis, internal injuries, nerve pain, bee sting, and toothache. The first-century physician Dioscorides recorded the plant's medicinal uses in his foundational pharmacopoeial text, helping transmit knowledge of the plant into the Western tradition.

Medieval European Use

In the Middle Ages, Althaea was prescribed by Paracelsus as an abscess emollient and cleanser, and by Lonicerus and Matthiolus as an expectorant and diuretic, for internal injuries, externally as an ulcer emollient, and for burns treatment.

Ethnobotanical Breadth

A. officinalis has been traditionally used as a food (the roots) and herbal medicine to treat different health problems. Known throughout ancient Egyptian, Arab, Greek, and Roman cultures, this herb has been used continuously for at least 2,000 years. In traditional folk practices, it was given to soothe and moisten mucous membranes of the respiratory, digestive, and urinary tracts, and also as an external poultice.

Marshmallow root is traditionally used as a demulcent and emollient in irritation of oral and pharyngeal mucosa and associated dry cough, in mild gastric complaints (including nephrolithiasis, enteritis, diarrhoea, gastric and duodenal ulcers), and topically as a gargle in mouth inflammations, and for eye and skin inflammations, burns, furunculosis, and carbunculosis.

Marshmallow's use extended to Ayurvedic and Unani healing traditions. It has become an important herb in Ayurvedic medicine and Unani healing practices, which utilize many different plants to boost immunity and prevent disease.

Culinary Use

Historically, most of the mallows have been used as food, being mentioned by early classic writers. The young leaves can be cooked, the flower buds can be pickled, and when boiled first and fried with onions and butter, the roots are said to form a palatable dish. This plant has been used in beverages, desserts, candies, cosmetic creams, and was the "root" of the original marshmallow confectionery.

3. Key Constituents and Active Compounds

Polysaccharide Mucilage (Primary Constituent)

It is the root, harvested in autumn, that is prized in herbalism for its extraordinarily high mucilage content. Mucilage can make up as much as 35% of the dry weight of the root. It is a complex polysaccharide — a long-chain sugar molecule — that swells dramatically on contact with water and forms a soft, slippery gel.

Marshmallow root contains polysaccharide mucilage composed of L-rhamnose, D-galactose, D-galacturonic acid, and D-glucuronic acid. Root extract of Althaea officinalis contains water-miscible polysaccharides (acidic polysaccharides), mostly galacturorhamnans, arabinans, glucans, and arabinogalactans.

Other Major Phytochemical Classes

Many compounds have been extracted from A. officinalis, including starch (25–35%), pectins (11%), saccharose (10%), mucilage (5%), flavonoids, caffeic acid, p-coumaric acid, isoquercitrin, coumarins, phytosterols, tannins, and many amino acids.

Different parts of A. officinalis contain diverse classes of bioactive compounds such as polysaccharides (mucilage), flavonoids, phenolic acids, coumarins, terpenoids, fatty acids, and phytosterols.

The key constituents in the herb include mucilage, flavonoids that include kaempferol and quercetin, and glycosides.

Low Molecular Weight Constituents

Phytochemical investigation of low molecular weight root extract revealed the presence of N-phenylpropenoyl-L-amino acid amides, approximately 8% glycine betaine, about 9% total amino acids with proline as the main compound, and about 61% mono- and oligomeric carbohydrates with sucrose as the main compound. Further fractionation revealed the presence of a hypolaetin diglycoside and four hypolaetin glycosides with O-sulfocarbohydrate moieties, as well as 4'-O-methylisoscutellarein-8-O-β-D-(3″-O-sulfo)glucuronopyranoside and the diglycosylated coumarin haploperoside D.

Pharmacopeial Quality Standards

National pharmacopoeias, such as the British Pharmacopoeia, set limits in relation to the mucilage content, which is measured through the swelling index — not less than 10 in the root and a minimum of 12 in the leaf. To ensure high mucilage content, it is important to harvest at the right time: the root should be collected from two-year-old plants in autumn, and the leaves collected just before flowering.

4. Mechanisms of Action

Demulcent and Mucosal Protective Action

Application of medicinal extracts of marshmallow roots shows immediate effects like a protective film on the inflamed mucosa. Because the soothing layer reduces irritation of the mucous system, a faster regeneration is supported by defense mechanisms required to protect the respiratory tract from environmental injury.

Purified polysaccharides (carbohydrates content >95%) from Althaea officinalis root were investigated for bioadhesive effect on isolated porcine buccal membranes. Polysaccharides from marshmallow root showed a moderate adhesion to epithelial tissue, and the adhesive effect was concentration-dependent. This bioadhesive behavior is considered the mechanistic basis of the plant's demulcent properties on mucosal surfaces.

Their pharmaceutical use involves forming a layer that protects the epithelial membranes. The standard oral use of root extract is associated with the adhesive properties of the polysaccharides to the epithelial mucosa, which protects from mechanical injuries and microbial invasion.

The effectiveness of root extract is not only due to the mechanical protective effects of high molecular weight polysaccharides but also includes other components with healing properties.

Hyaluronidase Inhibition

Aqueous root extract inhibited the enzymatic activity of surface-displayed human hyaluronidase-1 on Escherichia coli F470 cells with an IC₅₀ of 7.7 mg/mL, and downregulated mRNA expression of hyaluronidase-1 (hyal-1) in HaCaT keratinocytes at 125 and 250 μg/mL. In addition to their physical properties, constituents of the mucilage may interact with the key mucosal enzyme, hyaluronidase. Inhibition of this enzyme is believed to contribute to the anti-inflammatory and tissue-protective effects of the extract, as hyaluronidase degrades hyaluronic acid in the connective tissue matrix.

Anti-Inflammatory and Antioxidant Effects

The aqueous extract of marshmallow is helpful in lowering hyperlipidemia, inflammation, and reducing gastric ulcers, and in inhibiting platelet adhesion without showing adverse effects. This plant can also prevent inflammation through inhibition of cytokines, interleukin-6, and tumor necrosis factor synthesis and/or release.

Increases of phagocytic and macrophage activities and the number of T lymphocytes are the main immunomodulatory effects of the marshmallow root extract.

Antitussive Mechanisms

Tracheobronchial smooth muscle contractility was inhibited by extracts of Althaea root in studies in rats, while in a model of airway inflammation in guinea pigs, the polysaccharide rhamnogalacturonan from A. officinalis exerted cough-suppressing effects in a dose-dependent manner, suggesting a potential role in the treatment of asthma.

Mucilage is sensitive to both heat and alcohol; therefore, it is best taken as a powder or extracted in cold or warm water to preserve its gel-forming capacity and therapeutic efficacy.

5. Scientific Evidence by Area of Use

5.1 Dry Cough and Pharyngeal / Oral Irritation

Regulatory status: The HMPC concluded that, on the basis of long-standing use, marshmallow root preparations can be used to treat irritation of the mouth or throat and associated dry cough, and can also be used to relieve mild discomfort of the stomach and gut. For mouth or throat irritation and associated dry cough, marshmallow root medicines can usually be used in adults, adolescents, and children over the age of 3 years.

German Commission E and ESCOP: In 1989, the German Commission E approved both marshmallow leaf and root for irritation of the oral and pharyngeal mucosa and associated dry cough. The root was also approved for mild inflammation of the gastric mucosa. The ESCOP monograph lists indications of dry irritating cough, irritation of the mucous membranes of the mouth and throat, and mild gastrointestinal complaints and irritation of the gastric mucosa.

Key human/consumer-based evidence (Fink et al., 2018): Cough preparations containing aqueous marshmallow root extracts have a long history as medicinal products in Germany. Two prospective, non-interventional surveys aimed to document users' impressions of effectiveness and tolerability. Consumers (n = 822) buying either lozenges or syrup of the aqueous marshmallow root extract STW42 to treat dry cough were recruited in pharmacies in two independently performed surveys and asked to fill in a questionnaire covering a treatment duration of 7 days. This consumer-reported outcome shows that both preparations showed a good effect with respect to the symptomatic treatment of oral or pharyngeal irritation and associated dry cough, with a very rapid onset of effects in the majority of cases. A very rapid onset of therapeutic effects was reported in the majority of cases within ten minutes.

Limitations: These surveys are non-interventional and rely entirely on consumer-reported outcomes. They lack a placebo comparator group, blinding, and objective clinical end-points. The results therefore cannot establish efficacy in a regulatory clinical-trial sense. Most of the research into marshmallow root to date has involved animal studies, very small-scale human studies, or in vitro studies. More studies are necessary to understand the benefits of the root for humans.

Animal/preclinical antitussive evidence: A 100 mg/kg complex extract and 50 mg/kg polysaccharide isolated from the roots of A. officinalis were effective as antitussive agents in cats. The cough suppressant activity of the polysaccharide was more effective than prenoxdiazine but not dropropizine; marshmallow extract was less effective than the isolated polysaccharide. An antitussive effect of marshmallow root extract was also found in an animal study using cats.

COVID-19 associated cough (RCT): One randomised clinical trial aimed to compare the effects of nebulised Althaea officinalis and eucalyptus on cough severity in hospitalised COVID-19 patients. Thirty-six adults with confirmed COVID-19 were randomly allocated to three groups: marshmallow nebuliser, eucalyptus nebuliser, or control (no intervention). Cough severity was assessed using a visual analogue scale (VAS) two hours before intervention and two hours after daily treatment. This trial is small and represents a highly specific clinical context; results cannot be generalized broadly.

Overall evidence strength for cough/throat: Moderate by traditional use standards, supported by the pharmacopoeial recognition of multiple national and European bodies. Clinical-trial-level human evidence remains limited; the strongest human data are large-scale consumer surveys without placebo control. Preclinical antitussive data in animals are more mechanistically detailed but not directly translatable.

5.2 Gastrointestinal Complaints (Gastritis, Gastric Ulcer, Mild Indigestion)

The HMPC monograph recognises traditional use for irritation of the mucous membranes of the mouth and throat, dry irritating cough, and relief of gastric complaints.

Marshmallow soothes irritation in the digestive system, such as that which is caused by gastritis or stomach upsets. This provides almost immediate relief, because the effect is almost entirely from the physical properties of the mucilage on the mucosal lining of the upper digestive tract.

Animal study (gastric ulcer, PMC 2019): A study aimed to inspect the gastro-protective as well as in vitro and in vivo antioxidant potential of Althaea officinalis and Solanum nigrum extracts on pyloric-ligation/indomethacin-induced gastric ulceration in rats. Rats were divided into six groups: normal control, gastric ulcer control, two standard pretreatment groups receiving omeprazole and misoprostol, and two test pretreatment groups receiving Althaea officinalis and Solanum nigrum. Pretreatments were administered orally for 14 days, and on the 15th day animals were exposed to pyloric ligation followed by indomethacin injection. This study is animal-based; no direct human clinical trial data on gastric ulcers from A. officinalis alone are available.

Marshmallow may also help with short-term constipation by softening the stool. Its effects on the lower digestive tract may take several hours due to transit time.

Overall evidence strength for gastrointestinal use: Weak to preliminary. The therapeutic rationale is mechanistically plausible (mucosal coating), supported by long-standing traditional use and a Commission E/HMPC approval based on tradition, but direct randomized controlled human clinical trials on gastrointestinal outcomes are lacking.

5.3 Skin Conditions and Wound Healing

The antimicrobial and wound healing potential of Althaea officinalis L. hydroalcoholic extract was studied in comparison with ciprofloxacin, gentamicin, and penicillin antibiotics on clinical strains including Pseudomonas aeruginosa, Escherichia coli, Staphylococcus aureus, and Listeria monocytogenes. Results showed that although Althaea officinalis L. extract was not effective on Gram-negative bacteria, it was efficacious on Gram-positive bacteria.

The root has remarkable wound-healing properties; when applied as a poultice, it expels toxins and bacteria from wounds and hastens the wound-healing process. Beside wounds, it is also useful in burns and bruises.

Extracts obtained from the roots and flowers of marshmallow have antibacterial (both Gram-positive and Gram-negative bacteria), antifungal, anti-inflammatory, anti-mycobacterial, and anti-cough properties, as well as antiviral, anti-yeast, anti-complement, and free radical-scavenging activities.

Marshmallow is also available in skin care products, such as creams and salves, to help reduce skin irritation and make the skin appear brighter and healthier.

In vitro anti-inflammatory and anti-oxidative evidence: A study was performed to investigate whether the herbal medicinal product has anti-inflammatory or anti-oxidative effects on pro-inflammatorily activated macrophages or after oxidative stress induction, with special attention to the effects of A. officinalis on the mechanism of intracellular defense and on migratory capacity of macrophages. Treatment of PMA-differentiated human THP-1 macrophages with Phytohustil® increased their viability without affecting the cell number, and these data support and may explain the positive effect of Phytohustil® observed in patients during the therapy of inflamed buccal mucosal membranes or treatment of cough.

Overall evidence strength for skin/wound healing: Primarily preclinical (animal models and in vitro) with no controlled human clinical trials specifically for wound healing or dermatological conditions. Traditional use is extensive and mechanistic plausibility is reasonable.

5.4 Respiratory Conditions Beyond Cough

In a model of airway inflammation in guinea pigs, the polysaccharide rhamnogalacturonan from A. officinalis exerted cough-suppressing effects in a dose-dependent manner, suggesting a potential role in the treatment of asthma. These results are animal-based and require human validation.

5.5 Urinary Tract

Traditional use of marshmallow as a diuretic and for urinary complaints, including cystitis and urinary tract irritation, is historically documented. Empirical medicine includes cough, diarrhea, cystitis, and leucorrhoea among uses. No prospective controlled clinical trials in humans evaluating urinary outcomes for A. officinalis alone are currently available in the peer-reviewed literature reviewed here.

5.6 Vulvovaginal Candidiasis

A randomized double-blinded controlled clinical trial on the efficacy of complementary treatment with marshmallow in vulvovaginal candidiasis was published (Amini et al., 2023, in Explore, vol. 19, no. 6, pp. 813–819), indicating growing interest in clinical investigation beyond the traditional respiratory and gastrointestinal areas. Further detail of outcomes would require access to the full text of this trial.

5.7 Immunomodulatory Effects

Increases of phagocytic and macrophage activities and the number of T lymphocytes are the main immunomodulatory effects of the marshmallow root extract. These effects have been described in preclinical models and remain to be systematically evaluated in human trials.

6. Body Systems and Health Areas Associated with Marshmallow

• Respiratory system: Dry, irritative cough; sore throat; pharyngeal and oral mucosal irritation; potential bronchospasm reduction (preclinical).
• Gastrointestinal system: Gastritis; mild gastric and duodenal inflammation; constipation (stool softening); diarrhoea (traditional use).
• Integumentary system (skin): Minor wounds; burns; inflammatory skin conditions; furunculosis; topical soothing and emollient.
• Urinary system: Traditional use in urinary tract irritation, cystitis, and nephrolithiasis.
• Immune system: Preclinical immunomodulatory activity via macrophage and T-lymphocyte activation.
• Oral and buccal mucosa: Mouth ulcers; buccal mucosal inflammation; pharyngeal gargle applications.

7. Dosage Forms and Dosages Reported in Sources

Marshmallow root is the common name for the dried root of Althaea officinalis L. Preparations covered by the HMPC include comminuted root, macerate-based syrups, dry extracts, and liquid extracts.

The EMA/HMPC Community Herbal Monograph specifies, for traditional use preparations:

• Comminuted herbal substance (tea/macerate): Approximately 150 mL of cold water poured over 1 to 2 teaspoons (approximately 0.5 to 3 g) of sliced marshmallow root, left to stand for 1 to 2 hours with occasional stirring.
• Liquid extract: Liquid extract at a ratio of 1:19.5–23.5, with water as extraction solvent.
• Syrup (macerate-based): Syrup prepared from macerate, corresponding to 2–6.5 g of herbal substance per 100 mL.
• Dry extract: Dry extract at a ratio of 3–9:1 extraction solvent.

In the Fink et al. (2018) consumer surveys, the product used was the aqueous marshmallow root extract STW42, administered as either lozenges or syrup over a treatment duration of 7 days.

In the animal antitussive studies reviewed by the EMA, the polysaccharide was tested for antitussive activity in unanesthetised cats of both sexes at doses of 50 to 100 mg/kg body weight administered orally. The cough was induced by mechanical stimulation. The antitussive effect of marshmallow root extract and isolated mucilage polysaccharide was compared with Althaea syrup at 1,000 mg/kg, prenoxdiazine at 30 mg/kg, dropropizine at 100 mg/kg, and codeine at 10 mg/kg.

Cold extraction is considered superior to hot infusion for marshmallow because boiling can break down the long polysaccharide chains and reduce the gel-forming capacity.

8. Safety Considerations and Drug Interactions

General Safety

Marshmallow is generally well tolerated in adults, with allergic reactions reported rarely. Marshmallow is "generally recognized as safe" (GRAS) in amounts found in foods by the U.S. Food and Drug Administration.

According to the Drug and Lactation Database report (LactMed, 2024), marshmallow is generally recognized as safe (GRAS) in amounts found in foods by the US Food and Drug Administration.

No case of overdose has been reported in the EMA monograph documentation.

Drug Interactions: Absorption Delay

Marshmallow may delay the absorption of other medications taken at the same time due to its mucilage content. This is a mechanistically plausible interaction: the coating properties of the gel-forming polysaccharides on the gastrointestinal mucosa may physically impede the absorption of co-administered drugs. It is therefore prudent to separate the intake of marshmallow preparations from other oral medications.

Pregnancy and Lactation

It is advised to seek advice from a medical herbalist before using marshmallow during pregnancy and lactation. Orally, marshmallow is a purported galactogogue and is included in some proprietary mixtures promoted to increase milk supply; however, no scientifically valid clinical trials support this use. No data exist on the excretion of any components of marshmallow into breastmilk or on the safety and efficacy of marshmallow in nursing mothers or infants.

Hypersensitivity

Hypersensitivity to the active substance is listed as a contraindication in the European Union herbal monograph on Althaea officinalis L., radix. Individuals with known hypersensitivity to Malvaceae family plants should exercise caution.

Heavy Metal Considerations in Commercial Products

A 2022 PMC study examined heavy metal content in commercial marshmallow root preparations. Comparison of estimated results with the oral permitted daily exposure value for chromium in final drugs suggested by the ICH Q3D R1 guideline (10,700 μg/day) showed that all the products analyzed were below this value (the highest result was 278.40 ng/day). Despite conservative assumptions, the margin of exposure values obtained for chromium in daily dose for each marshmallow root cough syrup were above 10,000; therefore, exposure to chromium would not cause a health risk for specific population groups (children and adults).

Use in Children

For mouth or throat irritation and associated dry cough, marshmallow root medicines can usually be used in adults, adolescents, and children over the age of 3 years. The EMA/HMPC monograph provides guidance on age-specific suitability within its traditional use framework.

9. Regulatory and Pharmacopoeial Status

The HMPC has classified marshmallow root as a traditional herbal medicinal product. ESCOP indications include dry irritating cough, irritation of the oral and pharyngeal mucosa, and for the relief of mild gastrointestinal discomfort and irritation of the gastric mucosa. These indications are based on human experience and long-standing use. Marshmallow root has been classified by the HMPC as a traditional herbal medicinal product under Article 16a of Directive 2001/83/EC for use in the specified indications exclusively based on long-standing use.

In the United States, marshmallow leaves and roots are used as components of herbal teas, dietary supplement products, and topical demulcent preparations. Marshmallow flower and root, and extracts thereof, are also classified by the FDA as generally recognized as safe (GRAS) natural flavoring substances when used in the minimum quantity required.

Quality is defined in the European Pharmacopoeia (Ph. Eur.). Pharmacopoeial quality marshmallow root should have a swelling index of not-less-than 10, and for marshmallow leaf, not-less-than 12.

10. Summary of Evidence Strength

Modern studies support a range of therapeutic and pharmacological properties, including antitussive, gastroprotective, wound healing, anti-inflammatory, and antioxidant effects. Recent scientific studies strongly support the therapeutic potential of A. officinalis, most importantly its antitussive, gastro-protective, anti-inflammatory, and wound-healing activities.

Further in vivo studies and human clinical research trials are needed for an inclusive understanding of the mechanisms of biological and therapeutic effects, and for exploring the functional food and nutraceutical applications of this valuable plant.

Most of the research into marshmallow root to date has involved animal studies, very small-scale human studies, or in vitro studies. More studies are necessary to understand the benefits of the root for humans.

In summary: the strongest evidence for marshmallow root is for symptomatic relief of dry cough and oral/pharyngeal mucosal irritation, supported by pharmacopoeial recognition in Europe and two large consumer-reported surveys. Evidence for gastrointestinal, dermatological, and urinary indications is based primarily on animal/in vitro data and centuries of traditional use, accepted by regulatory bodies under the traditional use framework but not verified by adequately powered randomised controlled trials.

References

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