Cite this article as: Ekasari DP, Basuki

S, Kurniasih W, Brahmanti H, Rofiq A.

Effect of Physalis angulata leaf extract

cream on Interleukin-4, Interleukin-6,

and Immunoglobulin-E in mice with in-

duced atopic dermatitis. Univ Med 2023;

42:150 -9. doi: 10.18051/UnivMed.

2023.v42:150-159

May-August 2023
UNIVERSA MEDICINA

Vol.42- No.2

pISSN: 1907-3062 / eISSN: 2407-2230

Effect of Physalis angulata leaf extract cream on

Interleukin-4, Interleukin-6, and Immunoglobulin-E

in mice with induced atopic dermatitis

Dhany Prafita Ekasari1 , Santosa Basuki1, Wuriandaru Kurniasih1* ,

Herwinda Brahmanti1 , and Aunur Rofiq1

ABSTRACT

BACKGROUND

The prevalence of atopic dermatitis (AD) and allergic or irritant contact

dermatitis has been increasing significantly in the general population.

Interleukin- 4 (IL-4), interleukin-6 (IL-6), and immunoglobulin E (IgE)

play a key role in the pathogenesis of AD. Physalis angulata (PA)

leaves reportedly have anti-inflammatory effects by impeding IL-4, IL-

6, and IgE. This study aimed to evaluate the effect of PA leaf extract

cream on IL-4, IL-6, and IgE using 2,4-dinitrochlorobenzene (DNCB)

to induce AD-like skin inflammation in a mice model.

METHODS

This study used an experimental design involving 30 BALB/c mice,

that were randomized into 3 groups: 1) control group receiving no

treatment; 2) Vehicle treatment group receiving vehicle cream

preparation; 3) PA treatment group receiving 10% PA leaf extract

cream after induction of AD-like skin inflammation by DNCB. After

30 days, tissue samples were extracted from the skin lesions to measure

IL-4 and IL-6 levels, and serum to measure IgE using ELISA. One-

way Anova, Kruskal-Wallis and Mann-Whitney tests were used to

analyze the data.

RESULTS

Group 3 (PA treatment) had significantly lower IL-4 (281.15 ± 43.14

pg/mL) than group 2 (vehicle cream treatment) (388.89±135.88 pg/ml)

(p=0.001). However, although IL-6 and IgE levels were lower in group

3 than in group 2, the differences were statistically not significant

(p=0.096 and p=0.479 respectively).

CONCLUSION

There were lower levels of IL-4, IL-6, and IgE in the group receiving PA leaf

extract cream than in the group receiving vehicle cream preparation.

Therefore, PA leaf extract cream may have therapeutic potential in AD.

Keywords: Atopic dermatitis, Physalis angulata, BALB/c mice,

dinitrochlorobenzene

1Department of Dermatology and

Venereology, Faculty of Medicine,

Universitas Brawijaya, Malang,

Indonesia

*Correspondence:

Wuriandaru Kurniasih

Jl. Percetakan Negara IVA no. 9A.

Jakarta Pusat 10560

Email: swuriandaru@gmail.com

ORCID: 0000-0001-8790-5918

Date of first submission, March 17,

2023

Date of final revised submission, July

13, 2023

Date of acceptance, July 24, 2023

This open access article is distributed

under a Creative Commons Attribution-

Non Commercial-Share Alike 4.0

International License

150

DOI: http://dx.doi.org/10.18051/UnivMed.2023.v42:150-159

ORIGINAL ARTICLE

mailto:swuriandaru@gmail.com
https://orcid.org/0000-0002-2469-7127
https://orcid.org/0000-0001-8790-5918
https://orcid.org/0000-0002-1970-6551
https://univmed.org/ejurnal/index.php/medicina/article/view/1451

151

Univ Med Vol. 42 No. 2

INTRODUCTION

Atopic dermatitis (AD) is a chronic
inflammatory skin disease with characteristic
symptoms and clinical signs, such as itching,
erythema, oozing/cru sting, excor iations,
lichenification, and dry skin. This condition is
caused by inflammation of the skin as a result of
increased histamine and inflammatory cytokine
levels.(1-3) According to the World Health
Organization Global Burden of Diseases at least
230 million people worldwide suffer from AD.(4)

The prevalence of AD in children is about 10%
to 20% whereas in adults it is about 5-10%.(5)

Atopic dermatitis is marked by infiltration
of the inflammatory cytokine interleukin-4 (IL-4)
producing cells in the skin and high levels of IL-4
in peripheral blood. The high IL-4 levels stimulate
Th2 cells and provide positive feedback causing
these cells to synthesize more IL-4.(6) Enhanced
regulation of Th2 immunity can also cause
maturation of B cells and differentiation of plasma
cells, resulting in IgE hypersecretion and release
of mast cells that will aggravate AD.(7) The
presence of damaged keratinocytes disturbing the
skin barrier, as well as an increased number of
macrophages, cause increased secretion of IL-
6, which then triggers Th2 differentiation and
inhibits Th1 polarization.(8)

Topical immunosuppressant steroids or
calcineurin inhibitors are the most frequent
medications used because of their rapid effect in
repairing AD lesions. However, the prolonged use
of steroids can cause various side effects such
as skin atrophy, telangiectasia, acne, and
hypertrichosis. Therefore, the development of
new pharmacological agents as a safe alternative
therapy is very much needed, considering that
AD is chronic and recurrent.(9,10) Currently, there
have been many developments in various types
of therapy that can target the specific mediators
involved in the pathogenesis of AD. These targets
include IL-4, IL-13, IgE, IL-6, B cells, IL-5, IL-
31, Janus Kinase-Signal Transducer and Activator
of Transcription (JAK-STAT), phosphodiesterase
-4 (PDE-4), IL-12, IL-17, IL-23, IL-22, histamine

H4 receptor (H4R), thymic stromal lymphopoietin
(TSLP) and peroxisome proliferator-activated
receptor-gamma (PPAR-).(11)

Physalis angulata (PA) reportedly contains
flavonoids such as quercetin and steroids such as
physalin and angulatin-A.(12) Quercetin has been
developed for AD treatment resulting in lower
levels of nuclear factor kappa B (NF-κB), TSLP,
IL-4, IL-6, and IgE.(10) The steroid content of PA
such as physalin has also been much studied as
an anti-inflammatories agent that can inhibit
various types of proinflammatory cytokines such
as NF-κB and IL-6.(13) Physalis angulata was
reported to have a mechanism of action on the
skin as an immunomodulator and anti-
inflammatory agent with effects similar to
corticosteroids and was suggested to be able to
increase wound healing factors but not to reduce
tumor growth factor β1 (TGF-β1) production in
normal human keratinocytes, in contrast to
corticosteroids which can inhibit the wound
healing process and cause skin atrophy. Topically
applied Physalis angulata is also reported as a
new and innovative phytopharmaceutical with
va rious pharmacologi cal effects that are
potentially useful to protect human skin, especially
against inflammation.(14) Another study also
showed that PA cream containing physalin-E
conferred benefits as an anti-inflammatory agent
in acute and chronic dermatitis in experimental
animals, which has therapeutic potential for the
chronic and recurrent inflammatory disease
AD.(15) Our study might give suggestions about
whether Physalis angulata is a potential anti-
inflammatory drug. The objective of this study
was to evaluate the effect of PA leaf extract
cream against levels of IL-4, IL-6, and IgE in the
development of a BALB/c mouse model that
resembles AD with 2,4-dinitrochlorobenzene
(DNCB) induction.

METHODS

Study design
This was an experimental study using an

animal model with a post-test only control group

152

design. This study wa s conducted at the
Integrated Biomedical Laboratory Unit, Faculty
of Medicine, Universitas Brawijaya, Dr Saiful
Anwar General Hospital, Malang from October
until November 2021.

Preparation of PA leaf extract and
phytochemical tests

Physalis angulata leaves were obtained
from Malang, East Java. The leaves were oven-
dried at 40 0C and made into a powder.
Subsequently, the leaves were extracted by
macerating in 70% ethanol. The maceration
process consisted of soaking 200 grams of
powdered PA leaves in 1 liter of 70% ethanol.
After five days the solution was filtered to
separate the residue from the filtrate, from which
the ethanol was evaporated using a rotary
evaporator, leaving only the pure extract without
the ethanol.

To analyze the plant extract, phytochemical
tests were carried out at the Malang Medicinal
Plant Station, consisting of quantitative analysis
of quercetin and qualitative analysis of flavonoids
and steroids.

Preparation of PA leaf extract cream
The formulation of the cream was identical

to that used in the study of Herdiana et al., (16),
except for the green tea used as perfume, while
the 10% w/w concentration of the PA leaf extract
was identical to the study of Abdul-Nasir-Deen
et al.(17) T he vehicle cream had the same
composition except for the PA leaf extract. The
materials used in the cream were glycerin 10%,
triethanolamine 2%, corn oil 20%, stearic acid
7%, cetyl alcohol 2%, methylparaben 0.1%, and
distilled water 100%. The cream was prepared
using Tano’s method, commencing by warming
up the stearic acid, corn oil, and cetyl alcohol to a
temperature of 70°C. The temperature was then
lowered to 65°C, and triethanolamine was slowly
added (Mixture 1). Glycerin and water in separate
containers were heated to 80°C, stirred, and
cooled down to 35°C (Mixture 2). Mixtures 1 and
2 were combined, while being stirred manually

until they increased in volume and formed a
smooth cream emul sion ( Mixture 3).
Methylparaben and PA leaf extract were added
while stirr ing until a smooth cream was
formed.(16)

Experimental animals
The research animals were 6-week-old male

BALB/c mice weighing 20-30 grams, obtained
from the Bioscience Laboratory, Universitas
Brawijaya (Malang, Indonesia). All mice were
acclima tized f or one week at controlled
temperature (23±3°C) and humidity (55±15%) in
a cycle of 12 hours light and 12 hours darkness.
Body weight and food intake were measured
once a week. The sample size was determined
by the Federer formula: (t-1) (r-1) >15 (t=number
of treatments; r=number of replications); (3-1)(r-
1) >15; 2(r-1)>15; r>8.5. In anticipation of a drop-
out rate of 10%, a total sample of 30 was obtained
for the three groups.

Procedure of AD i nduction in m ice
development and treatment model

This study used 30 mice that were randomly
assigned to three groups: group 1 was the control
group consisting of mice that were not given any
treatment; group 2 was the vehicle cream group
consisting of mice with DNCB-induced AD that
were given the vehicle cream preparation; and
group 3 was the AD treatment group consisting
of mice with DNCB-induced AD that were given
10% PA leaf extract cream. The AD in the
BALB/c mice was induced with DNCB using
the procedure of Lim et al.,(3) as follows: A 2x2
cm area of mouse dorsal skin was shaved on day
0 and cleaned with sterile gauze and 0.9% NaCl.
Sensitization with DNCB 0.5% was done for 3
consecutive days, namely on days 1, 2, and 3
using 0.15 mL of 0.5% DNCB on the shaved
dorsal skin area. Subsequently the sensitized skin
was challenged on days 14, 17, 20, 23, 26, and 29
(every 3 days) with 0.15 mL of 1% DNCB in
groups 2 (vehicle cream) and 3 (PA leaf extract
cream) at 8:00 a.m.(3) In groups 2 and 3 on day 4
of sensitization, skin lesions resembling AD were

Ekasari , Basuki , Kurniasih, et al Physalis angulata leaf extract cream

153

Univ Med Vol. 42 No. 2

found, such as erythema, erosion, excoriation,
scaling, and dry skin.(18)

On days 14 to 29, group 2 BALB/c mice
were given vehicle cream topically on the dorsal
skin every day, while group 3 was given 10% PA
leaf extract cream. The respective creams were
given in amounts of 0.1 g for the 2x2 cm areas
on the dorsal skin of the mice with DNCB-induced
AD.(3,17,19) The vehicle and PA creams were
applied every day at 2:00 p.m. on the respective
animals. On day 30th, the mice were euthanized
by cervical dislocation. The mechanism of AD
induction in the mice is depicted in the Figure 1.

Analysis of mouse serum and skin
After being left to stand at room temperature

for 2 hours, each of the blood samples was
centrifuged at 3000 g for 15 minutes and the
supernatant was collected for determining IgE
levels (ELISA kit Thermo Scientific, USA).
Examination of levels of IL-4 (ELISA kit Cusabio,
USA) and IL-6 (ELISA kit, Mybiosource, USA)
was performed on 200 mg of skin tissue that was
put in a 1.5ml Eppendorf tube, homogenized in 1
ml PBS using mortar and pestle, and stored
overnight at -20 °C. The levels of each cytokine
were then measured using the ELISA kits.

Figure 1. Induction of atopic dermatitis-like inflammation in BALB mice with 2,4-dinitrochlorobenzene (DNCB)

Figure 2. Atopic dermatitis-like lesion in 2,4-dinitrochlorobenzene (DNCB) treated BALB/c mice

154

Statistical analysis
Data obtaine d fr om the study was

quantitative data, comprising mouse skin IL-4 and
IL-6 levels, and mouse serum IgE in all three
groups. Quantitative data was then processed
with the Shapiro-Wilk normality test using SPSS
software (v21.0). If the data was normally
distributed, it was next analyzed with one-way
ANOVA to find differences between the three
groups. If the data distribution was not normal,
the Kruskal-Wallis test was used for analysis. A p-
va lue <0.05 was cons ider ed sta tistically
significant.

Ethical clearance
Ethical approval of the study on BALB/c

mice was obtained from the Ethics Research
Commission, Brawijaya University (Animal Care
and Use Committee) with the Ethical Clearance
letter No. 037-KEP-UB-2021.

RESULTS

Phytochemical Results
Phytochemical testing of 70% ethanolic PA

leaf extract found the presence of flavonoids, but
did not find steroid compounds. On quantitative
analysis, a mean quercetin level of 7.61% was
obtained.

Effect of PA leaves on AD-like skin lesions
induced by DNCB in mice

A total of 30 skin lesions on day four had
met the criteria for lesions resembling atopic
dermatitis, namely erythema, erosion, excoriation,
or crusting, while repeated DNCB application
induced skin lesions similar to marked AD with

clearly visible erythema, excoriation, and
lichenification on the dorsal skin. Healing of the
observable skin lesions resulted in better looking
skin, especially in the PA leaf extract cream group
(group 3) compared to the vehicle cream group
(group 2). Administration of PA leaf extract cream
resulted in visible repair of proven lesions,
accompanied by decreases in erythema, edema,
lichenification, dry skin, and excoriations, although
of insufficient potential compared to the mice that
did not receive any treatment (group 1).

Effect of PA cream on IL-4, IL-6, and IgE
levels

Based on the results of ANOVA analysis, it
was found that there was a significant difference
in the mean IL-4 level in the three treatment
groups (p= 0.001). The mean difference between
IL-4 levels in group 1 and group 2 was statistically
significant (p<0.001). However, the mean
difference between IL-4 levels in group 1 and
group 3 was not significant (p=0.226), whereas
the mean IL-4 level in group 2 was significantly
different from the mean in group 3 (p=0.024)
(Table 1). It was found that the p value for IgE
was 0.479 (p>0.05), signifying that there was a
nonsignificant difference between the groups at
an error rate of 5% (Table 1). In contrast, mean
IgE in group 2 was higher than in groups 1 and 3,
and mean IgE levels in group 3 that was given
PA cream was lower than in group 2 that was
given vehicle cream preparation.

The IL-6 normality test showed that the
Kolmogorov-Smirnov test value in group 3 had a
p=0.007 (p<0.05), which means that it had an
abnormal distribution. Then, Kruskal-Wallis and
Mann-Whitney tests were performed. Analysis

Treatment groups
p value

Control (n=10)
DNCB + vehicle

cream (n=10)
DNCB + PA cream

(n=10)
Interleukin-4 (pg/mL)@
Interleukin-6 (pg/mL)$
Immunoglobulin E (ng/mL)@

216.09 ± 42,64
4.05 (3.93-4.10)
125.04 ± 4.76

388.89 ± 135.97
4.17 (4.09-4.27)
128.51 ± 7.53

281.15 ± 43.14
4.13 (4.05-4.14)

126 ± 6.75

0.000
0.011
0.479

Table 1. The effect of PA leaves on IL-4, IL-6 and IgE by treatment groups

Note: Data presented as mean ± SD, except for Interleukin-6 [median (Q1-Q3)]; @ One-way Anova test; $ Kruskal-Wallis test;
PA: Physalis angulata; DNCB: 2,4-dinitrochlorobenzene; Significant at p<0.05

Ekasari , Basuki , Kurniasih, et al Physalis angulata leaf extract cream

155

Univ Med Vol. 42 No. 2

results of the Kruskal-Wallis test obtained a p-
value of 0.011 (p>0.05), signifying that although
IL-6 was slightly lower in group 3 than in group
2, there was no significant between-group
difference in the effect. After post-hoc analysis,
only the mean difference in IL-6 between group
1 and group 2 was statistically significant (p =
0.008 <0.05). On the other hand, the mean IL-6
levels in groups 1 and 3 were not significantly
different (p=0.053), while the mean IL-6 level in
group 2 also did not differ significantly from that
in group 3 (p=0.096) (Table 2).

DISCUSSION

The preliminary phytochemical tests of the
ethanolic PA leaf extract revealed the presence
of flavonoids, but not of steroids were. In this
study flavonoids such as quercetin accounted for
7.16% while the ster oid content was not
detectable. The mice in the PA leaf extract cream
group had significantly lower IL-4 levels than the
mice in the vehicle cream group. However,
although the IL-6 and IgE levels in the PA leaf
extract cream were lower than in the vehicle
cream group, the between-group difference was
statistically not significant for both parameters.

Our study results are similar to those of
Abdul-Nasir-Deen et al.,(17) where the methanolic
PA leaf extract, which also contained flavonoids
but no steroids, reportedly still had anti-
inflammatory properties and reduced paw edema
in a mouse model of dermatitis. Hou et al.(20)

concluded that a cream made of quercetin, which
is a flavonoid, is useful in reducing AD symptoms.
Quercetin cream was applied on the dorsal side
of the left ears of the A D mice (C57BL/6 mice
treated with topical MC903, a low-calcemic
vitamin D3 analog) and reportedly reduced the
expression of CCL17, CCL22, IL-4, IL-6, IFN-
γ, and TNF-α.

Possible cause why our PA leaves do not
contain steroids is because in our study as well
as in previous studies, the fresh PA leaves came
from different locations, e.g. from Bogor in the
study by Herdiana et al.(16) and from Kalimantan
in the study by Iswahyudi et al.(21) The place of
origin of fresh PA leaves can influence the
contained metabolites. The diversity of secondary
metabolites is determined by various factors, such
as genetics, age, season at harvest time,
environmental fluctuations, soil conditions, and
biochemical interactions between competing
plants, that may regulate the synthesis of various
secondary metabolites.(22,23) In addition, the
solvents used for extracting the processed
materials and the drying method (sun-, air-, or
oven-drying) can also cause quantitative changes
in the composition of the phytochemical
compounds.(21) The quantity of the metabolites is
also affected by the location or origin of the PA.
Akomolafe et al.(24) from Nigeria reported that
the most abundant type of flavonoid found in PA
leaf extract is quercetin at 56.74 mg/g. In contrast,
Nguyen and Kim (12) in Vietnam reported that
quercetin is found in PA leaves at much lower
concentration, in the range of 40.12-66.10 mg/
kg.

Atopic dermatitis is characterized by three
main features, namely abnormalities of the Th2
immune response, disruption of the skin barrier,
and chronic pruritus.(25) Th2 cells produce IL-4
and IL-13, which can increase vascular adhesion,

Parameter Compared Groups p-value
IL-4a 1 2 0.000*

3 0.226
2 3 0.024*

IL-6b 1 2 0.008*
3 0.053
2 3 0.096

IgEc 1 2 0.462
3 0.925
2 3 0.691

Table 2. Results of Tukey multiple
comparison test

Notes: Group 1 = no treatment, Group 2 = DNCB
induced mice treated with vehicle cream, Group 3 =

DNCB induced mice treated with PA cream. * Significant
at p<0.05; aOne-Way ANOVA, followed by Tukey test
showed significant differences between group 1 and 2

(p=0,000) and group 2 vs. 3 (p=0.024); bKruskal-Wallis
test, followed by Mann-Whitney test showed a significant

difference between group 1 and 2 (p=0.008); cOne-Way
ANOVA, followed by Tukey test showed no significant

between-group difference

156

which is molecularly related to the adhesion of
eosinophils in dermatitis lesions. Th2 cells induce
proliferation of B cells, which can produce IgE,
which then binds to the surface of mast cells,
and subsequently, mast cells release inflammatory
mediators and cytokines, such as histamine, IL-
6, IL-1β, or TNF-α.(3)

Lesions in AD skin are marked by an
excessive expression of IL-4, IL-13, and TSLP
secreted by keratinocytes.(26) The IL-4 cytokine
interferes with the skin barrier and inhibits the
FLG (profilaggrin) gene expression, as well as
the synthesis of other proinflammatory cytokines
that cause inflammation in AD. Interleukin-4 and/
or IL-13 are strongly associated with three of
the abovementioned AD characteristics which are
key elements in the Th2 response. These
cytokines could trigger and control the immune
response in AD so that specific antagonism
against these cytokines has developed as a
therapeutic target in AD.(25,27) Interleukin-6 that
is especially produced by activated macrophages,
and IL-4 that is mainly released by T cells, are
key mediators in the initiation and development
of AD. Interleukin-6 also can influence the
enhancement of T cells and B cells. The enhanced
release of proinflammatory cytokines could be
detected at different AD phases which shows
that cytokines are closely involved in the
development of AD.(28) Immunoglobulin E plays
a role in AD via binding to mast cells and
basophils that have high affinity IgE receptors
(FCeRI), whereupon these cells will then release
a signal for degr a nulation and cause
inflammation.(29)

Atopic dermatitis affects the human immune
system and causes clinical symptoms such as
erythema, skin edema, excoriation, lichenification,
and abnormal epidermal thickening that are
observed in mice with DNCB-induced AD.(28)

The immune response in mice with DNCB-
induced AD can be observed from the increased
serum levels of IgE, IL-4, and IL-6 in the study,
and this condition is correlated with enhanced
infiltration of inflammatory cells and mast cells in
the dorsal skin. However, AD symptoms appear

to be reduced after treatment with PA leaf extract
cream for two weeks. Our study shows that PA
leaf extract cream can significantly lower IL-4
levels in the skin of the DNCB-sensitized mice.
The PA leaf extract cream can also lower IL-6
levels in the mouse skin and IgE levels in mouse
serum compared with mice that were only given
the vehicle cream preparation.

The mechanism of action of the PA leaf
extract cream in AD is due to the existence of
the flavonoid quercetin, as well as steroids such
as physalin that have been reported by many to
be able to suppress TSLP or NF-kB which is a
path in the formation of IL-4 or to directly inhibit
IL-4, IL-6, and IgE.(10) Abnormalities of the
epidermal barrier in AD increases the enzyme
kallikrein-5, which then binds to PAR2 and triggers
NF-κB, which in turn can increase the release of
TSLP cytokines by keratinocytes.(30,31) Thymic
stromal lymphopoietin induces dendritic cells and
activated Langerhans cells to migrate to the lymph
nodes as antigen-presenting cells (APC) and
convert naive T cells into Th2 cells.(32,33) The Th2
cells could return to the dermis and release IL-4
and IL-13 which can trigger the signs and
symptoms of AD. In addition, Th2 causes a
change in the IgE class produced by the B cells.(31)

The immunoglobulin E that is produced then
stimulates mast cells, which degranulate when
bound to specific allergens and release various
types of molecules including IL-4. Increasing IL-
4 will also aggravate AD by reducing epidermal
diff erentiation and downregulating AMP
expression thereby increasing the risk of
infection.(34)

Quercetin is a pleiotropic molecule that can
be used against various molecular targets to
control proinflammatory cytokines and therefore
has potential for AD therapy.(35) Several studies
have demonstrated that quercetin constitutes a
potent anti-AD agent that can be given orally or
topically. Karuppagounder et al. (36) used quercetin
orally (at 50 mg/kg) for two weeks in the NC/
Nga AD mouse model and reported that quercetin
could lower serum IL-4 levels and modulate
HMGB1/RAGE/ NF-κB signaling and Nrf2

Ekasari , Basuki , Kurniasih, et al Physalis angulata leaf extract cream

157

Univ Med Vol. 42 No. 2

protein induction. The study of Hou et al.(20)

concludes that administration of 1% quercetin
cream for seven days can reduce the expression
of IL-4, CCL17, CCL22, IL-6, IFN-γ, and TNF-
α in the ears of C57BL/6 mice with MC903-
induced AD. The quercetin derivative quercetin-
3-O-(2”-gallate)-α-l-rhamnopyranoside (QGR)
has also been reported to lower the expression
of IL-4, IL-5, and IL-13 when 1% QGR was
given topically to NC/Nga mice for four weeks.(37)

Treatment with quercetin derivatives could push
the expression of proinflammatory cytokines
through modulation of NF-κB, IL-4, IL-5, and IL-
13, serum IgE, and levels of eosinophils, iNOS,
and COX2, HMGB1, RAGE which play an
essential role as inflammatory mediators.
Quercetin has also been reported to inhibit the
HMGB1, NF-κB, J AK/STAT, and TSLP
pathways in the NC/Nga AD mouse model. In
addition, it has been shown that quercetin inhibits
cytokines and other pro-inflammatory agents, such
as IL-1β, IL-6, and TNF, and increases IL-10
levels in liposaccharide-induced inflammation in
mice.(10,36) According to the literature, quercetin
can inhibit NF-κB, TSLP, and IL-4 pathways
which are unique inflammatory pathways in AD.
However, this does not preclude the possibility
that the quercetin contained in the PA leaf extract
cream can inhibit IL-4 through other pathways,
in view of the fact that the pathophysiology of
AD is very complex, because PA could inhibit a
variety of signaling pathways or cytokines.

One of the limitations of this study is that
the PA leaf extract contained no steroids, which
are considered important for suppressing the
inflammation of atopic dermatitis. Therefore it is
necessary to search for PA leaves that contain
both flavonoids and steroids, in the expectation
that they can provide a more synergistic effect
against the AD-like inflammation in the mice.
Another limitation is that there was no comparison
of the PA cream with other standard topical
agents for AD, such as topical corticosteroids and
calcineurin inhibitors. It is still unclear whether
the improvement in IL-4, IL-6, and IgE levels due
to PA leaf extract cream equals or surpasses that

of topical steroids or calcineurin inhibitors. Even
so, the IL-4, IL-6, and IgE levels in mice given
PA cream at a concentration of 10% proved to
be lower than in mice given only the vehicle
cream. Further studies are needed on the
proportion of the extract in different creams, on
experiments with other preparations, such as
ointments or gels, and on the use of solvents and
other extraction methods to obtain a maximal yield
of flavonoids and steroids, thus providing
adequate treatment of AD lesions.

CONCLUSIONS

Physalis angulata leaf extract cream at
10% concentration can inhibit the inflammatory
response in mice DNCB-induced AD lesions by
lower ing IL-4, IL-6, and IgE levels. The
therapeutic use of PA leaf extract cream is
exceedingly promising and has the potential to be
developed into standard AD therapy.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

ACKNOWLEDGEMENT

The authors would like to tha nk the
Biomedical Labora to ry Unit, Brawij aya
University.

FUNDING

Non-tax state revenue fund, Faculty of
Medicine , Brawij aya Unive rsity ( Dana
Penerimaan Negara Bukan Paj ak/PNPB,
Fakultas Kedokteran Universitas Brawijaya).

AUTHOR CONTRIBUTIONS

DPE: basic concept, design, writing the
manuscript and performing the experiment. SB:
supervising, critical reviewing and final approval
of the manuscript. WK: analyzing, interpreting
data, and helping draft the manuscript. HB and

158

AR: critical reviewing and final approval of the
manuscript. All authors have read and approved
the final manuscript.

REFERENCES

1. Peng W, Novak N. Pathogenesis of atopic
dermatitis. Clin Exp Allergy 2015;45:566-74. doi:
10.1111/cea.12495.

2. Hur SS, Choi SW, Lee DR, Park JH, Chung TH.
Advanced effect of Moringa oleifera
bioconversion by Rhizopus oligosporus on the
treatment of atopic dermatitis: preliminary study.
Evid Based Complement Alternat Med 2018;2018:
7827565. doi: 10.1155/2018/7827565.

3. Lim JM, Lee B, Min JH, et al. Effect of peiminine
on DNCB-induced atopic dermatitis by inhibiting
inflammatory cytokine expression in vivo and in
vitro. Int Immunopharmacol 2018;56:135-42. doi:
10.1016/j.intimp.2018.01.025.

4. Rodrigues MA, Torres T. JAK/STAT inhibitors
for the treatment of atopic dermatitis. J Dermatolog
Treat 2019;31:33-40. doi: 10.1080/09546634.
2019.1577549.

5. Simpson EL, Leung DYM, Eichenfield LF,
Boguniewicz M. Atopic dermatitis: In: Kang S,
Amagai M, Bruckner Al et al., editors. Fitzpatrick’s
dermatology in general medicine, 9th ed. New York:
McGraw Hill; 2019. p.363-84.

6. Bao L, Shi VY, Chan LS. IL-4 up-regulates
epidermal chemotactic, angiogenic, and pro-
inflammatory genes and down-regulates
antimicrobial genes in vivo and in vitro: relevant
in the pathogenesis of atopic dermatitis. Cytokine
2013;61:419-25. doi: 10.1016/j.cyto.2012.10.031.

7. Bao L, Zhang H, Chan LS. The involvement of
the JAK-STAT signaling pathway in chronic
inflammatory skin disease atopic dermatitis. Jak-
Stat 2013;2:24137. doi: 10.4161/jkst.24137.

8. Sroka-Tomaszewska J, Trzeciak M. Molecular
mechanisms of atopic dermatitis pathogenesis.
Int J Mol Sci 2021;22:4130. doi: 10.3390/
ijms22084130.

9. Jang S, Ohn J, Kim JW et al. Caffeoyl–Pro–His
amide relieve DNCB-induced atopic dermatitis-
like phenotypes in BALB/c mice. Sci Rep 2020;
10:1-9. doi: 10.1038/s41598-020-65502-2.

10. Karuppagounder V, Arumugam S, Thandavarayan
RA, Sreedhar R, Giridharan VV, Watanabe K.
Molecular targets of quercetin with anti-
inflammatory properties in atopic dermatitis. Drug
Discovery Today 2016;21:632-9. doi: 10.1016/
j.drudis.2016.02.011.

11. Lee DE, Clark AK, Tran KA, Shi VY. New and
emerging targeted systemic therapies: a new era
for atopic dermatitis. J Dermatolog Treat 2018;29:
364-74. doi: 10.1080/09546634.2017.1373736.

12. Nguyen KNH, Kim KH. Determination of phenolic
acids and flavonoids in leaves, calyces, and fruits
of Physalis angulata L. in Viet Nam. Pharmacia
2021;68:501-09. doi:10.3897/pharmacia.68.e66044.

13. Yang YJ, Yi L, Wang Q, Xie BB, Dong Y, Sha CW.
Anti-inflammatory effects of physalin E from
Physalis angulata on lipopolysaccharide-
stimulated RAW 264.7 cells through inhibition of
NF-κB pathway. Immunopharmacol
Immunotoxicol 2017;39:74-9. doi: 10.1080/
08923973.2017.1282514.

14. Pereda MDCV, Dieamant G, Nogueira C, et al.
Sterol standardized phytopharmaceutical from
ground cherry: Corticoid like properties on human
keratinocytes and fibroblasts and its effects in a
randomized double blind placebo controlled
clinical trial. J Cosmet Dermatol 2018;00:1-13. doi:
10.1111/jocd.12851.

15. Pinto NB, Morais TC, Carvalho KMB, et al.
Topical anti-inflammatory potential of physalin E
from Physalis angulata on experimental dermatitis
in mice. Phytomedicine 2010;17:740-3. doi: 10.1016/
j.phymed.2010.01.006.

16. Herdiana Y, Susilo H, Muztabadihardja. Formulasi
krim pencerah wajah ekstrak etanol 70% daun
ciplukan (Physalis angulata L. [thesis]. Program
Studi Farmasi FMIPA, Universitas Pakuan Bogor;
2014.

17. Abdul-Nasir-Deen AY, Boakye YD, Osafo N, et
al. Anti-inflammatory and wound healing
properties of methanol leaf extract of Physalis
angulata L. South African J Botany 2020;133:124-
31. doi: 10.1016/j.sajb.2020.06.030.

18. Hamad AF, Han JH, Rather IA. Mouse model of
DNCB-induced atopic dermatitis. Bangladesh J
Pharmac 2017;12:147-50. doi: 10.3329/bjp.v12i2.
31950.

19. Serafini MR, Detoni CB, Menezes PD, et al. UVA-
UVB photoprotective activity of topical
formulations containing Morinda citrifolia
extract. BioMed Res Int 2014. doi: 10.1155/2014/
587819.

20. Hou DD, Zhang W, Gao YL, et al. Anti-
inflammatory effects of quercetin in a mouse
model of MC903-induced atopic dermatitis. Int
Immunopharmacol 2019;74:105676. doi: 10.1016/
j.intimp.2019.105676.

21. Iswahyudi I. Analisis fitokimia dan profil
kromatografi lapis tipis ekstrak etanol daun
ciplukan (Physalis angulata l.) dengan berbagai

Ekasari , Basuki , Kurniasih, et al Physalis angulata leaf extract cream

159

Univ Med Vol. 42 No. 2

metode pengeringan simplisia. J Mahasiswa
Farmasi Fakultas Kedokteran UNTAN 2015;3.

22. Mastuti R, Rosyidah M. Diversity of bioactive
secondary metabolites produced by medicinal
plants of Physalis angulata L. (Ciplukan). IOP
Conf. Ser.: Earth Environ Sci 743:012081. doi:
10.1088/1755-1315/743/1/012081.

23. Mastuti R, Batoro J, Waluyo B. Pengaruh elisitor
kitosan terhadap kandungan withanolid tunas in
vitro aksesi tanaman Physalis angulata dari Pulau
Madura. J Tumbuhan Obat Indonesia 2021;14:1-
4. doi: 10.22435/jtoi.v14i1.43011.

24. Akomolafe SA, Oyeleye SI, Olasehinde TA, Oboh
G. Phenolic characterization, antioxidant activities,
and inhibitory effects of Physalis angulata and
Newbouldia laevis on enzymes linked to erectile
dysfunction. Int J Food Properties. 2018;21:645-
54. doi: 10.1080/10942912.2018.1446149.

25. Furue M, Ulzii D, Vu YH, Tsuji G, Kido-Nakahara
M, Nakahara T. Atopic Dermatitis and type 2
immune deviation . Curr Treat Options Allergy
2019;6:200-10. doi: 10.1007/s40521-019-00219-w.

26. Huet F, Severino-Freire M, Chéret J, et al.
Reconstructed human epidermis for in vitro
studies on atopic dermatitis: a review. J Dermatol
Sci 2018;89:213-8. doi: 10.1016/j.jdermsci.2017.
11.015.

27. Munera-Campos M, Carrascosa JM. Innovation
in atopic dermatitis: from pathogenesis to
treatment. Actas Dermosifiliogr (English Edition)
2020;111:205-21. doi:10.1016/j.adengl.2020.03.001.

28. Wang L, Xian YF, Hu Z, et al. Efficacy and action
mechanisms of a Chinese herbal formula on
experimental models of atopic dermatitis. J
Ethnopharmacol 2021;274:114021. doi: 10.1016/
j.jep.2021.114021.

29. Giménez Arnau AM, Ribas Llauradó C,
Mohammad Porras N, Deza G, Pujol RM, Gimeno
R. IgE and high affinity IgE receptor in chronic
inducible urticaria, pathogenic, and management
relevance. Clin Transl Allergy 2022;e12117. https:/
/doi.org/10.1002/clt2.121171.

30. Čepelak I, Dodig S, Pavić I. Filaggrin and atopic
march. Biochem Med (Zagreb) 2019;29:214-27.
doi: 10.11613/BM.2019.020501.

31. Weidinger S, Beck LA, Bieber T, Kabashima K,
Irvine AD. Atopic dermatitis. Nat Rev Dis Primers
2018;4:1. doi: 10.1038/s41572-018-0001-z.

32. Kim JE, Kim JS, Cho DH, Park HJ. Molecular
mechanisms of cutaneous inflammatory disorder:
atopic dermatitis. Int J Mol Sci 2016;17:1234. doi:
10.3390/ijms17081234.

33. Rerknimitr P, Otsuka A, Nakashima C, Kabashima
K. The etiopathogenesis of atopic dermatitis:
barrier disruption, immunological derangement,
and pruritus. Inflamm Regen 2017;37:1-5. doi:
10.1186/s41232-017-0044-7.

34. Silverberg JI, Kantor R. The role of interleukins 4
and/or 13 in the pathophysiology and treatment
of atopic dermatitis. Dermatol Clin 2017;35:327-
34. doi: 10.1016/j.det.2017.02.005.

35. Wu S, Pang Y, He Y, et al. A comprehensive review
of natural products against atopic dermatitis:
Flavonoids, alkaloids, terpenes, glycosides and
other compounds. Biomed Pharmacother 2021;
140:111741. doi:10.1016/j.biopha.2021.111741.

36. Karuppagounder V, Arumugam S, Thandavarayan
RA, et al. Modulation of HMGB 1 translocation
and RAGE/NFκB cascade by quercetin treatment
mitigates atopic dermatitis in NC/Nga transgenic
mice. Exp Dermatol 2015;24:418-23. doi: 10.1111/
exd.12685.

37. Park EJ, Kim JY, Jeong MS, et al. Effect of topical
application of quercetin-3-O-(2 3 -gallate)-α-l-
rhamnopyranoside on atopic dermatitis in NC/
Nga mice. J Dermatol Sci 2015;77:166-72. doi:
10.1016/j.jdermsci.2014.12.005.