Ruscus

Ruscus (Ruscus aculeatus L.) — Butcher's Broom: A Comprehensive Reference

1. Identity, Botanical Description, and Natural Source

Taxonomy and Nomenclature

Ruscus aculeatus L., commonly known as butcher's broom, is a member of the Asparagaceae family and a perennial shrub native to the Mediterranean and Black Sea regions, naturalized in parts of Europe and North America. The Latin specific epithet aculeatus means "prickly." The plant is also referred to in the scientific and regulatory literature by the drug name Rusci rhizoma or Rusci aculeati rhizoma. Common names include box holly, butcher's broom, Jew's myrtle, knee holly, kneeholm, pettigree, Rusci rhizoma, and sweet broom.

Botanical Description

Ruscus aculeatus is an evergreen, perennial herbaceous species, growing up to 80 cm. The representatives of this species are sometimes described as subshrubs or shrubs; however, the shoots of Ruscus are not woody. It is a low evergreen dioecious shrub with flat shoots known as cladodes that give the appearance of stiff, spine-tipped leaves. Small greenish flowers appear in spring, borne singly in the centre of the cladodes. The female flowers are followed by a red berry, and the seeds are bird-distributed, but the plant also spreads vegetatively by means of rhizomes. It is native to Eurasia and some northern parts of Africa and occurs in woodlands and hedgerows, where it is tolerant of deep shade, and also on coastal cliffs.

The genus Ruscus L. belongs to the family Asparagaceae and includes six species distributed from Macaronesia through Europe and North Africa. Plants of this genus are primarily found in forests, often growing in deep shade. Among these species, Ruscus aculeatus L. is the most widespread.

Parts Used and Medicinal Drug Definition

By pharmacopoeial definition, the herbal drug consists of the dried, whole or fragmented underground parts of Ruscus aculeatus L. The highest concentration of ruscogenins is located in the rhizome. The aerial parts are used empirically as diuretics and the underground parts (roots and rhizomes) to alleviate the symptoms of several disorders of venous insufficiency, edema, urinary system, premenstrual syndrome, and hemorrhoids.

Common Forms and Preparations

Recognized herbal preparations include dried powdered root and dry extracts with varying drug-to-extract ratios and solvents, such as dry extract (4.5–6.5:1; water), dry extract (5–8.5:1; 80% v/v ethanol), dry extract (6–9:1; 96% v/v ethanol), and dry extract (15–20:1; 60% v/v methanol). Aqueous preparations (infusions and decoctions) and hydroethanolic extracts from both the aerial part and the roots and rhizomes have been prepared and studied. In recent decades, R. aculeatus extracts have been incorporated into numerous pharmaceutical and cosmetic preparations, particularly those intended to improve venous tone, reduce swelling, and alleviate symptoms of chronic venous disorders. Preparations are used both internally and externally as ointment preparations, and as suppositories for hemorrhoids.

2. Traditional and Historical Use

Ancient and Classical Mediterranean Use

In ancient Greece, butcher's broom was used as a laxative or diuretic, and it was also believed to remove kidney stones when added to wine. It is reported to have been used medicinally for approximately 2,000 years as an anti-inflammatory, vasoconstrictor, and tonicizer. Ruscus aculeatus is a subshrub used in traditional medicine in different parts of the world, namely in Europe and the Iberian Peninsula. According to reported folk knowledge, the aerial parts are mainly used as diuretics and the underground organs are used for the treatment of disorders of the urinary system and as a laxative.

European Folk Medicine

The common name, butcher's broom, hails from one of its original uses: in Europe, Ruscus species were traditionally harvested for their flat and stiff branches to make small brooms that were used for clearing off and cleaning butchering blocks. Recent research has uncovered that butcher's broom contains some antibacterial compounds, suggesting that in addition to the functional physical properties of Ruscus species, increased effectiveness in cleaning due to unrecognized antibacterial oils may have contributed to its popularity and subsequent nickname.

The empirical medicinal uses include the aerial parts being used as diuretics and the underground parts (roots and rhizomes) to alleviate the symptoms of several disorders of venous insufficiency, edema, urinary system, premenstrual syndrome, and hemorrhoids. The rhizomes of Ruscus species possess anti-inflammatory activity and are regularly used in traditional medicine for the treatment of urinary ailments, abdominal pain, vascular prevention, and skin disease.

Regional Traditions Beyond Western Europe

The aboveground parts of the plant are traditionally used as diuretics, mainly in Mediterranean countries and the Middle East. The related species Ruscus hyrcanus is used in traditional Iranian medicine as a diuretic, hemostatic, vasoconstrictor, antimicrobial, and anti-inflammatory agent.

Entry into Modern Phytomedicine

Ruscus aculeatus has been used as a herbal substance or herbal preparation notably in France and Germany, since 1986 and 1978, respectively. This use is fully documented at least since 1976 for the following indications: relief of symptoms of discomfort and heaviness of legs related to minor venous circulatory disturbances. The German Commission E, ESCOP, and the European Medicines Agency's Committee on Herbal Medicinal Products (HMPC) have all issued formal monographs on Rusci rhizoma (see Section 6 below).

Popular use of R. aculeatus is mostly based on empirical knowledge and beliefs; therefore, some of its therapeutic applications lack scientific foundation.

3. Key Constituents and Active Compounds

Steroidal Saponins — Primary Actives

Phytochemical investigations of R. aculeatus have revealed a complex chemical profile dominated by steroidal saponins of both the spirostanol and furostanol types. In general, steroidal saponins possess a C₂₇ carbon skeleton, usually derived from oxidized cholesterol, and contain one or more sugar residues attached at various positions. Spirostanol saponins are characterized by a bicyclic ketal structure at C-22, whereas furostanol saponins typically contain a hemiketal group at C-22 and an additional sugar moiety linked to C-26. The principal aglycone of the spirostanol saponins identified in R. aculeatus is ruscogenin.

The major steroidal sapogenins, neoruscogenin (NR) and ruscogenin (R), occurring in the mixture at approximately 75:25 (NR:R), are the secondary metabolites responsible for the principal bioactivities and are used clinically to treat vascular disorders such as varicose veins and hemorrhoids. Phytochemical examination of the underground parts of Ruscus aculeatus has led to the isolation of a total of twelve steroidal saponins, including seven new ones. The furostanol saponin bearing a diglycoside moiety and its corresponding spirostanol saponin exhibited cytostatic activity on leukemia HL-60 cells in preclinical research, though this application has not been pursued clinically.

The dried rhizomes and roots of butcher's broom contain a mixture of various steroid saponins, such as the spirostanol saponins ruscin, ruscuside, and the aglyca ruscogenin.

Phenolic Compounds and Other Constituents

Other constituents that have been isolated from R. aculeatus include sterols, triterpenes, flavonoids, coumarins, sparteine, tyramine, and glycolic acid. Nine phenolic compounds have been detected across different extract types. Apigenin-C-hexoside-C-pentoside isomer II was the major compound in aqueous extracts, while quercetin-O-deoxyhexoside-hexoside was predominant in hydroethanolic extracts. The phenolic fraction includes O-glycosylated derivatives of quercetin and kaempferol.

Nuclear Receptor Ligand Activity

Neoruscogenin has been identified as a potent and high-affinity agonist of the nuclear receptor RORα (NR1F1). This finding is of pharmacological interest because RORα is involved in regulation of circadian rhythm, immunity, and lipid metabolism, though this area of research in the context of R. aculeatus remains at the preclinical stage.

4. Mechanisms of Action

Alpha-Adrenergic Venoconstriction

Ruscus aculeatus is an alpha-adrenergic agonist that causes venous constriction by directly activating postjunctional alpha1- and alpha2-receptors, in turn stimulating the release of noradrenaline at the level of the vascular wall. It was concluded that the venoconstrictor response to R. aculeatus extract is not due to the activation of cholinergic, serotoninergic, or prostaglandinergic receptors. The effect, being inhibited by phentolamine but persisting after chemical denervation with 6-hydroxydopamine, suggests a direct effect on postjunctional α-adrenergic receptors of the smooth muscle cells. However, it appears that the release of norepinephrine stored in adrenergic nerve endings is also involved in the contractile effect of R. aculeatus extract.

Animal and in vitro studies show butcher's broom to have a vasoconstrictive effect. The mechanism of this effect remains somewhat unclear. Some studies indicate direct postjunctional alpha-1 and alpha-2 adrenergic receptor activation by its steroidal saponins; others indicate vasoconstriction is due to alpha-adrenergic blockade. Hamster cheek pouch studies show that prazosin and diltiazem block butcher's broom's inhibition of histamine-induced permeability increase while rauwolscine does not, indicating that butcher's broom's venoconstrictive effect is mediated by calcium and alpha-1 adrenergic receptors.

In anaesthetised dog models, R. aculeatus caused a dose-dependent constriction of the saphenous vein and potentiated the dose-response curve to local norepinephrine; these responses were antagonized by phentolamine.

Venotonic and Anti-Edema Properties

Ruscus aculeatus also possesses venotonic properties: it reduces venous capacity and pooling of blood in the legs and exerts protective effects on capillaries, the vascular endothelium, and the lymphatic system. Both norepinephrine and R. aculeatus extract caused a concentration-dependent contraction of lymphatic thoracic duct rings, and the contractile activity of R. aculeatus was partially inhibited by prazosin, consistent with alpha-1 adrenergic receptor involvement in the lymphatic system as well.

Reduction of Vascular Permeability

Researchers have found that when Ruscus extract is applied topically, a dose-dependent inhibition of the macromolecular permeability-increasing effect of histamine occurs. Ruscus extract given intravenously (5 mg/kg) inhibits the macromolecular permeability-increasing effect of bradykinin, leukotriene B4, and histamine. Butcher's broom has been shown to reduce vascular permeability.

Anti-Inflammatory Activity

The extracts of R. aculeatus have strong anti-inflammatory activity, act as anti-elastase, and decrease capillary permeability. The ruscogenins from butcher's broom showed remarkable anti-elastase activity in vitro but were inactive against hyaluronidase. The mode of action of ruscogenins as anti-inflammatory agents is not fully understood, but one proposed mechanism suggests that ruscogenins suppress leukocyte migration through both protein and mRNA regulation.

Endothelium-Derived Relaxing Factor Release

Research cited in the EMA reference list identified that Ruscus extract releases endothelium-derived relaxing factor in arteries and veins. This dual vasoconstrictive and endothelium-dependent vasodilatory action on arterial versus venous smooth muscle may explain why clinical use is associated with improvement in venous tone without systemic arterial hypertension in most cases.

5. Scientific Evidence by Area of Use

5.1 Chronic Venous Insufficiency (CVI) and Chronic Venous Disease (CVD)

Monograph-Level Recognition: The ESCOP monograph indicates supportive use for chronic venous insufficiency: aching, tired and heavy legs, tingling, and swelling of the legs. The German Commission E monograph covers complaints of chronic venous insufficiency, pain and heaviness in the legs, nocturnal calf cramps, itching, and swelling. The EMA HMPC monograph lists traditional use for complaints associated with chronic venous insufficiency.

Single-Agent Randomized Controlled Trial: A placebo-controlled RCT by Vanscheidt et al. (2002), published in Arzneimittelforschung, examined the efficacy and safety of a butcher's broom preparation (Ruscus aculeatus L. extract) compared to placebo in patients with chronic venous insufficiency. Studies mentioned in the ESCOP monograph were reviewed and present serious limitations as detailed in the EMA assessment report. Despite widespread use, studies regarding R. aculeatus alone remain limited. Many investigations have focused on complex formulations such as Cyclo 3 Fort, which also contains hesperidin methylchalcone and ascorbic acid, making it difficult to attribute the observed effects solely to R. aculeatus.

Meta-Analysis of the Combination Product (Cyclo 3 Fort): The most cited clinical evidence base concerns Cyclo 3 Fort, a preparation combining Ruscus aculeatus extract with hesperidin methyl chalcone (HMC) and ascorbic acid. A meta-analysis (Kakkos and Allaert, Int Angiol 2017) found that Ruscus compared to placebo, assessed as a continuous variable, reduced pain (SMD=–0.80, 95% CI: –1.21 to –0.39), heaviness (SMD=–1.23, 95% CI: –1.60 to –0.86), fatigue (SMD=–1.16, 95% CI: –1.71 to –0.61), feeling of swelling (SMD=–2.27, 95% CI: –3.83 to –0.70), and paresthesia (SMD=–0.86, 95% CI: –1.51 to –0.21). Regarding objective assessments, Ruscus compared with placebo reduced ankle circumference (SMD=–0.74, 95% CI: –1.01 to –0.47) and leg or foot volume (SMD=–0.61, 95% CI: –0.91 to –0.31). The existing evidence, where sufficient, was mostly of high quality. The authors' conclusion states that based on high-quality evidence, Ruscus extracts are highly effective in reducing symptoms and edema of patients with CVD. Limitation: Because Cyclo 3 Fort is a multi-component preparation, the isolated contribution of the Ruscus extract component cannot be definitively established from this data.

Open-Label Studies: In a clinical and capillaroscopic evaluation (Aguilar Peralta et al., Int Angiol 2007), 124 patients with CVI were assessed using the CEAP symptom scale at baseline and at 2, 4, 6, and 8 weeks. Treatment consisted of two capsules per day of Ruscus aculeatus 150 mg/HMC 150 mg/ascorbic acid 100 mg for 8 weeks. Of 124 patients studied (89% female, mean age 52.5 years), initial intense reports were 79% pain, 85% heaviness, 74% cramps, and 82% edema, decreasing to 20%, 12%, 8%, and 14% respectively within two weeks, with symptomatology largely absent at the end of treatment. This study is open-label and uncontrolled, limiting its interpretability.

5.2 Hemorrhoids

The ESCOP monograph lists supportive therapy for symptoms of haemorrhoids, such as itching and burning, as a recognized therapeutic indication. The German Commission E approved butcher's broom for itching and burning in hemorrhoids, and the EMA HMPC lists traditional use for burning and itching associated with haemorrhoids.

The efficacy of Cyclo 3 Fort (containing Ruscus aculeatus extract and hesperidin methylchalcone) in the treatment of acute attack of hemorrhoids was investigated in an open-label multicenter study. 124 patients were treated for one week, with 6 capsules daily for the first 3 days, then 4 capsules daily. Symptoms studied included painful symptoms, accompanying symptoms, and local signs. Analysis of results demonstrated a statistically significant decrease in all scores between day 0 and day 7, with an average decrease of 4.9 points in painful symptoms (p=0.0001), a decrease of 1.3 points in accompanying symptoms (p=0.0001), and a decrease of 3.6 points in local signs (p=0.0001).

In a separate open-label multicenter study of 124 patients with hemorrhoids, 69% of patients and 75% of treating physicians rated the butcher's broom combination extract Cyclo 3 Fort as having good or excellent efficacy. Ninety-two percent of physicians rated the treatment as safe and well tolerated. These studies are open-label and used multi-ingredient preparations; placebo-controlled data for butcher's broom alone in hemorrhoids is limited.

5.3 Lymphedema and Post-Mastectomy Edema

In a double-blind, placebo-controlled clinical trial, 57 patients with secondary lymphedema of the upper limb after previous treatment for breast cancer were treated for 3 months with an extract of Ruscus + Hesperidin Methyl Chalcone (Cyclo 3 Fort) or placebo; all patients also underwent manual lymphatic drainage twice weekly. With Cyclo 3 Fort, the reduction in volume of arm edema, the main assessment criterion, was 12.9% after 3 months of treatment compared with placebo (p=0.009). Decreased edema tended to be more marked in the forearm. Cyclo 3 Fort was well tolerated with minimal adverse reaction.

Meta-analysis indicated high efficacy of Ruscus aculeatus extracts in relation to a number of non-specific symptoms and a decrease in the volume of the lower leg in patients with CVD. Finding evidence for other symptoms and signs of CVD requires additional research.

5.4 Orthostatic Hypotension

Ruscus aculeatus, a phytotherapeutic agent containing ruscogenins and flavonoids, may prove useful for the treatment of orthostatic hypotension (OH) if denervation is not so advanced that it has compromised receptor activity at the venous wall. It is an alpha-adrenergic agonist that causes venous constriction by directly activating postjunctional alpha1- and alpha2-receptors, in turn stimulating the release of noradrenaline at the level of the vascular wall, and possesses venotonic properties: it reduces venous capacity and pooling of blood in the legs.

A 2001 review in the Journal of Alternative and Complementary Medicine aimed to provide evidence for what appears to be an effective, safe, and inexpensive botanical therapy for OH and to encourage further studies, by reviewing OH and therapies currently available and evaluating the properties of Ruscus aculeatus, its mechanism of action, and its suitability as a therapeutic agent for OH. With proven phlebotherapeutic properties, including vasoconstrictive action and venotonic properties, Ruscus aculeatus shows promise for ameliorating the symptoms of OH; it was noted to clearly deserve wider research and study as a treatment for OH. Evidence strength: This is a narrative review with a case report. No adequately powered, placebo-controlled RCT in orthostatic hypotension has been published. Evidence is preliminary.

5.5 Diabetic Retinopathy

An older, small study in patients with nonproliferative diabetic retinopathy (N=60) reported positive findings for the use of R. aculeatus extract in microvascular-associated retinopathy. Evidence in this area is very limited: one small, older study with no reported replication in contemporary literature. This cannot be considered established at this time.

5.6 Antioxidant, Antimicrobial, and Anti-Tumor Properties

The bioactive potential of hydroethanolic and aqueous extracts of R. aculeatus has been assessed in terms of antioxidant, anti-tumor, anti-inflammatory, hepatotoxicity, and antimicrobial properties. Results are consistent with findings demonstrating that plants of the Asparagaceae family have anti-inflammatory properties mainly due to the existence of steroidal saponins, primarily ruscogenin. These findings are derived from laboratory and in vitro experiments; no clinical evidence exists to support therapeutic use in cancer, infection, or as a primary antioxidant supplement.

5.7 Overall Strength-of-Evidence Assessment

Positive findings for vascular insufficiency and related conditions have been reported; however, clinical trials using R. aculeatus alone are generally lacking. Therefore, butcher's broom cannot be recommended for any indication based solely on its individual clinical trial record. The available data support the plant's traditional use, yet further well-designed experimental and clinical studies are needed to clarify its mechanisms of action, confirm its therapeutic potential, and ensure safety and standardization in medicinal preparations.

6. Regulatory and Monograph Status

The German Commission E monograph covers complaints of chronic venous insufficiency, pain and heaviness in the legs, nocturnal calf cramps, itching, and swelling. The ESCOP monograph covers supportive therapy for chronic venous insufficiency and for burning and pain in hemorrhoids. The EMA HMPC monograph designates traditional use for complaints associated with chronic venous insufficiency and hemorrhoids (burning, itching).

The ESCOP monograph covers therapeutic indications as supportive therapy for symptoms of chronic venous insufficiency, such as painful, tired and heavy legs, tingling and swelling, and supportive therapy for symptoms of haemorrhoids. In vitro and in vivo experiments with butcher's broom demonstrate its vasoconstrictive and vasoprotective effects. Pharmacological studies in humans concern effects on venous function, and controlled clinical studies with butcher's broom demonstrated therapeutic use in patients with chronic venous insufficiency, varicosis, and hemorrhoids.

7. Dosage Forms and Dosages Reported in Studies and Monographs

Oral Solid Dosage — EMA HMPC Monograph (2018)

The EMA HMPC monograph for one category of dry extract specifies a single dose of 150 to 200 mg, taken 2 to 3 times daily. For another standardized dry extract specification, the monograph lists a single dose of 350 mg, 3 times daily.

Combination Product Doses Used in Clinical Studies

In the Aguilar Peralta et al. (2007) clinical study, treatment consisted of two capsules per day of Ruscus aculeatus 150 mg/HMC 150 mg/ascorbic acid 100 mg during 8 weeks.

In the hemorrhoids study, 124 patients were treated for one week with 6 capsules of Cyclo 3 Fort daily for the first 3 days, then 4 capsules daily.

Topical and Other Forms

Preparations are available for both internal and external use, and cosmetic products for cellulite and stretch marks of pregnancy often contain butcher's broom extracts. External ointments and suppositories are recognized forms, particularly for hemorrhoids.

8. Body Systems and Health Areas

• Venous and Cardiovascular System: The rhizome and root have been employed in folk medicine for the treatment of venous insufficiency, hemorrhoids, edema, and various dermatological and urinary ailments.
• Lymphatic System: Cyclo 3 Fort (including Ruscus aculeatus) is used in the management of lymphedema.
• Autonomic Nervous System / Blood Pressure Regulation: Venotonic and alpha-adrenergic effects with potential application in orthostatic hypotension, as described above.
• Urinary System: A classical remedy from Europe claimed that the rhizomes could be used as a diuretic.
• Gastrointestinal / Anorectal: Supportive therapy for symptoms of haemorrhoids.
• Integumentary / Cosmetic: Extracts are found in some pharmaceutical and cosmetic products, such as creams for varicose veins and hemorrhoids.
• Ocular Microcirculation: Limited and preliminary data in diabetic retinopathy as noted above.

9. Safety Considerations and Interactions

Adverse Effects — Gastrointestinal

In a clinical trial in patients with chronic phlebopathy of the lower limbs (N=40), no adverse events were attributable to R. aculeatus therapy alone; however, reports of edema, nausea, and abdominal pain from multi-ingredient preparations exist. Allergic contact dermatitis has been reported with topical formulations, whereas oral administration has been associated with GI adverse effects (i.e., chronic diarrhea, lymphocytic colitis, cytolytic hepatitis). Using the rhizome of Ruscus aculeatus has been associated rarely with gastric complaints including nausea, diarrhea, and colitis.

Allergic / Dermatological Reactions

Using the rhizome of Ruscus aculeatus has been associated rarely with gastric complaints. Ruscogenins may cause allergic skin reactions on local application of the plant due to sensitivity. Allergic contact dermatitis to ruscogenins from topical vasoconstrictor creams has been documented in the peer-reviewed literature (Landa et al., Contact Dermatitis, 1990; Ramirez-Hernandez et al., Contact Dermatitis, 2006).

Pregnancy and Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking. Preparations have been studied in pregnancy-related varicosities; however, safety has not been established. The EMA HMPC monograph lists hypersensitivity to the active substance(s) as a contraindication.

Drug Interactions

No drug interactions are well documented. Theoretically, interactions with alpha-adrenergic–stimulating agents are possible, as butcher's broom contains substances with alpha-adrenergic stimulating activity. An interaction of pharmacodynamic antagonism has been noted between alfuzosin (an alpha-blocker used in benign prostatic hyperplasia) and butcher's broom, rated as minor/significance unknown. Because of the alpha-adrenergic mechanism, caution is warranted with concomitant use of other vasoactive or alpha-adrenergic agents.

Evidence Quality for Safety

There are only a few studies on the adverse effects of Ruscus extract, and they mostly involve isolated case reports. The broader long-term safety profile, particularly for chronic oral use, has not been systematically characterized in large-scale prospective studies.

References

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• Current Insights into the Phytochemistry and Pharmacological Properties of Ruscus aculeatus — PMC (2025)
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