Herbs & Botanicals · Herbs · Purple coneflower, taken for colds

Echinacea

Q: Does echinacea prevent colds?

It might lower the chance a little. The independent Cochrane review found no single prevention trial that proved it, but a post hoc pooling suggested 10% to 20% fewer colds, and a 2019 pooled analysis found a risk ratio of 0.78, which the authors said might not matter much in daily life. Trials that were not clearly positive used other products. Many of the positive trials used one maker's fresh-plant extract. Certainty is low and reviews disagree.

Q: Does echinacea treat a cold once I have it?

Probably not much. Most of the best-designed trials found that taking it after symptoms start did not shorten the cold or make it clearly milder; the Cochrane review found only 1 of 7 treatment trials with a significant benefit. A few trials of specific standardised fresh-plant products found some benefit, so results depend heavily on the product. Certainty is low.

Q: How long should I take echinacea?

Keep courses short. The EU limit for the fresh-herb juice is no more than 10 days for a cold, and it advises seeing a doctor if symptoms last longer. In the trials, prevention blocks lasted about 2 to 4 months in a few maker-sponsored studies, and the longest ran about 6 months. Long-term safety beyond that is not established.

Q: Which species and plant part should I choose?

No species or part has been shown to be best. The three species (E. purpurea, E. angustifolia, E. pallida) differ chemically, and so do the herb, root and whole plant. The EU monograph for the fresh juice covers E. purpurea only, and E. angustifolia root extracts did not work in the large virus-challenge trial. Choose a product that names the species and the part used, and do not assume a result from one product applies to another.

Q: Is echinacea safe for children?

Be careful. The EU does not recommend it under 12 years for lack of data, and the US NIH says to ask the child's health care provider first. In one large trial of 407 children aged 2 to 11, rash occurred in 7.1% of infections treated with echinacea versus 2.7% with placebo. A 2025 pooled analysis found mild side effects moderately more common (risk ratio 1.38). Benefits in children are mixed and several trials were funded by the product maker.

Q: Can I take echinacea in pregnancy or while breastfeeding?

Ask a doctor first. The EU does not recommend it in pregnancy or breastfeeding unless a doctor advises. A Norwegian cohort of 363 pregnancies exposed to echinacea found no link to malformations or adverse outcomes, and the US NIH says up to 7 days in the first trimester is possibly safe, so a past exposure is not a reason for alarm. The data are too small to exclude rare problems. Breastfeeding data are very limited.

Q: Can I take echinacea if I have an autoimmune disease or take immune-suppressing medicine?

Ask your specialist first. The EU advises against it in autoimmune disease, immune deficiency and immune suppression because echinacea is described as an immune stimulant. This is a precaution based on theory: no trial showed flare-ups, and one 2016 review calls the contraindication questionable. A small pilot of 51 people with autoimmune uveitis reported no adverse reactions. Do not combine it with transplant medicines unless a specialist agrees.

Q: Does echinacea interact with medicines?

Possibly, but the findings are mixed. In small volunteer studies echinacea root changed how the body handles midazolam (a CYP3A medicine, in opposite directions in liver and gut) and slowed caffeine clearance by about a quarter in one study. Other studies found no change with lopinavir-ritonavir, docetaxel or warfarin (clotting did not change). One case report links it with low platelets during etoposide chemotherapy. The EU says no interactions have been reported and the NIH says the evidence is conflicting. Ask a pharmacist, especially with chemotherapy, transplant or narrow-margin medicines.

Q: Who should not use echinacea because of allergy?

Anyone allergic to echinacea or to other daisy-family (Asteraceae) plants such as ragweed, chrysanthemum, marigold or daisies should not use it. People with hay fever, allergic asthma, eczema or a past severe reaction should ask a doctor first. Reports describe hives, swelling, asthma attacks and anaphylaxis, some after the first dose. Stop and get emergency help for trouble breathing, throat swelling or fainting.

Q: What are the side effects?

Usually mild: stomach upset, nausea, abdominal pain and rash. In a 4-month trial of 755 healthy adults, 49.9% on a fresh-herb extract and 47.5% on placebo reported any adverse event, and stopping because of side effects was rare. Serious but rare reports include allergic reactions, a few severe skin reactions listed by the EU, and isolated liver injury cases. How often these happen is unknown.

Echinacea purpurea (L.) Moench, E. angustifolia DC. and E. pallida (Nutt.) Nutt. · also called Purple coneflower, narrow-leaf purple coneflower or Kansas snakeroot (E. angustifolia), pale purple coneflower (E. pallida), equinácea (Spanish), échinacée pourpre (French), Roter Sonnenhut (German)

Echinacea is a group of three North American daisy-family plants. The flowering tops, the roots or both are used as fresh juice, alcohol tinctures, dry extracts in capsules and tablets, tea, lozenges and throat sprays. It is bought mostly to ward off or shorten colds. This profile covers echinacea as a herb and supplement. The three species and the many kinds of product are not interchangeable, so a result from one product should not be assumed for another.

General information, not medical advice. Last substantive update October 24, 2026 · Not medically reviewed. A named clinician has not signed off on this page. How this page is made

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About Echinacea

Echinacea (purple coneflower) is a group of three North American daisy-family plants used for centuries by Plains peoples for wounds and infections and, since the late 1800s, widely bought in Europe and North America to prevent or shorten colds. It is one of the most-tested herbs, yet the evidence stays low in certainty because the products differ so much. For preventing colds there may be a small benefit; for treating a cold that has started, most independent trials found none. Many of the positive trials involve one maker's fresh-plant extract. The anxiety findings come from a single patented extract. The main cautions are allergy to daisy-family plants, autoimmune disease and immune suppression (a theory-based precaution), children under 12, pregnancy and a few medicine interactions. Quality varies between brands.

What it is

Echinacea is a genus of daisy-family (Asteraceae) plants native to North America. Three species are sold as the herb: Echinacea purpurea (purple coneflower), E. angustifolia (narrow-leaf) and E. pallida (pale). The flowering tops (aerial parts), the root or the whole plant are used, fresh or dried.

It is taken as pressed juice, alcohol tinctures, dry extracts in capsules and tablets, tea, lozenges and throat sprays, and applied to the skin as creams. Many shelf products are blends that also contain sage, elderberry, zinc or vitamin C.

The word coneflower is also used for other plants, such as Rudbeckia, which are different plants.

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What makes it distinctive

Echinacea does not have one active ingredient. Four very different groups are suggested to matter: alkamides, caffeic acid derivatives (cichoric acid in E. purpurea, echinacoside in E. angustifolia and E. pallida), polysaccharides and glycoproteins. None has been proven to be the one that matters in people.

In test tubes and animals, echinacea extracts stimulate some immune cells, bind a cannabinoid-type receptor (CB2) and, in a dish, inactivate some enveloped viruses such as coronaviruses. That is lab work. Only the alkamides have been followed in human blood, at very low levels, and nobody has shown these levels explain any health effect.

The three species differ chemically, and so do the plant parts and the solvents used. Juice, alcohol tinctures, dry extracts and tea are different things. A good result with one maker's extract of fresh E. purpurea cannot be assumed for a root capsule, an E. angustifolia tincture or another brand.

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Historical and current uses

The EU medicines agency reports, quoting older sources, that peoples of the North American plains used echinacea, especially E. angustifolia root, for more ailments than almost any other plant: wounds, burns, bites and stings, toothache, sore throat and cough. Which tribes used which species for what was not checked here.

Echinacea reached Europe in the late 1800s and 1900s, and commercial growing of E. purpurea began in Germany in the late 1930s. Most studies since 1939 used pressed juice of the flowering plant.

Today the EU lists the pressed juice of fresh E. purpurea herb for well-established short-term prevention and treatment of the common cold (up to 10 days), and several root products as traditional herbal medicines for cold symptoms, mild acne or small wounds. In the US it is sold as a dietary supplement, which is not approved by the FDA before sale.

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What the research shows

Prevention and treatment are kept separate because they give different answers. For prevention, the independent Cochrane review (24 trials, 4,631 people) found no single comparison significant but a possible 10% to 20% lower risk in a post hoc pooling; a 2019 pooled analysis found a risk ratio of 0.78 and warned the benefit may be too small to matter. For treatment, only 1 of 7 trials reporting cold length found a significant benefit. Certainty is low, and the reviews disagree with each other.

Many of the positive trials, and several of the reviews that report larger benefits, are linked to the maker of one brand of fresh-plant alcohol extract of E. purpurea. Trials of other products, such as pressed-juice powder, root capsules, unrefined herb-and-root blends and E. angustifolia root extracts, mostly found no clear effect. Some pooled analyses are by authors paid by manufacturers, so they are weighed with care.

In children the results are mixed (one large trial found no benefit and more rash; maker-linked trials found fewer infections). The anxiety findings come from one patented extract of E. angustifolia root, and the largest trial did not beat placebo on its main anxiety measure. For skin, herpes, HPV, immune markers and athletes the studies are small, uncontrolled or null. No trial was found comparing echinacea head to head with elderberry, and vitamin C appears only as the comparison arm in one children's trial.

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Root, leaf, powder, extract: what is the difference?

Pressed juice or alcohol extract of fresh plant

Juice pressed from the fresh flowering herb, or an alcohol extract of freshly harvested plant (for example 95% herb and 5% root). The EU well-established cold use is for expressed juice, 1.5 to 4.5 mL a dose and 6 to 9 mL a day, for no more than 10 days.

This is the form behind most positive cold trials, and several of those trials are linked to the maker of one brand. A trial of freeze-dried pressed-juice powder found no benefit, so two products from the same species can give opposite results.

Root tinctures and liquid extracts

Alcohol-and-water extracts, usually of root. EU traditional-use monographs describe E. pallida root tincture (1:5, 50% ethanol) and E. angustifolia root tincture (1:5, 45% ethanol, 1 to 2 mL three times a day).

The E. angustifolia root extracts tested in the large virus-challenge trial showed no effect on infection or symptoms. In a small study a tincture gave higher and faster alkamide peaks in blood than tablets. Alcohol content matters for children, pregnancy and anyone avoiding alcohol.

Capsules and tablets (dry extract or powder)

Dry extract (for example a 60% ethanol extract) or powdered herb or root. Doses in trials ranged from 200 mg of extract to several grams of raw herb or root a day.

Two US trials of root or whole-plant capsules found no benefit for treating colds. Many abstracts do not state the extract ratio, and whole-plant blends cannot be tied to one species. Milligrams of one product cannot be converted to another.

Tea (infusion or decoction)

Cut root or herb steeped in hot water. The EU traditional-use monograph for E. angustifolia root describes 1 g in 150 mL of boiling water, three times a day, for cold symptoms.

No placebo-controlled trial of echinacea tea was found. Water extracts contain a different mix of compounds than alcohol extracts, so trial results for tinctures and capsules cannot be applied to tea.

Lozenges and throat sprays

Solid forms dissolved in the mouth, and alcohol-based sprays (often echinacea with sage, up to two puffs ten times a day in one trial).

The spray trial had no placebo group and cannot credit the effect to echinacea alone. No clinical trial of an echinacea lozenge was found. Lozenges raised blood alkamide levels with dose in one small study.

Skin creams and ointments

Creams made from alkamides, creams and gels for skin care, and ointments with 10% to 20% pressed juice for small wounds (EU traditional use, up to 1 week).

The eczema and skin-hydration studies are small and early and do not apply to swallowed products. The EU says echinacea products should not be applied to the breast of a breastfeeding mother.

Patented E. angustifolia root extract (EP107)

A standardised extract of E. angustifolia root, taken as 20 or 40 mg twice a day in the anxiety trials.

All the anxiety and mood evidence is for this one product. It does not apply to other echinacea supplements.

At a glance

Traditional uses history, not proof

Peoples of the North American plains used echinacea, especially E. angustifolia root, for wounds, burns, bites, toothache, sore throat and cough (as reported by the EU medicines agency, quoting older sources)
European and American medicine adopted it from the late 1800s for infections and colds; most studies since the 1930s used fresh pressed juice of the flowering plant
EU well-established use: short-term prevention and treatment of the common cold with the pressed juice of fresh E. purpurea herb, for no more than 10 days
EU traditional use: cold symptoms with certain root extracts, mild acne spots, and small skin wounds (ointment, up to 1 week)

Studied for research

Preventing colds in adults, low certainty
Treating a cold once it has started, low certainty (most independent trials found no benefit)
Children's respiratory infections, low certainty (mixed, several trials funded by the product maker)
Anxiety, low certainty (one patented E. angustifolia root extract)
Mood, very low certainty
Eczema cream, skin hydration, genital herpes, HPV-related lesions, immune lab markers: very low or low, small studies

Main compounds

Alkamides (alkylamides), found mainly in the root; the only group measured in human blood, at very low levels
Caffeic acid derivatives: cichoric acid is the main one in E. purpurea; echinacoside in E. angustifolia and E. pallida roots
Polysaccharides and glycoproteins (water-soluble parts of unknown importance in people)

Common forms

Pressed juice or alcohol extract of fresh plant (the form behind the EU cold monograph and many maker-linked trials)
Root or herb tinctures and dry extracts in capsules or tablets (doses from about 200 mg of extract to several grams of raw root in trials)
Tea of cut root (traditional use only; no placebo-controlled tea trial found)
Lozenges, throat sprays (often with sage) and creams or ointments

Research links: NIH NCCIH: Echinacea · EU herbal monograph: Echinacea purpurea herb, fresh (EMA) · EU draft herbal monograph: Echinacea purpurea root (EMA) · Research Library · Genes & Biomarkers Library

The plant and its history

Accepted scientific name: Echinacea purpurea (L.) Moench (the herb-market 'echinacea' is three species: E. purpurea, E. angustifolia DC. and E. pallida (Nutt.) Nutt.)
Naming authority: GBIF accepted names: E. purpurea (L.) Moench, published in Methodus 591 (1794); E. angustifolia DC., Prodr. 5: 554 (1836); E. pallida (Nutt.) Nutt., Trans. Amer. Philos. Soc. 7: 354 (1840); genus Echinacea Moench (1794). NCBI Taxonomy gives the same authorities.
Synonyms: Rudbeckia purpurea L. (basionym of E. purpurea); Echinacea purpurea var. purpurea; Echinacea serotina (Nutt.) DC. (listed by GBIF as a synonym of E. purpurea); Echinacea intermedia Lindl.; Brauneria purpurea (L.) Britton; Lepachys purpurea (L.) Raf.; Echinacea angustifolia var. strigosa McGregor; Echinacea pallida var. angustifolia (DC.) Cronquist (a synonym of E. angustifolia); Brauneria angustifolia (DC.) A.Heller; Rudbeckia pallida Nutt. (basionym of E. pallida); Brauneria pallida (Nutt.) Britton
Common names: Echinacea (English); Purple coneflower (English); Eastern purple coneflower (E. purpurea) (English); Narrow-leaf purple coneflower, Kansas snakeroot, black sampson (E. angustifolia) (English); Pale purple coneflower (E. pallida) (English); Equinacea; equinácea púrpura (E. purpurea) (Spanish); Equinácea de hoja estrecha (E. angustifolia) (Spanish); Equinácea pálida (E. pallida) (Spanish); Échinacée pourpre (French); Roter Sonnenhut; Purpur-Sonnenhut (German)
Botanical family: Asteraceae (daisy family, order Asterales), so a person allergic to ragweed, daisies, chrysanthemums or marigolds may react to it; the EU monograph lists hypersensitivity to Asteraceae as a contraindication.
Classification: Plantae > Tracheophyta > Magnoliopsida > Asterales > Asteraceae > Echinacea > Echinacea purpurea; E. angustifolia; E. pallida
Native range: The genus is native only to eastern and central North America (wet to dry prairies and open woodland), with ten species and a few more depending on the author (Wikipedia, secondary; not checked in Plants of the World Online). E. purpurea is the common garden and farm species and is cultivated commercially in Germany since the late 1930s (EMA).
Habitat: Drought-tolerant perennials of prairies and open woods (Wikipedia, secondary).
What the plant looks like: Roots: Taproots in most species; E. purpurea grows from a short caudex with fibrous roots (Wikipedia, secondary).; Stems: Erect and usually unbranched, up to about 140 cm (Wikipedia).; Leaves: Alternate, usually rough and hairy; shape varies by species (Wikipedia).; Flowers: Single heads at the end of long stalks, with a spiny central 'cone' and drooping or spreading ray petals ranging from dark purple to pale pink, white or yellow; flowers in summer. Pollen is usually yellow and usually white in E. pallida (Wikipedia).; Fruit: Three or four-angled dry fruits (cypselae) with a persistent crown (Wikipedia).
Cultivation: Not verified from a primary source. E. purpurea has been farmed in Germany since the late 1930s (EMA).
Harvest and processing: Ph. Eur. herb is the whole or cut flowering aerial parts of E. purpurea; the EU monograph covers juice pressed from the fresh herb as soon as possible after harvest and kept by pasteurisation or by a suitable amount of ethanol (EMA). Root preparations: dry extract (DER 5.5-7.5:1; 45% ethanol), water extract (DER 4:1), tincture 1:5 in 55% ethanol (draft root report). Drying and harvest-timing practice were not verified.
Look-alikes and adulterants: Name: Other Echinacea species; Note: Roots and herb of E. angustifolia, E. pallida and E. purpurea are sold as 'echinacea' and may be mixed, which changes the chemistry as described above. E. tennesseensis and E. laevigata are rare wild species that were historically under US protection (Wikipedia, secondary): they are not the supplement plants.; Name: Rudbeckia and other 'coneflowers'; Note: Echinacea purpurea was first described as Rudbeckia purpurea by Linnaeus in 1753 and moved to Echinacea by Moench in 1794 (Wikipedia, GBIF, NCBI). Rudbeckia (black-eyed Susan) is a different genus and is not an Echinacea substitute.; Name: Species mix-ups and substitution risk; Note: Barnes and colleagues (p16102249) report that commercial echinacea products may contain one or more of the three species and that some do not meet pharmacopoeia quality standards. Adulteration with other plants was not documented in the EMA reports read here; contamination and adulteration belong to the safety file.
Sustainability and conservation: Not verified for the three medicinal species. Wikipedia (secondary) notes two other Echinacea species, E. tennesseensis and E. laevigata, were listed as endangered in the USA (E. tennesseensis since delisted, E. laevigata now threatened); wild-harvest pressure on E. angustifolia or E. pallida was not documented in the sources read.

The plant and the parts used

Close-up of echinacea (Echinacea purpurea) root — The root, one of the parts used.

Traditional use and history history, not clinical proof

Tradition or era	Documented use	Source
Indigenous peoples of the North American plains and prairies (before European settlement; the sources give no dates)	EMA reports, quoting Foster (1996), that Echinacea species were used by American Indians for more ailments than any other plant: E. angustifolia was universally used as an antidote for snakebite and other venomous bites and stings; traditional healers used it on wounds, burns and insect bites, chewed the root for toothache and throat infections, and took it by mouth for pain, coughs, stomach cramps and snake bites. A 2021 paper states that historical ethnobotanies of prairie peoples show treatment of many painful conditions with Echinacea. Specific tribes were NOT checked in this work, because the EMA text does not name them.	s-ema-ar-echinacea-herba-2014
Native American medicine in general (review, 2000)	A review notes that many botanicals sold as supplements today were used by Native Americans, that seven of the ten most common ones were used extensively by them, and that there are very few data to support such use.	p10919925
Late 1700s: first European mention of E. purpurea (1787)	EMA states that E. purpurea was first mentioned in 1787, for treating ulcers on horses' backs caused by saddles; the plant was then largely neglected until the Eclectic Dispensatory of 1852. EMA quotes this from older sources not checked in the original.	s-ema-ar-echinacea-herba-2014
United States, from about 1880 (Meyers Blood Purifier)	EMA (quoting Hostettmann 2003) says the first Echinacea preparation, Meyers Blood Purifier, appeared around 1880, for rheumatism, neuralgia and rattlesnake bites.	s-ema-ar-echinacea-herba-2014
Germany and Europe, 1895 to the 1930s	By 1895 Echinacea products were available in Germany for homeopathic physicians; demand grew and supplies ran short over the next 30 years; commercial growing of E. purpurea began in Germany in the late 1930s, bringing Echinacea products to a wide European audience. Most pharmacology and clinical studies since 1939 used fresh pressed juice of the flowering plant. Forms included ointment, liquids for outside and inside use, and ampoules for injection (Rote Liste 1961, per EMA).	s-ema-ar-echinacea-herba-2014
Modern European regulation: EU herbal monographs 2008 and 2014/2015	Dried E. purpurea herb and root have European Pharmacopoeia monographs (herb 01/2008:1823; root 01/2008:1824). The EU monograph on fresh E. purpurea herb (juice) lists well-established use for short-term prevention and treatment of the common cold by mouth (single dose 1.5-4.5 mL juice, daily 6-9 mL, not more than 10 days, not for children under 12) and traditional use for small superficial wounds on the skin (not more than 1 week). Not recommended for people with progressive systemic disorders, autoimmune disease, immunodeficiency or immunosuppression, or who are allergic to Asteraceae. A root report (traditional use, dry extracts) is in draft form.	s-ema-monograph-echinacea-herba-2015
Commission E (1989), ESCOP (2003) and WHO (1999)	EMA reports that these three monographs recommend semi-solid preparations for skin use and state no pharmacodynamic or pharmacokinetic drug interactions of Echinacea purpurea herb preparations in humans (as EMA reports). Their oral indications were not read in the originals here.	s-ema-ar-echinacea-herba-2014

Traditional use shows how a plant was used. It does not show that a supplement works or is safe today.

What is inside, and how it may work

What the plant contains and how those compounds act in cells and animals. Laboratory and animal mechanisms are not proven effects in people.

Main compounds

Compound	Family	Where it is concentrated	Activity studied	Level of evidence
Dodeca-2E,4E,8Z,10Z-tetraenoic acid isobutylamide (main alkamide, one isomer) PubChem 11413953	alkamide (alkylamide: fatty-acid isobutylamide)	Root; also aerial parts of E. purpurea EMA gives 3.45 mg/g in E. purpurea flower heads of young plants; roots have much more (four alkamides above 1 mg/g). The USP herb monograph asks for at least 0.01% dodecatetraenoic acid isobutylamides. Dried root alkamide total quoted as 0.01-0.7% (s-ema-ar-echinacea-radix-2016).	Binds CB2 cannabinoid receptors (Ki about 60 nM) in cell tests and lowers LPS-driven TNF-alpha, IL-1beta and IL-12p70 in whole blood in a CB2-independent way too; raises IL-6 at 50 nM. The only Echinacea constituent group with measured human blood levels, which were very low (below 1 ng/mL for typical doses). Broken down by liver enzymes (CYP1A2, 2C9, 2D6, 2E1). ^{87 31 15 113 103 116}	Laboratory research
Dodeca-2E,4E,8Z,10E-tetraenoic acid isobutylamide (E/Z isomer partner) PubChem 6440539	alkamide	Root; aerial parts The extract literature reports the 10E and 10Z forms together as 'dodeca-2E,4E,8Z,10E/Z-tetraenoic acid isobutylamides'; they are not separated in most papers.	Reported together with the 10Z isomer; the human blood studies measure the two forms as one signal. ^{113 112 37 116}	Laboratory research
Undeca-2Z,4E-diene-8,10-diynoic acid isobutylamide and related diyne alkamides	alkamide (alkamide with two triple bonds)	Root (prominent in E. purpurea and E. angustifolia roots) EMA lists it among four root alkamides above 1 mg/g in E. purpurea; no consistent content figure across products.	In the lab, a terminal-triple-bond alkylamide of this kind blocked the liver-enzyme breakdown of another alkylamide (mechanism-based inactivation). Alkamides from E. angustifolia root (A5, A7, A8) blocked COX-2 enzyme activity in a human cell line. PubChem CID not found for the exact isomers. ^{66 50 117}	Laboratory research
Cichoric acid (chicoric acid; 2,3-O-dicaffeoyltartaric acid) PubChem 5281764	caffeic acid derivative (hydroxycinnamic acid ester)	Aerial parts and root of E. purpurea; the main caffeic acid derivative of E. purpurea 1-5% of dried E. purpurea herb; 0.6-2.1% (or 1.7-2.4% in a second quote) of E. purpurea root; Ph. Eur. root requires at least 0.5% caftaric plus cichoric acid, herb at least 0.1% (s-ema-ar-echinacea-herba-2014, s-ema-ar-echinacea-radix-2016).	Antioxidant in test-tube radical tests. Crossed gut-cell layers poorly and could not be found in human blood after tablets, so effects inside the body are unproven. In macrophages it showed little or no effect on COX-2 or cytokines in the work EMA quotes. ^{67 116 117}	Laboratory research
Caftaric acid (2-O-caffeoyltartaric acid) PubChem 6440397	caffeic acid derivative	Aerial parts and root of E. purpurea About 0.2-0.8% of E. purpurea root (EMA quote); used with cichoric acid as the pharmacopoeia marker.	Antioxidant in test tubes, but the weakest radical-quencher of the compounds in one quoted study (EC50 20.5 microM versus 6.6 microM for echinacoside). Predicted by computer docking to bind spike protein of SARS-CoV-2; this is a prediction only. ^{106 117}	Laboratory research
Echinacoside PubChem 5281771	caffeic acid derivative (phenylethanoid glycoside)	Roots of E. angustifolia and E. pallida (main caffeic acid derivative there); practically absent from E. purpurea aerial parts No content figure verified for E. angustifolia or E. pallida roots in this file.	Strong antioxidant in test tubes (highest DPPH-quenching capacity in the compounds tested); anti-hyaluronidase and anti-inflammatory activity in rat studies quoted by EMA (original not checked). Crossed gut-cell layers poorly. ^{67 117}	Animal research
Cynarin (1,3-dicaffeoylquinic acid) PubChem 5281769	caffeic acid derivative	Roots of other Echinacea species (E. angustifolia) EMA: characteristic of other Echinacea species and practically absent from E. purpurea aerial parts. One lab paper nonetheless reported cynarin in a water extract from fresh E. purpurea aerial parts (p24434371), so this is a point on which sources differ.	No specific activity data verified here. ^{28 116}	Laboratory research
Verbascoside PubChem 5281800	caffeic acid derivative (phenylethanoid glycoside)	Root Listed by EMA among root caffeic acid derivatives; no content figure.	No activity data verified here. ¹¹⁷	Laboratory research
Chlorogenic acid PubChem 1794427	caffeic acid derivative	Root Listed by EMA among root caffeic acid derivatives; no content figure.	No activity data verified here. ¹¹⁷	Laboratory research
Caffeic acid PubChem 689043	hydroxycinnamic acid	Building block of the derivatives above Not a major free constituent per the sources read.	Studied in rabbits: after IV doses, about 55-63% was passed in urine unchanged within 2 hours (EMA, citing Uang and Hsu 1997, original not checked). ¹¹⁶	Animal research
Polysaccharides (e.g. PS I 4-O-methyl-glucuronoarabinoxylan about 35,000 Da; PS II acidic arabinorhamnogalactan about 450,000 Da; a xyloglucan)	polysaccharide	Aerial parts and root 2-7% of dried E. purpurea herb (EMA quoting Glavac 2012); a water extract from fresh herb was 80% polysaccharide in one lab study (p24434371).	In cells, a polysaccharide-rich extract switched on macrophages (IL-6, TNF, IL-12, nitric oxide via TLR4, ERK, p38, JNK, NF-kappaB) and in mice lowered Listeria load after oral dosing. In human T-cell lines it enhanced or reduced IL-2 and interferon-gamma depending on cell density. No single molecule has a PubChem CID, as these are mixtures. ^{100 28 14 116}	Animal research
Arabinogalactans and an arabinogalactan-containing glycoprotein	polysaccharide and glycoprotein	Root EMA root report: glycoprotein sugar part of about 64-84% arabinose, 2-5% galactose and 6% galactosamine (quoted from older texts, original not checked).	Described by EMA as one of the groups suggested to carry immune effects; no direct activity data checked here. ¹¹⁷	Laboratory research
Polyacetylenes, ketoalkenes and ketoalkynes	polyacetylene (polyyne)	Root, notably in E. pallida EMA root report: small amounts of polyynes (0.01 mg/100 g) in E. purpurea root; ketoalkenes and ketoalkynes are linked to light-triggered antifungal action.	In the lab, light (near UV) boosted antifungal effects of Echinacea extracts, mostly attributed to ketoalkenes and ketoalkynes (EMA quoting Binns 2000). No CIDs looked up. ¹¹⁷	Laboratory research
Essential oil (volatile oil)	terpenoids	Herb: 0.08-0.32%; root about 0.1% 0.08-0.32% in E. purpurea herb; about 0.1% in E. purpurea root (EMA).	No activity data verified here. Components include the compounds listed next. ^{116 117}	Laboratory research
Beta-caryophyllene PubChem 5281515	sesquiterpene	Herb and root volatile oil No content figure verified.	No activity data verified here for Echinacea. ¹¹⁶	Laboratory research
Caryophyllene oxide PubChem 1742210	sesquiterpene oxide	Herb and root volatile oil No content figure verified.	No activity data verified here. ¹¹⁶	Laboratory research
Germacrene D PubChem 5317570	sesquiterpene	Herb volatile oil No content figure verified.	No activity data verified here. ¹¹⁶	Laboratory research
Humulene (alpha-humulene) PubChem 5281520	sesquiterpene	Root volatile oil No content figure verified.	No activity data verified here. ¹¹⁷	Laboratory research
Bornyl acetate and borneol PubChem 93009	monoterpenoids	Herb volatile oil No content figure verified. Borneol is PubChem CID 64685 (C10H18O).	No activity data verified here. ¹¹⁶	Laboratory research
Tussilagine and isotussilagine (pyrrolizidine alkaloids) PubChem 149801	pyrrolizidine alkaloid (saturated type)	Root EMA root report lists them as small amounts and calls them 'non toxic' pyrrolizidine alkaloids. No content figure verified.	They have a fully saturated ring (hexahydropyrrolizine in PubChem naming), unlike the double-bonded liver-toxic types. The toxicity statement is EMA's; this file did not test it. Safety belongs in the safety file. ¹¹⁷	Laboratory research

Mechanisms, receptors and pathways

Target or pathway	Gene or receptor	What was found	Level
Cannabinoid type 2 receptor (CB2) and the endocannabinoid system	CNR2 (CB2); CNR1 (CB1) weakly	Alkamides from Echinacea bound CB2 with a Ki of about 60 nM (CB1 above 1500 nM) and raised calcium in CB2-carrying cells; this fit with the early finding that alkamides switch on TNF-alpha gene activity through CB2, cAMP, p38/MAPK, JNK and NF-kappaB. Mixed root and herb extracts gave stronger-than-additive CB2 signalling and more IL-10. In rats, oral root extract reduced inflammatory pain, partly reversed by cannabinoid-receptor blockers. The anti-inflammatory effects on TNF-alpha, IL-1beta and IL-12 in whole blood did not require CB2, so CB2 is only part of the story. Concentrations used (nanomolar) are above typical human blood levels of about 0.2-10 ng/mL measured after dosing, which is a gap between the lab and the body. Not shown to matter in humans. ^{31 87 15 62 113 37}	Laboratory research
Cytokines in human blood cells (alkamides)	TNF, IL1B, IL12A/IL12B, IL6, IL10, IL8 (CXCL8)	In whole blood in a test tube, alkamides lowered LPS-driven TNF-alpha, IL-1beta and IL-12p70 (5-500 nM). In healthy volunteers who took E. purpurea tincture or tablets, blood drawn 23-24 h later and stimulated with LPS showed lower TNF-alpha and IL-8 (and, with lozenges, lower IL-12p70, IL-6 and IL-10); IL-6 did not change in the tincture/tablet study. These are small studies (10 people in the best-described one) of changes in blood-cell test readings, not of actual illness. ^{87 112 37}	Human data
Macrophage activation by polysaccharides	TLR4, MAPK1/3 (ERK), MAPK14 (p38), MAPK8 (JNK), NFKB1; IL6, TNF, IL12, NOS2	An endotoxin-free E. purpurea polysaccharide-rich extract made mouse macrophages release IL-6, TNF, IL-12 and nitric oxide through TLR4-dependent and -independent routes, and oral dosing lowered Listeria in the spleen of infected mice. A water-soluble polysaccharide extract (80% polysaccharide) from fresh aerial parts boosted IL-2 and interferon-gamma in dense human Jurkat T-cell cultures but modestly lowered interferon-gamma in sparse ones. Whether polysaccharides get into the blood after swallowing is not shown. ^{100 28}	Animal research
Tonic interferon signalling and antiviral innate immunity	JAK1; interferon-stimulated genes; pattern recognition receptors; endogenous retrovirus (HERV) sequences	In THP-1 monocytes Echinaforce switched on antiviral innate immunity genes involving tonic interferon signalling, partly through JAK1 (the inhibitor filgotinib confirmed this), and changed DNA methylation around repeat elements including endogenous retroviral sequences. A cell line in a dish; the authors' suggestion about protection from coronaviruses is a hypothesis. ²¹	Laboratory research
Direct antiviral (virus-killing) action	Viral envelope and spike protein; TMPRSS2 (host enzyme, predicted)	On direct contact, Echinaforce inactivated common-cold coronavirus 229E (IC50 3.2 microg/mL) and, at about 50 microg/mL, SARS-CoV-1, MERS-CoV and SARS-CoV-2; it protected pre-treated reconstituted nasal tissue but pre-treating ordinary cells did not stop infection and treating after infection did little. Another study found activity against SARS-CoV-2 variants of concern (EC50 3.62-12.03 microg/mL) and used computer docking to predict binding of alkamides, caftaric acid and feruloyl-tartaric acid to spike and TMPRSS2 (a prediction only). Test-tube data from one commercial extract and company-linked authors; no protection from infection was shown in people here. ^{96 106}	Laboratory research
Cyclooxygenase-2 (COX-2) and prostaglandin E2	PTGS2 (COX-2)	In human neuroglioma cells, an E. angustifolia root CO2 extract lowered prostaglandin E2, and three alkamides (A5, A7, A8) blocked COX-2 enzyme activity, yet none lowered COX-2 mRNA or protein; the extract and most alkamides actually increased COX-2 levels without more prostaglandin. EMA also quotes work on 5-lipoxygenase inhibition by root alkamide fractions (original not checked). ^{50 117}	Laboratory research
Cough and airway tone (polysaccharide-phenolic-protein complex)	Not identified	A 10 kDa complex isolated from E. purpurea flowering parts suppressed cough about as much as codeine and relaxed airways more than salbutamol in animal tests, per the authors. Species and doses are not in the abstract. Not tested in people. ¹⁴	Animal research
Antioxidant effects	Not applicable (direct radical scavenging)	Echinacoside and cichoric acid scavenge free radicals in test tubes, and cichoric acid with an alkamide mixture or high-molecular-weight water extract was stronger together (EMA, quoting Dalby-Brown 2005, original not checked). Test-tube chemistry only; caffeic acid conjugates barely cross gut-cell layers. ^{117 67}	Laboratory research
Liver drug-metabolising enzymes and P-glycoprotein (herb-drug effects)	CYP3A4, CYP1A2, CYP2C9, CYP2D6, ABCB1 (P-gp), NR1I2 (PXR)	In people, E. purpurea root 400 mg four times daily for 8 days increased clearance of IV midazolam by 34% (liver CYP3A induction) while raising oral midazolam availability (intestinal CYP3A inhibition) and lowered caffeine oral clearance (CYP1A2); 500 mg three times daily for 28 days lowered midazolam AUC (ratio 0.73) but did not change lopinavir-ritonavir or fexofenadine; a third study of four botanicals found no significant effect on CYP1A2, 2D6, 2E1 or 3A4 ratios; warfarin (S-form) clearance rose slightly without a clinically meaningful change in INR; docetaxel levels did not change in 10 patients. In liver cells, extracts activated PXR and raised CYP3A4, CYP1A2 and MDR1 gene activity. Overall: modest and product-dependent, mixed across studies. ^{35 82 38 2 34 5}	Human data
Liver breakdown of alkamides	CYP1A1, CYP1A2, CYP2A13, CYP2C9, CYP2D6, CYP2E1	Human liver microsomes broke down alkamides in a NADPH-dependent way (epoxidation, hydroxylation, de-alkylation); recombinant CYP1A1/1A2/2A13/2D6 were most active on the main tetraene alkamide, with CYP2E1 making the dominant hydroxylated product in microsomes and CYP2C9 the epoxides. A terminal-alkyne alkamide inhibited the breakdown of another one (mechanism-based inactivation). ^{66 103}	Laboratory research

Absorption, metabolism and elimination

Absorption: Only alkamides have been followed in human blood. After one dose of E. purpurea (Echinaforce) tablets, tablets for children or a throat spray, the peak of the main dodecatetraenoic acid isobutylamides in blood was only about 0.22 ng/mL (p18240099). In 10 volunteers a tincture peaked at 30 minutes (0.40 ng/mL) and tablets at 45 minutes (0.12 ng/mL), with about a quarter as much absorbed from the tablets (p16995328). Lozenges with 0.07, 0.21 and 0.9 mg of alkamides gave peaks of 0.65, 1.00 and 8.88 ng/mL at 32, 25 and 19 minutes; absorption was linear with dose and so fast (about 6 minutes) that some may pass through the mouth lining (p18583121). An E. angustifolia root extract (60% ethanol, 2.5 mL, n = 11) peaked at 30 minutes at 10.88 ng/mL (p15901750). In a phase I tablet trial alkylamides appeared in blood after 20 minutes (p18007516). In gut-cell layers (Caco-2), alkamides crossed easily, apparently by simple diffusion, while caftaric acid, echinacosides and cichoric acid crossed poorly (p18007516; EMA citing Jager 2002 and Matthias 2004, originals not checked).
Distribution: No human tissue-distribution data were found. Blood levels of alkamides are in the low ng/mL range and 'only a fraction of the dose', and caffeic acid conjugates (cichoric acid, caftaric acid, echinacosides) could not be found in blood at all after tablets (p18007516). Whether polysaccharides, glycoproteins or other water-soluble components reach the blood or act on the gut lining and mouth is not known.
Metabolism: Human liver microsomes broke down alkamides by cytochrome P450 enzymes: epoxides, hydroxylated and de-alkylated products formed, with CYP1A2, CYP2D6, CYP2E1 and CYP2C9 named for the main tetraene alkamide (p15885678, p20135639). In an extract alkamides were broken down less than the pure compounds, and one alkamide with a terminal triple bond blocked the breakdown of another (p15885678). In rats the absolute oral bioavailability of the tetraene alkamides was 29.2 +/- 2.3% as pure compounds and 47.1 +/- 7.2% from a root extract, with a half-life of 123 versus 36 minutes (EMA quoting Ardjomand-Woelkart 2011, original not checked).
Elimination: No human elimination or urinary data were found for alkamides. Rat data above suggest a short half-life (36 min pure; 123 min in a root extract). For caffeic acid, rabbits passed about 55-63% unchanged in urine within 2 hours after IV doses (EMA quoting Uang and Hsu 1997, original not checked); this is a building block, not a measured human Echinacea result.
Bioavailability: Absolute human oral bioavailability is not established because there is no intravenous comparison in people. Relative exposure differs by form: tincture gave higher and faster alkamide peaks than tablets in one small study (p16995328), and all three Echinaforce products gave very similar low peaks in another (p18240099). Lozenge levels rose in proportion to dose (p18583121). The authors of these studies connect low ng/mL blood levels with changes in blood-cell test readings 23-24 hours later, but this is not a proven cause. Herb-drug interactions have been tested: midazolam clearance changed in opposite directions in liver and gut (p14749695), midazolam exposure fell with 28 days of E. purpurea (p20653355), a four-botanical study found no significant CYP effect (p15536458), S-warfarin clearance rose slightly with no clinically meaningful change in INR (p20573086) and docetaxel was unchanged (p23701184). Interaction advice belongs in the safety file.

^{113 112 37 111 67 66 103 35 82 38 2 34 116}

Isolated compounds versus whole extracts

Echinacea does not have one 'active ingredient'. Four very different groups are suggested to matter: alkamides, caffeic acid derivatives, polysaccharides, and glycoproteins (EMA, ESCOP), and none has been proven to be the one that matters in people. Alkamides are the only group found in human blood, at very low levels, and they bind CB2 receptors in cell tests but also work in ways that do not need CB2 (p16547349). Cichoric acid and the other caffeic acid derivatives barely cross gut-cell layers and could not be found in blood after tablets (p18007516); in the lab they act mainly as antioxidants. Polysaccharide-rich extracts activate macrophages and T-cell lines in test tubes and animals (p18618312, p24434371) but their absorption is unmeasured. Mixing the root and herb extracts gave stronger-than-additive effects on CB2 signalling, IL-10 and TNF-alpha in human cells (p19303464), and an alkamide with a terminal triple bond changed the liver breakdown of another alkamide (p15885678), so the whole extract is plausibly more than its parts, but 'synergy' is shown only in test tubes. The extract also differs by plant part, species and solvent: juice, ethanol tinctures, dry extracts and teas are not interchangeable. Practical point: a result with one brand (for example Echinaforce) cannot be assumed for another, and results with E. purpurea cannot be assumed for E. angustifolia or E. pallida.

Nutritional composition

A nutrient table is not meaningful for echinacea: it is taken as a small amount of juice, tincture, extract, tea or capsule for its plant compounds, not as a food. No vitamin or mineral content was verified for any Echinacea part and none is claimed here. The compounds that matter are listed under the compound section above (alkamides, caffeic acid derivatives, polysaccharides, glycoproteins).

Products, quality and comparisons

Independent evidence comes first. Nothing in this section is a paid ranking. If a product link is added later, it will be marked clearly as an affiliate link and will never change what the research says.

Quality indicators

Species named in full (Echinacea purpurea, E. angustifolia or E. pallida) and the plant part stated (fresh herb, root, or mixed)
Preparation stated: pressed juice, tincture with ratio and alcohol percent, dry extract with extract ratio and solvent, or powder
Marker compounds in mg per serving (alkamides, chicoric acid, polysaccharides) if the maker claims standardization, with the test method
The Ph. Eur. monograph reference where used (1824 purpurea root, 1822 pallida root, 1821 angustifolia root, per the EU monographs)
Batch or lot number and a certificate of analysis on request
Honest label for other ingredients (sage, elderberry, zinc, vitamin C) and for alcohol content

Identity and authenticity

A 2018 study tested 53 Echinacea products sold in Europe with HPTLC and DNA metabarcoding. Echinacea DNA was detected in 34 of the 38 products retained for the DNA test (89 percent). The DNA test could not separate one Echinacea species from another because the genus varies little. Across all products, the ingredients listed on labels matched what was found only 43 percent of the time.
Authors of that study note that species are hard to tell apart by shape because they overlap and hybridize, and mention deliberate adulteration as a concern. Unverified in this file: the exact adulterants found were not in the abstract.
E. purpurea, E. angustifolia and E. pallida differ chemically, so a trial of one may not apply to another. The Turner 2005 trial of E. angustifolia root found no effect, while the E. purpurea herb extracts tested elsewhere gave mixed results.

Standardization and extract strength

The Goel 2004 trial named a fresh-plant liquid with alkamides 0.25 mg/mL, cichoric acid 2.5 mg/mL and polysaccharides 25 mg/mL (Echinilin), and found a 23.1 percent lower symptom score in the per-protocol group.
Alkamides are mostly in the root and cichoric acid is a main phenolic of the herb; in a 2019 lab study chicoric and caftaric acids were the main phenolics and the best solvent differed by plant part (water for caftaric acid from leaves; 40 percent ethanol for chicoric acid from flowers and roots).
A 2020 US National Toxicology Program paper found that in one E. purpurea root extract chosen for testing, caftaric, chicoric and chlorogenic acids and the main alkamide were only a small fraction of the extract, and said selecting a representative product is difficult.
Pharmacokinetics show alkamides reach a peak in blood about 30 to 45 minutes after a dose; tincture gave a higher peak than tablets with the same alkamide content (0.40 vs 0.12 ng/mL).
No agreed single 'active compound' is established for echinacea; a marker percentage on a label does not prove the product will behave like a trial product.

Third-party testing

US dietary supplements are not approved by the FDA before sale; the content can differ from the label. We did not re-read independent testing programs' lists (USP, NSF, ConsumerLab and others) and cannot say which echinacea products carry a seal.
A seal speaks for that programme's test, not for effect. Ask for the lot's certificate of analysis.

Contaminants and adulterants

Heavy metals, pesticides, microbes and solvent residues in echinacea supplements were not covered by the sources we read for this file.
A lab study of high-pressure pasteurization of E. purpurea was found in searches but not read, so no statement is made about it.

Reading a product label

Find the species and the part used (herb, root, whole plant).
Is it juice, tincture, dry extract or powder? Note extract ratio, solvent and alcohol percent.
Compare mg per serving and servings per day with the trial or monograph dose you care about; do not assume equality.
Check for added sage, elderberry, zinc, vitamin C or other herbs; a combination cannot be credited to echinacea alone.
Look at the stated use: short-course, not year-round, unless the product says otherwise and a clinician agrees.
Check allergy warnings for daisy-family plants (Asteraceae) and the age limit (the monographs advise against use under 12 years).
Look for a lot number, expiry date and a certificate of analysis.

Certifications and what they actually mean

Certification	What it means	What it does not tell you
EU traditional herbal medicinal product registration or well-established-use authorisation	European regulators accept the product for a stated mild indication (for example cold relief) based on long-standing or well-established use at the doses in the EU herbal monograph.	Traditional-use status does not claim trial-proven efficacy. Rules apply to the product, not to all supplements.
European Pharmacopoeia monograph compliance (Ph. Eur. 1821, 1822, 1824)	The EU root monographs state that the material complies with these pharmacopoeia standards for E. angustifolia, E. pallida and E. purpurea roots.	A maker's statement; check a certificate of analysis.
Independent third-party seal (USP, NSF or similar)	A named programme tested a sample against its own criteria.	We did not verify any echinacea listing; a seal is not proof of effect.

Comparing price and servings

Do not compare bottle prices. Step 1: cost per serving = bottle price / servings per bottle. Step 2: servings per day needed to reach the daily amount of the same type of preparation (for example mL of juice or mg of dry extract). Step 3: cost per day = cost per serving x servings per day. If a marker such as alkamides or cichoric acid is stated by the same test method, cost per mg of marker = bottle price / (servings x mg per serving). Compare only products of the same preparation type. Leave prices blank until a real current product is entered; no prices are included here.

Extract types compared

Extract	Plant part	Standardization	Trials	Evidence note	Safety note	Limitations	Studies
Echinaforce (fresh E. purpurea extract) and its tablet, junior and hotdrink forms	herb 95% + root 5%	Fresh-plant alcohol extract; tablets 400 mg in the children's trial	Brinkeborn 1999 (treatment); Jawad 2012 (4 months prevention, 755 adults); Ogal 2021 (children, 1,200 mg/day); Kolev 2022 (2,400 mg/day, open); Raus 2015 (vs oseltamivir)	Positive results in most of these maker-linked trials: fewer colds, fewer antibiotic courses in children, noninferiority to oseltamivir in flu.	Jawad: adverse drug reactions 9% echinacea vs 10% placebo; Ogal: fewer adverse events than vitamin C control.	Most trials sponsored by or linked to the maker; one used vitamin C as control and one had no placebo; results do not apply to other brands.	^{13 55 80 59 88}
Pressed juice powder (freeze-dried)	aerial parts	100 mg three times a day; no marker data in the abstract	Yale & Liu 2004 (128 adults)	No difference from placebo in symptoms or time to resolution.	Not reported as a concern in the abstract.	Single small trial; shows that two products from the same species can differ in results.	¹¹⁴
Echinilin (fresh E. purpurea liquid)	fresh plant (part not in abstract)	Alkamides 0.25, cichoric acid 2.5, polysaccharides 25 mg/mL	Goel 2004 (282 adults)	23.1% lower daily symptom scores in the per-protocol group.	A few adverse events in both groups.	Only 128 of 282 caught a cold; one trial.	³³
E. angustifolia root extracts (CO2, 60% ethanol, 20% ethanol)	root	Chemically defined; three profiles	Turner 2005 (437 volunteers, rhinovirus)	No significant effect of any extract on infection or symptoms.	Not reported in the abstract.	Challenge model with one virus; alkamides peak at 30 minutes (PK study).	^{105 111}
Unrefined mixed herb and root capsules	herb 25% + E. purpurea root 25% + E. angustifolia root 50%	Not stated	Barrett 2002 (148 students)	No detectable benefit or harm.	No harm detected.	One mixture; cannot be tied to one species.	⁹
Dried-root tablets (species not in abstract)	root	Dose as dried-root equivalent	Barrett 2010 (719 people)	Non-significant trend to shorter illness (0.53 days, CI -1.25 to 0.19).	Not stated in abstract.	Variability limited power.	¹⁰
Fluid extract	unspecified	Not stated	Grimm 1999 (108 adults)	No significant effect on incidence, duration or severity.	Side effects 20% vs 13% (P=0.44).	Small.	³⁶
60% ethanolic extract (Korean trial)	unspecified	200 mg a day	Lee 2024 (80 adults)	NK-cell activity and some cytokines rose; no change in cold or fatigue scores.	No adverse reactions reported.	Biomarker study.	⁶⁰

Compare Echinacea with another ingredient

Compare with

Echinacea vs Elderberry

Both are marketed for colds and flu and both have mixed evidence. No trial compares them directly. Elderberry's best results come from a few small trials of specific products; echinacea has more trials but very different products and mostly non-significant results.

	Echinacea	Elderberry
Benefits studied	Preventing and shortening colds; some flu and sore-throat uses	Duration and severity of colds and flu, mostly in adults
Evidence certainty	low: the 2014 Cochrane review (24 trials, 4,631 people) did not pool; none of 12 prevention comparisons was significant (post hoc pooling suggests 10-20 percent fewer colds) and only 1 of 7 treatment trials showed shorter colds; the 2019 meta-analysis found prevention RR 0.78 (0.68-0.88) but no clear effect on duration; reviewers cite very different products and risk of selective reporting	low: the 2019 meta-analysis (180 people) reports a large effect but no numbers in its abstract; the 2020 rapid review of 5 studies says symptoms may be shorter within 48 hours of onset but did no pooling; the 2020 emergency-room trial of 87 people found no benefit
Typical studied dose	Varies by product: for example 300 mg/day pressed juice powder (no benefit), 1,200 mg/day in children, 2,400 mg/day for adult prevention; EU juice monograph 6-9 mL a day for up to 10 days	60 ml a day of syrup for 5 days in one trial (15 mL four times a day); other products vary
Head-to-head trial	None found against elderberry; one echinacea drink was noninferior to oseltamivir in 473 flu patients	None found
Safety and interactions	Echinacea: Short courses: mild stomach upset and rash most often; rare allergic reactions, including severe ones; rash in children in one trial (7.1 vs 2.7 percent); healthy-volunteer data show changes in midazolam and caffeine clearance (CYP3A, CYP1A2); avoid with daisy-family allergy	No serious events in short trials; raw berries are poisonous; pregnancy data lacking
Forms	Juice, tincture, capsules and tablets, tea, lozenges, throat spray, ointment	Syrup, capsule, lozenge, juice, gummy
Cost note	Use the price-per-day formula; no prices stored	Use the price-per-day formula; no prices stored

^{57 18 46 44 64 88} Read the full comparison

Echinacea vs Vitamin C

Vitamin C is taken every day to shorten colds a little, with its clearest benefit in people under extreme physical stress; echinacea is used at the first signs or in prevention blocks with uneven results. Only one trial used vitamin C as a comparison for echinacea, and it was not a placebo.

	Echinacea	Vitamin C
Benefits studied	Preventing and shortening colds; some flu and sore-throat uses	Cold prevention and shortening
Evidence certainty	low: the 2014 Cochrane review (24 trials, 4,631 people) did not pool; none of 12 prevention comparisons was significant (post hoc pooling suggests 10-20 percent fewer colds) and only 1 of 7 treatment trials showed shorter colds; the 2019 meta-analysis found prevention RR 0.78 (0.68-0.88) but no clear effect on duration; reviewers cite very different products and risk of selective reporting	mixed: the 2013 Cochrane review (29 comparisons, 11,306 people) found no reduction in cold risk in the general community (RR 0.97, 0.94-1.00) but a halving of risk in 598 people under heavy exercise stress (RR 0.48, 0.35-0.64); regular use shortened colds 8% in adults and 14% in children; no consistent effect when taken only after a cold started
Typical studied dose	Varies by product: for example 300 mg/day pressed juice powder (no benefit), 1,200 mg/day in children, 2,400 mg/day for adult prevention; EU juice monograph 6-9 mL a day for up to 10 days	0.2 g a day or more in the review's trials; 1-2 g a day in children shortened colds by 18%
Head-to-head trial	One children's prevention trial used vitamin C 50 mg three times a day as the control for echinacea: fewer infection episodes with echinacea (OR 0.52, 0.30-0.91); it was not a placebo, so it does not show vitamin C is useless	Only as a control arm in the children's trial (see left)
Safety and interactions	Echinacea: Short courses: mild stomach upset and rash most often; rare allergic reactions, including severe ones; rash in children in one trial (7.1 vs 2.7 percent); healthy-volunteer data show changes in midazolam and caffeine clearance (CYP3A, CYP1A2); avoid with daisy-family allergy	Described in the review as low cost and safe; not re-verified here
Forms	Juice, tincture, capsules and tablets, tea, lozenges, throat spray, ointment	Tablets, powders, foods
Cost note	Use the price-per-day formula; no prices stored	Use the price-per-day formula; no prices stored

^{57 80 49}

Echinacea vs Zinc

Both are taken at the first sign of a cold and both have uneven evidence. Zinc's review is recent and graded; it suggests a possible shortening of colds. No trial compares the two.

	Echinacea	Zinc
Benefits studied	Preventing and shortening colds; some flu and sore-throat uses	Prevention and treatment of the common cold
Evidence certainty	low: the 2014 Cochrane review (24 trials, 4,631 people) did not pool; none of 12 prevention comparisons was significant (post hoc pooling suggests 10-20 percent fewer colds) and only 1 of 7 treatment trials showed shorter colds; the 2019 meta-analysis found prevention RR 0.78 (0.68-0.88) but no clear effect on duration; reviewers cite very different products and risk of selective reporting	low: 2024 Cochrane review of 34 trials (8,526 people): little or no effect on preventing colds (RR 0.93, 0.85-1.01); as treatment may shorten colds (-2.37 days, -4.21 to -0.53; low certainty; very uneven results)
Typical studied dose	Varies by product: for example 300 mg/day pressed juice powder (no benefit), 1,200 mg/day in children, 2,400 mg/day for adult prevention; EU juice monograph 6-9 mL a day for up to 10 days	Zinc gluconate lozenges 45 to 276 mg a day for 4.5 to 21 days in the review's lozenge trials
Head-to-head trial	None found	None found
Safety and interactions	Echinacea: Short courses: mild stomach upset and rash most often; rare allergic reactions, including severe ones; rash in children in one trial (7.1 vs 2.7 percent); healthy-volunteer data show changes in midazolam and caffeine clearance (CYP3A, CYP1A2); avoid with daisy-family allergy	Not summarised in this file
Forms	Juice, tincture, capsules and tablets, tea, lozenges, throat spray, ointment	Lozenges, tablets, syrups, nasal
Cost note	Use the price-per-day formula; no prices stored	Use the price-per-day formula; no prices stored

^{57 18 76}

Echinacea vs Vitamin D

Vitamin D is studied for prevention, mainly in people who start low; echinacea for first-sign use and prevention blocks. The two have not been compared, and the recent vitamin D update lost statistical significance.

	Echinacea	Vitamin D
Benefits studied	Preventing and shortening colds; some flu and sore-throat uses	Preventing acute respiratory infections
Evidence certainty	low: the 2014 Cochrane review (24 trials, 4,631 people) did not pool; none of 12 prevention comparisons was significant (post hoc pooling suggests 10-20 percent fewer colds) and only 1 of 7 treatment trials showed shorter colds; the 2019 meta-analysis found prevention RR 0.78 (0.68-0.88) but no clear effect on duration; reviewers cite very different products and risk of selective reporting	mixed: the 2017 individual-participant meta-analysis (11,321 people) found a lower risk (adjusted OR 0.88, 0.81-0.96), strongest with very low levels (OR 0.30, 0.17-0.53); the 2025 update of 40 trials (61,589 people) found OR 0.94 (0.88-1.00, p=0.057), not statistically significant
Typical studied dose	Varies by product: for example 300 mg/day pressed juice powder (no benefit), 1,200 mg/day in children, 2,400 mg/day for adult prevention; EU juice monograph 6-9 mL a day for up to 10 days	Daily, weekly or bolus doses; the 2025 update found no effect modification by dose size
Head-to-head trial	None found	None found
Safety and interactions	Echinacea: Short courses: mild stomach upset and rash most often; rare allergic reactions, including severe ones; rash in children in one trial (7.1 vs 2.7 percent); healthy-volunteer data show changes in midazolam and caffeine clearance (CYP3A, CYP1A2); avoid with daisy-family allergy	No change in serious adverse events in either meta-analysis
Forms	Juice, tincture, capsules and tablets, tea, lozenges, throat spray, ointment	Capsules, drops, tablets
Cost note	Use the price-per-day formula; no prices stored	Use the price-per-day formula; no prices stored

^{57 18 65 56}

Echinacea vs Andrographis (Andrographis paniculata)

Andrographis has more trials with larger reported effects on symptoms, but reviewers call the quality poor and many used mixtures. The single head-to-head study in children favoured the Andrographis product, and it had no placebo group.

	Echinacea	Andrographis (Andrographis paniculata)
Benefits studied	Preventing and shortening colds; some flu and sore-throat uses	Symptom relief in acute respiratory infections (cough, sore throat, time to recovery)
Evidence certainty	low: the 2014 Cochrane review (24 trials, 4,631 people) did not pool; none of 12 prevention comparisons was significant (post hoc pooling suggests 10-20 percent fewer colds) and only 1 of 7 treatment trials showed shorter colds; the 2019 meta-analysis found prevention RR 0.78 (0.68-0.88) but no clear effect on duration; reviewers cite very different products and risk of selective reporting	low: 2017 review of 33 trials (7,175 people): cough SMD -0.39 (-0.67 to -0.10) and sore throat SMD -1.13 (-1.37 to -0.89) versus placebo, but methodological quality overall poor
Typical studied dose	Varies by product: for example 300 mg/day pressed juice powder (no benefit), 1,200 mg/day in children, 2,400 mg/day for adult prevention; EU juice monograph 6-9 mL a day for up to 10 days	Varied; not tabulated here
Head-to-head trial	One children's trial (130 children) found the Andrographis product Kan Jang more effective than an echinacea preparation (Immunal) when each was added to standard treatment; neither was compared with placebo	Kan Jang vs Immunal (see left)
Safety and interactions	Echinacea: Short courses: mild stomach upset and rash most often; rare allergic reactions, including severe ones; rash in children in one trial (7.1 vs 2.7 percent); healthy-volunteer data show changes in midazolam and caffeine clearance (CYP3A, CYP1A2); avoid with daisy-family allergy	No major adverse events; minor ones mostly gastrointestinal
Forms	Juice, tincture, capsules and tablets, tea, lozenges, throat spray, ointment	Capsules and tablets, often in mixtures
Cost note	Use the price-per-day formula; no prices stored	Use the price-per-day formula; no prices stored

^{52 98 57}

Other supplements people compare it with

Elderberry (Colds and flu): A few small trials of specific products; one emergency-room trial found no benefit. Evidence: low. ^{46 44 64}
Vitamin C (Cold prevention, heavy exercise stress): No community-wide benefit but a large effect in people under extreme exercise stress in the Cochrane review. Evidence: mixed. ⁴⁹
Zinc lozenges (Cold treatment): May shorten colds; non-serious side effects more common. Evidence: low. ⁷⁶
Vitamin D (Respiratory infection prevention): Helped most when levels were very low; 2025 update not statistically significant overall. Evidence: mixed. ^{65 56}
Andrographis (Symptoms of respiratory infection): Reported symptom benefits; poor study quality. Evidence: low. ⁵²
Oseltamivir (prescription antiviral) (Influenza): Used as the comparison drug in a maker-linked echinacea trial; ask a clinician. Not evaluated beyond that abstract. Evidence: insufficient. ⁸⁸

Where to buy

Check the label first. Whatever you buy, look for these:

The plant part and the extract type or ratio on the label
A standardized amount of the active compounds, where relevant
A third-party testing mark (USP, NSF or ConsumerLab)
Interactions: ask a pharmacist if you take medicines, are pregnant or have a medical condition

Talk to a pharmacist or doctor before you start any supplement, especially if you take medicines. See the Safety tab for interactions.

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18benefits and uses looked at

119studies and sources checked

Low certaintybest evidence rating found

14lab markers tracked in trials

11 low certainty5 very low certainty2 not enough evidence

What was looked at

The 18 benefits and uses checked for Echinacea, each with how strong the evidence is. Tap one to open it.

Preventing colds and respiratory infections (adults)Low certainty
Treating a cold once it has started (adults)Low certainty
Deliberately caught colds (virus challenge studies)Low certainty
Children: preventing and treating respiratory infectionsLow certainty
Fewer complications and less antibiotic useLow certainty
Flu and sore throatLow certainty
COVID-19 and coronavirusesNot enough evidence
AnxietyLow certainty
Mood and wellbeingVery low certainty
Children who keep getting infections (colds, tonsillitis, ear infections)Low certainty
Eczema (atopic dermatitis), as a skin creamVery low certainty
Skin hydration and fine lines (cosmetic)Very low certainty
Recurrent genital herpesLow certainty
HPV-related cervical lesions and genital wartsVery low certainty
Immune markers (cytokines, saliva antibodies)Very low certainty
Athletes: blood oxygen carriers and enduranceLow certainty
Anxiety and moodLow certainty
Carpal tunnel pain (mixed product)Not enough evidence

Lab markers tracked in the studies

Respiratory virus detection and viral loadNasal interleukin-8 and neutrophilsAntibiotic courses and daysState-Trait Anxiety Inventory (STAI)HADS-A and Hamilton Anxiety Scale (HAM-A)Positive and negative affect (PANAS)Saliva antibody (s-IgA)Inflammation signals in blood (IL-6, TNF-alpha, IL-8, IL-10)Erythropoietin (EPO)Hemoglobin and hematocritMaximal oxygen uptake (VO2max)Eczema severity score (local SCORAD)Skin barrier fats (ceramides, cholesterol)Skin moisture (corneometer reading)

What is Echinacea good for?

The main proposed uses and how strong the human evidence is for each. "Low" is the best rating any echinacea use reached here. "Low", "very low" and "insufficient" mean few, small, mixed or product-specific trials. Nothing here is a proven treatment, and the ratings are this profile's reading of the reviews, not formal grades unless stated. Colds are split into prevention (taking it daily beforehand) and treatment (taking it after symptoms start) because the results differ.

Preventing colds and respiratory infections (adults)Low certaintyTaking echinacea every day for weeks to months might slightly lower the chance of catching a cold. The independent Cochrane review (2014) found none of 12 prevention comparisons significant on its own, but a post hoc pooling suggested 10% to 20% fewer colds. A 2019 pooled analysis found a risk ratio of 0.78 and said the benefit might not matter much in daily life. One large 4-month trial (755 adults) found fewer colds with a fresh-herb extract, while other trials found nothing. Many of the positive trials used one maker's extract, and several reviews include maker-funded trials. Treating a cold once it has started (adults)Low certaintyMost of the best-designed trials found that echinacea taken after symptoms begin does not shorten the cold or clearly make it milder. The Cochrane review found only 1 of 7 treatment trials with a significant benefit, and a 2019 pooled analysis found no clear change in cold length (about half a day shorter, not significant). A few trials of specific standardised fresh-plant products did find benefit, so the answer depends on the product and the reviews disagree. Deliberately caught colds (virus challenge studies)Low certaintyIn studies where volunteers were deliberately infected with a cold virus, echinacea did not clearly protect them. Pooling three studies suggested a clinical cold was somewhat more likely with placebo (odds ratio 1.55), but symptom scores did not differ. The one large trial of three E. angustifolia root extracts (437 volunteers) found no effect on infection or symptoms. Children: preventing and treating respiratory infectionsLow certaintyResults in children are mixed. The largest US treatment trial (407 children aged 2 to 11) found no benefit and more rashes (7.1% of infections versus 2.7%). A 2021 trial of a maker's extract in children aged 4 to 12 found fewer infection episodes than with vitamin C (odds ratio 0.52) and far fewer antibiotic courses (6 versus 24), but vitamin C is not a placebo and one author works for the maker. In toddlers prone to ear infections, echinacea taken during colds did not help and was linked to more infections (65% versus 41%). A 2025 pooled analysis of 9 trials reported fewer infections (risk ratio 0.81) but more mild side effects (1.38). A 2025 review rated its own evidence highly; that rating is not adopted here because the trials differ and several were funded by the product maker. Fewer complications and less antibiotic useLow certaintyA 2024 pooled analysis by industry-linked authors (30 trials, 5,652 people) reported less need for antibiotics (risk ratio 0.60) and fewer complications. A 2015 pooled analysis of six trials reported fewer complications such as pneumonia, ear infection and tonsillitis. These effects are large but come from different products and limited trials with possible bias, so they should be treated as unproven. Flu and sore throatLow certaintyOne trial of 473 people with early flu found an echinacea hot drink (a maker's product) about as good as the antiviral oseltamivir (recovery by day 10 of 90.1% versus 84.8%), but it had no placebo group, so it cannot show echinacea beats placebo. A throat spray combining echinacea and sage did about as well as a standard throat spray (response 63.8% versus 57.8%), also without a placebo. COVID-19 and coronavirusesNot enough evidenceEchinacea extracts inactivate coronaviruses in lab dishes, but that has not been shown to work in people. The one human study (120 adults) was open (no placebo), sponsor-funded and small: 5 versus 14 positive swabs, with no significant drop in symptomatic episodes. AnxietyLow certaintyAll the anxiety evidence is for one patented extract of E. angustifolia root (EP107), from a small research network. A 7-day placebo-controlled trial found state anxiety fell about 11 points versus 3 with placebo in volunteers with high anxiety scores. The largest trial (108 adults with mild-to-moderate anxiety, 6 weeks) found anxiety fell in every group, including placebo, with no difference on its main measure. A 2025 paper reported a benefit on one anxiety scale but not on the other. This is early and cannot be extended to other echinacea products. No trial studied people with a diagnosed anxiety disorder. Mood and wellbeingVery low certaintyIn the 6-week trial of the same patented E. angustifolia extract, mood scores and emotional wellbeing improved more than with placebo, even though anxiety did not. These were secondary results that need confirming. A 7-day trial found no change in depression or stress scores. No trial tested echinacea for diagnosed depression or for memory and thinking. Eczema (atopic dermatitis), as a skin creamVery low certaintyA cream made from echinacea alkylamides lowered local eczema severity scores in a published set of trials and raised skin barrier fats. The abstract gives no group sizes or numbers, so this is early evidence for a cream, not for pills or teas. Skin hydration and fine lines (cosmetic)Very low certaintyA small Thai study of 10 healthy adults found a cream and gel raised skin moisture and reduced wrinkle measurements after one month. There was no comparison group described, and the extract lost strength in storage within 2 to 4 months. Recurrent genital herpesLow certaintyA 6-month crossover trial in 50 people with frequent genital herpes found no significant difference from placebo in how often or how severely it came back. Lab studies show activity against the virus, which did not carry over to people. HPV-related cervical lesions and genital wartsVery low certaintyTwo small Italian studies tested echinacea supplements. In 153 women with mild cervical changes, echinacea plus vaginal hyaluronic acid did better at 12 months than either alone (persistent lesions 5/51 versus 14/48 for hyaluronic acid alone). In people treated for genital warts, a supplement was linked to fewer relapses in those over 25. Both studies were small without a placebo, and the combination effect cannot be credited to echinacea alone. This does not replace HPV screening or follow-up. Immune markers (cytokines, saliva antibodies, NK cells)Very low certaintySmall studies measured immune signals. In 10 healthy people a single capsule was followed by lower inflammatory signals and higher IL-10 after 24 hours, with no comparison group. In an exercise study of 32 people, 4 weeks of echinacea kept saliva antibodies from falling after hard exercise. In 80 adults, 200 mg a day of a 60% ethanol extract for 8 weeks raised natural killer cell activity but did not change cold or fatigue scores. Markers are not the same as being healthier. Athletes: blood oxygen carriers and enduranceLow certaintyA 2024 pooled analysis of 6 small studies (107 athletes) found no clear change in hemoglobin, erythropoietin or maximal oxygen uptake. The studies differed a lot from one another. Carpal tunnel pain (mixed product)Not enough evidenceOne Italian trial of 60 people compared shock wave therapy with a supplement that contained echinacea plus alpha lipoic acid, conjugated linoleic acid and quercetin. Both improved up to 6 months. With several ingredients and no placebo, echinacea's own effect is unknown.

Benefits, one by one

Each card is a research question, not a promise. Tap a goal to filter. Open a card to see the studies, doses and limits.

Preventing colds and respiratory infections (adults)

Low certainty

Taking echinacea every day for weeks to months might slightly lower the chance of catching a cold. The best independent review found a possible 10% to 20% lower risk but no single trial that proved it, and the effect may not matter much in daily life.

9 studiesAlcohol (ethanol) extract of fresh E. purpurea herb (about 95% herb, …

Studies, doses and limits

What the trials found

Cochrane review (Karsch-Volk 2014, 10 prevention trials): none of 12 comparisons was individually significant, but a post hoc pooling suggested a 10% to 20% lower risk of a cold. David 2019 pooled prevention trials and found a risk ratio of 0.78 (95% CI 0.68 to 0.88), saying the benefit might not be clinically meaningful. Shah 2007 reported a larger drop (odds ratio 0.42) but is less cautious and had an erratum. Schapowal 2015 (6 high-quality trials, 2,458 people) found fewer recurrent infections (RR 0.649). Gancitano 2024 (industry-linked authors) found RR 0.75 for at least one infection. Individual trials: Jawad 2012 (755 healthy adults, E. purpurea herb extract, 4 months) found fewer colds, especially in people who took it as directed. Kolev 2022 (120 adults, open trial without placebo) found fewer SARS-CoV-2-positive swabs (5 vs 14) but no significant drop in symptomatic episodes. Tiralongo 2012 (175 air travellers, root extract) was borderline (p=0.05). O'Neil 2008 (E. purpurea capsules, 8 weeks) found no difference in sick days. Many positive trials used the same manufacturer's alcohol extract of fresh E. purpurea herb.

Results

Small possible reduction in colds with some products; not consistent across products or trials.

Effect sizes as reported

Cochrane post hoc relative risk reduction 10% to 20%; David 2019 RR 0.78 (0.68 to 0.88); Schapowal 2015 RR 0.649 (0.545 to 0.774); Gancitano 2024 RR 0.75 (0.69 to 0.81); Shah 2007 OR 0.42 (0.25 to 0.71).

Why this rating

Individual trials are mostly not significant, pooled results differ between reviews (the Cochrane authors refused to pool the main analysis), products and plant parts vary widely, and the most positive reviews involve authors paid by a manufacturer. The reviewers themselves described the effect as of questionable clinical relevance.

Form and dose studied

Alcohol (ethanol) extract of fresh E. purpurea herb (about 95% herb, 5% root), taken daily for 4 months in Jawad 2012; 2,400 mg a day of a similar extract in Kolev 2022; root extract standardised to 4.4 mg alkylamides in the travel trial; E. purpurea capsules in O'Neil 2008.

Who was studied

Mostly healthy adults. Three trials in Schapowal's pooling involved people who catch infections often, were stressed or had a weaker immune state.

Limits

Many different products; most trials small or short; several reviews include trials funded by the makers; prevention trials run for weeks to months, so long-term safety is not shown.

Why researchers looked

Echinacea is mainly bought to ward off colds, so cold prevention is its most studied immune use.

Traditional use

Plains Indian peoples of North America used echinacea roots for infections, wounds and sore throats; European and American medicine later adopted it for colds and flu.

Proposed mechanism Laboratory research

Lab and animal work suggests echinacea extracts may stimulate certain immune cells and may act directly on some enveloped viruses (such as flu and coronaviruses) in a dish. This is not shown to be how it works in people.

A proposed mechanism does not show that the effect happens in people.

Adverse events were similar to placebo in the large prevention trial (Jawad 2012). Cochrane noted a trend towards more drop-outs from adverse events in prevention trials.

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Treating a cold once it has started (adults)

Low certainty

Most of the best-designed trials found that echinacea taken after cold symptoms begin does not shorten the cold or make it clearly milder. A few trials of specific standardised products found some benefit, so results depend heavily on the product.

9 studiesTested: E. purpurea juice or alcohol extracts (aerial parts), E. angu…

Studies, doses and limits

What the trials found

Cochrane 2014: only 1 of 7 treatment trials reporting duration found a significant benefit; the authors concluded benefits for treating colds were not shown. David 2019 found cold duration was not significantly different (mean difference -0.45 days). Shah 2007 reported 1.4 days shorter colds. Negative trials: Barrett 2010 (719 people, E. angustifolia root tablets, 10.2 g in the first 24 hours; 0.53 days shorter, CI -1.25 to 0.19, not significant), Barrett 2002 (148 students, unrefined mixture of species and parts, no benefit), Yale 2004 (128 adults, E. purpurea pressed juice, 100 mg three times a day, no difference). Turner 2005 (E. angustifolia root, deliberate infection) found no effect. Positive trials: Goel 2004 (282 adults who often get colds, standardised fresh E. purpurea, symptom scores 23.1% lower in the per-protocol analysis) and Brinkeborn 1999 (Echinaforce and a 7-times concentrate worked better than placebo; a root-only product did not). Aucoin 2020 (rapid review) concluded echinacea may help symptoms if started at the first sign, particularly products using E. purpurea or E. purpurea plus E. angustifolia with standardised active compounds.

Results

Mixed: no benefit in the best-known independent trials and in the Cochrane review; benefit in a few standardised-product trials.

Effect sizes as reported

Cochrane: no pooled treatment effect; David 2019 duration MD -0.45 days (CI as printed 1.85 to 0.94); Shah 2007 WMD -1.44 days (-2.24 to -0.64); Barrett 2010 -0.53 days (-1.25 to 0.19); Goel 2004 symptom scores 23.1% lower (p<0.01, per-protocol).

Why this rating

Reviews disagree, individual trials split roughly evenly, and benefit seems to depend on the specific product (species, plant part and extraction). The Cochrane authors call a weak benefit from some products possible but not shown.

Form and dose studied

Tested: E. purpurea juice or alcohol extracts (aerial parts), E. angustifolia root tablets, mixed unrefined capsules. Dosing ranged from 300 mg of pressed juice a day (Yale 2004) up to 5.1 to 10.2 g of dried root a day (Barrett 2010).

Who was studied

Healthy adults and students who caught a cold naturally; trial in adolescents and adults aged 12 to 80 (Barrett 2010).

Limits

Pooled results mix many products; self-reported symptoms; people start at different stages of the cold; several positive trials involve the manufacturer.

Why researchers looked

Many people start echinacea at the first sign of a cold hoping to shorten it.

Traditional use

Used traditionally for colds, coughs and sore throats, typically as a fresh-root tincture or tea.

Proposed mechanism Laboratory research

Possible immune-stimulating and mild anti-inflammatory effects seen in lab studies; none proven to explain any effect in people.

A proposed mechanism does not show that the effect happens in people.

Adverse events were similar between echinacea and placebo in most treatment trials.

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Deliberately caught colds (virus challenge studies)

Low certainty

In studies where volunteers were deliberately infected with a cold virus, echinacea did not clearly protect them. Pooling three studies suggested a small protective effect, but the one large trial of root extract found nothing.

4 studiesE. angustifolia root extracts (Turner 2005); E. purpurea 2.5 mL three…

Studies, doses and limits

What the trials found

Schoop 2006 pooled 3 challenge studies: the chance of a clinical cold was 55% higher with placebo (OR 1.55, CI 1.02 to 2.36, p=0.043), but symptom scores were not significantly different. Individual studies: Turner 2000 (infection 44% vs 57%, illness 36% vs 43%, not significant), Sperber 2004 (48 adults, E. purpurea; colds in 58% vs 82%, p=0.114, too small to be conclusive), and Turner 2005 in the New England Journal of Medicine (437 volunteers randomised, 399 analysed; three E. angustifolia root extracts; no significant effect on infection, symptoms, IL-8 or virus levels).

Results

Mostly null in the individual studies; borderline positive when pooled.

Effect sizes as reported

Schoop 2006 OR 1.55 (1.02 to 2.36) for a cold with placebo vs echinacea; symptom score difference -1.96 (-4.83 to 0.90).

Why this rating

Small studies, different products, a borderline pooled result and a large null trial of one root extract.

Form and dose studied

E. angustifolia root extracts (Turner 2005); E. purpurea 2.5 mL three times a day for 14 days (Sperber 2004); dose not stated for Turner 2000 in the abstract.

Who was studied

Healthy adult volunteers in quarantine-style studies.

Limits

Results apply to a single virus type (rhinovirus 39) and to the specific extracts tested.

Why researchers looked

Deliberate infection removes guesswork about who was exposed and when, giving a cleaner test than waiting for natural colds.

Proposed mechanism Pharmacological theory

Not established; these trials test whether any benefit shows up under controlled exposure.

A proposed mechanism does not show that the effect happens in people.

No important safety signal reported in the abstracts.

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Children: preventing and treating respiratory infections

Low certainty

For children, treatment trials were mixed: the largest US trial found no benefit and more rashes, while brand-specific trials found shorter illness at a higher dose or fewer infections. A 2025 review found benefits, but its evidence is limited and several trials were funded by the product maker.

5 studiesEchinaforce Junior (400 mg alcohol extract of fresh E. purpurea) thre…

Studies, doses and limits

What the trials found

Treatment: Taylor 2003 (JAMA, 407 children aged 2 to 11, 707 colds) found no difference in duration (median 9 days in both) or severity, and rash was more frequent with echinacea (7.1% vs 2.7%, p=0.008). Weishaupt 2020 (79 children aged 4 to 12, no placebo) found that 5 tablets a day (2,000 mg) shortened episodes by up to 1.7 days compared with 3 tablets a day. Prevention: Ogal 2021 (about 201 children aged 4 to 12, controlled with vitamin C, not placebo; 2 x 2 months) found 32.5% fewer infection episodes (OR 0.52, CI 0.30 to 0.91). Reviews: Pham 2025 (9 trials) reported lower incidence (RR 0.81) but also more adverse events (RR 1.38); Mazi 2025 (5 trials) reported some benefit, noting mixed results.

Results

Mixed. A large treatment trial was negative; a small dose-comparison and a vitamin-C-controlled prevention trial were positive.

Effect sizes as reported

Taylor 2003 duration p=0.89; rash 7.1% vs 2.7%; Weishaupt 2020 up to 1.7 days shorter at 5 vs 3 tablets (p<0.02); Ogal 2021 OR 0.52 (0.30 to 0.91); Pham 2025 incidence RR 0.81 (0.75 to 0.87), adverse events RR 1.38 (1.08 to 1.78).

Why this rating

Few trials, one large negative trial, positive trials from a single manufacturer's product, and a control that was not an inert placebo in the prevention trial. One review graded certainty as high, but its own text lists concerns about bias.

Form and dose studied

Echinaforce Junior (400 mg alcohol extract of fresh E. purpurea) three times a day for prevention; 1,200 to 2,000 mg extract a day for treatment in Weishaupt 2020.

Who was studied

Children aged 2 to 12.

Limits

Different products and doses; no placebo in two key positive designs; rash signal in the one large negative trial.

Why researchers looked

Children get many colds, and parents look for options that avoid antibiotics.

Traditional use

Echinacea has long been used in family remedies for colds; paediatric evidence is much newer.

Proposed mechanism Pharmacological theory

Not shown in children; proposed immune and antiviral effects come from lab studies.

A proposed mechanism does not show that the effect happens in people.

Rash was more common with echinacea in Taylor 2003; people allergic to daisy-family plants should avoid echinacea.

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Fewer complications and less antibiotic use

Low certainty

A few manufacturer-linked analyses and trials report that people on echinacea needed fewer antibiotics, mostly in children. Those results are large but come from limited trials with potential bias, so they should be treated as unproven.

5 studiesAlcohol extracts of fresh E. purpurea (Echinaforce) in the main trial…

Studies, doses and limits

What the trials found

Gancitano 2024 (30 trials, 5,652 people) reported lower need for antibiotics (RR 0.60, CI 0.39 to 0.93) and 70% fewer antibiotic days (IRR 0.29), with complications reduced (RR 0.44). Schapowal 2015 found complications (pneumonia, ear infection, tonsillitis) less frequent (RR 0.503). Ogal 2021 in children: 6 antibiotic courses in 6 children vs 24 courses in 15 children on vitamin C. Pham 2025 reported antibiotic use RR 0.18 in children. Weishaupt 2020 reported an antibiotic prescription rate of 4.6% (no comparison group).

Results

Large reductions reported in sponsor-linked analyses and in one vitamin-C-controlled children's trial.

Effect sizes as reported

Antibiotic need RR 0.60 (0.39 to 0.93), antibiotic days IRR 0.29 (0.11 to 0.74) Gancitano 2024; complications RR 0.503 (0.384 to 0.658) Schapowal 2015; antibiotic use RR 0.18 (0.13 to 0.25) Pham 2025 (children).

Why this rating

Results come from few trials, mainly with one manufacturer's alcohol extract, and the two largest effect estimates come from reviews with authors paid by that manufacturer or with signs of publication bias.

Form and dose studied

Alcohol extracts of fresh E. purpurea (Echinaforce) in the main trials.

Who was studied

Mostly children aged 4 to 12 and generally healthy adults.

Limits

Antibiotic prescribing depends on local habits; outcome counts are small; products are not interchangeable.

Why researchers looked

Reducing unnecessary antibiotics matters for public health, so researchers look at whether preventing infections cuts antibiotic use.

Traditional use

Not a traditional use; a modern research outcome.

Proposed mechanism Pharmacological theory

Proposed: fewer viral infections lead to fewer secondary bacterial complications. Not demonstrated directly.

A proposed mechanism does not show that the effect happens in people.

Echinacea should not replace antibiotics for a bacterial infection or for a sick child; see a clinician for high fever or worsening illness.

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Flu and sore throat

Low certainty

One trial found an echinacea hot drink performed about as well as the flu drug oseltamivir for early flu, but it had no placebo group. A spray combining echinacea and sage was about as good as a standard throat spray for sore throat.

2 studiesEchinaforce Hotdrink for 10 days (Raus 2015); echinacea/sage spray, 2…

Studies, doses and limits

What the trials found

Raus 2015 (473 people with early flu symptoms, E. purpurea hot drink for 10 days vs 5 days of oseltamivir): recovery at day 10 was 90.1% vs 84.8%; complications 2.46% vs 6.45% (p=0.076); fewer side effects with echinacea; the design only tested whether echinacea was not worse, with no placebo group. Schapowal 2009 (154 people, echinacea/sage spray vs chlorhexidine/lidocaine spray): response in 3 days 63.8% vs 57.8%, similar; no placebo group.

Results

Similar to comparators in two trials without placebo arms.

Effect sizes as reported

Recovery at 10 days 90.1% vs 84.8% (echinacea hot drink vs oseltamivir); sore throat response 63.8% vs 57.8% (echinacea/sage spray vs chlorhexidine/lidocaine).

Why this rating

No placebo groups, product-specific, sponsor-linked, and flu recovers on its own.

Form and dose studied

Echinaforce Hotdrink for 10 days (Raus 2015); echinacea/sage spray, 2 puffs every 2 hours (Schapowal 2009).

Who was studied

Adults and teens with early flu symptoms or acute sore throat in primary care.

Limits

Comparator trials cannot show echinacea beats placebo; combination product for sore throat.

Why researchers looked

Echinacea is marketed for flu and sore throats, and a small number of branded trials exist.

Traditional use

Traditional throat and infection remedy; the combination with sage follows European herbal practice.

Proposed mechanism Laboratory research

Lab studies show the extract can inactivate influenza and other enveloped viruses on contact; whether that happens in the body is not shown.

A proposed mechanism does not show that the effect happens in people.

Fewer nausea and vomiting events than oseltamivir in Raus 2015; echinacea should not replace medical care for severe flu.

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COVID-19 and coronaviruses

Not enough evidence

Echinacea extracts inactivate coronaviruses in lab dishes. In people, there is no proof it prevents or treats COVID-19: the one human study was small, open (no placebo) and sponsor-funded.

4 studiesEchinaforce extract in the human study (2,400 mg a day for prevention…

Studies, doses and limits

What the trials found

Kolev 2022 (120 healthy adults, open, no placebo, sponsor-funded): 5 vs 14 SARS-CoV-2-positive swabs (RR 0.37, p=0.03), but symptomatic episodes were not significantly different (RR 0.70) and numbers were tiny. Lab studies: Signer 2020 and Vimalanathan 2022. Aucoin 2020 found no studies of echinacea in COVID-19-like illness.

Results

No reliable human evidence; lab inactivation of virus on contact.

Effect sizes as reported

Kolev 2022 SARS-CoV-2-positive samples RR 0.37 (p=0.03); symptomatic episodes RR 0.70 (p>0.05). Lab EC50 3.62 to 12.03 micrograms/mL.

Why this rating

Only one small unblinded human study; the rest is lab work.

Form and dose studied

Echinaforce extract in the human study (2,400 mg a day for prevention).

Who was studied

Healthy adults in one trial.

Limits

No placebo and no blinding; a handful of positive swabs; sponsor-funded.

Why researchers looked

Lab results with coronaviruses led to a small trial during the COVID-19 pandemic.

Proposed mechanism Laboratory research

In lab dishes the extract inactivated common-cold coronavirus, MERS, SARS-CoV-1 and SARS-CoV-2 and blocked cell entry in some assays; computer models suggest binding to the spike protein. Lab results do not show effects in people.

A proposed mechanism does not show that the effect happens in people.

Not a substitute for vaccination or medical treatment.

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Anxiety

Low certainty

A few small trials of one specific patented extract of Echinacea angustifolia root (EP107) found lower anxiety scores, but the largest 6-week trial did not beat placebo on its main anxiety measure. This evidence is early and comes from one research group's product.

6 studiesE. angustifolia root extract EP107: 20 to 40 mg twice a day (human tr…

Studies, doses and limits

What the trials found

Haller 2020: a placebo-controlled trial of 40 mg twice a day for 7 days of E. angustifolia root extract in volunteers with high anxiety scores (STAI) found state anxiety fell about 11 points vs about 3 with placebo (p<0.01); depression and stress scores did not change. Haller 2013: in healthy volunteers with high anxiety scores, 2 tablets a day (20 mg each) lowered STAI scores while 1 tablet did not. Lopresti 2021 (108 adults with mild-to-moderately severe anxiety, 6 weeks, 20 or 40 mg twice a day): anxiety fell in all groups but not more than placebo on the main measure (CUXOS). Haller 2025: with the HADS anxiety scale the extract beat placebo; the Hamilton anxiety total score did not.

Results

Positive in the researcher group's short trials; null on the main outcome in the longer independent-style trial (anxiety was lower than baseline in all groups).

Effect sizes as reported

Haller 2020 state anxiety about -11 vs -3 points (p<0.01); Lopresti 2021 no difference from placebo on CUXOS; Haller 2025 HADS-A better than placebo, HAM-A total not significant (numbers not in abstracts).

Why this rating

Small trials, one patented extract, authors holding patents on its use, mixed results across anxiety scales, and short follow-up.

Form and dose studied

E. angustifolia root extract EP107: 20 to 40 mg twice a day (human trials). Not the same as typical cold-remedy products.

Who was studied

Adult volunteers with high anxiety scores; adults with mild-to-moderate anxiety.

Limits

Evidence cannot be extended to other echinacea products; no trials in people with clinical anxiety disorders reported in the abstracts; follow-up up to 6 weeks.

Why researchers looked

Researchers noticed that some echinacea compounds (alkylamides) affect brain signalling and tested them in anxiety models.

Traditional use

Not a traditional use of echinacea.

Proposed mechanism Animal research

In rat brain slices, one echinacea extract reduced excitatory nerve signalling in the hippocampus, a brain area involved in anxiety. In rats, certain preparations reduced anxiety-like behaviour in several tests. This has not been shown to explain the human effect.

A proposed mechanism does not show that the effect happens in people.

Adverse effects were rare and mild in Haller 2020; no signs of sedation or reward in rats.

^{42 41 63 43 54 40}

Mood and wellbeing

Very low certainty

One 6-week trial found better positive and negative mood scores and emotional wellbeing with Echinacea angustifolia than placebo, even though anxiety did not change more than with placebo. This is a secondary result and not yet confirmed.

2 studiesEP107 E. angustifolia extract, 20 or 40 mg twice a day for 6 weeks.

Studies, doses and limits

What the trials found

Lopresti 2021: both doses of E. angustifolia extract (EP107) gave larger improvements than placebo on PANAS positive and negative affect and the SF-36 emotional wellbeing score; the authors say these were secondary outcomes and need confirming. Haller 2020 found no change in depression (BDI) or stress (PSS) scores over 7 days. No trial of echinacea for diagnosed depression or for memory or thinking tasks was found in this review.

Results

One positive secondary result, one null in a different trial.

Effect sizes as reported

Numbers not in abstracts.

Why this rating

Secondary outcomes from a single trial, with a different 7-day trial showing no change in depression or stress scores.

Form and dose studied

EP107 E. angustifolia extract, 20 or 40 mg twice a day for 6 weeks.

Who was studied

Adults with mild-to-moderate anxiety.

Limits

Not tested in depression; single research product.

Why researchers looked

Researchers looked for mood effects alongside the anxiety work.

Proposed mechanism Preliminary mechanism

Unknown; lab data on hippocampal signalling are only a possible lead.

A proposed mechanism does not show that the effect happens in people.

No safety concerns noted in the abstracts.

^{63 42}

Children who keep getting infections (colds, tonsillitis, ear infections)

Low certainty

In children, echinacea has been tested to prevent repeat infections. Results are mixed. A 2021 trial in children aged 4 to 12 found fewer infection episodes and far fewer antibiotic courses than vitamin C. A mixed echinacea-propolis-vitamin C syrup cut illness episodes by about half in toddlers. But in ear-infection-prone toddlers, echinacea taken during colds did not help and may have raised the risk. Product type and the way it was used seem to matter.

6 studiesEchinaforce Junior 400 mg three times daily for two 2-month blocks; o…

Studies, doses and limits

What the trials found

2021 trial (Switzerland/UK, children 4-12 years): Echinaforce Junior 400 mg three times daily vs vitamin C 50 mg, two 2-month periods. Infection episodes OR 0.52 (95% CI 0.30-0.91); antibiotic courses 6 vs 24; complications 11 vs 30. One author works for the maker. 2004 trial (430 children aged 1-5): echinacea-propolis-vitamin C elixir for 12 weeks gave 0.9 vs 1.8 episodes per child (p<.001); the mixture means echinacea cannot be credited alone. 2020 Egyptian study (300 children with recurrent tonsillitis, not clearly randomized): echinacea added to azithromycin gave fewer attacks than azithromycin alone. 2008 US trial (90 toddlers with recurrent ear infections): echinacea taken for 10 days at each cold was linked to more infections (65% vs 41%; RR 1.59, 95% CI 1.04-2.42). A 2025 meta-analysis of 9 trials found fewer infections (RR 0.81) and less antibiotic use (RR 0.18) but moderately more mild side effects (RR 1.38); a 2025 systematic review of 5 trials reported similar direction and mentions high-certainty ratings by its own GRADE assessment.

Results

Fewer infection episodes and antibiotic courses in the better trials; no benefit, and possibly harm, for ear infections in one small trial.

Effect sizes as reported

Infection episodes OR 0.52 (95% CI 0.30-0.91) in the 2021 trial; meta-analysis: incidence RR 0.81 (0.75-0.87), antibiotic use RR 0.18 (0.13-0.25), ear infection episodes RR 0.56 (0.44-0.73), adverse events RR 1.38 (1.08-1.78).

Why this rating

Products and doses vary widely; the largest trial used vitamin C rather than placebo and has a manufacturer link; one trial mixes herbs; one trial points the other way; the tonsillitis study was not clearly randomized. A review reports high certainty on its own GRADE, but the compiler rates the whole picture low because of these problems. Cold and flu treatment itself is covered in the immune and respiratory section.

Form and dose studied

Echinaforce Junior 400 mg three times daily for two 2-month blocks; other trials used syrups and extracts at varied doses.

Who was studied

Children from 1 to 12 years; most data from European and Middle Eastern trials.

Limits

Mixed products; comparator not always inactive; short follow-up; some trials had company links.

Why researchers looked

Young children get many infections and parents look for ways to cut antibiotic use.

Traditional use

Echinacea has long been used for infections in North America and Europe. Use in children is a modern research question.

Proposed mechanism Preliminary mechanism

Lab and animal work suggests echinacea extracts affect immune cells and may act on some viruses. This has not been shown to explain the trial results.

A proposed mechanism does not show that the effect happens in people.

Adverse events were moderately more common in the pooled analysis (mostly mild: stomach upset, skin rash). Echinacea may be a poor choice for toddlers prone to ear infections based on one trial. Ask a paediatrician before giving any herb to a child.

^{80 16 1 108 84 68}

Eczema (atopic dermatitis), as a skin cream

Very low certainty

A cream made from echinacea alkylamides lowered eczema severity scores in a published trial and improved skin barrier fats. The abstract gives no group sizes or numbers, so this is early evidence for a cream, not for pills or teas.

1 studiesAlkylamide extract in a cream (strength not stated).

Studies, doses and limits

What the trials found

Oláh 2017 combined lab work and three human trials. A patch test found the cream well tolerated. In an eczema trial, local SCORAD (severity score) fell versus baseline and versus the comparator. In a third trial, skin lipids (ceramide EOS, cholesterol) were higher at Day 15 than at baseline. Group sizes, doses, trial length and the comparator are not in the abstract.

Results

Lower local eczema severity score than the comparator cream; better skin barrier fats.

Effect sizes as reported

Statistically significant fall in local SCORAD; no numbers or confidence intervals in the abstract.

Why this rating

One report with three small trials, no group sizes or numbers in the abstract, a cream from a specific research group, no independent repeat found.

Form and dose studied

Alkylamide extract in a cream (strength not stated).

Who was studied

People with atopic eczema; population details not in the abstract.

Limits

Details missing from the abstract; comparator unclear; not tested on other skin conditions here.

Why researchers looked

Eczema is a long-lasting itchy skin condition and people look for gentle anti-inflammatory creams.

Traditional use

Echinacea was used on wounds and skin problems by Native American peoples, but the eczema work is modern and based on a specific extract.

Proposed mechanism Laboratory research

In lab-grown skin cells, the extract lowered inflammatory signals (IL-6, IL-8). The alkylamides are thought to act on the CB2 receptor, part of the body's own cannabinoid system, according to the authors.

A proposed mechanism does not show that the effect happens in people.

Echinacea can cause allergic skin reactions in people allergic to daisy-family plants (Asteraceae); the patch test found the cream well tolerated in that trial. Do not put it on broken or infected skin without medical advice.

⁸¹

Skin hydration and fine lines (cosmetic)

Very low certainty

A small Thai study of 10 healthy adults found that echinacea cream and gel raised skin moisture and reduced wrinkle measurements after one month. There was no placebo group described, so it is a very early cosmetic finding.

1 studiesEchinacea purpurea cream and gel (strength not stated); shelf life sh…

Studies, doses and limits

What the trials found

Yotsawimonwat 2010: 10 healthy volunteers aged 25-40 used the cream or gel for 1 month. The moisture reading rose by up to 10.6 and 11.4 AU and wrinkle measures fell 9.47% (cream) and 14.92% (gel). No irritation. The extract itself lost strength within 2 to 4 months in storage.

Results

Higher skin moisture readings and lower wrinkle measures; no irritation.

Effect sizes as reported

Hydration +10.6 (cream) and +11.4 (gel) AU; wrinkles -9.47% and -14.92%; no p-values given in the abstract.

Why this rating

Ten healthy people, no placebo group described, no statistics given in the abstract.

Form and dose studied

Echinacea purpurea cream and gel (strength not stated); shelf life short.

Who was studied

Healthy adults aged 25 to 40.

Limits

Tiny; uncontrolled; short; the products degraded in storage.

Why researchers looked

Echinacea contains plant chemicals that protect against oxidation, and makers add it to skin products.

Traditional use

Traditional skin use was for wounds and sores, not for wrinkles.

Proposed mechanism Laboratory research

The authors link the effect to antioxidant plant chemicals in the extract. This was measured in the lab, not shown in the skin.

A proposed mechanism does not show that the effect happens in people.

No irritation in this study.

¹¹⁵

Recurrent genital herpes

Low certainty

A 6-month crossover trial in 50 people with frequent genital herpes found no significant benefit from Echinacea purpurea compared with placebo. Lab studies show activity against herpes virus, but this did not carry over to people.

1 studiesEchinaforce (E. purpurea plant and root extract); dose not stated in …

Studies, doses and limits

What the trials found

Vonau 2001, London: 50 people with frequently recurring genital herpes took Echinaforce for 6 months and placebo for 6 months in a double-blind crossover. Recurrence frequency and severity (history, clinical review, visual analogue scales) showed no significant difference.

Results

No benefit shown.

Effect sizes as reported

No statistically significant difference; no numbers in the abstract.

Why this rating

One small trial with a clear null result; dose not in the abstract. Rated low because the evidence is one trial, pointing against a benefit. A cold-sore (oral herpes) trial was not found.

Form and dose studied

Echinaforce (E. purpurea plant and root extract); dose not stated in the abstract.

Who was studied

Adults with frequent genital herpes recurrences.

Limits

One trial, 50 people, dose not in the abstract.

Why researchers looked

Herpes comes back repeatedly and people look for immune-boosting options.

Traditional use

Echinacea has been promoted in the popular press for herpes; this is not a documented traditional use.

Proposed mechanism Laboratory research

Lab studies show echinacea extracts can block herpes virus in cells. That has not been shown to work in people.

A proposed mechanism does not show that the effect happens in people.

No safety concern reported in the abstract.

¹⁰⁷

HPV-related cervical lesions and genital warts

Very low certainty

Two small Italian studies tested echinacea supplements for HPV-related problems. In women with mild cervical changes, a combination of echinacea plus vaginal hyaluronic acid did better at 6 and 12 months than either alone. In people treated for genital warts, a root-extract supplement was linked to fewer relapses in those over 25. Both studies are small and have design weaknesses.

2 studiesOral echinacea extracts (E. angustifolia plus E. purpurea) with or wi…

Studies, doses and limits

What the trials found

Riemma 2022 (153 women with low-grade cervical lesions, 3 months of treatment): persistent CIN-1 at 6 months 15/51 (echinacea plus hyaluronic acid) vs 23/48 (echinacea alone) vs 27/49 (hyaluronic acid alone); at 12 months 5/51 vs 15/48 vs 14/48 (p=0.03 for each comparison). No difference at 3 months. De Rosa 2019 (genital warts after CO2 laser, supplement group n=64, 4 months): relapses were significantly fewer in the supplement group among people over 25, in both men and women.

Results

Fewer persistent lesions with the combined arm at 6 and 12 months; fewer wart relapses in over-25s.

Effect sizes as reported

Persistent CIN-1 at 12 months 5/51 vs 14/48 (hyaluronic acid alone), p=0.03; wart relapse numbers not in the abstract text read.

Why this rating

Two small studies with design problems: in the first, echinacea alone did not clearly beat hyaluronic acid alone; the second has no placebo and its description of itself is inconsistent.

Form and dose studied

Oral echinacea extracts (E. angustifolia plus E. purpurea) with or without vaginal hyaluronic acid; wart study used root extracts for 4 months.

Who was studied

Women with low-grade cervical lesions; men and women after wart laser treatment.

Limits

Single-blind or unblinded; no placebo; small; combination effect cannot be credited to echinacea alone. Does not replace HPV screening or follow-up.

Why researchers looked

HPV usually clears on its own but can leave lesions that need follow-up, so women and clinicians look for immune support.

Traditional use

Not a traditional use; a modern question based on echinacea's immune effects.

Proposed mechanism Pharmacological theory

The authors propose that echinacea boosts the immune response against the virus. This is a theory in these studies.

A proposed mechanism does not show that the effect happens in people.

No safety concern reported in the abstracts. See the safety section for general cautions.

^{90 19}

Immune markers (cytokines, saliva antibodies)

Very low certainty

Two small human studies measured immune signals. In 10 healthy people, a single echinacea capsule was followed by lower pro-inflammatory signals and higher IL-10 after 24 hours, with no comparison group. In an exercise study of 32 people, 4 weeks of echinacea kept saliva antibody (s-IgA) from falling after hard exercise. Neither shows a health benefit by itself.

2 studiesSingle 10 mg E. angustifolia softgel; E. purpurea supplement for 4 we…

Studies, doses and limits

What the trials found

Dall'Acqua 2015: 10 healthy volunteers took one 10 mg E. angustifolia lipophilic softgel; blood at 24 hours showed lower IL-6, TNF-alpha and IL-8 and higher IL-10 than before (no control group, no values in the abstract). Hall 2007: 32 people did an exercise test before and after 4 weeks of echinacea or placebo; saliva s-IgA fell 45% in the placebo group and rose 7% in the echinacea group.

Results

Cytokine and s-IgA measures moved in the direction of less immune dip or less inflammation signalling.

Effect sizes as reported

s-IgA after exercise: -45% (placebo) vs +7% (echinacea); cytokine changes direction only.

Why this rating

One uncontrolled 10-person single-dose study and one small trial; no clinical outcome; immune markers do not equal being healthier. The abstract does not give a dose for the exercise trial.

Form and dose studied

Single 10 mg E. angustifolia softgel; E. purpurea supplement for 4 weeks (dose not in abstract).

Who was studied

Healthy adults.

Limits

Tiny; no placebo in the cytokine study; markers only; no reference ranges given.

Why researchers looked

Researchers measure immune signals to see whether echinacea changes how the immune system behaves.

Traditional use

Echinacea is traditionally taken to strengthen resistance to infection.

Proposed mechanism Laboratory research

Alkylamides in echinacea are reported to lower IL-6, TNF-alpha and IL-8 gene activity and raise IL-10 in blood cells. In a lab (Jurkat T-cell) study a water extract rich in sugars both raised and lowered cytokine release depending on cell density, so effects are not simple.

A proposed mechanism does not show that the effect happens in people.

Echinacea may stimulate immune activity; people with autoimmune conditions are usually advised to check with a doctor (see safety section).

^{17 39}

Athletes: blood oxygen carriers and endurance

Low certainty

Some athletes take echinacea hoping to raise red blood cell production and fitness. A 2024 meta-analysis of 6 small studies (107 athletes) found no clear change in hemoglobin, erythropoietin or maximal oxygen uptake.

1 studiesVaried supplements and doses.

Studies, doses and limits

What the trials found

Deccy 2024 pooled 6 studies with 107 athletes. Hemoglobin effect size 0.38 (95% CI -0.04 to 0.80, I2=70%), hematocrit 0.34 (-0.10 to 0.78, I2=86%), erythropoietin -0.29 (-0.75 to 0.17, I2=67%), maximal oxygen uptake -0.20 (-0.60 to 0.21, I2=0%). None reached significance; there was a lot of difference between studies for blood measures.

Results

No effect on aerobic capacity or red blood cell measures.

Effect sizes as reported

See above; all confidence intervals include zero.

Why this rating

Meta-analysis of 6 small studies with high inconsistency; the authors call the evidence base limited. The result is probably a true lack of large effect, but small effects cannot be excluded.

Form and dose studied

Varied supplements and doses.

Who was studied

Athletes.

Limits

Few small trials with different products.

Why researchers looked

Early reports suggested echinacea might raise erythropoietin (the hormone that signals red blood cell production).

Traditional use

No traditional use for athletic performance.

Proposed mechanism Pharmacological theory

A theory that echinacea could increase erythropoietin, mainly from animal and small human studies; the meta-analysis did not support it.

A proposed mechanism does not show that the effect happens in people.

Not a safety study.

²⁰

Anxiety and mood

Low certainty

In a 6-week trial of 108 adults with mild-to-moderate anxiety, an echinacea angustifolia extract (EP107) did not reduce anxiety more than placebo. Mood and emotional wellbeing scores improved more, but only in secondary measures that need confirming.

1 studiesEP107 E. angustifolia extract, 20 or 40 mg twice daily.

Studies, doses and limits

What the trials found

Lopresti 2021 (Perth, 108 adults, 104 analysed): placebo vs EP107 20 mg or 40 mg twice daily for 6 weeks. The anxiety scale (CUXOS) fell in all groups with no difference from placebo. Positive and negative mood scores (PANAS) and SF-36 emotional wellbeing improved more with echinacea.

Results

No extra anxiety benefit over placebo; some mood gains in secondary measures.

Effect sizes as reported

Anxiety: no difference from placebo; mood scores better than placebo (values not in the abstract).

Why this rating

One 6-week trial; main anxiety result null; mood gains only in secondary outcomes; a single narrow extract. If the mind section covers this herb's anxiety evidence, read it there too.

Form and dose studied

EP107 E. angustifolia extract, 20 or 40 mg twice daily.

Who was studied

Adults with mild-to-moderate anxiety.

Limits

One trial; secondary outcomes; one extract.

Why researchers looked

An earlier pair of human trials suggested the extract might calm anxiety quickly (reported in this trial's abstract, not read).

Traditional use

Not a traditional use for anxiety.

Proposed mechanism Pharmacological theory

The authors suggest an effect on mood-related brain chemistry; not shown in this trial.

A proposed mechanism does not show that the effect happens in people.

No safety concern is stated in the abstract.

⁶³

Carpal tunnel pain (mixed product)

Not enough evidence

One Italian trial of 60 people with carpal tunnel syndrome compared shock wave therapy with a supplement containing echinacea, alpha lipoic acid, conjugated linoleic acid and quercetin. Both improved pain and function up to 6 months. Because the supplement had several ingredients and there was no placebo, echinacea's own effect is unknown.

1 studiesPerinerv-type supplement (dose not stated).

Studies, doses and limits

What the trials found

Notarnicola 2015: 60 patients randomised to shock wave therapy or the supplement. Both groups improved in pain, symptom severity, function and nerve tests up to 6 months; the supplement group showed a trend to better pain relief.

Results

Both treatments improved symptoms; no placebo to compare.

Effect sizes as reported

Trend only; no numbers in the abstract.

Why this rating

Mixed ingredients, no placebo, no numbers in the abstract.

Form and dose studied

Perinerv-type supplement (dose not stated).

Who was studied

Adults with carpal tunnel syndrome.

Limits

Cannot separate echinacea from other ingredients.

Why researchers looked

Echinacea alkylamides are thought to act on the body's cannabinoid system, which affects pain, so a pain trial was run.

Traditional use

No traditional use for carpal tunnel.

Proposed mechanism Pharmacological theory

The authors say echinacea acts on the body's cannabinoid system; this is a theory in this study.

A proposed mechanism does not show that the effect happens in people.

No safety information in the abstract.

⁷⁸

Connections to the rest of health

How Echinacea connects to the rest of our health knowledge graph. Every link says what kind of connection it is. A safety link (for example to the liver) is a warning, not a benefit. A study that merely mentions a topic never creates a benefit link.

Explore every connection: goals, body systems, organs, symptoms, genes

Kind of connection Connected to Search

A. Wellness goals

Connected to	Kind of connection	Evidence status	Context	Studies
Immune Support	Potential benefit	Low certainty	Preventing colds and respiratory infections (adults): Taking echinacea every day for weeks to months might slightly lower the chance of catching a cold. The best independent review found a possible 10% to 20% lower risk but no single trial that proved it, and the effect may not matter much in daily life. Treating a cold once it has started (adults): Most of the best-designed trials found that echinacea taken after cold symptoms begin does not shorten the cold or make it clearly milder. A few trials of specific standardised products found some benefit, so results depend heavily on the product.	^{57 18 95 92 29 55 59 102 79 4 10 9 114 33 13 93 104 99 105 101 110 80 84 68 88 91 16 1 108 107 90 19}
Immune Support	Preliminary mechanism	Not enough evidence	COVID-19 and coronaviruses: Echinacea extracts inactivate coronaviruses in lab dishes. In people, there is no proof it prevents or treats COVID-19: the one human study was small, open (no placebo) and sponsor-funded.	^{59 96 106 4}
Anxiety Support	Potential benefit	Low certainty	Anxiety: A few small trials of one specific patented extract of Echinacea angustifolia root (EP107) found lower anxiety scores, but the largest 6-week trial did not beat placebo on its main anxiety measure. This evidence is early and comes from one research group's product. Anxiety and mood: In a 6-week trial of 108 adults with mild-to-moderate anxiety, an echinacea angustifolia extract (EP107) did not reduce anxiety more than placebo. Mood and emotional wellbeing scores improved more, but only in secondary measures that need confirming.	^{42 41 63 43 54 40}
Calm Relaxation	Potential benefit	Low certainty	Anxiety: A few small trials of one specific patented extract of Echinacea angustifolia root (EP107) found lower anxiety scores, but the largest 6-week trial did not beat placebo on its main anxiety measure. This evidence is early and comes from one research group's product.	^{42 41 63 43 54 40}
Mood Balance	Potential benefit	Very low certainty	Mood and wellbeing: One 6-week trial found better positive and negative mood scores and emotional wellbeing with Echinacea angustifolia than placebo, even though anxiety did not change more than with placebo. This is a secondary result and not yet confirmed. Anxiety and mood: In a 6-week trial of 108 adults with mild-to-moderate anxiety, an echinacea angustifolia extract (EP107) did not reduce anxiety more than placebo. Mood and emotional wellbeing scores improved more, but only in secondary measures that need confirming.	^{63 42}
Healthy Skin	Potential benefit	Very low certainty	Eczema (atopic dermatitis), as a skin cream: A cream made from echinacea alkylamides lowered eczema severity scores in a published trial and improved skin barrier fats. The abstract gives no group sizes or numbers, so this is early evidence for a cream, not for pills or teas.	⁸¹
Inflammation Balance	Potential benefit	Very low certainty	Eczema (atopic dermatitis), as a skin cream: A cream made from echinacea alkylamides lowered eczema severity scores in a published trial and improved skin barrier fats. The abstract gives no group sizes or numbers, so this is early evidence for a cream, not for pills or teas.	⁸¹
Healthy Skin	Preliminary mechanism	Very low certainty	Skin hydration and fine lines (cosmetic): A small Thai study of 10 healthy adults found that echinacea cream and gel raised skin moisture and reduced wrinkle measurements after one month. There was no placebo group described, so it is a very early cosmetic finding.	¹¹⁵
Womens Wellness	Potential benefit	Very low certainty	HPV-related cervical lesions and genital warts: Two small Italian studies tested echinacea supplements for HPV-related problems. In women with mild cervical changes, a combination of echinacea plus vaginal hyaluronic acid did better at 6 and 12 months than either alone. In people treated for genital warts, a root-extract supplement was linked to fewer relapses in those over 25. Both studies are small and have design weaknesses.	^{90 19}
Immune Support	Biological association	Very low certainty	Immune markers (cytokines, saliva antibodies): Two small human studies measured immune signals. In 10 healthy people, a single echinacea capsule was followed by lower pro-inflammatory signals and higher IL-10 after 24 hours, with no comparison group. In an exercise study of 32 people, 4 weeks of echinacea kept saliva antibody (s-IgA) from falling after hard exercise. Neither shows a health benefit by itself.	^{17 39}
Inflammation Balance	Biological association	Very low certainty	Immune markers (cytokines, saliva antibodies): Two small human studies measured immune signals. In 10 healthy people, a single echinacea capsule was followed by lower pro-inflammatory signals and higher IL-10 after 24 hours, with no comparison group. In an exercise study of 32 people, 4 weeks of echinacea kept saliva antibody (s-IgA) from falling after hard exercise. Neither shows a health benefit by itself.	^{17 39}
Endurance Support	Demonstrated clinical effect	Low certainty	Athletes: blood oxygen carriers and endurance: Some athletes take echinacea hoping to raise red blood cell production and fitness. A 2024 meta-analysis of 6 small studies (107 athletes) found no clear change in hemoglobin, erythropoietin or maximal oxygen uptake.	²⁰
Physical Stamina	Demonstrated clinical effect	Low certainty	Athletes: blood oxygen carriers and endurance: Some athletes take echinacea hoping to raise red blood cell production and fitness. A 2024 meta-analysis of 6 small studies (107 athletes) found no clear change in hemoglobin, erythropoietin or maximal oxygen uptake.	²⁰
Joint Support	Preliminary mechanism	Not enough evidence	Carpal tunnel pain (mixed product): One Italian trial of 60 people with carpal tunnel syndrome compared shock wave therapy with a supplement containing echinacea, alpha lipoic acid, conjugated linoleic acid and quercetin. Both improved pain and function up to 6 months. Because the supplement had several ingredients and there was no placebo, echinacea's own effect is unknown.	⁷⁸
Inflammation Balance	Preliminary mechanism	Not enough evidence	Carpal tunnel pain (mixed product): One Italian trial of 60 people with carpal tunnel syndrome compared shock wave therapy with a supplement containing echinacea, alpha lipoic acid, conjugated linoleic acid and quercetin. Both improved pain and function up to 6 months. Because the supplement had several ingredients and there was no placebo, echinacea's own effect is unknown.	⁷⁸

B. Body systems

Connected to	Kind of connection	Evidence status	Context	Studies
Immune system	Adverse effect or risk	Low certainty	Allergic reactions (hives, asthma, anaphylaxis) are the main immune-related harm. The immune-stimulation concern in autoimmune disease is theoretical (EU monographs). Allergic reactions (hives, asthma, anaphylaxis) are the main immune-related harm; the immune-stimulation concern in autoimmune disease is theoretical. Preparation or compound: Echinacea purpurea products in general	^{72 71 26 53}
Respiratory system	Adverse effect or risk	Low certainty	Acute asthma attacks after first doses are described in Australian reports. Safety relationship, not a benefit. Preparation or compound: Echinacea products in allergy-prone people	^{72 26}
Hepatic system	Adverse effect or risk	Very low certainty	Isolated reports; controlled trials of echinacea alone have not linked it to liver injury (per LiverTox summary). Preparation or compound: Unspecified	^{74 89}
Reproductive system	Contraindication	Low certainty	Pregnancy and lactation: not recommended unless a doctor advises (EU monographs), though a large cohort found no excess malformations. Pregnancy and breastfeeding: not recommended unless a doctor advises (EU), though a large cohort found no excess malformations. Preparation or compound: Echinacea products	^{26 48}
Immune system	Contraindication	Very low certainty	Autoimmune disease and immune suppression: EU monographs advise against use as a precaution. Autoimmune disease and immune suppression: EU monographs advise against use as a precaution, not on proven harm. Preparation or compound: Echinacea products	^{26 27 3}
Digestive system	Adverse effect or risk	Low certainty	Stomach upset, nausea and abdominal pain are the most common side effects. Preparation or compound: Echinacea products	^{73 53}
Immune System	Biological association	Low certainty	Studied for: Preventing colds and respiratory infections (adults) Studied for: Treating a cold once it has started (adults)	^{57 18 95 92 29 55 59 102 79 4 10 9 114 33 13 93 104 99 105 101 110 80 84 68 88 91 96 106 16 1 108 81 107 90 19 17 39}
Respiratory System	Biological association	Low certainty	Studied for: Preventing colds and respiratory infections (adults) Studied for: Treating a cold once it has started (adults)	^{57 18 95 92 29 55 59 102 79 4 10 9 114 33 13 93 104 99 105 101 110 80 84 68 88 91 96 106 16 1 108}
Stress Mood	Biological association	Low certainty	Studied for: Anxiety Studied for: Mood and wellbeing	^{42 41 63 43 54 40}
Nervous System	Biological association	Low certainty	Studied for: Anxiety Studied for: Mood and wellbeing	^{42 41 63 43 54 40 78}
Integumentary System	Biological association	Very low certainty	Studied for: Eczema (atopic dermatitis), as a skin cream Studied for: Skin hydration and fine lines (cosmetic)	^{81 115}
Reproductive System	Biological association	Low certainty	Studied for: Recurrent genital herpes Studied for: HPV-related cervical lesions and genital warts	^{107 90 19}
Cardiovascular System	Biological association	Low certainty	Studied for: Athletes: blood oxygen carriers and endurance	²⁰
Musculoskeletal System	Biological association	Low certainty	Studied for: Athletes: blood oxygen carriers and endurance Studied for: Carpal tunnel pain (mixed product)	^{20 78}

C. Body parts and organs

Connected to	Kind of connection	Evidence status	Context	Studies
Skin	Adverse effect or risk	Low certainty	Rash in children (7.1% versus 2.7% of infections); erythema nodosum case; severe skin reactions listed by EU as reported. Rash in children (7.1% of infections versus 2.7%); a case of erythema nodosum; severe skin reactions listed by the EU as reported. Preparation or compound: Echinacea purpurea (oral)	^{101 97 26}
Liver	Adverse effect or risk	Very low certainty	Isolated case reports of liver injury; frequency unknown. A safety relationship, not a benefit. Isolated case reports of liver injury; frequency unknown; controlled trials of echinacea alone have not linked it to liver injury. Preparation or compound: Echinacea alone or in herbal mixtures (not specified in the cases we read)	^{89 58 74}

D. Symptoms

Connected to	Kind of connection	Evidence status	Context	Studies
Common cold (prevention)	Potential benefit	Low certainty	Possible 10% to 20% lower risk of a cold in a post hoc pooling; not proven in single trials; many positive trials are maker-linked. Preparation or compound: Mostly fresh-plant E. purpurea extracts, daily for weeks to months	^{57 18 92 55}
Common cold (treatment)	Potential benefit	Low certainty	Most independent trials found no shorter cold; a few trials of specific standardised products did. Preparation or compound: Varies by product	^{57 18 10 33}
Respiratory infections in children	Potential benefit	Low certainty	Mixed: one large trial found no benefit and more rash; maker-linked trials found fewer infections. Preparation or compound: Varies by product	^{101 80 84}
Anxiety	Potential benefit	Low certainty	Small trials of one patented E. angustifolia root extract; the largest trial did not beat placebo on its main measure. Preparation or compound: EP107 E. angustifolia root extract, 20 to 40 mg twice a day	^{42 63 43}

G. Root causes and contributing factors

Connected to	Kind of connection	Evidence status	Context	Studies
Medication side effects	Drug or supplement interaction	Low certainty	Mild changes in CYP3A and CYP1A2 activity in volunteers; case report of low platelets with etoposide. Preparation or compound: Echinacea purpurea root and extracts	^{35 82 12}
Medicine interactions	Drug or supplement interaction	Low certainty	Small, mixed changes in CYP3A and CYP1A2 activity in volunteers; a case report of low platelets with etoposide.	^{35 82 12 2}

I. Biomarkers

Connected to	Kind of connection	Evidence status	Context	Studies
Respiratory virus detection and viral load	Biological association	Low certainty	Measured in trials: mixed. A lab change is not the same as a health benefit.	^{59 80 55 105}
Nasal interleukin-8 and neutrophils	Biological association	Low certainty	Measured in trials: no-change. A lab change is not the same as a health benefit.	^{10 105}
Antibiotic courses and days	Biological association	Low certainty	Measured in trials: lowered. A lab change is not the same as a health benefit.	^{80 29 84}
State-Trait Anxiety Inventory (STAI)	Biological association	Low certainty	Measured in trials: lowered. A lab change is not the same as a health benefit.	^{42 41}
HADS-A and Hamilton Anxiety Scale (HAM-A)	Biological association	Low certainty	Measured in trials: mixed. A lab change is not the same as a health benefit.	^{43 63}
Positive and negative affect (PANAS)	Biological association	Very low certainty	Measured in trials: raised. A lab change is not the same as a health benefit.	⁶³
Saliva antibody (s-IgA)	Biological association	Very low certainty	Measured in trials: raised. A lab change is not the same as a health benefit.	³⁹
Inflammation signals in blood (IL-6, TNF-alpha, IL-8, IL-10)	Biological association	Very low certainty	Measured in trials: mixed. A lab change is not the same as a health benefit.	¹⁷
Erythropoietin (EPO)	Biological association	Low certainty	Measured in trials: no-change. A lab change is not the same as a health benefit.	²⁰
Hemoglobin and hematocrit	Biological association	Low certainty	Measured in trials: no-change. A lab change is not the same as a health benefit.	²⁰
Maximal oxygen uptake (VO2max)	Biological association	Low certainty	Measured in trials: no-change. A lab change is not the same as a health benefit.	²⁰
Eczema severity score (local SCORAD)	Biological association	Very low certainty	Measured in trials: lowered. A lab change is not the same as a health benefit.	⁸¹
Skin barrier fats (ceramides, cholesterol)	Biological association	Very low certainty	Measured in trials: raised. A lab change is not the same as a health benefit.	⁸¹
Skin moisture (corneometer reading)	Biological association	Very low certainty	Measured in trials: raised. A lab change is not the same as a health benefit.	¹¹⁵

J. Genes, receptors and enzymes

Connected to	Kind of connection	Evidence status	Context	Studies
CB2 cannabinoid receptor (CNR2)	Preliminary mechanism	In vitro	Alkamides bind CB2 (Ki about 60 nM) and activate calcium signalling in CB2-carrying cells; some of their cytokine effects need CB2, others do not	^{87 31 15 62}
CB1 cannabinoid receptor (CNR1)	Preliminary mechanism	In vitro	Weak or no binding by the pure alkamides tested (Ki above 1500 nM); some root extracts showed CB1 activity in a receptor-movement assay that tracked alkamide content	^{87 62}
TNF (tumour necrosis factor)	Preliminary mechanism	In vitro	Alkamides switched on TNF mRNA but blocked LPS-driven TNF protein in human monocytes; whole-blood TNF fell in volunteers 23-24 h after dosing	^{31 87 112 37}
IL6, IL10, IL12, IL1B, CXCL8 (IL-8)	Preliminary mechanism	Human	Cytokine shifts in human blood cells and in volunteers' LPS-stimulated blood; IL-10 rose with combined root and herb extracts; direction depends on stimulus and timing	^{87 112 37 15}
IL2 and IFNG (interferon-gamma)	Preliminary mechanism	In vitro	Polysaccharide-rich extract enhanced or reduced IL-2 and interferon-gamma in Jurkat T-cells depending on cell density	²⁸
PTGS2 (COX-2)	Preliminary mechanism	In vitro	Three E. angustifolia alkamides blocked COX-2 enzyme activity in a human cell line but did not lower its expression	⁵⁰
CYP3A4 and CYP3A (intestinal and liver)	Preliminary mechanism	Human	Human studies show both inhibition (intestine) and induction (liver); liver-cell studies show PXR activation raising CYP3A4 expression	^{35 82 5 38}
CYP1A2	Preliminary mechanism	Human	Oral clearance of caffeine fell in one human study; extract raised CYP1A2 expression in liver cells; no significant change in another study	^{35 5 38}
CYP2C9, CYP2D6, CYP2E1	Preliminary mechanism	In vitro	Involved in breakdown of the main alkamide in liver preparations; no clinically relevant change in CYP2C9 or 2D6 activity in people in the studies read	^{103 35 38}
ABCB1 (P-glycoprotein, MDR1)	Preliminary mechanism	In vitro	Extract raised MDR1 expression via PXR in liver cells; fexofenadine (a P-gp substrate) showed no change in healthy volunteers	^{5 82}
NR1I2 (pregnane X receptor, PXR)	Preliminary mechanism	In vitro	Echinacea fractions and a capsule activated PXR 3.5- to 5-fold in liver cells	⁵
TMPRSS2 (host enzyme) and SARS-CoV-2 spike protein	Preliminary mechanism	In vitro	Computer docking predicted alkamide, caftaric acid and feruloyl-tartaric acid binding; this is a prediction	¹⁰⁶

K. Biological pathways

Connected to	Kind of connection	Evidence status	Context	Studies
Tonic interferon / JAK1 signalling	Preliminary mechanism	In vitro	Echinaforce switched on antiviral innate-immunity genes in THP-1 monocytes; the response depended partly on JAK1	²¹
TLR4 and MAPK/NF-kappaB signalling	Preliminary mechanism	Animal	Polysaccharide-rich extract activated macrophages through TLR4-dependent and -independent routes and ERK, p38, JNK, NF-kappaB	^{100 31}
Midazolam clearance (CYP3A phenotype)	Preliminary mechanism	Human	Used in human studies to measure CYP3A; fell in AUC by 23-27% with E. purpurea	^{35 82}

L. Active compounds

Connected to	Kind of connection	Evidence status	Context	Studies
Dodeca-2E,4E,8Z,10Z-tetraenoic acid isobutylamide (main alkamide, one isomer)	Biological association	In vitro	Binds CB2 cannabinoid receptors (Ki about 60 nM) in cell tests and lowers LPS-driven TNF-alpha, IL-1beta and IL-12p70 in whole blood in a CB2-independent way too; raises IL-6 at 50 nM. The only Echinacea constituent group with measured human blood levels, which were very low (below 1 ng/mL for typical doses). Broken down by liver enzymes (CYP1A2, 2C9, 2D6, 2E1). Preparation or compound: Root; also aerial parts of E. purpurea	^{87 31 15 113 103 116}
Dodeca-2E,4E,8Z,10E-tetraenoic acid isobutylamide (E/Z isomer partner)	Biological association	In vitro	Reported together with the 10Z isomer; the human blood studies measure the two forms as one signal. Preparation or compound: Root; aerial parts	^{113 112 37 116}
Undeca-2Z,4E-diene-8,10-diynoic acid isobutylamide and related diyne alkamides	Biological association	In vitro	In the lab, a terminal-triple-bond alkylamide of this kind blocked the liver-enzyme breakdown of another alkylamide (mechanism-based inactivation). Alkamides from E. angustifolia root (A5, A7, A8) blocked COX-2 enzyme activity in a human cell line. PubChem CID not found for the exact isomers. Preparation or compound: Root (prominent in E. purpurea and E. angustifolia roots)	^{66 50 117}
Cichoric acid (chicoric acid; 2,3-O-dicaffeoyltartaric acid)	Biological association	In vitro	Antioxidant in test-tube radical tests. Crossed gut-cell layers poorly and could not be found in human blood after tablets, so effects inside the body are unproven. In macrophages it showed little or no effect on COX-2 or cytokines in the work EMA quotes. Preparation or compound: Aerial parts and root of E. purpurea; the main caffeic acid derivative of E. purpurea	^{67 116 117}
Caftaric acid (2-O-caffeoyltartaric acid)	Biological association	In vitro	Antioxidant in test tubes, but the weakest radical-quencher of the compounds in one quoted study (EC50 20.5 microM versus 6.6 microM for echinacoside). Predicted by computer docking to bind spike protein of SARS-CoV-2; this is a prediction only. Preparation or compound: Aerial parts and root of E. purpurea	^{106 117}
Echinacoside	Biological association	Animal	Strong antioxidant in test tubes (highest DPPH-quenching capacity in the compounds tested); anti-hyaluronidase and anti-inflammatory activity in rat studies quoted by EMA (original not checked). Crossed gut-cell layers poorly. Preparation or compound: Roots of E. angustifolia and E. pallida (main caffeic acid derivative there); practically absent from E. purpurea aerial parts	^{67 117}
Cynarin (1,3-dicaffeoylquinic acid)	Biological association	In vitro	No specific activity data verified here. Preparation or compound: Roots of other Echinacea species (E. angustifolia)	^{28 116}
Verbascoside	Biological association	In vitro	No activity data verified here. Preparation or compound: Root	¹¹⁷
Chlorogenic acid	Biological association	In vitro	No activity data verified here. Preparation or compound: Root	¹¹⁷
Caffeic acid	Biological association	Animal	Studied in rabbits: after IV doses, about 55-63% was passed in urine unchanged within 2 hours (EMA, citing Uang and Hsu 1997, original not checked). Preparation or compound: Building block of the derivatives above	¹¹⁶
Polysaccharides (e.g. PS I 4-O-methyl-glucuronoarabinoxylan about 35,000 Da; PS II acidic arabinorhamnogalactan about 450,000 Da; a xyloglucan)	Biological association	Animal	In cells, a polysaccharide-rich extract switched on macrophages (IL-6, TNF, IL-12, nitric oxide via TLR4, ERK, p38, JNK, NF-kappaB) and in mice lowered Listeria load after oral dosing. In human T-cell lines it enhanced or reduced IL-2 and interferon-gamma depending on cell density. No single molecule has a PubChem CID, as these are mixtures. Preparation or compound: Aerial parts and root	^{100 28 14 116}
Arabinogalactans and an arabinogalactan-containing glycoprotein	Biological association	In vitro	Described by EMA as one of the groups suggested to carry immune effects; no direct activity data checked here. Preparation or compound: Root	¹¹⁷
Polyacetylenes, ketoalkenes and ketoalkynes	Biological association	In vitro	In the lab, light (near UV) boosted antifungal effects of Echinacea extracts, mostly attributed to ketoalkenes and ketoalkynes (EMA quoting Binns 2000). No CIDs looked up. Preparation or compound: Root, notably in E. pallida	¹¹⁷
Essential oil (volatile oil)	Biological association	In vitro	No activity data verified here. Components include the compounds listed next. Preparation or compound: Herb: 0.08-0.32%; root about 0.1%	^{116 117}
Beta-caryophyllene	Biological association	In vitro	No activity data verified here for Echinacea. Preparation or compound: Herb and root volatile oil	¹¹⁶
Caryophyllene oxide	Biological association	In vitro	No activity data verified here. Preparation or compound: Herb and root volatile oil	¹¹⁶
Germacrene D	Biological association	In vitro	No activity data verified here. Preparation or compound: Herb volatile oil	¹¹⁶
Humulene (alpha-humulene)	Biological association	In vitro	No activity data verified here. Preparation or compound: Root volatile oil	¹¹⁷
Bornyl acetate and borneol	Biological association	In vitro	No activity data verified here. Preparation or compound: Herb volatile oil	¹¹⁶
Tussilagine and isotussilagine (pyrrolizidine alkaloids)	Biological association	In vitro	They have a fully saturated ring (hexahydropyrrolizine in PubChem naming), unlike the double-bonded liver-toxic types. The toxicity statement is EMA's; this file did not test it. Safety belongs in the safety file. Preparation or compound: Root	¹¹⁷

Each connection is stored with the ingredient, the connected record, the kind of connection, the evidence status, the supporting studies, the preparation or compound involved, and a review date (last reviewed October 24, 2026).

Evidence at a glance: what changed in 14 lab markers

Tap a number to show only those markers. Counts are markers, not people.

Organ function1 Other3433

The evidence

The research centre for Echinacea. Every record here was checked against PubMed or the publisher's page; we never list a study we have not verified.

Evidence by outcome

Bars show how many studies we found for each outcome, not how well it works. People are added up across trials only (reviews are not added, to avoid double counting).

How we rate evidence

High certainty

Several well-run trials or reviews agree; further research is unlikely to change the picture much.

Moderate certainty

Good trials point the same way, but some doubt remains.

Low certainty

Small, short or inconsistent trials. The finding could change with better research.

Very low certainty

Very little or very weak human data. Treat as a possibility only.

Mixed findings

Trials or reviews disagree with each other.

Not enough evidence

Not enough human research to say either way.

Evidence against

Good research found no benefit, or found harm.

We take the reviewers' own risk-of-bias and GRADE statements where they exist, and otherwise judge from study size, design, consistency, directness and whether a product matches what is sold. Many publications do not make evidence high. Method note: We searched PubMed, NIH NCCIH, the EU herbal monographs and other regulators' pages, opened each source and recorded the study design, people, product, dose and result as reported. Most studies were read as abstracts only; the EU monographs and assessment reports were read in full. Some sources (the NIH LiverTox and LactMed entries and the Commission E and WHO monographs) could not be read directly, and nothing is claimed about them beyond what is marked. Facts about early Native American use and ancient history rest on the EU assessment report and encyclopedia summaries and are marked as not verified at source. No study is cited that we could not verify.

Study library: every study we checked 119

Design Research type Plant part Year from Search

Study	Design	People	Product, dose, length	Result
Abdel-Naby Awad 2020 Echinacea can help with Azithromycin in prevention of recurrent tonsillitis in children. Am J Otolaryngol · PMID 32487336 · DOI	Prospective comparative	300 Children with recurrent tonsillitis (100 per group)	Commercial echinacea oral suspension added to azithromycin unspecified 5 ml three times daily for 10 days each month 6 months · vs Azithromycin alone, or no preventive treatment	Both treated groups had fewer attacks and milder symptoms than no treatment; the azithromycin plus echinacea group did better than azithromycin alone. Fewer attacks with azithromycin plus echinacea than with azithromycin alone; numbers not given in the abstract Methods, limits and funding Outcomes: Number of tonsillitis attacks and symptom severity Limitations: Described as a prospective comparative study, not clearly randomized or blinded in the abstract. Echinacea was only an add-on to an antibiotic, so its own effect is unknown. Product, species and plant part are not stated. No numbers in the abstract. Read: abstract
Abdul 2010 Pharmacokinetic and pharmacodynamic interactions of echinacea and policosanol with warfarin in healthy subjects. British Journal of Clinical Pharmacology · PMID 20573086 · DOI	Controlled trial	12 12 healthy men with known CYP2C9 and VKORC1 genotype, open-label randomised crossover	Echinacea at recommended doses (product not named in the abstract) unspecified Recommended dose 2 weeks before a single warfarin dose · vs Warfarin alone; policosanol	(S)-warfarin apparent clearance was higher with echinacea (90% CI of ratio 1.01-1.18) and its plasma level lower, but this did not produce a clinically significant change in INR (90% CI of INR AUC 0.91-1.31) and platelet aggregation was unaffected. Small rise in (S)-warfarin clearance, no INR change (Clearance ratio 90% CI 1.01-1.18; INR AUC 90% CI 0.91-1.31) Methods, limits and funding Outcomes: Warfarin levels, INR, platelet aggregation Limitations: Single warfarin dose in healthy men, not long-term warfarin patients. Read: abstract
Ardjomand-Woelkart 2016 Review and Assessment of Medicinal Safety Data of Orally Used Echinacea Preparations. Planta Medica · PMID 26441065 · DOI	Systematic review	Published literature on interactions, contraindications, adverse events, duration and pregnancy	Orally used Echinacea preparations unspecified Long-term studies up to 6 months	The authors say safety data are product specific. In human studies of standardised E. purpurea preparations, no significant inhibition of CYP2D6 or CYP3A4 was found, though liver-microsome experiments gave contradictory results. Adverse events in trials of single-ingredient preparations were generally mild and mostly without proven cause. Because of long-term studies up to 6 months with no toxicity concerns reported, they say echinacea can be recommended for long-term use. They call the contraindications for autoimmune disease and immune suppression questionable, because lipophilic (alkamide-containing) preparations suppress cellular immune responses and benefits in autoimmunity were reported. They found no association with malformations in pregnancy in a literature review, while noting mouse data on embryonic blood-vessel growth. They conclude the preparations are well tolerated in children and adults. Methods, limits and funding Outcomes: Safety profile Limitations: Abstract only. The conclusions are more reassuring than the regulatory monographs; the authors' own view, not a consensus. Per the 2014 Cochrane review's conflict statement, both authors took part in echinacea trials included there; their funding for this review was not checked. Read: abstract
Aucoin 2020 The effect of Echinacea spp. on the prevention or treatment of COVID-19 and other respiratory tract infections in humans: A rapid review. Adv Integr Med · PMID 32837894 · DOI	Systematic review	Human studies of Echinacea for acute respiratory tract infections (rapid review written during COVID-19)	Echinacea (E. purpurea, E. angustifolia and combinations) unspecified Varied · vs Placebo	Echinacea may help symptoms of respiratory infections and colds, especially when started at the first sign. The studies that reported benefit used E. purpurea or E. purpurea plus E. angustifolia with standardised amounts of active compounds. No studies in COVID-19-like illness were found. Few adverse events were reported. Not a pooled analysis Methods, limits and funding Outcomes: Duration and severity of respiratory infections; cytokine changes; adverse events Limitations: Rapid review (shortcuts in the search and appraisal); no pooled numbers; no COVID-19 studies found. Funding and conflicts: No competing interests declared Read: abstract
Awortwe 2015 Echinacea purpurea up-regulates CYP1A2, CYP3A4 and MDR1 gene expression by activation of pregnane X receptor pathway. Xenobiotica · PMID 25377539 · DOI	Laboratory research in-vitro	Human liver (HepG2) cells	Echinacea purpurea crude extracts, fractions and a capsule product unspecified · vs Control	Two fractions and a capsule product strongly activated the pregnane X receptor (about 3.5 to 5-fold) and raised CYP1A2, CYP3A4 and MDR1 (P-glycoprotein) expression. The authors conclude echinacea can cause herb-drug interactions by this route. Methods, limits and funding Outcomes: PXR activation; CYP1A2, CYP3A4 and MDR1 expression Limitations: Cell experiment only. Read: abstract
Balciunaite 2020 Identification of Echinacea Purpurea (L.) Moench Root LysM Lectin with Nephrotoxic Properties. Toxins · PMID 32013058 · DOI	Animal research animal	15 15 male Balb/C mice	Purified lectin (about 40 kDa) from E. purpurea root, injected root 5 microg, injected four times a week 5 weeks	The purified root lectin caused statistically significant kidney glomerular vacuolisation (p<0.05) and kidney tubular necrosis (p<0.001) in mice. Methods, limits and funding Outcomes: Kidney tissue changes Limitations: An isolated protein injected into mice; not an oral product and not evidence that echinacea supplements harm human kidneys. Read: abstract
Barcz 2007 Influence of Echinacea purpurea intake during pregnancy on fetal growth and tissue angiogenic activity. Folia Histochemica et Cytobiologica · PMID 18292834	Animal research animal	Pregnant mice	Alcoholic E. purpurea products (Echinapur, Esberitox, Immunal forte) unspecified · vs Standard diet	Angiogenic activity of fetal tissue was increased with Esberitox, decreased with Immunal forte and not different with Echinapur. VEGF and bFGF were lower in all echinacea groups than in controls. With Echinapur and Esberitox the number of fetuses per litter was slightly lower, near the edge of statistical significance. The authors say human fetal development might be affected and that these products should not be recommended in pregnancy. Methods, limits and funding Outcomes: Fetal blood-vessel growth activity, VEGF and bFGF, litter size Limitations: Mouse study with commercial multi-ingredient or alcoholic products; effects differed between products; relevance to people is unknown. No numbers in the abstract. Read: abstract
Barnes 2005 Echinacea species (Echinacea angustifolia (DC.) Hell., Echinacea pallida (Nutt.) Nutt.,Echinacea purpurea (L.) Moench): a review of their chemistry, pharmacology and clinical properties J Pharm Pharmacol · PMID 16102249 · DOI	Narrative review	Review of laboratory, animal and human work on three Echinacea species	E. angustifolia, E. pallida, E. purpurea preparations unspecified various	Says the three species have a long medicinal history, that alkamides and caffeic acid derivatives are considered important, that the constituent profile differs between species, that some marketed products fail quality standards, and that clinical evidence is not definitive. Methods, limits and funding Outcomes: Chemistry, pharmacology, clinical properties and safety Limitations: Narrative review from 2005; not a systematic search, and now old. Read: abstract
Barrett 2002 Treatment of the common cold with unrefined echinacea. A randomized, double-blind, placebo-controlled trial. Ann Intern Med · PMID 12484708 · DOI	Controlled trial	148 148 students with a recently started cold	Unrefined Echinacea purpurea herb (25%) and root (25%) with E. angustifolia root (50%) in capsules root+herb 1 g six times on day 1, then three times a day (up to 10 days) Up to 10 days · vs Placebo	No statistically significant differences; severity curves almost identical. Cold lasted 6.27 days with echinacea vs 5.75 days with placebo. Duration difference -0.52 day; adjusted hazard ratio 1.24 (Duration -1.09 to 0.22 days; hazard ratio 0.86 to 1.78) Methods, limits and funding Outcomes: Cold severity and duration Limitations: Small trial in college students; one unrefined mixed product. Funding and conflicts: Not stated in the abstract Read: abstract
Barrett 2010 Echinacea for treating the common cold: a randomized trial. Ann Intern Med · PMID 21173411 · DOI	Controlled trial	719 Adults and adolescents aged 12 to 80 with a new common cold	Echinacea angustifolia root tablets root 10.2 g dried root equivalent in the first 24 hours, then 5.1 g a day for 4 days 5 days · vs Placebo pills, open-label echinacea, and no pills	No statistically significant difference between blinded echinacea and blinded placebo for severity or duration, though results leaned toward benefit. IL-8 and neutrophil counts were also not significantly different. Severity difference 28 points (p=0.089); duration 0.53 days shorter (p=0.075) (Severity -69 to 13; duration -1.25 to 0.19 days) Methods, limits and funding Outcomes: Area under the curve for global severity of cold symptoms; illness duration; nasal-wash interleukin-8 and neutrophils Limitations: The authors note higher-than-expected variability, so the trial was not powered to detect small benefits. One dose and one product only. Funding and conflicts: Funded by the US National Center for Complementary and Alternative Medicine (NIH) Registration: ClinicalTrials.gov NCT00065715 Read: abstract
Borchers 2000 Inflammation and Native American medicine: the role of botanicals Am J Clin Nutr · PMID 10919925 · DOI	Narrative review	Review of North American botanicals used by Native peoples	Three purple coneflower (Echinacea) species among many botanicals unspecified	Notes that many botanicals sold today as supplements were used by Native Americans, that seven of the ten most common botanicals sold in the USA were used extensively by them, and that there are very few data to support such use. Methods, limits and funding Outcomes: Immune effects of Native American medicinal plants Limitations: Review from 2000; the abstract does not itemise specific Echinacea uses. Read: abstract
Bossaer 2012 Probable etoposide interaction with Echinacea. Journal of Dietary Supplements · PMID 22607644 · DOI	Case report	1 61-year-old man with lung cancer on cisplatin plus etoposide with radiation	Echinacea (product not stated) unspecified	He was admitted on day 8 of the first cycle with very low platelets (lowest 16 x 10^3/L, needing platelet transfusion). He was found to be taking echinacea, which was stopped. In the next cycle without echinacea his platelet low point was 44 x 10^3/L and no transfusion was needed. The authors call it a probable interaction and suggest avoiding echinacea with etoposide. Methods, limits and funding Outcomes: Low platelets during chemotherapy Limitations: Single case; chemotherapy itself lowers platelets and cisplatin and radiation were also given. The CYP3A4 mechanism is the authors' idea, not shown. Read: abstract
Brinkeborn 1999 Echinaforce and other Echinacea fresh plant preparations in the treatment of the common cold. A randomized, placebo controlled, double-blind clinical trial. Phytomedicine · PMID 10228604 · DOI	Controlled trial	559 559 healthy adults recruited; 246 caught a cold and were analysed	Echinaforce (E. purpurea, 95% herb and 5% root), its 7-times concentrate, a special root preparation herb 2 tablets three times a day Until recovered, up to 7 days · vs Placebo	Echinaforce and its concentrate worked better than placebo; the special root preparation did not. Not given in the abstract Methods, limits and funding Outcomes: Complaint index (12 symptoms, doctor recorded) Limitations: Abstract gives no numbers or dose details. Funding and conflicts: Not stated in the abstract Read: abstract
Capek 2015 Chemical and pharmacological profiles of Echinacea complex Int J Biol Macromol · PMID 25999016 · DOI	In vitro and animal animal	Animal tests of airway response (species not stated in the abstract)	Polysaccharide-phenolic-protein complex (about 10 kDa) isolated from E. purpurea flowering herb aerial parts · vs codeine and salbutamol	The complex had cough-suppressing action similar to codeine and a bronchodilator action reported as larger than salbutamol in the animal tests. Methods, limits and funding Outcomes: Cough suppression and bronchodilation Limitations: Animal data from one lab; the abstract does not give species or doses; not tested in people. Read: abstract
Chicca 2009 Synergistic immunomopharmacological effects of N-alkylamides in Echinacea purpurea herbal extracts Int Immunopharmacol · PMID 19303464 · DOI	Laboratory research in-vitro	Human immune cells (PBMCs) in culture	Ethanolic E. purpurea root and herb tinctures and their N-alkylamides root and herb · vs single extracts vs combination	Combining the root and herb extracts gave more than the sum of the parts: more CB2-driven calcium release, much more anti-inflammatory IL-10, and stronger lowering of TNF-alpha than either alone. Alkylamides were also reported to act on endocannabinoid transport and breakdown. Methods, limits and funding Outcomes: Calcium release through CB2; LPS-driven cytokines Limitations: Cells in a dish; synergy not shown in people. Funding and conflicts: Co-authors from the product maker (Bioforce); funding not stated in the abstract. Read: abstract
Cohen 2004 Effectiveness of an herbal preparation containing echinacea, propolis, and vitamin C in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled, multicenter study. Arch Pediatr Adolesc Med · PMID 14993078 · DOI	Controlled trial	430 Children aged 1 to 5 years	Chizukit elixir: echinacea 50 mg/mL plus propolis 50 mg/mL plus vitamin C 10 mg/mL unspecified Dose volume not stated in abstract 12 weeks (winter) · vs Placebo elixir	Illness episodes 138 vs 308 (55% reduction); 0.9 vs 1.8 episodes per child (p<.001); fever days per child 2.1 vs 5.4. Side effects rare, mild and transient. About 50% fewer episodes per child with the mixture Methods, limits and funding Outcomes: Number of illness episodes, days with fever Limitations: The product mixes echinacea with propolis and vitamin C, so echinacea alone cannot be credited. Echinacea species and plant part not given in the abstract. Read: abstract
Dall'Acqua 2015 Pharmacokinetics and immunomodulatory effect of lipophilic Echinacea extract formulated in softgel capsules. Eur J Pharm Biopharm · PMID 26455420 · DOI	Human uncontrolled	10 10 healthy human volunteers	E. angustifolia lipophilic extract softgel capsule (10 mg) unspecified 10 mg, single dose Blood tested before and 24 hours after	Reported lower IL-6, TNF-alpha and IL-8 and higher IL-10 at 24 hours than before. Direction of change only; no values given in the abstract Methods, limits and funding Outcomes: Blood levels and gene activity of IL-2, IL-6, IL-8, IL-10, TNF-alpha Limitations: Ten people, one dose, no placebo group, 24 hours only. The abstract attributes the effect to one alkylamide. Read: abstract
David 2019 Echinacea for the prevention and treatment of upper respiratory tract infections: A systematic review and meta-analysis. Complement Ther Med · PMID 31126553 · DOI	Meta-analysis	Randomised double-blind placebo-controlled trials in otherwise healthy people of any age	Echinacea-containing preparations (any) unspecified Varied · vs Placebo	Prevention: pooled risk ratio 0.78. Duration: no significant effect. Safety: no significant difference from placebo in the short term. Prevention RR 0.78; duration mean difference -0.45 days; safety RR 1.09 (Prevention 0.68 to 0.88; duration (as printed) 1.85 to 0.94; safety 0.95 to 1.25) Methods, limits and funding Outcomes: Prevention of upper respiratory infection, duration of infection, safety (adverse events) Limitations: The authors state a risk of selective reporting and a lot of clinical heterogeneity; they deviated from their protocol. The abstract does not give the number of participants. The printed duration confidence interval looks mis-typed (as printed in the abstract), so only the direction is relied on. Funding and conflicts: No conflict stated in the abstract Registration: PROSPERO CRD42018090783 Read: abstract
De Rosa 2019 Effect of Immunomodulatory Supplements Based on Echinacea Angustifolia and Echinacea Purpurea on the Posttreatment Relapse Incidence of Genital Condylomatosis: A Prospective Randomized Study. Biomed Res Int · PMID 31111049 · DOI	Controlled trial	Men and women treated with CO2 laser for genital warts (condylomatosis); Group A n=64	HPVADL18 oral supplement: dry root extracts of E. purpurea and E. angustifolia (exact doses cut off in the abstract text read) root Not fully readable in the abstract text read 4 months of treatment; follow-up at 1, 6 and 12 months · vs Group B: laser only, follow-up	Relapse incidence differed between groups and fell over 12 months in both. Relapses were significantly fewer with the supplement in people over 25, in both men and women. Fewer relapses in the supplement group in people over 25; exact numbers not in the abstract text read Methods, limits and funding Outcomes: Relapse of genital warts Limitations: The abstract calls it both randomized and single-arm; the supplement group size is the only one clearly given; no placebo; the abstract text read was incomplete. Read: abstract
Deccy 2024 Echinacea Supplementation Does Not Impact Aerobic Capacity and Erythropoiesis in Athletes: A Meta-Analysis. Nutrients · PMID 38999738 · DOI	Meta-analysis	107 Athletes; 6 studies	Echinacea supplements (products varied) unspecified Varied Varied · vs Placebo	No significant change in hemoglobin, hematocrit, erythropoietin or VO2max. Hemoglobin effect size 0.38 (95% CI -0.04 to 0.80, I2=70%); hematocrit 0.34 (-0.10 to 0.78, I2=86%); erythropoietin -0.29 (-0.75 to 0.17, I2=67%); VO2max -0.20 (-0.60 to 0.21, I2=0%) (see effect) Methods, limits and funding Outcomes: Hemoglobin, hematocrit, erythropoietin, maximal oxygen uptake (VO2max) Limitations: Only 6 small studies; high inconsistency between studies for blood measures; the authors call the evidence base limited. Read: abstract
Declerck 2021 Echinacea purpurea (L.) Moench treatment of monocytes promotes tonic interferon signaling, increased innate immunity gene expression and DNA repeat hypermethylated silencing of endogenous retroviral sequences BMC Complement Med Ther · PMID 33980308 · DOI	Laboratory research in-vitro	THP-1 human monocyte cell line	Echinaforce (standardised E. purpurea extract) herb · vs untreated cells	The extract switched on antiviral 'innate immunity' genes involving tonic interferon signalling, depended partly on JAK1 (confirmed with the inhibitor filgotinib), and changed DNA methylation around repeat sequences including endogenous retrovirus sequences. The authors suggest this could help against common-cold coronaviruses. Methods, limits and funding Outcomes: Gene activity, DNA methylation, protein kinase activity Limitations: One cell line in a dish; claims about SARS-CoV-2 are the authors' hypothesis, not tested in people. Funding and conflicts: Co-author employed by A. Vogel Bioforce AG; others declare no conflict. Read: abstract
EMA 2012 Community herbal monograph on Echinacea angustifolia DC., radix (EMA/HMPC/688216/2008) European Medicines Agency · Source	Authoritative guidance n/a	Adolescents, adults and elderly	See traditional_prep	Traditional use for supportive treatment of common cold: tea 1 g in 150 mL three times a day; powder 500 mg up to 3 times a day; tincture 1-2 mL three times a day; liquid extract 0.25-1 mL three times a day; see a doctor if symptoms last over 10 days. Methods, limits and funding Outcomes: Posology, duration, warnings Limitations: Older monograph (2008, document dated 2012); a newer revision may exist; not checked. Read: full-text
EMA 2015 European Union herbal monograph on Echinacea purpurea (L.) Moench, herba recens (EMA/HMPC/48704/2014 Corr 1) European Medicines Agency · Source	Authoritative guidance n/a	Adolescents, adults and elderly	See traditional_prep	Well-established use for short-term prevention and treatment of common cold: expressed juice 1.5-4.5 mL per dose, 6-9 mL a day, no more than 10 days, not under 12 years. Traditional use cutaneous: 10-20 g/100 g juice ointment, 2-3 times a day, no more than 1 week. Methods, limits and funding Outcomes: Posology, duration, warnings Limitations: Regulator summary of the evidence, not a new trial. Read in full (7 pages). Read: full-text
EMA 2017 European Union herbal monograph on Echinacea purpurea (L.) Moench, radix (EMA/HMPC/424583/2016) European Medicines Agency · Source	Authoritative guidance n/a	Adolescents, adults and elderly	See traditional_prep	Traditional use: dry extract (DER 5.5-7.5:1, ethanol 45%) 40 mg every second hour, 360 mg a day for common cold symptoms; dry aqueous extract (DER 4:1) 150-300 mg a day for mild acne; see a doctor if cold lasts over 10 days or acne over 2 weeks. Methods, limits and funding Outcomes: Posology, duration, warnings Limitations: Traditional use based on long-standing use only. Read the dosing and composition sections. Read: full-text
EMA 2018 European Union herbal monograph on Echinacea pallida (Nutt.) Nutt., radix (EMA/HMPC/737380/2017) European Medicines Agency · Source	Authoritative guidance n/a	Adolescents, adults and elderly	See traditional_prep	Traditional use for relief of common cold symptoms: dry extract 24-30 mg per dose, 90-96 mg a day; tincture 1:5 (ethanol 50%) 25 drops per dose, 125 drops a day; see a doctor if symptoms last over 10 days. Methods, limits and funding Outcomes: Posology, duration, warnings Limitations: Traditional use only. Read the dosing and composition sections. Read: full-text
European Medicines Agency 2015 European Union herbal monograph on Echinacea purpurea (L.) Moench, herba recens (EMA/HMPC/48704/2014 Corr 1) EMA monograph, adopted 24 November 2014, corrected version dated 24 November 2015 · Source	Authoritative guidance		Echinacea purpurea fresh aerial parts: expressed juice and dried expressed juice unspecified (fresh flowering aerial parts) Adolescents, adults, elderly: single dose 1.5-4.5 ml expressed juice, daily dose 6-9 ml (well-established use, oral) Not more than 10 days (oral); not more than 1 week (cutaneous traditional use)	Read in full (7 pages). Well-established use: short-term prevention and treatment of the common cold; do not use for more than 10 days. Traditional use: small superficial wounds, skin use, not more than 1 week. Contraindication: hypersensitivity to the active substance and to other plants of the Asteraceae (Compositae) family. Not recommended in progressive systemic disorders, autoimmune diseases, immunodeficiencies, immunosuppression and diseases of the white blood cell system. Possible risk of severe hypersensitivity reactions in atopic patients, who should consult a doctor. Not recommended under 12 years (insufficient data). Interactions: none reported. Pregnancy and lactation: limited data (several hundreds of exposed pregnancies) indicate no adverse effects; in the absence of sufficient data use is not recommended unless advised by a doctor; no fertility data; products containing echinacea should not be applied to the breast of breastfeeding women. Driving: no studies. Undesirable effects: rash, urticaria, itching, facial swelling; severe reactions (Stevens-Johnson syndrome, angioedema, Quincke oedema, bronchospasm with airway obstruction, asthma, anaphylactic shock) have been reported, frequency not known; association with autoimmune diseases cannot be excluded. Overdose: no case reported. Preclinical: expressed juice showed no toxicity in single-dose (rodent), 4-week repeated-dose (rodent) and in vitro and in vivo genotoxicity studies; reproductive toxicity and carcinogenicity tests not performed. Methods, limits and funding Outcomes: Regulatory safety statements Limitations: Covers only one preparation (fresh-herb expressed juice), not capsules, root extracts or tinctures. A regulatory summary, not new data. Read: full-text
European Medicines Agency 2016 Draft European Union herbal monograph on Echinacea purpurea (L.) Moench, radix (EMA/HMPC/424583/2016) EMA draft monograph released for consultation 22 November 2016 (draft status; whether it was finalised was not checked) · Source	Authoritative guidance		Echinacea purpurea root dry extracts (ethanol 45% DER 5.5-7.5:1; water DER 4:1) root Common cold: 40 mg extract every second hour, 360 mg a day; mild acne: 50-100 mg per dose, 150-300 mg a day See a doctor if symptoms last more than 10 days (cold) or 2 weeks (acne)	Read in full (7 pages). Traditional use only. Contraindication: hypersensitivity to the active substance and other Asteraceae (Compositae). Not recommended in progressive systemic disorders, autoimmune diseases, immunodeficiencies, immunosuppression and diseases of the white blood cell system. Possible risk of anaphylactic reactions in atopic patients. Not recommended under 12 years. Interactions: none reported. Pregnancy and lactation: safety not established, use not recommended; no fertility data. Undesirable effects: hypersensitivity (skin) reactions, frequency not known. No overdose cases reported. Reproductive toxicity, genotoxicity and carcinogenicity tests not performed. Methods, limits and funding Outcomes: Regulatory safety statements (draft) Limitations: Draft document from 2016; the final version may differ. Root preparations only. Read: full-text
Fonseca 2014 Echinacea purpurea (L.) Moench modulates human T-cell cytokine response Int Immunopharmacol · PMID 24434371 · DOI	Laboratory research in-vitro	Human Jurkat T-cells (cell line)	EchNWA: water-soluble polysaccharide-rich extract of fresh E. purpurea aerial parts aerial parts dose-ranging · vs untreated cells	The extract was 80% polysaccharides (mostly a 10 kDa entity), contained cynarin, cichoric and caftaric acids and no detectable alkylamides. It boosted IL-2 and interferon-gamma in strongly packed T-cells after stimulation but modestly lowered interferon-gamma in sparse cells; it did nothing without stimulation. The authors attribute this to the polysaccharides, not the phenolics. Methods, limits and funding Outcomes: IL-2 and interferon-gamma release Limitations: Cell line, test tube only. Note that the abstract says cynarin was present, although EMA says cynarin is practically absent from E. purpurea aerial parts; the authors do not explain the difference. Funding and conflicts: Not stated in the abstract. Read: abstract
Gancitano 2024 Echinacea Reduces Antibiotics by Preventing Respiratory Infections: A Meta-Analysis (ERA-PRIMA). Antibiotics (Basel) · PMID 38667040 · DOI	Meta-analysis	5652 30 clinical trials (39 comparisons) of echinacea for prevention or treatment of respiratory tract infections	Echinacea preparations; subgroup of alcoholic extracts from freshly harvested E. purpurea unspecified Varied · vs Placebo or control	Fewer infections, complications and antibiotic days with echinacea; alcoholic extracts of fresh E. purpurea gave the largest effect. Adverse events were similar to control. Monthly occurrence RR 0.68; at least one infection RR 0.75; recurrent infections RR 0.60; complications RR 0.44; need for antibiotics RR 0.60; antibiotic days IRR 0.29 (0.61 to 0.77; 0.69 to 0.81; 0.46 to 0.80; 0.36 to 0.54; 0.39 to 0.93; 0.11 to 0.74) Methods, limits and funding Outcomes: Monthly infection occurrence; people with at least one infection; recurrent infections; complications; antibiotic use; safety Limitations: Pooled prevention and treatment trials and many products. Several authors received consulting fees from the maker of a leading echinacea product. Its estimates are larger than the independent Cochrane and David 2019 reviews. Funding and conflicts: Authors R.S., W.C.A. and S.L.J. received honoraria from A. Vogel AG; the statistician was paid by the same company Read: abstract
German Federal Health Agency German Commission E monographs on Echinacea (as summarised by secondary sources) Secondary web summaries; the original Bundesanzeiger text was not found · Source	Authoritative guidance		Echinacea purpurea herb / E. pallida root unspecified Continuous use about 6 to 8 weeks at most (as reported second-hand)	Not read at source. Search summaries say the Commission E advised against use in progressive systemic diseases (tuberculosis, leukosis, collagenosis, multiple sclerosis, HIV infection, AIDS and other autoimmune diseases) and discouraged continuous use beyond about 8 weeks. One summary attributes the list to the E. pallida root monograph, not the E. purpurea herb monograph. Methods, limits and funding Outcomes: Regulatory safety statements Limitations: Second-hand only. Exact wording, dates and which species each statement applies to are NOT verified. Read: summary-only
Gertsch 2004 Echinacea alkylamides modulate TNF-alpha gene expression via cannabinoid receptor CB2 and multiple signal transduction pathways FEBS Lett · PMID 15556647 · DOI	Laboratory research in-vitro	Primary human monocytes/macrophages (cell culture)	Echinaforce tincture (E. purpurea) and its alkylamides herb	The tincture switched on TNF-alpha mRNA in the cells but not TNF-alpha protein, and strongly blocked LPS-driven TNF-alpha protein early on (prolonged later). The alkylamides were responsible, working through CB2 cannabinoid receptors, cAMP, p38/MAPK, JNK and NF-kappaB. Methods, limits and funding Outcomes: TNF-alpha gene and protein; receptor pathway Limitations: Cells in a dish; effects on the common cold in people not shown here. Authors from the product maker. Funding and conflicts: Co-authors from the product maker (Bioforce); funding not stated in the abstract. Read: abstract
Gilroy 2003 Echinacea and truth in labeling. Archives of Internal Medicine · PMID 12639203 · DOI	Case series in-vitro	59 59 single-herb echinacea products bought in Denver stores in August 2000	Retail echinacea products unspecified	6 of 59 (10%) contained no measurable echinacea. The species found matched the label in 31 (52%). Of 21 products labelled standardised, 9 (43%) met the standard on the label. The authors conclude echinacea from retail stores often does not contain the labelled species and a standardisation claim does not guarantee accurate labelling. Methods, limits and funding Outcomes: Species and content versus label Limitations: Products bought in 2000 in one US city; may not reflect today's market. Read: abstract
Goel 2004 Efficacy of a standardized echinacea preparation (Echinilin) for the treatment of the common cold: a randomized, double-blind, placebo-controlled trial. J Clin Pharm Ther · PMID 14748902 · DOI	Controlled trial	282 Adults 18 to 65 with 2 or more colds in the previous year (128 developed a cold: 59 echinacea, 69 placebo)	Echinilin, a standardised fresh-plant Echinacea purpurea preparation unspecified 10 doses on day 1, then 4 doses a day 7 days · vs Placebo	Total daily symptom scores were 23.1% lower with echinacea than placebo in people who followed the protocol. Symptom scores 23.1% lower (p<0.01), per-protocol analysis Methods, limits and funding Outcomes: Daily symptom scores; response rate Limitations: Analysis was of the people who followed the protocol (per-protocol), and only about 45% of enrolled people got a cold. Single trial. Funding and conflicts: Not stated in the abstract Read: abstract
Goey 2013 The effect of Echinacea purpurea on the pharmacokinetics of docetaxel. British Journal of Clinical Pharmacology · PMID 23701184 · DOI	Clinical trial	10 10 evaluable cancer patients receiving docetaxel, before-and-after design	Commercial Echinacea purpurea extract (oral drops) unspecified 20 drops three times a day 14 days · vs Own docetaxel cycle without echinacea	Docetaxel AUC was 3278 +/- 1086 before and 3480 +/- 1285 ng.h/ml after echinacea (not significant). Half-life 30.8 to 25.6 h (P=0.56). Peak 2224 to 2097 ng/ml (P=0.30). The authors conclude the product at the recommended dose may be combined safely with docetaxel. No significant change Methods, limits and funding Outcomes: Docetaxel blood levels Limitations: Only 10 patients, two weeks of echinacea, one product; small studies can miss modest effects. Read: abstract
Gorski 2004 The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo. Clinical Pharmacology & Therapeutics · PMID 14749695 · DOI	Clinical trial	12 12 healthy volunteers (6 men), open-label, before and after	Echinacea purpurea root root 400 mg four times a day 8 days · vs Own baseline (probe drugs caffeine, tolbutamide, dextromethorphan, midazolam given before and after)	IV midazolam clearance rose 34% (32 to 43 L/h, P=.003) and its exposure (AUC) fell 23% (127 to 102 microg.h/L, P=.024), meaning liver CYP3A activity went up. Oral midazolam availability rose (0.23 to 0.33, P=.028): liver availability fell (0.72 to 0.61, P=.006) while gut availability rose (0.33 to 0.61, P=.015), so the gut enzyme was reduced. Overall oral clearance of midazolam did not change (P=.655). Caffeine oral clearance fell from 6.6 to 4.9 L/h (P=.049), suggesting CYP1A2 was slowed. Tolbutamide (CYP2C9) fell 11%, not judged relevant; dextromethorphan (CYP2D6) unchanged. The authors advise caution with drugs dependent on CYP3A or CYP1A2. Midazolam IV clearance +34%; caffeine oral clearance about -26% (Midazolam oral availability 90% CI 108%-153%; caffeine oral clearance ratio 90% CI 58%-96%) Methods, limits and funding Outcomes: CYP1A2, CYP2C9, CYP2D6 and CYP3A activity Limitations: Small, open-label, not placebo-controlled, one root product at a high dose. Opposite gut and liver effects make the net effect drug-dependent. Read: abstract
Grimm 1999 A randomized controlled trial of the effect of fluid extract of Echinacea purpurea on the incidence and severity of colds and respiratory infections. Am J Med · PMID 10230741 · DOI	Controlled trial	108 Adults with more than 3 colds in the past year	Fluid extract of E. purpurea unspecified 4 mL twice a day (8 mL a day) 8 weeks · vs Placebo juice	At least one infection 65% vs 74% (RR 0.88); no significant difference in incidence, duration or severity. RR 0.88 (95% CI 0.60 to 1.22) Methods, limits and funding Outcomes: Incidence, duration, severity of colds Limitations: Small; not powered for small effects. Read: abstract
Guiotto 2008 Pharmacokinetics and immunomodulatory effects of phytotherapeutic lozenges (bonbons) with Echinacea purpurea extract Phytomedicine · PMID 18583121 · DOI	Pharmacokinetic study	Healthy volunteers (number not stated in the abstract)	E. purpurea extract lozenges herb 0.07, 0.21 and 0.9 mg of the main alkamides single dose per level · vs three dose levels compared	Alkamides were measurable 10-20 minutes after dosing; peak levels were 0.65 +/- 0.41 ng/mL (0.07 mg), 1.00 +/- 0.21 ng/mL (0.21 mg) and 8.88 +/- 5.89 ng/mL (0.9 mg), reached at 32, 25 and 19 minutes. Absorption was linear with dose and very fast (half-life of absorption about 6 minutes), suggesting some may enter through the lining of the mouth. IL-12p70, IL-8, IL-6, IL-10 and TNF were lower 24 h after dosing, not dose-dependent. Methods, limits and funding Outcomes: Alkamide blood levels; cytokines 24 h later Limitations: Number of volunteers not given in the abstract; cytokine change was not tied to any illness outcome. Funding and conflicts: Authors include company-affiliated researchers; funding not stated in the abstract. Read: abstract
Gurley 2004 In vivo assessment of botanical supplementation on human cytochrome P450 phenotypes: Citrus aurantium, Echinacea purpurea, milk thistle, and saw palmetto. Clinical Pharmacology & Therapeutics · PMID 15536458 · DOI	Controlled trial	12 12 healthy volunteers, each taking four supplements in turn with 30-day washouts	Echinacea purpurea extract (one of four botanicals) unspecified 28 days · vs Own baseline	No significant effect on CYP1A2, CYP2D6, CYP2E1 or CYP3A4 activity was found for the four supplements. The authors describe the echinacea effects as minor and say further study is merited. Cichoric acid content matched the label. No significant change Methods, limits and funding Outcomes: CYP1A2, CYP2D6, CYP2E1, CYP3A4 phenotype ratios Limitations: Single-time-point ratios rather than full pharmacokinetics; may be less sensitive than the Gorski and Penzak designs. Read: abstract
Hall 2007 Echinacea purpurea and mucosal immunity. Int J Sports Med · PMID 17436202 · DOI	Controlled trial	32 32 people who completed an exercise protocol known to lower mucosal immunity	Echinacea purpurea supplement unspecified 4 weeks · vs Placebo	Before the supplement, exercise lowered s-IgA by 69% (placebo group) and 43% (echinacea group). After 4 weeks, s-IgA fell 45% in placebo and rose 7% in echinacea; secretion rate fell 45% vs 7%. Infection counts did not differ; duration was 8.6 days (placebo) vs 3.4 days (echinacea). s-IgA fall after exercise 45% (placebo) vs a 7% rise (echinacea) after 4 weeks Methods, limits and funding Outcomes: Saliva s-IgA concentration and secretion rate before and after exercise; upper respiratory infection log Limitations: Small; dose not in the abstract; no confidence intervals; infection duration is self-logged. Infection duration belongs to the respiratory section. Read: abstract
Haller 2010 The effect of Echinacea preparations in three laboratory tests of anxiety: comparison with chlordiazepoxide. Phytother Res · PMID 21031616 · DOI	Animal research animal	Rats in anxiety tests	Five Echinacea preparations compared with chlordiazepoxide unspecified 3 to 8 mg/kg for the extract that worked across a wide range Lab · vs Chlordiazepoxide; vehicle	Three of five preparations reduced anxiety-like behaviour; only one did so across a wide dose range, without making the rats less active. Not applicable Methods, limits and funding Outcomes: Elevated plus-maze, social interaction, shock-induced social avoidance Limitations: Animal work; only some preparations worked, so results cannot be assumed for other products. Funding and conflicts: Not stated in the abstract Read: abstract
Haller 2013 The anxiolytic potential and psychotropic side effects of an echinacea preparation in laboratory animals and healthy volunteers. Phytother Res · PMID 22451347 · DOI	Controlled trial	Rats, and healthy human volunteers scoring high on STAI	Echinacea angustifolia extract (20 mg tablets in humans) unspecified 1 or 2 tablets a day (20 mg each) 1 week of treatment, followed 2 more weeks · vs Placebo not described in abstract for humans	Rats showed less anxiety with no sign of harm up to 3000 mg/kg. In people, 2 tablets a day lowered STAI scores within 3 days; 1 tablet did not. Higher dose lowered STAI (numbers not in abstract) Methods, limits and funding Outcomes: Rat anxiety tests; human STAI scores Limitations: Mixed rat and human report; human part appears small and uncontrolled in the abstract wording. Funding and conflicts: Not stated in the abstract Read: abstract
Haller 2020 Double-blind placebo controlled trial of the anxiolytic effects of a standardized Echinacea extract. Phytother Res · PMID 31876052 · DOI	Controlled trial	Volunteers scoring above 45 on state or trait anxiety (STAI)	Standardised Echinacea angustifolia root extract root 40 mg twice a day 7 days, then 3-week washout · vs Placebo	State anxiety fell about 11 points on echinacea vs about 3 on placebo (p<0.01), lasting through the washout. Depression and stress scores were unchanged. State anxiety about -11 vs about -3 points (p<0.01) Methods, limits and funding Outcomes: State-Trait Anxiety Inventory (STAI), Beck Depression Inventory, Perceived Stress Scale Limitations: Short; participants not clinically diagnosed (volunteers with high scores); same research group and patented extract as other positive trials; number of people not stated in the abstract. Funding and conflicts: Not stated in the abstract (authors hold patent applications per a later paper) Read: abstract
Haller 2025 The Effects of Echinacea (EP107(TM)) on Anxiety: A Comparison of Anxiety Measures in a Randomized, Double Blind, Placebo-Controlled Study. Pharmaceuticals (Basel) · PMID 40006076 · DOI	Controlled trial	Adults with anxiety (multicenter, placebo-controlled)	Echinacea angustifolia EP107 extract root · vs Placebo	Anxiety was lower than placebo on HADS-A. HAM-A total score was not significantly different, though three psychic-anxiety items were better than placebo. HADS-A significantly better than placebo; HAM-A total not significant (numbers not in abstract) Methods, limits and funding Outcomes: HADS anxiety subscale and Hamilton Anxiety Scale (HAM-A) Limitations: Re-analysis built on a hypothesis from the earlier negative trial, with patent-holding authors; abstract gives no numbers. Funding and conflicts: Two authors own patent applications on echinacea for anxiety; one author employed by Anxiofit Ltd Read: abstract
Harnett 2020 The effects of Sambucus nigra berry on acute respiratory viral infections: A rapid review of clinical studies. Adv Integr Med · PMID 32864330 · DOI	Systematic review	936 5 clinical studies of black elderberry, adults	Black elderberry mono-preparations (extract or lozenge) Varied Up to 16 days · vs Placebo	May reduce duration and severity when taken within 48 hours of onset; no evidence for COVID-19; rapid review, no pooling. Methods, limits and funding Outcomes: Cold and flu symptoms Limitations: Rapid review without grading. Read: abstract
Harput Doner 2025 Botanical Adulterants Prevention Bulletin: Echinacea (reported by NutraIngredients, 29 July 2025) News report of the 31st BAPP bulletin (July 2025); the bulletin itself was not read · Source	Authoritative guidance		Echinacea roots, aerial parts and extracts unspecified	News report read. States: most authenticity problems likely come from inadvertent blending of two Echinacea species in the same batch, though some cases are intentional; American feverfew or prairie dock (Parthenium integrifolium) was historically the main adulterant of echinacea roots but recent authenticity studies have not reported it; some products substitute Cistanche species (E. angustifolia extracts adulterated with Cistanche in one case); some products combine undeclared leaf extracts with root extracts. Methods, limits and funding Outcomes: Adulteration and mislabelling Limitations: News summary of a bulletin we did not read. Author spelling taken from the news article. Read: summary-only
Hawkins 2019 Black elderberry (Sambucus nigra) supplementation effectively treats upper respiratory symptoms: A meta-analysis of randomized, controlled clinical trials. Complement Ther Med · PMID 30670267 · DOI	Meta-analysis	180 Elderberry supplementation, upper respiratory symptoms	Black elderberry (Sambucus nigra) Varied various · vs Placebo	Large mean effect size reported; no numeric effect or CI in the abstract. Methods, limits and funding Outcomes: Symptom reduction Limitations: Only 180 participants; no numbers in abstract. Read: abstract
Health Canada Echinacea Root (Health Canada non-prescription drugs labelling standard) Health Canada labelling standard web page (read 24 Oct 2026) · Source	Authoritative guidance		Echinacea root root	Read. The labelling standard page lists a warning only for sore-throat claims ('If symptoms are severe or persist for more than 2 days consult a doctor'), says dosage should be specified for adults, and gives no contraindications, pregnancy, breastfeeding, autoimmune or age statements. Its reference list includes a 1987 article titled 'Detection of Parthenium integrifolium L. adulteration of Echinacea purpurea'. Methods, limits and funding Outcomes: Labelling statements Limitations: A labelling standard, not a full safety assessment; absence of warnings on this page does not mean absence of risk. Read: full-text
Heitmann 2016 Pregnancy outcomes after prenatal exposure to echinacea: the Norwegian Mother and Child Cohort Study. European Journal of Clinical Pharmacology · PMID 26895223 · DOI	Cohort study	68522 68,522 Norwegian women and their children; 363 (0.5%) used echinacea in pregnancy	Echinacea (self-reported) unspecified Not recorded in the abstract Not recorded in the abstract · vs Women who did not use echinacea	Use of echinacea was not associated with an increased risk of malformations or adverse pregnancy outcomes. Users were older, delivered more often before 2002 and smoked less. No increased risk found Methods, limits and funding Outcomes: Malformations and common adverse pregnancy outcomes Limitations: Only 363 exposed pregnancies; self-reported use by questionnaire; product, dose and timing not given in the abstract; small numbers can miss uncommon outcomes. Read: abstract
Hemilä 2013 Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev · PMID 23440782 · DOI	Systematic review	11306 29 trial comparisons of vitamin C for colds	Vitamin C 0.2 g/day or more 0.2 g a day or more various · vs Placebo	General community RR 0.97 (0.94-1.00); 598 people under heavy exercise stress RR 0.48 (0.35-0.64); colds 8% shorter in adults and 14% in children; no consistent effect when started after symptoms began. RR 0.97 (community) (95% CI 0.94 to 1.00) Methods, limits and funding Outcomes: Colds, duration, severity Limitations: Cochrane 2013. Read: abstract
Hinz 2007 Alkamides from Echinacea inhibit cyclooxygenase-2 activity in human neuroglioma cells Biochem Biophys Res Commun · PMID 17599805 · DOI	Laboratory research in-vitro	H4 human neuroglioma cells	CO2 extract of E. angustifolia root and eight isolated alkamides root 48 h · vs untreated cells	The extract lowered prostaglandin E2. Three alkamides (A5, A7, A8) interfered with COX-2 enzyme activity. None of the COX-2-reducing alkamides lowered COX-2 mRNA or protein; the extract and most alkamides actually increased COX-2 levels without more prostaglandin. Methods, limits and funding Outcomes: COX-2 activity and prostaglandin E2 formation Limitations: Cell line only. Read: abstract
Hoban 2019 Analysis of spontaneous adverse drug reactions to echinacea, valerian, black cohosh and ginkgo in Australia from 2000 to 2015. Journal of Integrative Medicine · PMID 31113761 · DOI	Case series	Spontaneous reports to the Australian TGA, 2000-2015, for four herbs	Echinacea purpurea (and three other herbs) unspecified	Most reports for the four herbs were mild or moderate. Every herb had life-threatening reports, and in each life-threatening case the herb was taken together with prescription medicines. The authors say most severe reactions involved a herb-drug interaction. The abstract gives its liver numbers only for black cohosh, not echinacea. Methods, limits and funding Outcomes: Severity of reported reactions Limitations: Abstract only; echinacea-specific counts were not in the abstract. Spontaneous reports cannot give rates or prove cause. Read: abstract
Hu 2017 Andrographis paniculata (Chuān Xīn Lián) for symptomatic relief of acute respiratory tract infections in adults and children: A systematic review and meta-analysis. PLoS One · PMID 28783743 · DOI	Meta-analysis	7175 33 RCTs of Andrographis paniculata in acute respiratory infections	Andrographis paniculata (alone or in herbal mixtures) Varied various · vs Placebo and usual care	Cough SMD -0.39 (-0.67 to -0.10); sore throat SMD -1.13 (-1.37 to -0.89); methodological quality overall poor; minor adverse events mostly gastrointestinal. Sore throat SMD -1.13 (95% CI -1.37 to -0.89) Methods, limits and funding Outcomes: Symptom relief Limitations: Poor quality, much heterogeneity, often herbal mixtures. Registration: CRD42016035679 Read: abstract
Huntley 2005 The safety of herbal medicinal products derived from Echinacea species: a systematic review. Drug Safety · PMID 15853441 · DOI	Systematic review	Clinical studies and spontaneous reports (WHO and national programmes); combination and homeopathic products excluded	Echinacea mono-preparations (E. angustifolia, E. pallida, E. purpurea) unspecified	Six databases, WHO and national reporting data, and 23 manufacturers' files were searched. Adverse events were not commonly reported. Stomach and gut upsets and rashes were most frequent. In rare cases echinacea can be linked to allergic reactions that may be severe. Short-term use had a relatively good safety profile with a slight risk of transient, reversible events. People with allergy or asthma should think carefully before using it. Use in pregnancy and lactation seemed ill-advised because of too little data. Methods, limits and funding Outcomes: Adverse events, allergy, pregnancy Limitations: Abstract only. No event rates in the abstract. Searches ended before 2005. Read: abstract
Hájos 2012 The effects of an Echinacea preparation on synaptic transmission and the firing properties of CA1 pyramidal cells in the hippocampus. Phytother Res · PMID 21717515 · DOI	Laboratory research in-vitro	Brain slices (rat hippocampus)	Echinacea extract that worked in anxiety tests unspecified Several lab concentrations Lab · vs Untreated slices	The extract reduced excitatory nerve signalling and changed firing of CA1 cells; no change in inhibitory signalling. Not applicable Methods, limits and funding Outcomes: Nerve-cell signalling Limitations: Lab tissue study; suggests a possible explanation, not proof in people. Funding and conflicts: Not stated in the abstract Read: abstract
Jawad 2012 Safety and Efficacy Profile of Echinacea purpurea to Prevent Common Cold Episodes: A Randomized, Double-Blind, Placebo-Controlled Trial. Evid Based Complement Alternat Med · PMID 23024696 · DOI	Controlled trial	755 755 healthy adults	Alcohol extract of freshly harvested Echinacea purpurea (95% herb, 5% root) herb 4 months · vs Placebo	Fewer cold episodes and episode days and fewer painkiller-treated episodes; fewer virally confirmed colds, especially enveloped-virus infections; strongest in people with recurrent infections and people who took it as directed. Safety was not worse than placebo. Not given in the abstract Methods, limits and funding Outcomes: Cold episodes, episode days, virally confirmed colds, safety Limitations: Benefit grew with compliance, which can be a sign of other differences between people; abstract gives no numbers. Funding and conflicts: Echinaforce is an A. Vogel product; funding and author links are not stated in this abstract Read: abstract
Jolliffe 2025 Vitamin D supplementation to prevent acute respiratory infections: systematic review and meta-analysis of stratified aggregate data. Lancet Diabetes Endocrinol · PMID 39993397 · DOI	Meta-analysis	61589 40 trials, stratified aggregate data	Vitamin D Any various · vs Placebo	OR 0.94 (0.88-1.00, p=0.057), not statistically significant; serious adverse events OR 0.96 (0.90-1.04). OR 0.94 (95% CI 0.88 to 1.00) Methods, limits and funding Outcomes: Acute respiratory infection risk Limitations: Funnel-plot asymmetry noted. Read: abstract
Karsch-Völk 2014 Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev · PMID 24554461 · DOI	Systematic review	4631 24 double-blind trials (healthy adults and some children), 10 prevention trials and 15 treatment trials (one did both)	Echinacea single-ingredient preparations (many species and plant parts) unspecified Varied · vs Placebo	No prevention comparison out of 12 was statistically significant; a post hoc pooling suggested a 10% to 20% lower risk of a cold. Only 1 of 7 treatment trials that reported cold duration found a significant effect. Drop-outs from side effects did not differ, with a trend to more in prevention trials. The authors concluded echinacea had not been shown to help treat colds, though a weak benefit from some products is possible. Post hoc pooled relative risk reduction 10% to 20% in prevention (as stated in the abstract); no pooled treatment effect (not pooled) Methods, limits and funding Outcomes: Colds: number of people with at least one cold (prevention); cold duration (treatment); drop-outs from side effects Limitations: Authors chose not to pool the main analysis because the trials differ a lot. 8 of 24 trials had high risk of bias, 6 unclear. Only 7 trials used E. purpurea aerial parts. Some review authors had been involved in 8 of the included trials (they did not extract or grade those). Funding and conflicts: Review authors report involvement in some included trials; no other conflict stated for two authors Read: abstract
Kocaman 2008 Echinacea-induced severe acute hepatitis with features of cholestatic autoimmune hepatitis. European Journal of Internal Medicine · PMID 18249315 · DOI	Case report	1 One patient	Echinacea unspecified	Only the title was available (no abstract in PubMed): a report of severe acute hepatitis with features of cholestatic autoimmune hepatitis attributed to echinacea. Details (product, doses, other medicines, outcome) were not read. Methods, limits and funding Outcomes: Liver injury Limitations: Title only; details unknown. Read: summary-only
Kolev 2022 Echinacea Purpurea For the Long-Term Prevention of Viral Respiratory Tract Infections During Covid-19 Pandemic: A Randomized, Open, Controlled, Exploratory Clinical Study. Front Pharmacol · PMID 35559249 · DOI	Controlled trial	120 120 healthy adults aged 18 to 75, followed through the COVID-19 pandemic	Echinaforce (Echinacea purpurea alcoholic extract) chewable tablets unspecified 2400 mg a day for prevention; 4000 mg a day for up to 10 days during acute illness About 5 months (3 cycles of 2, 2 and 1 month, with 1-week breaks) · vs No treatment (open, no placebo)	SARS-CoV-2-positive swabs 5 vs 14 (RR 0.37, p=0.03). Symptomatic episodes 10 vs 14 (not significant). Echinacea during illness lowered viral load and fever days but not overall symptom severity. SARS-CoV-2-positive samples RR 0.37 (p=0.03); symptomatic episodes RR 0.70 (p>0.05); fever days 1 vs 11 (p=0.003) Methods, limits and funding Outcomes: Virus-positive swabs including SARS-CoV-2, symptomatic episodes, viral load, fever days Limitations: No placebo and no blinding, so expectations may colour results; small numbers (5 vs 14 positives); sponsor-funded; the authors call for confirmatory studies. Funding and conflicts: Sponsored by A. Vogel AG (supplied product); several authors paid by the sponsor Read: abstract
Lee 2024 A randomized, double-blind, placebo-controlled study on immune improvement effects of ethanolic extract of Echinacea purpurea (L.) Moench in Korean adults. Phytother Res · PMID 38743584 · DOI	Controlled trial	80 Healthy Korean adults	60% ethanolic extract of E. purpurea (EPE) unspecified 200 mg a day 8 weeks · vs Placebo	NK-cell activity and IL-2, IFN-gamma, TNF-alpha rose significantly vs placebo; no change in WURSS-21 or fatigue scores; no adverse reactions reported. Methods, limits and funding Outcomes: NK-cell activity, cytokines, WURSS-21, fatigue scale Limitations: Laboratory markers, not illness outcomes; part of the plant not stated in abstract. Read: abstract
Liatsos 2006 Severe thrombotic thrombocytopenic purpura (TTP) induced or exacerbated by the immunostimulatory herb Echinacea. American Journal of Hematology · PMID 16493617 · DOI	Case report	1 One patient	Echinacea unspecified	Only the title was available (no abstract in PubMed): a letter reporting severe thrombotic thrombocytopenic purpura (a blood-clotting and low-platelet condition) 'induced or exacerbated' by echinacea. Details were not read. Methods, limits and funding Outcomes: Blood disorder Limitations: Title only; details unknown. Read: summary-only
Liu 2021 Interactions of Echinacea spp. Root Extracts and Alkylamides With the Endocannabinoid System and Peripheral Inflammatory Pain Front Pharmacol · PMID 33986678 · DOI	In vitro and animal animal	Cells expressing cannabinoid receptors plus rats with inflammatory pain	Root extracts of several E. angustifolia and E. purpurea accessions root oral, dose-dependent (doses not given in the abstract) not given · vs CB1/CB2 blockers	Activity at cannabinoid receptors differed between plant accessions and could be predicted from alkylamide content. Four isolated alkylamides activated CB2 but not CB1. Oral root extract of either species reduced inflammatory pain in rats, and this was partly reversed by cannabinoid-receptor blockers. The authors link this to Indigenous prairie use for painful conditions. Methods, limits and funding Outcomes: Cannabinoid receptor activity; pain in rats Limitations: Rats and cells; no human pain data. Part-funded by an industry-partnered grant, authors state no personal financial interest. Funding and conflicts: Mitacs grant with industry partner; authors declare no conflict. Read: abstract
Lopresti 2021 An investigation into the anxiety-relieving and mood-enhancing effects of Echinacea angustifolia (EP107™): A randomised, double-blind, placebo-controlled study. J Affect Disord · PMID 34217960 · DOI	Controlled trial	108 Adults with mild-to-moderately severe anxiety (104 analysed)	Echinacea angustifolia extract EP107 unspecified 20 mg or 40 mg twice a day (the abstract also quotes 40 and 80 mg a day) 6 weeks · vs Placebo	Anxiety fell in all groups but not more than with placebo. Positive and negative affect and emotional wellbeing improved more than placebo, which the authors suggest may be an antidepressant-like effect. Anxiety not different from placebo; PANAS and SF-36 emotional wellbeing better than placebo (numbers not in abstract) Methods, limits and funding Outcomes: Anxiety (CUXOS), positive and negative affect (PANAS), SF-36 wellbeing, insomnia (BIS) Limitations: The mood findings came from secondary outcomes only and need confirming; the main anxiety outcome was negative. Funding and conflicts: Not stated in the abstract (product EP107 is a patented extract; funding unknown) Read: abstract
Macknin 2020 Elderberry Extract Outpatient Influenza Treatment for Emergency Room Patients Ages 5 and Above: a Randomized, Double-Blind, Placebo-Controlled Trial. J Gen Intern Med · PMID 32929634 · DOI	Controlled trial	87 Emergency-room patients over 4 years with confirmed influenza	Elderberry extract 15 mL (5.7 g) four times a day (adults) for 5 days 5 days · vs Placebo	4.9 vs 5.3 days (p=0.57): no benefit found. Methods, limits and funding Outcomes: Days to mild or no symptoms Limitations: Small sample. Registration: NCT03410862 Read: abstract
Martineau 2017 Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ · PMID 28202713 · DOI	Meta-analysis	11321 25 trials, individual participant data	Vitamin D2 or D3 Daily, weekly or bolus various · vs Placebo	Adjusted OR 0.88 (0.81-0.96); stronger with baseline level below 25 nmol/L (OR 0.30, 0.17-0.53); serious adverse events OR 0.98 (0.80-1.20). aOR 0.88 (95% CI 0.81 to 0.96) Methods, limits and funding Outcomes: Acute respiratory tract infection Limitations: Evidence graded high quality by the authors for these analyses. Read: abstract
Matthias 2005 Cytochrome P450 enzyme-mediated degradation of Echinacea alkylamides in human liver microsomes Chem Biol Interact · PMID 15885678 · DOI	Laboratory research in-vitro	Human liver microsome preparations (test tube)	Echinacea alkylamides (extract and pure synthetic compounds) unspecified	Alkylamides were broken down in a time- and NADPH-dependent way, which points to cytochrome P450 enzymes. One alkylamide with a terminal triple bond (undeca-2-ene-8,10-diynamide) blocked the breakdown of another and acted as a mechanism-based inactivator of P450s. Metabolites were epoxides, hydroxylated and de-alkylated forms. Methods, limits and funding Outcomes: Breakdown of alkylamides by liver enzymes Limitations: Test tube only; does not show what happens in people taking tablets. Read: abstract
Matthias 2005 Bioavailability of Echinacea constituents: Caco-2 monolayers and pharmacokinetics of the alkylamides and caffeic acid conjugates Molecules · PMID 18007516 · DOI	Pharmacokinetic study plus cell model	Caco-2 gut-cell layers plus a phase I clinical trial in healthy volunteers (number of volunteers not given in the abstract)	Ethanolic Echinacea liquid extract made into tablets unspecified (alkylamide-rich ethanolic extract) one tablet; the abstract does not give the mg single dose, plasma followed for 12 h	Caffeic acid conjugates crossed the cell layer poorly; alkylamides crossed rapidly. In healthy volunteers alkylamides appeared in blood within 20 minutes of a tablet; caffeic acid conjugates could not be found in any blood sample. Methods, limits and funding Outcomes: Gut-layer passage; blood levels of alkylamides and caffeic acid conjugates Limitations: Abstract gives no numbers or sample size for the human part. Authors are from a herbal company laboratory. Read: abstract
Mazi 2025 Role of Echinacea in the management and prevention of acute respiratory tract infections in children: A systematic review of the evidence. J Family Community Med · PMID 41234257 · DOI	Systematic review	5 randomised trials of echinacea in children with acute cough or respiratory tract infection	Echinacea purpurea (tablets and hydro-ethanolic extracts looked most consistent) unspecified Up to 2000 mg/day in the higher-dose trials Varied · vs Placebo or control	The authors say echinacea may reduce infections, viral load, symptom severity and antibiotic prescriptions, with benefit varying by product and dose; some studies showed no difference from placebo. Not pooled Methods, limits and funding Outcomes: Symptom duration, infection incidence, viral load, antibiotic prescriptions Limitations: Only 5 trials with some concerns about randomisation, blinding and selective reporting. The authors' own GRADE rating says high certainty for symptom duration and antibiotic use, which we do not adopt because of these concerns and the small number of trials. Funding and conflicts: No conflicts declared Read: abstract
Miller 1998 Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Archives of Internal Medicine · PMID 9818800 · DOI	Systematic review	Narrative review of herb-drug interactions	Echinacea (and other herbs) unspecified Use beyond 8 weeks	The review states that if used beyond 8 weeks echinacea could cause liver toxicity and should not be used with other known liver-toxic drugs (examples named: anabolic steroids, amiodarone, methotrexate, ketoconazole). It also notes echinacea lacks the 1,2-saturated necrine ring tied to the liver toxicity of pyrrolizidine alkaloids. Methods, limits and funding Outcomes: Potential liver and drug concerns Limitations: 1998 narrative review. The 8-week liver warning is a precaution based on reasoning, not on cases we could find. Not a review of trials. Read: abstract
Modarai 2011 Safety of Herbal Medicinal Products: Echinacea and Selected Alkylamides Do Not Induce CYP3A4 mRNA Expression. Evidence-Based Complementary and Alternative Medicine · PMID 19906827 · DOI	Laboratory research in-vitro	Human liver (HepG2) cells	Echinaforce extract and four alkylamides unspecified 22, 11.6 and 1.16 microg/mL extract; 1.62 and 44 nM alkylamides 96 hours · vs Vehicle; rifampicin 50 microM	Neither the extract nor the alkylamides changed CYP3A4 mRNA, whereas rifampicin raised it 3.8-fold. No change Methods, limits and funding Outcomes: CYP3A4 mRNA Limitations: Cell experiment; contradicts the human induction seen in other studies, so cell results should not be used alone. Authors are linked to a manufacturer-related product (Echinaforce); funding not checked. Read: abstract
Mullins 1998 Echinacea-associated anaphylaxis. Medical Journal of Australia · PMID 9507713 · DOI	Case report	1 A woman with atopy; plus surveyed atopic patients	Commercial echinacea extract (taken with other supplements) unspecified	One atopic woman had anaphylaxis after taking several supplements including a commercial echinacea extract; allergy to echinacea was confirmed by skin-prick and RAST testing. Up to 5% of surveyed atopic patients regularly took echinacea. Echinacea-binding IgE was found in atopic people (19% by skin test; 20% moderate to strong by RAST). The author raises the possibility of severe reactions even with first-time use because of cross-reactivity with structurally similar allergens. Methods, limits and funding Outcomes: Anaphylaxis, IgE to echinacea Limitations: A single case plus an informal survey; a letter-length report. The cross-reactivity explanation is a possibility, not proven. Read: abstract
Mullins 2002 Adverse reactions associated with echinacea: the Australian experience. Annals of Allergy, Asthma & Immunology · PMID 11814277 · DOI	Case series	5 5 privately referred patients plus 51 reports to the Australian Adverse Drug Reactions Advisory Committee; skin-prick testing of 100 atopic people who had never taken echinacea	Echinacea products unspecified	Of the 5 patients, 2 had anaphylaxis, 1 had an acute asthma attack 10 minutes after the first-ever dose, 1 had recurrent mild asthma with each dose, and 1 had a rash that returned on rechallenge; 3 had positive skin-prick tests. Of the 51 national reports, 26 suggested possible IgE-mediated allergy: 4 anaphylaxis, 12 acute asthma, 10 hives or angioedema. These 26 were aged 2 to 58, 78% female, over half known to be atopic; 4 were hospitalised and 4 reacted after their first known exposure. Twenty percent of 100 atopic people who had never taken echinacea had a positive skin-prick test to it. Not applicable (case series) Methods, limits and funding Outcomes: Allergic and other reactions Limitations: Case reports and spontaneous reports cannot give how often reactions happen. Report selection and recall bias. The cross-reactivity idea is a hypothesis. Read: abstract
National Center for Complementary and Integrative Health (NIH) Echinacea: Usefulness and Safety (NCCIH Herbs at a Glance) NCCIH web page (read 24 Oct 2026; page date not shown in the text we read) · Source	Authoritative guidance		Echinacea purpurea, E. angustifolia, E. pallida (various) unspecified	Read in full. Says it is likely safe for most adults to consume E. purpurea extracts, and some E. purpurea plus E. angustifolia mixtures, for short periods. Some people have allergic reactions, which may be severe. Most common side effects are digestive (abdominal pain, nausea, stomach pain). Possibly safe for children for short periods of E. purpurea extract, but some children in a trial developed rashes that may have been allergic; there is concern that reactions could be severe in children; talk to the child's health care provider first. Conflicting evidence about interactions with drugs the liver breaks down; theoretical reasons to suspect interaction with immunosuppressants or caffeine. Some studies of solid or liquid extracts of E. purpurea and E. angustifolia suggest it is possibly safe for up to 7 days during the first trimester. Little is known about safety while breastfeeding. Notes dietary supplements are not approved by FDA before sale. Methods, limits and funding Outcomes: Safety summary Limitations: Consumer fact sheet. No numbers or frequencies. Does not describe the autoimmune question in detail. Read: full-text
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Echinacea (LiverTox: Clinical and Research Information on Drug-Induced Liver Injury) LiverTox record; the page blocks automated access · Source	Authoritative guidance		Echinacea (oral) unspecified	Not read at source (blocked). A search-engine summary of the record says echinacea is generally well tolerated with only few and minor adverse effects, but there have been isolated reports of serum enzyme elevations and clinically apparent liver injury attributed to it, and that in multiple controlled trials echinacea alone has not been linked to liver injury. The likelihood score letter was not confirmed. Methods, limits and funding Outcomes: Liver safety summary Limitations: Second-hand summary only. NOT verified against the record. The bookshelf number was taken from a search result and not checked. Read: summary-only
National Library of Medicine (NIH) 2024 Echinacea (LactMed, Drugs and Lactation Database) LactMed entry, last revised 15 October 2024 per a search summary; the page itself blocks automated access · Source	Authoritative guidance		Echinacea (oral) unspecified	Not read at source (blocked). A search-engine summary of the entry says: no specific use during breastfeeding; alkamides were detected in breast milk in only one mother; no data on safety and efficacy in nursing mothers or infants; some sources say safe in recommended doses, others advise avoiding it for lack of published safety data; reported side effects are mostly digestive, with occasional rash or allergy; may alter metabolism of drugs handled by cytochrome P450. Methods, limits and funding Outcomes: Breastfeeding safety Limitations: Second-hand summary only. NOT verified against the entry. Read: summary-only
Nault 2024 Zinc for prevention and treatment of the common cold. Cochrane Database Syst Rev · PMID 38719213 · DOI	Systematic review	8526 34 trials of zinc for colds	Zinc (lozenges, tablets, syrups, nasal) Gluconate lozenges 45-276 mg/day for 4.5-21 days various · vs Placebo	Prevention RR 0.93 (0.85-1.01, low certainty); treatment may shorten colds by 2.37 days (-4.21 to -0.53; low certainty, I2 97%). MD -2.37 days (treatment) (95% CI -4.21 to -0.53) Methods, limits and funding Outcomes: Cold risk and duration Limitations: Very uneven results across trials. Read: abstract
Neri 2006 Oral Echinacea purpurea extract in low-grade, steroid-dependent, autoimmune idiopathic uveitis: a pilot study. Journal of Ocular Pharmacology and Therapeutics · PMID 17238809 · DOI	Clinical trial	51 51 patients with low-grade steroid-dependent autoimmune uveitis (non-randomised comparison)	Echinacea purpurea extract unspecified 150 mg twice a day, added to steroid treatment 9 months follow-up · vs Steroid therapy alone	32 patients received echinacea plus steroids and the others steroids alone. Uveitis settled in 19 of 21 anterior and 9 of 11 intermediate uveitis patients on echinacea, with steroid-off times of 209 and 146 days; the abstract's figures for the comparison group are internally unclear, so they are not used here. No adverse reactions attributed to echinacea were recorded. The authors call it safe and effective. No harm signal in this small group Methods, limits and funding Outcomes: Uveitis control and adverse reactions Limitations: Small pilot, not described as randomised or blinded; group sizes in the abstract do not add up exactly (51 recruited, 32 + 20 listed). Cannot show safety in autoimmune disease in general. Read: abstract
Notarnicola 2015 Comparison of shock wave therapy and nutraceutical composed of Echinacea angustifolia, alpha lipoic acid, conjugated linoleic acid and quercetin (perinerv) in patients with carpal tunnel syndrome. Int J Immunopathol Pharmacol · PMID 25953494 · DOI	Controlled trial	60 Patients with carpal tunnel syndrome	Perinerv: E. angustifolia plus alpha lipoic acid, conjugated linoleic acid and quercetin unspecified Up to 6 months · vs Shock wave therapy (no placebo)	Both treatments improved pain, symptoms, function and nerve tests up to 6 months. A trend to better pain relief was seen with the supplement. Both improved; trend only for pain with the supplement; no numbers in the abstract Methods, limits and funding Outcomes: Pain, symptom severity, function, nerve tests Limitations: Mixed product, so echinacea cannot be credited; no placebo; the authors' attribution of the pain trend to echinacea is a guess. Read: abstract
O'Neil 2008 Effects of echinacea on the frequency of upper respiratory tract symptoms: a randomized, double-blind, placebo-controlled trial. Ann Allergy Asthma Immunol · PMID 18450126 · DOI	Controlled trial	90 90 hospital staff volunteers (58 analysed: 28 echinacea, 30 placebo)	Commercial Echinacea purpurea capsules unspecified 3 capsules twice a day 8 weeks (winter) · vs Placebo (parsley)	No significant difference (9 vs 14 sick days per person; p=0.67). 9 vs 14 sick days per person (z -0.42, p=0.67) Methods, limits and funding Outcomes: Frequency of upper respiratory symptoms Limitations: Large drop-out (32 of 90 not analysed); small; commercial capsules of unknown standardisation. Funding and conflicts: Not stated in the abstract Read: abstract
Ogal 2021 Echinacea reduces antibiotic usage in children through respiratory tract infection prevention: a randomized, blinded, controlled clinical trial. Eur J Med Res · PMID 33832544 · DOI	Controlled trial	201 Children aged 4 to 12 (about 103 on echinacea and 98 on control)	Echinaforce Junior tablets (400 mg freshly harvested Echinacea purpurea alcoholic extract) unspecified 400 mg three times a day Two periods of 2 months, with a 1-week break · vs Vitamin C 50 mg three times a day (control; not an inert placebo)	32.5% fewer infection episodes (OR 0.52); antibiotic courses 6 (5.8% of children) vs 24 (15.3%); infection complications 11 vs 30; influenza detections 3 vs 20. Infection episodes OR 0.52 (p=0.021); antibiotic days reduced by 80.2% (OR 0.30 to 0.91) Methods, limits and funding Outcomes: Respiratory tract infection episodes, antibiotic courses, complications, virus detections, adverse events Limitations: Control was vitamin C, not an inert placebo. Parent-reported diaries. Participant count here is the sum of the two analysis groups in the abstract (103 + 98). Funding and conflicts: One author a consultant to A. Vogel AG; another an employee; sponsor-linked Registration: ClinicalTrials.gov NCT02971384 Read: abstract
Oláh 2017 Echinacea purpurea-derived alkylamides exhibit potent anti-inflammatory effects and alleviate clinical symptoms of atopic eczema. J Dermatol Sci · PMID 28610718 · DOI	Controlled trial	Lab keratinocytes plus three human skin trials (patch test, atopic eczema, skin lipids); group sizes not given in the abstract	Echinacea purpurea alkylamide extract in a cream unspecified · vs Comparator cream (type not stated in abstract)	The cream was well tolerated in the patch test. Local SCORAD fell versus baseline and versus the comparator. Skin lipids (ceramide EOS, cholesterol) were higher at Day 15 than baseline. Lower local SCORAD than the comparator; numbers and confidence intervals are not given in the abstract Methods, limits and funding Outcomes: Local SCORAD (eczema severity score), skin irritation, skin lipids Limitations: Group sizes, doses, trial length and the comparator are not in the abstract. Alkylamide extract cream from a company-linked research group (affiliations only; no funding statement in the abstract). Cream only; not an oral product. Read: abstract
Penzak 2010 Echinacea purpurea significantly induces cytochrome P450 3A activity but does not alter lopinavir-ritonavir exposure in healthy subjects. Pharmacotherapy · PMID 20653355 · DOI	Clinical trial	13 13 healthy volunteers (8 men, 5 women), open-label single sequence	Echinacea purpurea (plant part not stated in the abstract) unspecified 500 mg three times a day 28 days (14 days with lopinavir-ritonavir, 14 days alone) · vs Own baseline	Lopinavir-ritonavir levels did not change with 14 days of echinacea: lopinavir AUC ratio 0.96 (90% CI 0.83-1.10), peak ratio 1.00 (0.88-1.12). Midazolam AUC fell (ratio 0.73, 90% CI 0.61-0.85, p=0.008) and its oral clearance rose (ratio 1.37, 1.10-1.63, p=0.02), showing CYP3A induction. Fexofenadine (P-glycoprotein) did not change. The authors say echinacea is unlikely to alter boosted protease inhibitors but may modestly lower other CYP3A drug levels. Midazolam exposure about -27% (AUC ratio 0.73 (0.61-0.85)) Methods, limits and funding Outcomes: Lopinavir and ritonavir levels; CYP3A (midazolam) and P-glycoprotein (fexofenadine) activity Limitations: Small, open-label, healthy volunteers, one product. Read: abstract
Perri 2006 Safety and efficacy of echinacea (Echinacea angustafolia, e. purpurea and e. pallida) during pregnancy and lactation. Canadian Journal of Clinical Pharmacology · PMID 17085774	Systematic review	Pregnancy and lactation literature	Echinacea unspecified	The reviewers cite a prospective cohort study showing that oral echinacea in the first trimester did not increase major malformations, and low-level (expert opinion) evidence that recommended doses are safe in pregnancy and lactation. They conclude it is non-teratogenic when used in pregnancy but advise caution during lactation until better human studies exist. Methods, limits and funding Outcomes: Pregnancy and lactation safety Limitations: Abstract only; 2006; the evidence for lactation was expert opinion only. Read: abstract
Pham 2025 Efficacy and safety of Echinacea purpurea in treating upper respiratory infections and complications of otitis media in children: Systematic review and meta-analysis. Clin Nutr ESPEN · PMID 40311928 · DOI	Meta-analysis	3169 9 randomised controlled trials in children with upper respiratory infection or otitis media (ear infection)	Echinacea purpurea (roots, leaves and flowers; capsules and extracts) unspecified Varied · vs Placebo	Reduced treatment duration, infection incidence and antibiotic use for upper respiratory infection, and fewer ear-infection episodes, but no shorter ear-infection treatment. Adverse events were moderately more common with echinacea (mostly mild). Duration SMD -0.19; incidence RR 0.81; antibiotic use RR 0.18; adverse events RR 1.38; ear-infection episodes RR 0.56 (SMD -0.30 to -0.09; RR 0.75 to 0.87; RR 0.13 to 0.25; RR 1.08 to 1.78; RR 0.44 to 0.73) Methods, limits and funding Outcomes: Treatment duration, infection incidence, antibiotic use, adverse events; ear-infection episodes Limitations: Funnel plot suggested publication bias and trials differ a lot; mixed plant parts and doses; the antibiotic-use result is very large and the abstract does not say how many trials it rests on. Participant count here is the sum of the treatment (1,518) and placebo (1,651) groups in the abstract. Funding and conflicts: No competing interest declared Read: abstract
Pilarska 2022 The Presence of Molds and Their Secondary Metabolites in Purple Coneflower-Based Dietary Supplements (Echinacea purpurea (L.) Moench). Toxins · PMID 36136545 · DOI	Case series in-vitro	21 21 purple coneflower supplements from the Polish market (sachets 5, dry raw material 3, capsules 9, tablets 4)	Retail E. purpurea supplements unspecified	Average mould count was 1012 colony-forming units per gram; the most common moulds were Aspergillus, Phoma and Eurotium. Mycotoxins found: zearalenone in 18 of 21 samples, deoxynivalenol in 5 of 21 and T-2 toxin in 3 of 21. The abstract does not say whether levels were above any legal limit. Methods, limits and funding Outcomes: Mould and mycotoxin contamination Limitations: One country, 21 samples; levels versus safety limits not in the abstract. Read: abstract
Raclariu 2018 What's in the box? Authentication of Echinacea herbal products using DNA metabarcoding and HPTLC. Phytomedicine · PMID 29895490 · DOI	Case series in-vitro	53 53 Echinacea herbal products sold across Europe	Retail echinacea products unspecified	Echinacea DNA was detected in 34 of 38 retained products (89%), but the method could not tell Echinacea species apart. All tested products showed differences between the label and what the DNA test found; overall ingredient fidelity was 43%. Methods, limits and funding Outcomes: Authenticity of ingredients Limitations: Authenticity method study; the abstract does not say which unlabelled plants were found or whether any were harmful. Read: abstract
Raduner 2006 Alkylamides from Echinacea are a new class of cannabinomimetics. Cannabinoid type 2 receptor-dependent and -independent immunomodulatory effects J Biol Chem · PMID 16547349 · DOI	Laboratory research in-vitro	Human cells and whole blood in a test tube; binding assays	Pure alkylamides from Echinacea (A1 = dodeca-2E,4E,8Z,10Z-tetraenoic acid isobutylamide; A2 = dodeca-2E,4E-dienoic acid isobutylamide) · vs anandamide, CB2 blocker SR144528	A1 and A2 bound CB2 more strongly than the body's own cannabinoids (Ki about 60 nM; CB1 above 1500 nM). They lowered LPS-driven TNF-alpha, IL-1beta and IL-12p70 (5-500 nM), but in a way that did not depend on CB2. Overall the effects are not only due to CB2 binding. Methods, limits and funding Outcomes: Binding to cannabinoid receptors; cytokines in whole blood Limitations: Test tube only; concentrations are nanomolar while human blood levels after a dose were around 0.2-10 ng/mL. Read: abstract
Rauš 2015 Effect of an Echinacea-Based Hot Drink Versus Oseltamivir in Influenza Treatment: A Randomized, Double-Blind, Double-Dummy, Multicenter, Noninferiority Clinical Trial. Curr Ther Res Clin Exp · PMID 26265958 · DOI	Controlled trial	473 Adults with flu symptoms for 48 hours or less, treated in primary care in the Czech Republic	Echinaforce Hotdrink (Echinacea purpurea formulation) unspecified 10 days · vs Oseltamivir (5 days then placebo); no placebo-only arm	Recovery was similar to oseltamivir (90.1% vs 84.8% recovered at 10 days). Complications 2.46% vs 6.45% (p=0.076), and fewer side effects (nausea, vomiting) with echinacea. Recovery at day 5 50.2% vs 48.8%; day 10 90.1% vs 84.8% (echinacea vs oseltamivir) Methods, limits and funding Outcomes: Proportion recovered each day (non-inferiority); complications; adverse events Limitations: No placebo group, so it cannot show that echinacea beats doing nothing; non-inferiority design; people recover from flu anyway; complications difference was not significant. Product-specific. Funding and conflicts: Not stated in the abstract (Echinaforce is an A. Vogel product) Registration: Eudra-CT 2010-021571-88 Read: abstract
Reznik 2021 [A medicinal liver injury with an immunomodulatory drug of natural origin. Case report]. Terapevticheskii Arkhiv · PMID 36286888 · DOI	Case report	1 39-year-old patient	Multi-herb 'immunostimulating collection' containing St John's wort, elecampane, kopeichnik, echinacea, licorice and rosehip unspecified Symptoms began 10 days after starting	Yellow skin and eyes, dark urine, pale stools and itching 10 days after starting the herbal mix. Viral hepatitis markers were negative. ALT rose to 2800 U/L and AST to 1776 U/L; total bilirubin was reported up to 577 (unit printed as U/l in the abstract). Everything cleared after stopping the mix and supportive treatment. Methods, limits and funding Outcomes: Liver injury Limitations: Six herbs were taken together, so echinacea cannot be named as the cause. Article in Russian; abstract only. Read: abstract
Riemma 2022 Echinacea angustifolia and Echinacea purpurea Supplementation Combined with Vaginal Hyaluronic Acid to Boost the Remission of Cervical Low-Grade Squamous Intraepithelial Lesions (L-SILs): A Randomized Controlled Trial. Medicina (Kaunas) · PMID 35630063 · DOI	Controlled trial	153 Women of reproductive age with HPV-related low-grade cervical lesions (CIN-1), Naples	Oral echinacea extracts (E. angustifolia and E. purpurea) with or without vaginal hyaluronic acid unspecified 3 months of treatment; follow-up to 12 months · vs Vaginal hyaluronic acid alone	No difference at 3 months. Persistent CIN-1 at 6 months: 15/51 (echinacea plus hyaluronic acid) vs 23/48 (echinacea alone) vs 27/49 (hyaluronic acid alone). At 12 months: 5/51 vs 15/48 vs 14/48. Combined arm better than each single arm at 6 and 12 months (p=0.03 for each comparison); echinacea alone was not compared with a no-treatment group Methods, limits and funding Outcomes: Persistent CIN-1 at 3, 6 and 12 months Limitations: Single-blind; modest size; benefit appeared only in the combination arm, so echinacea alone did not clearly beat hyaluronic acid alone (23/48 vs 27/49 at 6 months); the authors say sample size limits the quality of the evidence. Funding and conflicts: Authors declare no conflict of interest Read: abstract
Schapowal 2009 Echinacea/sage or chlorhexidine/lidocaine for treating acute sore throats: a randomized double-blind trial. Eur J Med Res · PMID 19748859 · DOI	Controlled trial	154 Adults and teens (12 or older) with acute sore throat	Echinacea/sage spray (combination product) unspecified 2 puffs every 2 hours, up to 10 times a day Up to 5 days · vs Chlorhexidine/lidocaine spray (no placebo)	Similar response (63.8% echinacea/sage vs 57.8% comparator). Response 63.8% vs 57.8% Methods, limits and funding Outcomes: Response rate in first 3 days (50% or more fewer symptoms) Limitations: Combination with sage; compared with another spray, not with placebo; cannot isolate echinacea. Participant count includes 133 analysed per protocol. Funding and conflicts: Not stated in the abstract Read: abstract
Schapowal 2015 Echinacea reduces the risk of recurrent respiratory tract infections and complications: a meta-analysis of randomized controlled trials. Adv Ther · PMID 25784510 · DOI	Meta-analysis	2458 6 randomised placebo-controlled trials (Jadad score 4 or more) in generally healthy people; recurrent respiratory infections	Echinacea extracts (ethanolic extracts and pressed juices) unspecified Varied · vs Placebo	Fewer recurrent infections and fewer complications with echinacea. Alcohol (ethanol) extracts looked better than pressed juices. Effect strongest in people who are susceptible, stressed or immune-weakened. Recurrent infections RR 0.649; susceptible people RR 0.501; virologically confirmed RR 0.420; complications RR 0.503 (0.545 to 0.774; 0.380 to 0.661; 0.222 to 0.796; 0.384 to 0.658) Methods, limits and funding Outcomes: Recurrent respiratory infections; infections in susceptible people; complications Limitations: Only 6 selected high-quality trials, fixed-effect model (assumes the trials are alike); the abstract does not say which products the six trials tested or state conflicts of interest. Funding and conflicts: Not stated in the abstract Read: abstract
Schoop 2006 Echinacea in the prevention of induced rhinovirus colds: a meta-analysis. Clin Ther · PMID 16678640 · DOI	Meta-analysis	3 experimental rhinovirus-challenge studies in volunteers	Echinacea extracts (various) unspecified Varied · vs Placebo	The chance of a clinical cold was 55% higher with placebo than with echinacea; total symptom scores did not differ significantly. Cold OR (placebo vs echinacea) 1.55; symptom score difference -1.96 (not significant) (OR 1.02 to 2.36; score -4.83 to 0.90) Methods, limits and funding Outcomes: Development of a symptomatic cold after deliberate rhinovirus infection; total symptom score Limitations: Only 3 studies, borderline result (p=0.043), pooled different products; authors say larger trials are needed. Funding and conflicts: Not stated in the abstract Read: abstract
Senica 2019 Which Plant Part of Purple Coneflower (Echinacea purpurea (L.) Moench) Should be Used for Tea and Which for Tincture? J Med Food · PMID 30222488 · DOI	Other trial lab-chemistry	Lab extracts of purple coneflower roots, flowers and leaves	Water, 40% ethanol and 100% ethanol extracts root, flower, leaf	Caftaric acid best from leaves in water (2673 mg/100 g dry weight); chicoric acid highest in 40% ethanol from flowers (1572) and roots (1396 mg/100 g dry weight); 100% ethanol gave the lowest yield. Methods, limits and funding Outcomes: Phenolic compounds by HPLC-MS Limitations: Lab chemistry, not human use. Read: abstract
Shah 2007 Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. Lancet Infect Dis · PMID 17597571 · DOI	Meta-analysis	14 unique studies of echinacea for colds (prevention and treatment)	Echinacea preparations (various) unspecified Varied · vs Placebo	Odds of developing a cold were 58% lower and colds were 1.4 days shorter; results held in several subgroup checks. Incidence OR 0.42; duration WMD -1.44 days (OR 0.25 to 0.71; WMD -2.24 to -0.64) Methods, limits and funding Outcomes: Cold incidence (odds ratio); cold duration (weighted mean difference) Limitations: Strong disagreement between studies (heterogeneity p<0.001). Pooled many different products. Its estimates are much larger than the Cochrane review and the later David 2019 review. An erratum was published for this article. Funding and conflicts: Not stated in the abstract Read: abstract
Signer 2020 In vitro virucidal activity of Echinaforce®, an Echinacea purpurea preparation, against coronaviruses, including common cold coronavirus 229E and SARS-CoV-2. Virol J · PMID 32907596 · DOI	Laboratory research in-vitro	Cell cultures and lab models of human nasal lining	Echinaforce (Echinacea purpurea extract) unspecified 3.2 to 50 micrograms/mL (lab concentrations) Lab · vs Untreated cultures	The extract inactivated common-cold coronavirus HCoV-229E (IC50 3.2 micrograms/mL), and MERS, SARS-CoV-1 and SARS-CoV-2 at about 50 micrograms/mL, but did not stop infection when cells were pre-treated. IC50 3.2 micrograms/mL for HCoV-229E Methods, limits and funding Outcomes: Virus infectivity after contact with the extract Limitations: Lab study only: shows the extract can inactivate virus on contact, not that swallowing it protects people. Funding and conflicts: Employees of A. Vogel AG among authors Read: abstract
Soon 2001 Recurrent erythema nodosum associated with Echinacea herbal therapy. Journal of the American Academy of Dermatology · PMID 11174391 · DOI	Case report	1 One patient	Echinacea herbal therapy unspecified	A case of recurrent erythema nodosum (tender red skin lumps) temporally and perhaps causally linked to echinacea use. Methods, limits and funding Outcomes: Skin reaction Limitations: Single case. The authors say 'perhaps causally'. Read: abstract
Spasov 2004 Comparative controlled study of Andrographis paniculata fixed combination, Kan Jang and an Echinacea preparation as adjuvant, in the treatment of uncomplicated respiratory disease in children. Phytother Res · PMID 14750201 · DOI	Controlled trial	130 Children 4-11 with uncomplicated colds	Immunal (E. purpurea extract) as add-on to standard treatment, vs Kan Jang (Andrographis) unspecified Not in abstract 10 days · vs Standard treatment alone	Kan Jang was significantly more effective than Immunal; Immunal did not show the same effect. Methods, limits and funding Outcomes: Symptom severity, nasal secretion, recovery Limitations: Not a placebo trial; both products were add-ons to standard treatment. Read: abstract
Sperber 2004 Echinacea purpurea for prevention of experimental rhinovirus colds. Clin Infect Dis · PMID 15156472 · DOI	Controlled trial	48 48 healthy adults deliberately infected with rhinovirus type 39	Echinacea purpurea (plant part not stated in the abstract) unspecified 2.5 mL three times a day 14 days (7 days before and 7 days after infection) · vs Placebo	92% infected on echinacea vs 95% on placebo; colds developed in 58% vs 82% (not statistically significant, p=0.114). Colds 58% vs 82% (p=0.114) Methods, limits and funding Outcomes: Infection rate; cold development Limitations: Too small to detect differences (authors' own comment). Funding and conflicts: Not stated in the abstract Read: abstract
Sullivan 2008 Echinacea-induced macrophage activation Immunopharmacol Immunotoxicol · PMID 18618312 · DOI	In vitro and animal animal	Mouse macrophages and mice infected with Listeria	Endotoxin-free E. purpurea extract enriched in plant polysaccharide (EP) unspecified oral (dose not given in the abstract) 3 days after infection · vs untreated	The polysaccharide extract made macrophages release IL-6, TNF, IL-12 and nitric oxide through TLR4-dependent and -independent routes involving ERK, p38, JNK and NF-kappaB, and oral dosing reduced the bacterial load of Listeria in the spleen of mice. Methods, limits and funding Outcomes: Cytokine and nitric oxide release; bacterial load in spleen Limitations: Mouse and cell work; whether this happens in people taking commercial products is unknown. Read: abstract
Taylor 2003 Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. JAMA · PMID 14657066 · DOI	Controlled trial	407 Children aged 2 to 11 years; 707 colds (337 treated with echinacea, 370 with placebo)	Echinacea purpurea (unspecified preparation in the abstract) unspecified Up to 10 days per cold, up to 3 colds over 4 months · vs Placebo	No difference in cold duration or severity. Rash occurred in 7.1% of colds treated with echinacea versus 2.7% with placebo. Median duration 9 days in both groups (p=0.89); rash 7.1% vs 2.7% (p=0.008) Methods, limits and funding Outcomes: Cold duration and severity (parent-recorded); adverse events Limitations: Single product and dose; the abstract does not give the plant part or dose. Funding and conflicts: Not stated in the abstract Read: abstract
Tiralongo 2012 Randomised, double blind, placebo-controlled trial of echinacea supplementation in air travellers. Evid Based Complement Alternat Med · PMID 22229040 · DOI	Controlled trial	175 Adults travelling long-haul by plane for 1 to 5 weeks	Echinacea root extract standardised to 4.4 mg alkylamides root Before, during and after travel (1-5 weeks) · vs Placebo	Symptoms rose in both groups during travel; the echinacea group had borderline significantly lower scores (P=0.05). Respiratory symptom scores borderline lower (P=0.05) Methods, limits and funding Outcomes: Upper respiratory symptoms before, after and 4 weeks after travel Limitations: Borderline result; self-reported symptoms; travel setting. Funding and conflicts: Not stated in the abstract Read: abstract
Toselli 2010 Metabolism of the major Echinacea alkylamide N-isobutyldodeca-2E,4E,8Z,10Z-tetraenamide by human recombinant cytochrome P450 enzymes and human liver microsomes Phytother Res · PMID 20135639 · DOI	Laboratory research in-vitro	Human recombinant enzymes and human liver microsomes (test tube)	N-isobutyldodeca-2E,4E,8Z,10Z-tetraenamide (pure alkylamide)	Main enzymes were CYP1A1, CYP1A2, CYP2A13 and CYP2D6 (recombinant); in liver microsomes CYP2E1 gave the main hydroxylated product, CYP2C9 the epoxides and CYP1A2 the de-alkylated product. Methods, limits and funding Outcomes: Which human enzymes break down the main alkamide Limitations: Test tube only. Read: abstract
Turner 2000 Ineffectiveness of echinacea for prevention of experimental rhinovirus colds. Antimicrob Agents Chemother · PMID 10817735 · DOI	Controlled trial	Volunteers deliberately infected with rhinovirus	Echinacea (preparation not specified in the abstract) unspecified · vs Placebo	Infection occurred in 44% (echinacea) vs 57% (placebo) and illness in 36% vs 43%; no significant difference. Infection 44% vs 57%; illness 36% vs 43% (not significant) Methods, limits and funding Outcomes: Infection and illness after rhinovirus exposure Limitations: Research letter; tiny abstract; numbers of people not given in the abstract. Funding and conflicts: Not stated in the abstract Read: abstract
Turner 2005 An evaluation of Echinacea angustifolia in experimental rhinovirus infections. N Engl J Med · PMID 16049208 · DOI	Controlled trial	437 437 volunteers randomised; 399 analysed after deliberate infection with rhinovirus type 39	Echinacea angustifolia root extracts (supercritical CO2, 60% ethanol, 20% ethanol) root Started 7 days before (prevention) or at infection (treatment); followed 5 days · vs Placebo	No significant effect of any extract on infection rate, symptoms, nasal secretions, IL-8, neutrophils or virus titre. No statistically significant differences Methods, limits and funding Outcomes: Infection rate; symptom severity; nasal secretions; IL-8; virus levels Limitations: Used E. angustifolia root only, not E. purpurea; experimental infection in a quarantine setting. Funding and conflicts: Not stated in the abstract Read: abstract
Vimalanathan 2022 Broad Antiviral Effects of Echinacea purpurea against SARS-CoV-2 Variants of Concern and Potential Mechanism of Action. Microorganisms · PMID 36363737 · DOI	Laboratory research in-vitro	Cell cultures and computer docking models	Echinaforce extract (Echinacea purpurea) unspecified Concentrations 3.62 to 12.03 micrograms/mL (lab) Lab · vs Untreated cultures	The extract blocked growth of all tested SARS-CoV-2 variants (including omicron) in cells and reduced entry of spike-pseudotyped particles; computer models suggested binding to spike protein and TMPRSS2. EC50 3.62 to 12.03 micrograms/mL Methods, limits and funding Outcomes: Virus propagation and cell entry for SARS-CoV-2 variants Limitations: Cell and computer study only; does not show any effect in people. Funding and conflicts: No conflict declared Read: abstract
Vonau 2001 Does the extract of the plant Echinacea purpurea influence the clinical course of recurrent genital herpes? Int J STD AIDS · PMID 11231867 · DOI	Controlled trial	50 Adults with frequently recurrent genital herpes, London clinic	Echinaforce, E. purpurea plant and root extract herb+root Dose not stated in abstract 6 months on each treatment (crossover, one year total) · vs Placebo	No statistically significant benefit of Echinaforce over placebo. No significant difference Methods, limits and funding Outcomes: Frequency and severity of recurrences (history, clinical review, visual analogue scales) plus blood and immune tests Limitations: Single centre; dose not in the abstract; no numbers reported in the abstract. Read: abstract
Wahl 2008 Echinacea purpurea and osteopathic manipulative treatment in children with recurrent otitis media: a randomized controlled trial. BMC Complement Altern Med · PMID 18831749 · DOI	Controlled trial	90 Children aged 12 to 60 months with recurrent ear infections (84 followed for at least 3 months)	E. purpurea root and seed alcohol extract root+seed Dose not stated in abstract; taken for 10 days at the first sign of each cold 6-month follow-up · vs Placebo (2x2 trial with osteopathic treatment or sham)	Ear infection occurred in 65% with echinacea vs 41% with placebo, a higher risk with echinacea. RR 1.59 (95% CI 1.04-2.42), borderline higher risk with echinacea (1.04-2.42) Methods, limits and funding Outcomes: At least one acute ear infection during follow-up Limitations: Small; borderline result; the authors say it may increase the risk, which could be chance. Taken only during colds, not as ongoing prevention. Registration: NCT00010465 Read: abstract
Waidyanatha 2020 A strategy for test article selection and phytochemical characterization of Echinacea purpurea extract for safety testing. Food Chem Toxicol · PMID 31931071 · DOI	Other trial lab-chemistry	One E. purpurea root extract chosen for US National Toxicology Program testing	Chemical and DNA characterisation root	Caftaric, chicoric and chlorogenic acids and the main alkamide made up only a small fraction of the extract. Methods, limits and funding Outcomes: Product selection and phytochemistry Limitations: Describes one extract. Read: abstract
Weishaupt 2020 Safety and Dose-Dependent Effects of Echinacea for the Treatment of Acute Cold Episodes in Children: A Multicenter, Randomized, Open-Label Clinical Trial. Children (Basel) · PMID 33333722 · DOI	Controlled trial	79 Children aged 4 to 12 with cold and flu episodes (68 children treated 130 episodes)	Echinaforce Junior tablets (alcoholic Echinacea purpurea extract) unspecified 1200 mg or 2000 mg extract a day (3 or 5 tablets daily) Per episode (average episode 7.5 days) · vs Two Echinacea dose levels compared; no placebo	Five tablets a day shortened episodes by up to 1.7 days compared with three tablets a day. Treatment was well tolerated. Episode duration reduced by up to 1.7 days (p<0.02) at the higher dose Methods, limits and funding Outcomes: Episode duration; tolerability; antibiotic prescriptions Limitations: No placebo group, so it shows a dose difference only and cannot show echinacea beats placebo. Sponsor-funded. Funding and conflicts: Sponsored by A. Vogel AG; two authors are employees of the company Read: abstract
Woelkart 2005 Bioavailability and pharmacokinetics of alkamides from the roots of Echinacea angustifolia in humans J Clin Pharmacol · PMID 15901750 · DOI	Pharmacokinetic study	11 11 healthy adults, randomised open crossover	Echinacea angustifolia root, 60% ethanol extract root 2.5 mL (one of the doses tested) single dose · vs different doses of the same extract	The main alkamides (dodeca-2E,4E,8Z,10E/Z-tetraenoic acid isobutylamides) peaked at 30 minutes at 10.88 ng/mL for the 2.5 mL dose. Methods, limits and funding Outcomes: Plasma levels of six alkamides Limitations: Single dose in healthy adults; abstract gives only the peak figure for the 2.5 mL dose. Read: abstract
Woelkart 2006 Bioavailability and pharmacokinetics of Echinacea purpurea preparations and their interaction with the immune system Int J Clin Pharmacol Ther · PMID 16995328 · DOI	Pharmacokinetic study with ex vivo immune test	10 10 volunteers (8 test, 2 placebo), randomised single-dose crossover	Echinaforce tincture versus Echinaforce tablets (E. purpurea) herb 4 mL tincture or 12 tablets, each with 0.07 mg of the main alkamides single dose; blood drawn up to 23 h · vs placebo	Tincture peaked at 30 minutes (0.40 ng/mL), tablets at 45 minutes (0.12 ng/mL). A quarter of the alkamide in tablets was absorbed relative to tincture. 23 hours after dosing, TNF-alpha and IL-8 were significantly lower in LPS-stimulated blood; IL-6 did not change significantly. Methods, limits and funding Outcomes: Alkamide blood levels; effects on blood cells stimulated with LPS in a test tube (TNF-alpha, IL-8, IL-6) Limitations: Only 10 people (2 on placebo); the immune read-out was done on blood in a test tube, not in people fighting an infection. Funding and conflicts: Authors include company-affiliated researchers (Bioforce); funding not stated in the abstract. Read: abstract
Woelkart 2008 Pharmacokinetics of the main alkamides after administration of three different Echinacea purpurea preparations in humans Planta Med · PMID 18240099 · DOI	Pharmacokinetic study	Healthy volunteers (number not stated in the abstract)	Echinaforce tablets, Echinaforce Junior tablets, and an Echinacea sore throat spray (E. purpurea) herb (Echinaforce) alkamides in the low-mg range per dose single dose	Peak blood level was 0.22 +/- 0.07 ng/mL after tablets, 0.22 +/- 0.15 ng/mL after the Junior tablets and 0.23 +/- 0.16 ng/mL after the throat spray; areas under the curve were 0.22, 0.20 and 0.23 ng/mL x h. All three products gave very similar, very low blood levels Methods, limits and funding Outcomes: Plasma levels of the main alkamides (dodeca-2E,4E,8Z,10E/Z-tetraenoic acid isobutylamides) Limitations: Small single-dose study of one brand; abstract does not give n. Funding and conflicts: Authors include employees or collaborators of the product maker (Bioforce/A. Vogel) per author list; funding not stated in the abstract. Read: abstract
Yale 2004 Echinacea purpurea therapy for the treatment of the common cold: a randomized, double-blind, placebo-controlled clinical trial. Arch Intern Med · PMID 15197051 · DOI	Controlled trial	128 128 adults with common cold symptoms for under 24 hours	Echinacea purpurea freeze-dried pressed juice of the aerial parts herb 100 mg three times a day Up to 14 days · vs Lactose placebo	No significant difference in symptom scores or time to resolution. No difference (time to resolution p=0.73) Methods, limits and funding Outcomes: Total symptom scores and time to symptom resolution Limitations: Modest sample size; one product and dose. Funding and conflicts: Not stated in the abstract Read: abstract
Yotsawimonwat 2010 Skin improvement and stability of Echinacea purpurea dermatological formulations. Int J Cosmet Sci · PMID 20384903 · DOI	Other	10 10 healthy volunteers aged 25-40	Echinacea purpurea extract in a cream and in a gel unspecified 1 month	No skin irritation. Hydration index rose by up to 10.6 AU (cream) and 11.4 AU (gel). Wrinkles decreased by 9.47% (cream) and 14.92% (gel). The extract lost stability quickly (shelf life 2 to 4 months at 4 C). Hydration up to 10.6 and 11.4 AU; wrinkle decrease 9.47% and 14.92%; no statistics given in the abstract Methods, limits and funding Outcomes: Skin irritation, skin hydration (corneometer), wrinkle reduction Limitations: Only 10 healthy people; no placebo or control group is described in the abstract; no p-values; very short. Read: abstract
s-ema-ar-echinacea-herba-2014 EMA/HMPC/557979/2013: Assessment report on Echinacea purpurea (L.) Moench, herba recens (final, 24 November 2014) · Source	Authoritative guidance n/a			Methods, limits and funding Read: full-text
s-ema-ar-echinacea-radix-2016 EMA/HMPC/424584/2016: Assessment report on Echinacea purpurea (L.) Moench, radix (DRAFT, 22 November 2016) · Source	Authoritative guidance n/a			Methods, limits and funding Read: full-text
s-gbif-echinacea GBIF Backbone Taxonomy: Echinacea Moench (genus key 3150914), E. purpurea (3150935), E. angustifolia (3150933), E. pallida (3150919) · Source	Reference database n/a			Methods, limits and funding Read: full-text
s-ncbi-taxonomy-echinacea NCBI Taxonomy: Echinacea (TaxId 53747), E. purpurea (53751), E. angustifolia (308558), E. pallida (53749) · Source	Reference database n/a			Methods, limits and funding Read: full-text

What we do not know yet

What the evidence supports: a possible small benefit from daily use for preventing colds, with low certainty. Treating an existing cold is mostly not supported by independent trials.
Products differ: species, plant part and extraction vary a lot and few head-to-head trials exist. Most positive prevention and children's trials used one maker's fresh-plant alcohol extract, and independent replication with placebo is limited.
The Cochrane review is more than a decade old and no newer independent review of that size was found. Several newer pooled analyses are by authors linked to makers.
Doses are missing from many abstracts, and full texts and funding details were not read for most studies, so conflicts of interest are marked as not stated where the abstract is silent.
Mind and mood: all anxiety and mood findings are from one patented extract, with no trial in people with diagnosed anxiety or depression and none for memory or thinking.
Safety: no study measures how often serious allergic reactions or liver injury happen. The autoimmune warning is theoretical, and there is no data beyond about 6 months, in children under 2 or in breastfed infants.
Interactions: the data are small volunteer studies with different products. There is no study with transplant drugs and none that measured real outcomes such as bleeding or rejection.
Pregnancy: 363 exposed pregnancies in one Norwegian cohort are too few to exclude rare malformations.
Quality: heavy metals, pesticides and solvent residues in echinacea products were not covered, and no independent testing seal was verified.
Not read at source: the NIH LiverTox and LactMed entries, the German Commission E and WHO monographs (only second-hand summaries were seen), and the final EU root monograph. Statements about them are not made here.

How new research is added

New studies are found by a saved PubMed search and are placed in a review queue. A person reads each one before it changes any evidence rating, safety wording or dose information. New publications never change ratings automatically.

Lab markers

What changed in blood or saliva tests during trials. A changed number is not the same as feeling or being healthier, and we give no "normal ranges".

Organ function 1

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Hemoglobin and hematocrit

No clear change in trials

Hemoglobin is the oxygen-carrying protein in red blood cells; hematocrit is the share of blood made of red cells.

Low certainty

Results and what it means

Why it was measured

Used to see whether echinacea raises red blood cell levels in athletes.

Statistical vs. clinical meaning

Small positive effect sizes whose confidence intervals include zero; high inconsistency between studies.

Safety implication

None reported.

Study	Result	People	Product
²⁰	Hemoglobin effect size 0.38 (95% CI -0.04 to 0.80, I2=70%); hematocrit 0.34 (-0.10 to 0.78, I2=86%); not statistically significant	Athletes (6 studies, 107 athletes)	Echinacea vs placebo

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Other 13

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Respiratory virus detection and viral load

Mixed results in trials

Swabs or nasal samples tested by PCR to see which viruses are present and how much.

Low certainty

Results and what it means

Why it was measured

Shows whether an infection is real and whether treatment lowers the amount of virus.

Statistical vs. clinical meaning

Lower virus counts in one sponsor-funded open trial and in two sponsor-linked trials; challenge trial with root extract found nothing. Fewer viruses in a swab is not the same as feeling better.

Safety implication

None identified.

Study	Result	People	Product
⁵⁹	SARS-CoV-2-positive samples 5 vs 14 (RR 0.37, p=0.03); viral load reduced by at least 2.12 log10 and time to clearing virus shorter by 8.0 days (all viruses) during illness	120 healthy adults, open trial	Echinaforce 2,400 mg/day for prevention, 4,000 mg/day during illness
⁸⁰	Influenza detections 3 vs 20 (p=0.012); enveloped-virus detections 29 vs 47 (p=0.0038)	Children aged 4 to 12	Echinaforce Junior 400 mg three times a day vs vitamin C
⁵⁵	Fewer virally confirmed colds, especially enveloped viruses (P<0.05)	755 healthy adults	E. purpurea herb extract, 4 months
¹⁰⁵	No effect on rhinovirus infection or virus titre	399 volunteers analysed	E. angustifolia root extracts

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Nasal interleukin-8 and neutrophils

No clear change in trials

Signals and white blood cells in nasal-wash fluid that rise during a cold and show the strength of the local inflammatory response.

Low certainty

Results and what it means

Why it was measured

Used to test whether echinacea changes the immune response in the nose during a cold.

Statistical vs. clinical meaning

Neither trial found a measurable effect on these immune markers; this does not rule out effects of other preparations.

Safety implication

None.

Study	Result	People	Product
¹⁰	Median IL-8 change 58 ng/L (echinacea) vs 39 ng/L (placebo) and neutrophil change 2 vs 1 cells/hpf: not statistically significant	719 people with a new cold	E. angustifolia root tablets, 5 days
¹⁰⁵	No significant effect on IL-8 or polymorphonuclear leukocyte concentrations	399 volunteers analysed	E. angustifolia root extracts

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Antibiotic courses and days

Lowered in trials

How many antibiotic prescriptions or days of antibiotic treatment people needed.

Low certainty

Results and what it means

Why it was measured

A practical measure of complications and clinical need.

Statistical vs. clinical meaning

Large relative reductions but from few trials with possible bias.

Safety implication

Fewer antibiotics could mean fewer side effects, but treatment decisions should be made with a clinician.

Study	Result	People	Product
⁸⁰	6 courses in 6 children vs 24 courses in 15 children; 45 vs 216 antibiotic days (reduction 80.2%, p<0.001)	Children aged 4 to 12	Echinaforce Junior 400 mg three times a day vs vitamin C
²⁹	Need for antibiotics RR 0.60 (0.39 to 0.93); antibiotic days IRR 0.29 (0.11 to 0.74)	Pooled trials (5,652 people)	Echinacea preparations
⁸⁴	Antibiotic use RR 0.18 (0.13 to 0.25) in children	Children, pooled trials	E. purpurea products

^{80 29 84}

▼

State-Trait Anxiety Inventory (STAI)

Lowered in trials

A questionnaire where people rate their current (state) and general (trait) anxiety. Higher scores mean more anxiety.

Low certainty

Results and what it means

Why it was measured

The most common self-rated anxiety scale in the echinacea anxiety work.

Statistical vs. clinical meaning

Self-rated scores; short trials from the group that developed the extract.

Safety implication

None noted.

Study	Result	People	Product
⁴²	State anxiety about 11 points lower vs about 3 with placebo (p<0.01); maintained after 3-week washout	Volunteers with STAI above 45	E. angustifolia root extract 40 mg twice a day for 7 days
⁴¹	2 tablets a day lowered STAI within 3 days; 1 tablet did not	Healthy volunteers with high STAI	E. angustifolia extract 20 mg tablets, 7 days

^{42 41}

↕

HADS-A and Hamilton Anxiety Scale (HAM-A)

Mixed results in trials

HADS-A is a self-rated scale focused on psychic anxiety (worry). HAM-A is rated by a clinician and includes many body symptoms.

Low certainty

Results and what it means

Why it was measured

Used to test whether the choice of scale explains why some echinacea trials found an effect and others did not.

Statistical vs. clinical meaning

The authors of the 2025 report explain the earlier null result by the type of scale, but that is a post hoc explanation not yet confirmed in a new trial.

Safety implication

None noted.

Study	Result	People	Product
⁴³	HADS-A better than placebo; HAM-A total not significant; 3 psychic-anxiety HAM-A items better than placebo (numbers not in abstract)	Adults with anxiety	E. angustifolia EP107 extract
⁶³	CUXOS anxiety reduction not different from placebo at 20 or 40 mg twice a day	104 adults with mild-to-moderately severe anxiety	EP107 extract for 6 weeks

^{43 63}

▲

Positive and negative affect (PANAS)

Raised in trials

A questionnaire where people rate how often they feel positive or negative emotions.

Very low certainty

Results and what it means

Why it was measured

Measures day-to-day mood rather than anxiety.

Statistical vs. clinical meaning

Secondary outcome in one trial; needs confirming.

Safety implication

None noted.

Study	Result	People	Product
⁶³	Greater improvement than placebo in positive and negative affect at both doses (numbers not in abstract)	104 adults with mild-to-moderately severe anxiety	EP107 20 or 40 mg twice a day, 6 weeks

⁶³

▲

Saliva antibody (s-IgA)

Raised in trials

The main antibody found in saliva and on the lining of the nose and throat, part of the body's first line of defence.

Very low certainty

Results and what it means

Why it was measured

Hard exercise lowers s-IgA for a while, and researchers asked whether echinacea blunts that dip.

Statistical vs. clinical meaning

A small trial with no confidence intervals. A higher s-IgA reading does not by itself mean fewer infections; in this trial infection counts did not differ.

Safety implication

None reported.

Study	Result	People	Product
³⁹	s-IgA fell 45% after exercise in the placebo group and rose 7% in the echinacea group after 4 weeks; secretion rate fell 45% vs 7%	32 people who completed an exercise protocol	Echinacea purpurea supplement vs placebo, 4 weeks

³⁹

↕

Inflammation signals in blood (IL-6, TNF-alpha, IL-8, IL-10)

Mixed results in trials

Small proteins released by immune cells. IL-6, TNF-alpha and IL-8 promote inflammation; IL-10 calms it.

Very low certainty

Results and what it means

Why it was measured

Used to see whether echinacea shifts the body toward less inflammatory signalling.

Statistical vs. clinical meaning

Ten people, one dose, no placebo; a 24-hour change may be chance or daily variation. Not a clinical outcome.

Safety implication

None reported in the abstract.

Study	Result	People	Product
¹⁷	Lower IL-6, TNF-alpha and IL-8 and higher IL-10 at 24 hours than before the capsule (direction only; values not given in the abstract)	10 healthy volunteers	One 10 mg E. angustifolia lipophilic softgel

¹⁷

●

Erythropoietin (EPO)

No clear change in trials

A hormone, made mainly by the kidneys, that tells the body to make red blood cells.

Low certainty

Results and what it means

Why it was measured

Early reports suggested echinacea might raise EPO, which athletes care about.

Statistical vs. clinical meaning

Interval includes zero; only 6 small studies; moderate inconsistency.

Safety implication

None reported.

Study	Result	People	Product
²⁰	Effect size -0.29 (95% CI -0.75 to 0.17, I2=67%); not significant	Athletes (6 studies, 107 athletes)	Echinacea vs placebo

²⁰

●

Maximal oxygen uptake (VO2max)

No clear change in trials

The most oxygen the body can use during hard exercise, a measure of aerobic fitness.

Low certainty

Results and what it means

Why it was measured

Tests whether echinacea improves endurance capacity.

Statistical vs. clinical meaning

Consistent across studies (I2=0%) but the studies are few and small.

Safety implication

None reported.

Study	Result	People	Product
²⁰	Effect size -0.20 (95% CI -0.60 to 0.21, I2=0%); not significant	Athletes (6 studies, 107 athletes)	Echinacea vs placebo

²⁰

▼

Eczema severity score (local SCORAD)

Lowered in trials

A clinician's score of how severe eczema is in an area of skin: redness, swelling, oozing, scratch marks, dryness and itch.

Very low certainty

Results and what it means

Why it was measured

Used to judge whether an eczema cream helps.

Statistical vs. clinical meaning

Reported as statistically significant, but without group sizes or values in the abstract.

Safety implication

Cream was well tolerated in a patch test in the same report.

Study	Result	People	Product
⁸¹	Local SCORAD fell significantly versus baseline and versus the comparator; numbers not given in the abstract	People with atopic eczema (group size not in the abstract)	Echinacea purpurea alkylamide cream

⁸¹

▲

Skin barrier fats (ceramides, cholesterol)

Raised in trials

Fats between skin cells that keep moisture in and irritants out; often low in eczema.

Very low certainty

Results and what it means

Why it was measured

Used to see whether the cream strengthens the skin barrier.

Statistical vs. clinical meaning

Compared with baseline in a trial whose size is not in the abstract.

Safety implication

None reported.

Study	Result	People	Product
⁸¹	Higher total epidermal lipids, ceramide EOS and cholesterol at Day 15 than baseline; more lipid layers seen under the microscope	Skin trial volunteers (number not in the abstract)	Echinacea purpurea alkylamide cream

⁸¹

▲

Skin moisture (corneometer reading)

Raised in trials

An instrument reading of how much water is in the top layer of skin.

Very low certainty

Results and what it means

Why it was measured

Used to test cosmetic moisturising effects.

Statistical vs. clinical meaning

Ten people, no placebo group described, no p-values in the abstract.

Safety implication

No irritation.

Study	Result	People	Product
¹¹⁵	Hydration index up by up to 10.6 AU (cream) and 11.4 AU (gel) after 1 month; wrinkles down 9.47% and 14.92%	10 healthy volunteers aged 25-40	Echinacea purpurea cream or gel, 1 month

¹¹⁵

Dosage and forms

What researchers actually gave people in trials. These are study numbers, not advice for you.

300–2400mg of extract a day in most trials

2–5weeks is how long most trials lasted

200–6,000mg a day: the full range tested

5studies with a stated dose

Study doses are not advice and may not suit you. Ask a clinician or pharmacist.

How to read these numbers: four different kinds of dose

Four kinds of numbers must not be mixed. (1) Studied doses are what volunteers took in trials. They vary a lot because the products differ: for example 300 mg a day of pressed-juice powder for up to 14 days (no benefit); 200 mg a day of a 60 percent ethanol extract for 8 weeks (immune lab markers rose, cold scores did not change); 1,200 mg a day of a fresh-plant extract in children for two 2-month periods; 2,400 mg a day of the same maker's tablets for adult prevention, with 4,000 mg a day for acute symptoms up to 10 days; 8 mL a day of fluid extract for 8 weeks (no benefit); and root-equivalent doses of 5.1 to 10.2 g of dried root a day for 5 days (no significant benefit). Many abstracts do not give the dose. Milligrams of one product cannot be converted to another. (2) Label serving sizes are set by the maker and need not match any trial. A bottle may hold juice, tincture, dry extract, root powder, or a blend with sage, elderberry, zinc or vitamin C. (3) Official guidance: the EU herbal monograph for the fresh herb of E. purpurea (well-established use) gives 1.5 to 4.5 mL of expressed juice per dose and 6 to 9 mL a day for the short-term prevention and treatment of the common cold, not for more than 10 days, and not recommended under 12 years. It advises a doctor if symptoms last more than 10 days, says the product is not recommended in progressive systemic disorders, autoimmune diseases, immunodeficiency or immunosuppression and diseases of the white blood cell system, lists hypersensitivity to plants of the daisy family (Asteraceae) as a contraindication, warns that atopic people should ask a doctor first, and advises against use in pregnancy and breastfeeding unless a doctor says so. The root monographs (E. purpurea, E. pallida, E. angustifolia) are traditional-use only, with 10 days as the point to see a doctor for a cold. A 2005 safety review found short-term use carried a slight risk of mild, reversible effects such as stomach upsets and rashes and rare, sometimes severe allergic reactions. (4) Traditional amounts are the tea, powder and tincture doses in the traditional preparations list. Short-course use is the common thread: the regulators and most trials describe starting at the first signs of a cold and stopping within about 10 days, or prevention blocks of about 2 months to 4 months in a few maker-sponsored trials. Long-term safety beyond those periods was not covered by the sources we read. Echinacea can change how the body handles some medicines: in healthy volunteers, 8 days of E. purpurea root changed the clearance of midazolam and caffeine, so people on medicines cleared by CYP3A or CYP1A2 enzymes should ask a pharmacist. None of these four is a prescription; ask a clinician first if you are pregnant, breastfeeding, allergic to daisy-family plants, have asthma or an immune or autoimmune condition, or take medicines.

Doses used in studies 5

Treating a cold

Adults within 24 h of cold onset · 128 people · compared with lactose placebo

300 mg a day

100 mg three times a day · Until relief or 14 days

Freeze-dried pressed juice of the aerial parts · aerial parts

What the trial found

No difference in symptom scores or time to resolution (P=0.73).

¹¹⁴

Treating a cold

College students with a recent cold · 148 people · compared with placebo

6,000 mg a day

1 g six times on day 1, then 1 g three times a day (3,000 mg a day) · Up to 10 days

Capsules of unrefined herb and root mixture · herb 25% + E. purpurea root 25% + E. angustifolia root 50%

What the trial found

No significant difference; mean duration 6.27 days (echinacea) vs 5.75 (placebo).

⁹

Preventing respiratory infections and antibiotic use

Children 4-12 · 201 people · compared with vitamin c 50 mg three times a day (not placebo)

1,200 mg a day

400 mg three times a day · Two 2-month periods, 1-week break

Echinaforce Junior tablets · herb (fresh alcoholic extract) · 400 mg per tablet

What the trial found

Episodes OR 0.52 (0.30-0.91); antibiotic courses 6 vs 24; flu detections 3 vs 20.

⁸⁰

Preventing virus infections (incl. SARS-CoV-2)

Healthy adults 18-75 · 120 people · compared with no intervention (open)

2,400 mg a day

Daily for prevention; 4,000 mg a day for acute symptoms up to 10 days · Cycles of 2, 2 and 1 month with 1-week breaks

Echinaforce chewable tablets · herb (as Echinaforce)

What the trial found

SARS-CoV-2 positive samples 5 vs 14 (RR 0.37, p=0.03); fever days 1 vs 11; symptom severity unchanged.

⁵⁹

Immune markers

Healthy Korean adults · 80 people · compared with placebo

200 mg a day

Once daily (schedule not stated) · 8 weeks

60% ethanolic extract of E. purpurea · unspecified

What the trial found

NK-cell activity and IL-2, IFN-gamma and TNF-alpha rose; cold-symptom and fatigue scores unchanged.

⁶⁰

Traditional preparations Ayurveda, not clinical dosing

Expressed juice of fresh flowering herb (E. purpurea herba recens)

European (EU herbal monograph, well-established use)

Single dose 1.5-4.5 mL expressed juice; daily dose 6-9 mL; for short-term prevention and treatment of the common cold; do not use for more than 10 days; start at first signs of a cold

The regulator classes this as well-established medicinal use, not traditional use; not recommended under 12 years. Product must be an expressed juice (drug-extract ratio 1.5-2.5:1) or the dried juice.

Dried expressed juice (E. purpurea herb)

European (EU herbal monograph)

Doses should correspond to the expressed juice posology above

Same limits: up to 10 days, not under 12 years.

Ointment or cream with expressed juice (E. purpurea herb), skin use

European (EU herbal monograph, traditional use)

10-20 g of expressed juice per 100 g of product; apply a small amount to the area 2-3 times a day; not for more than 1 week

For small superficial wounds only; traditional use exclusively; see a doctor if signs of skin infection. Not for the breast of breastfeeding women.

Dry ethanolic root extract (E. purpurea root, DER 5.5-7.5:1, ethanol 45%)

European (EU herbal monograph, traditional use)

40 mg every second hour, daily dose 360 mg (40 mg nine times a day), for relief of common cold symptoms; start at first signs; see a doctor if over 10 days

Oral and oromucosal (lozenge-type) solid forms; material complies with Ph. Eur. monograph 1824.

Dry aqueous root extract (E. purpurea root, DER 4:1, water)

European (EU herbal monograph, traditional use)

Adults and elderly: 50-100 mg per dose, 150-300 mg a day; adolescents: 50 mg per dose, 100 mg a day; for mild acne spots and pimples; see a doctor if over 2 weeks

Traditional use only; not recommended under 12 years.

Dry ethanolic root extract (E. pallida root, DER 4-8:1, ethanol 50%)

European (EU herbal monograph, traditional use)

24-30 mg per dose, 90-96 mg a day, for relief of common cold symptoms; see a doctor if over 10 days

Material complies with Ph. Eur. monograph 1822; oral and oromucosal.

Tincture of pale coneflower root (E. pallida root 1:5, ethanol 50%)

European (EU herbal monograph, traditional use)

25 drops per dose; 125 drops a day

Drop size and alcohol content: follow the product label; ethanol warning applies.

Tea (infusion or decoction) of narrow-leaved coneflower root (E. angustifolia root)

European (EU herbal monograph, traditional use)

1 g of cut root in 150 mL boiling water, infused at least 10 minutes (or simmered 10 minutes as a decoction), three times a day

Supportive treatment of common cold; start at first signs; see a doctor if over 10 days; not under 12 years.

Powdered root (E. angustifolia)

European (EU herbal monograph, traditional use)

500 mg up to three times a day

Same limits as the tea.

Tincture of narrow-leaved coneflower root (1:5, ethanol 45%)

European (EU herbal monograph, traditional use)

1-2 mL three times a day

Same limits as the tea.

Liquid extract of narrow-leaved coneflower root (DER 1:1, ethanol 45%)

European (EU herbal monograph, traditional use)

0.25-1 mL three times a day

No trial read; regulator documents only.

²³

Safety

What studies and official sources say about side effects, medicines and who should check first. Each point shows what kind of evidence it comes from.

Main points to know 10

Short-term use looks well tolerated in trials, but allergic reactions can be serious. A 2005 systematic review found that side effects with echinacea are not commonly reported, with stomach and gut upsets and rashes most frequent, and rare allergic reactions that may be severe. The 2014 Cochrane review (24 trials, 4631 people) found that drop-outs and side effects did not differ significantly from placebo, with a non-significant trend to more drop-outs from side effects in prevention trials. In a 4-month trial of 755 healthy adults, 49.9% of people on a fresh-herb extract and 47.5% on placebo reported at least one adverse event, and no serious events occurred with echinacea. NCCIH says it is likely safe for most adults for short periods, with digestive upset the most common effect. These trials were mostly short, used different products, and cannot rule out reactions that are uncommon. Systematic review ^{73 53 57 55 3}
People with allergies (hay fever, asthma, eczema) or allergy to daisy-family plants are the main group at risk. Echinacea belongs to the daisy family (Asteraceae), the same family as ragweed. The EU monographs list allergy to echinacea or other daisy-family plants as a reason not to use it and warn of possible severe reactions in people prone to allergy (atopic). Case reports and Australian drug-reaction reports describe anaphylaxis, asthma attacks, hives and swelling, some after the very first dose. In one Australian review 20% of 100 allergy-prone people who had never taken echinacea had a positive skin-prick test to it, which led the authors to suggest cross-reactivity with other allergens. This is a hypothesis; how often serious reactions happen is unknown. Case series ^{26 27 72 71 53}
Rash is the clearest signal in children. In a 2003 randomised trial of 407 children aged 2 to 11, rash occurred in 7.1% of infections treated with echinacea versus 2.7% with placebo (P=.008), although overall adverse events did not differ. A 2025 meta-analysis of 9 trials in children found adverse events moderately more common with echinacea (RR 1.38, 95% CI 1.08 to 1.78) but generally mild. NCCIH says reactions could be severe in children and to talk to the child's health care provider first. The EU monographs do not recommend use under 12 years. Controlled trial ^{101 84 73 26}
Autoimmune disease and weakened immunity: official advice says avoid it, but the evidence of harm is thin. Echinacea is traditionally described as an immune stimulant, so the EU monographs say it is not recommended in autoimmune diseases, immune deficiency, immune suppression and diseases of the white blood cell system, and that an association with autoimmune disease cannot be excluded. NCCIH says there are theoretical reasons to suspect an interaction with immunosuppressants. This is a precaution based on how echinacea is thought to act, not on trials showing flare-ups. One 2016 safety review calls the contraindication questionable, and a small pilot of 51 people with autoimmune uveitis reported no adverse reactions to echinacea. Individual case reports link echinacea with erythema nodosum, a blood-platelet disorder and a liver injury with autoimmune features, but their details are limited. Until better data exist, people with these conditions, or taking immune-suppressing medicines, should talk to their doctor first. Pharmacological theory ^{26 27 73 3 77 97 61 58}
Mild drug interactions are possible, mainly through liver enzymes. In healthy volunteers, echinacea root at 400 mg four times a day for 8 days raised liver CYP3A activity (IV midazolam clearance up 34%) while lowering gut CYP3A activity, and slowed caffeine clearance (CYP1A2) by about a quarter. A second study (500 mg three times a day for 28 days) found midazolam exposure fell 27%. Other studies found no change with lopinavir-ritonavir, docetaxel or a 28-day probe test, and only a small change in warfarin handling without a change in clotting (INR). The net effect depends on the drug. EU monographs say no interactions have been reported; NCCIH says the evidence is conflicting. Controlled trial ^{35 82 38 34 2 73}
Liver injury has been reported only in isolated cases. Case reports include a 39-year-old woman who developed jaundice 10 days after starting a six-herb immune mix that contained echinacea (liver enzymes in the thousands, recovered after stopping) and a letter describing acute hepatitis attributed to echinacea itself. A search summary of NIH's LiverTox says there have been isolated reports of enzyme elevations and clinically apparent liver injury, and that echinacea alone has not been linked to liver injury in multiple controlled trials. No study measures how often this happens. Case report ^{89 58 74 55}
Serious reactions in national reports usually involved other medicines too. In Australian spontaneous reports from 2000 to 2015, most reactions to echinacea, valerian, black cohosh and ginkgo were mild or moderate. Each herb had life-threatening reports, and in each of those the herb had been taken together with prescription medicines. The authors say most severe reactions involved a herb-drug interaction. Spontaneous reports cannot give rates and cannot prove the herb caused the reaction. Case series ⁵¹
Pregnancy and breastfeeding: reassuring cohort data, but official advice is cautious. A Norwegian cohort of 68,522 pregnancies, including 363 with echinacea use, found no link to malformations or adverse pregnancy outcomes. NCCIH says some studies suggest it is possibly safe for up to 7 days in the first trimester. The EU herba monograph notes several hundred exposed pregnancies without adverse effects but still does not recommend use in pregnancy and lactation unless a doctor advises it, and the root monograph draft does not recommend it. A mouse study raised a question about effects on fetal blood-vessel growth. For breastfeeding the data are very limited. Authoritative guidance ^{48 73 26 27 83 7}
Use short courses; the official limits are 10 days (EU) and long-term use has been tested up to about 6 months. The EU herba monograph says not to use the product for more than 10 days for prevention and treatment of the common cold, and not more than 1 week for the skin-use traditional product. Secondhand reports of the German Commission E say continuous use for more than 6 to 8 weeks was discouraged. A 1998 review warned about liver toxicity beyond 8 weeks, as a precaution. Against this, a 4-month trial of 755 adults found no safety signal and a 2016 review said published studies up to 6 months raised no toxicity concerns. Long-term safety beyond about 6 months is not established. Authoritative guidance ^{26 30 69 55 3}
Product quality and identity are a real safety issue. In a Denver survey of 59 retail products, 6 (10%) contained no measurable echinacea and only 52% matched the labelled species. In a European survey of 53 products, ingredient label fidelity was 43%. A small Polish survey of 21 supplements found moulds and mycotoxins. A 2025 industry bulletin summary says the historic adulterant, prairie dock (Parthenium), has not been reported in recent studies, while species mix-ups, undeclared leaf and Cistanche substitution are current concerns. Findings come from sampled products and vary by country and year. Laboratory research ^{32 86 85 45}

Side effects 11

Effect	How often	Severity and recovery	Evidence
Stomach and gut upset (abdominal pain, nausea, stomach pain) NCCIH calls these the most common side effects; the 2005 review says gut upsets and rashes are most frequent. No percentage in the sources we read.	Not established	mild Reversible	Authoritative guidance ^{73 53 3}
Rash EU monograph lists rash, urticaria, itching and facial swelling with frequency not known.	7.1% of infections treated with echinacea versus 2.7% with placebo in children aged 2 to 11 (Taylor 2003)	mild to moderate Usually reversible on stopping (recurred on rechallenge in one case)	Controlled trial ^{101 72 26 73}
Allergic reactions: hives, swelling (angioedema), asthma attacks In 51 Australian reports, 26 suggested IgE-mediated allergy (12 acute asthma, 10 hives or angioedema, 4 anaphylaxis); 4 were hospitalised. These are reports, not rates.	Not established	moderate to severe Resolves with treatment and avoidance; reactions can recur on re-exposure	Case series ^{72 71 26 53}
Anaphylaxis Confirmed by skin-prick and RAST testing in a woman with atopy. The EU monograph lists anaphylactic shock, frequency not known.	Not established	severe Needs emergency treatment	Case report ^{71 72 26}
Severe skin reactions (Stevens-Johnson syndrome) and bronchospasm with airway obstruction Listed in the EU herba monograph as reported, with frequency not known. We did not find the underlying case reports.	Not established	severe Unknown	Authoritative guidance ²⁶
Erythema nodosum (tender red lumps on the skin) A single case, described as perhaps causally linked.	Not established	moderate Recurred with echinacea in one reported patient	Case report ⁹⁷
Thrombotic thrombocytopenic purpura (low platelets with clotting) Only the title of this letter was available. Cannot be assessed further.	Not established	severe Unknown (details not read)	Case report ⁶¹
Low platelets during etoposide chemotherapy One patient on cisplatin, etoposide and radiation; chemotherapy itself lowers platelets.	Not established	severe Improved in the next cycle after echinacea was stopped	Case report ¹²
Liver injury (jaundice, high liver enzymes) See the liver section. Frequency unknown.	Not established	moderate to severe Recovered after stopping in the case we could read	Case report ^{89 58 74}
Possible association with autoimmune disease The EU monograph says an association with autoimmune diseases cannot be excluded. This is a caution, not a demonstrated effect.	Not established	unknown Unknown	Authoritative guidance ^{26 58}
Events in long trials looked similar to placebo One manufacturer's fresh-herb extract in healthy adults; may not apply to other products or to sick or allergic people.	177 of 355 (49.9%) on echinacea versus 172 of 362 (47.5%) on placebo reported any adverse event over 4 months; stopping because of side effects 0.8% versus 0.6%	mostly mild Not applicable	Controlled trial ^{55 59 57}

Liver

Liver injury from echinacea is described only in isolated case reports. The case we could read in detail is a 39-year-old woman who developed jaundice, dark urine, pale stools and itching 10 days after starting a herbal immune mix of six plants (St John's wort, elecampane, kopeichnik, echinacea, licorice, rosehip); ALT reached 2800 U/L and AST 1776 U/L, viral hepatitis tests were negative, and everything cleared after the mix was stopped. Because six herbs were taken together, echinacea cannot be named as the cause. A separate letter titled 'Echinacea-induced severe acute hepatitis with features of cholestatic autoimmune hepatitis' exists, but we could read only its title. A search summary of NIH's LiverTox record says echinacea is generally well tolerated, with isolated reports of enzyme elevations and clinically apparent liver injury, and that controlled trials of echinacea alone have not linked it to liver injury; we could not open the record to see its likelihood score or case list. A 1998 review warned that use beyond 8 weeks might cause liver toxicity and advised against combining with known liver-toxic drugs, while noting echinacea lacks the chemical ring structure that makes some pyrrolizidine alkaloids toxic to the liver. In the 4-month trial of 755 adults no clinically relevant changes in blood chemistry were reported, though liver enzymes were not reported separately in the text we read. ^{89 58 74 69 55}

How often. No study measures how often echinacea causes liver injury, so no rate can be given. LiverTox wording ('isolated reports') comes from a search summary, not from the record itself.

Monitoring. No monitoring is recommended in the sources we read. Anyone with yellow skin or eyes, dark urine, pale stools or severe itching should stop and see a doctor.

Reznik 2021, Terapevticheskii Arkhiv (article in Russian) (1 woman, aged 39 patients). Jaundice, dark urine, pale stools, itching, 10 days after starting; ALT up to 2800 U/L, AST up to 1776 U/L, viral hepatitis markers negative Other possible causes: Six-herb mixture including St John's wort and licorice; echinacea only one ingredient ⁸⁹
Kocaman 2008, European Journal of Internal Medicine (letter) (1 (details not read) patients). Title: severe acute hepatitis with features of cholestatic autoimmune hepatitis Other possible causes: Not available (title only) ⁵⁸

This is a safety connection. It is not evidence that Echinacea supports liver health.

Medicines and supplements 8

With	Why it matters	Importance	Evidence	What to do
Medicines the liver breaks down through CYP3A, including midazolam and many others prescription	Echinacea root (400 mg four times a day, 8 days) raised liver CYP3A activity and lowered gut CYP3A activity in 12 volunteers: IV midazolam clearance +34%, oral availability up (gut) while liver availability down. In 13 volunteers (500 mg three times a day, 28 days) midazolam exposure fell 27% (AUC ratio 0.73). A 28-day phenotype study in 12 volunteers found no significant change. Cell studies disagree: one showed PXR activation and higher CYP3A4 expression, another showed no change in CYP3A4 mRNA.	Modest, direction depends on the drug and how much is cleared by gut versus liver. The authors of the 2010 study say it may cause modest decreases in blood levels of some CYP3A drugs. Which real drugs are affected has not been tested.	Controlled trial Low certainty ^{35 82 38 5 70 73}	Tell the doctor or pharmacist if taking prescription medicines, especially those with a narrow safety margin (for example transplant, cancer or blood-thinning medicines), before using echinacea.
Caffeine and other medicines cleared by CYP1A2 otc	Oral clearance of caffeine fell from 6.6 to 4.9 L/h (P=.049, 90% CI of ratio 58%-96%) in 12 volunteers after 8 days of echinacea root. The 28-day phenotype study found no significant CYP1A2 effect.	Small and inconsistent; NCCIH says theoretical reasons suggest an interaction with caffeine. No study tested effects on caffeine sensitivity or other CYP1A2 drugs.	Controlled trial Very low certainty ^{35 38 73}	Heavy caffeine users may notice jitteriness; people on CYP1A2-dependent medicines should ask a pharmacist.
Ritonavir-boosted HIV protease inhibitors (lopinavir-ritonavir) prescription	Ritonavir is a strong CYP3A inhibitor and masked echinacea's induction.	In 13 volunteers lopinavir AUC ratio was 0.96 (90% CI 0.83-1.10) and ritonavir exposure did not change significantly after 14 days of echinacea 500 mg three times a day.	Controlled trial Low certainty ⁸²	No change was seen with this combination in the study, but ask the HIV care team before use.
Docetaxel (chemotherapy) prescription	Tested because echinacea may affect CYP3A4.	In 10 cancer patients, 14 days of echinacea drops did not significantly change docetaxel AUC (3278 versus 3480 ng.h/ml), half-life or peak.	Controlled trial Low certainty ³⁴	Not a reason to start echinacea during chemotherapy; discuss with the oncology team.
Etoposide (chemotherapy) prescription	Proposed CYP3A4 interaction (idea only).	One case report of severe low platelets in a patient on cisplatin, etoposide and radiation who was taking echinacea; the next cycle without echinacea had a milder platelet drop. Chemotherapy alone also causes this.	Case report Very low certainty ¹²	Avoid echinacea during chemotherapy unless the oncology team agrees.
Warfarin prescription	In 12 healthy men echinacea for 2 weeks increased (S)-warfarin apparent clearance (ratio 90% CI 1.01 to 1.18).	No clinically significant change in INR (AUC of INR 90% CI 0.91 to 1.31) or platelet aggregation after a single warfarin dose. Long-term warfarin patients were not tested.	Controlled trial Low certainty ²	People on warfarin should tell their clinician and have INR checked if they start or stop echinacea.
Immunosuppressant and immune-modifying medicines (for example cyclosporine, tacrolimus, corticosteroids, methotrexate, biologic drugs) prescription	Echinacea is described as an immune stimulant, so it might work against these drugs. The 2016 safety review points out that alkamide-rich preparations suppress some cellular immune responses, so the direction is unclear.	EU monographs do not recommend use with immunosuppression; NCCIH says a theoretical interaction. No human trial of echinacea with these drugs was found.	Pharmacological theory Very low certainty ^{26 27 73 3}	Do not combine unless a specialist agrees, particularly after an organ transplant.
Other medicines known to harm the liver (for example amiodarone, methotrexate, ketoconazole, anabolic steroids) prescription	A 1998 review said echinacea used beyond 8 weeks could cause liver toxicity and so should not be combined with known liver-toxic drugs (reasoning, not cases).	Not shown in studies; isolated liver case reports exist.	Pharmacological theory Very low certainty ^{69 89}	Keep courses short and check with the prescriber.

Who should check first 10

Situation	Advice	Evidence
Allergy to echinacea or to other daisy-family (Asteraceae/Compositae) plants such as ragweed, chrysanthemum, marigold, daisies	Do not use. Both EU monographs list hypersensitivity to the active substance and to other Asteraceae as a contraindication.	Authoritative guidance ^{26 27 73}
Allergy-prone people (hay fever, allergic asthma, eczema, past anaphylaxis)	Talk to a doctor first. The EU monographs warn of a possible risk of severe hypersensitivity or anaphylaxis in atopic patients.	Case series ^{26 72 71}
Autoimmune disease, immune deficiency, immune-suppressing treatment, diseases of the white blood cells	Not recommended in the EU monographs. This is a precaution based on echinacea's presumed immune stimulation rather than proven harm; seek specialist advice.	Pharmacological theory ^{26 27 3 77}
Progressive systemic illnesses such as tuberculosis, leukaemia, connective tissue disease, multiple sclerosis, HIV/AIDS	German Commission E contraindications, reported second-hand, list these. The EU monographs use the broader wording above.	Authoritative guidance ³⁰
Children under 12	Not recommended in the EU monographs for lack of data. Rash was more frequent in one trial of children aged 2 to 11. NCCIH says to ask the child's health care provider first.	Controlled trial ^{26 27 101 73 84}
Pregnancy	Not recommended unless a doctor advises (EU monographs). A Norwegian cohort found no excess malformations and NCCIH says possibly safe for up to 7 days in the first trimester, so exposure by accident is not a reason for alarm, but the data are limited.	Authoritative guidance ^{26 27 48 73 83 7}
Breastfeeding	Little is known (NCCIH). The EU monograph does not recommend use unless a doctor advises, and says echinacea products should not be applied to the breast. LactMed (second-hand summary) reports alkamides in the milk of one mother and no safety data.	Authoritative guidance ^{73 26 75 83}
Taking chemotherapy, transplant medicines or other medicines with a narrow safety margin	Ask the treating team first; see the interactions section.	Case report ^{12 82 73}
History of liver disease or unexplained liver tests	No formal contraindication in the sources we read; given isolated liver case reports, ask a doctor.	Case report ^{89 58}
Long continuous use	EU herba monograph: no more than 10 days for a cold; skin use no more than 1 week. See the duration note in key safety.	Authoritative guidance ^{26 30}

Overdose, product quality and regulators

Summary. Laboratory and animal tests of the best-studied preparation (fresh-herb expressed juice) show low toxicity, and no overdose has been reported in the EU monographs. Reproductive toxicity and cancer tests have not been done for that juice, so these are unknown. The main real-world risks are allergy and quality problems, not poisoning.

Animal. EU herba monograph: expressed juice of Echinacea purpurea showed no toxicity in single-dose rodent tests and 4-week repeated-dose rodent tests. Reproductive toxicity and carcinogenicity tests were not performed. A purified lectin injected into mice (5 microg four times a week for 5 weeks) caused kidney glomerular vacuolisation and tubular necrosis; this was an isolated protein by injection and not an oral product. In pregnant mice, alcoholic E. purpurea products changed blood-vessel growth activity in fetal tissue in a product-dependent way and slightly reduced litter size on the border of significance.

Human doses studied. Echinaforce fresh-herb extract at 2,400 mg extract a day (up to 4,000 mg a day during colds) for 4 months in 755 adults without a safety signal; 800 mg three times a day in cycles over about 23 weeks in 120 volunteers; echinacea root 400 mg four times a day for 8 days, and 500 mg three times a day for 28 days, in interaction studies.

High dose or long term signals. No toxic dose was identified in humans in the sources we read. Official limits on duration (10 days EU herba; 6 to 8 weeks Commission E, second-hand) are precautionary. Trials reached 4 to about 6 months.

Overdose response. The EU monographs state no case of overdose has been reported. We did not find any overdose case series.

Genotoxicity. EU herba monograph: expressed juice was negative in in vitro and in vivo genotoxicity studies. The draft root monograph says genotoxicity and carcinogenicity tests for root preparations had not been performed.

Echinacea is one of the best-selling herbs and it is often mislabelled. Studies of retail products found missing or wrong species, low fidelity to the label, and mould toxins. Allergy risk depends on what is actually in the bottle, so quality matters.

Wrong or missing echinacea in retail products. Of 59 single-herb products bought in Denver in 2000, 6 (10%) had no measurable echinacea, species matched the label in 31 (52%), and 9 of 21 products labelled standardised (43%) met the label standard. ³²

Label fidelity in Europe. In 53 products sold across Europe tested by HPTLC and DNA metabarcoding, echinacea DNA was found in 34 of 38 retained products (89%), the method could not separate Echinacea species, and overall ingredient fidelity to the label was 43%. ⁸⁶

Species mix-ups: E. purpurea, E. angustifolia and E. pallida. A 2025 BAPP bulletin summary says most authenticity problems likely come from inadvertent blending of two Echinacea species in the same batch, with some deliberate cases. Safety data are product-specific, and the roots, leaves and flowers differ in chemistry, so a mix-up changes what the person is exposed to. ^{45 3}

Prairie dock (Parthenium integrifolium, also called American feverfew). Historically the main adulterant of echinacea root; a 1987 German paper detected it in E. purpurea products. The 2025 BAPP summary says recent authenticity studies have not reported it. Prairie dock is also a daisy-family plant; whether it adds allergy risk was not found in our sources. The 'American feverfew' name should not be confused with feverfew (Tanacetum parthenium). ^{45 47}

Other substitutions: Cistanche and undeclared leaf. Reported in some root extracts, per the 2025 BAPP summary (the bulletin itself was not read). ⁴⁵

Mould and mycotoxins. In 21 Polish supplements the average mould count was 1012 cfu/g; zearalenone was present in 18 of 21, deoxynivalenol in 5 of 21 and T-2 toxin in 3 of 21 (levels versus limits not in the abstract). ⁸⁵

Body	Action	Date
European Medicines Agency, Committee on Herbal Medicinal Products (HMPC) (European Union)	Herbal monograph for Echinacea purpurea herba recens (expressed juice): well-established use for short-term prevention and treatment of the common cold, no more than 10 days; traditional use for small superficial wounds (skin use, no more than 1 week). Contraindicated in hypersensitivity to echinacea or other Asteraceae. Not recommended in autoimmune disease, immune deficiency, immune suppression and white-blood-cell diseases; atopic patients should consult a doctor; not recommended under 12 years; pregnancy and lactation not recommended unless advised by a doctor (several hundred exposed pregnancies without adverse effects). Undesirable effects: rash, urticaria, itching, facial swelling, and severe reactions including Stevens-Johnson syndrome, angioedema, asthma and anaphylactic shock, frequency not known. Interactions: none reported. No overdose reported. source	2014-11-24 (adopted); corrected version 2015-11-24
European Medicines Agency, HMPC (draft) (European Union)	Draft monograph for Echinacea purpurea radix dry extracts: traditional use for relief of common cold symptoms and for spots and pimples due to mild acne. Same contraindication for Asteraceae allergy; not recommended in autoimmune disease and immune suppression; possible anaphylactic risk in atopic patients; not recommended under 12 years; pregnancy and lactation not recommended; skin hypersensitivity reactions, frequency not known; interactions none reported. Whether a final version has replaced this draft was not checked. Monographs for E. angustifolia and E. pallida roots exist but were not read. source	2016-11-22
U.S. Food and Drug Administration / NIH (NCCIH) (United States)	Sold as a dietary supplement; not approved by FDA before sale (per NCCIH). NCCIH: likely safe for most adults for short periods; allergic reactions may be severe; common side effects are digestive; possibly safe for children short term but some developed rashes; conflicting evidence about interactions with liver-processed drugs and theoretical concern with immunosuppressants and caffeine; possibly safe up to 7 days in the first trimester; little known about breastfeeding. No FDA-specific echinacea safety action was found. source	NCCIH page read 2026-10-24 (page date not shown)
Health Canada (Canada)	Labelling standard for echinacea root lists dosage for adults and a sore-throat warning (see a doctor if severe or lasting more than 2 days); the page lists no contraindication, pregnancy or autoimmune statements. source

When to get medical help

Trouble breathing, wheezing, throat or tongue swelling, hives all over, dizziness or fainting soon after taking echinacea: call emergency services. This can be anaphylaxis.
A rash with blisters, peeling skin or sores in the mouth or eyes: stop echinacea and get urgent medical care.
Yellow skin or eyes, dark urine, pale stools, severe itching, or nausea with pain in the upper right belly: stop echinacea and get medical care the same day.
New easy bruising, tiny red or purple spots on the skin, nosebleeds or confusion, especially during chemotherapy: stop echinacea and get urgent care.
New asthma attacks or worse asthma after starting echinacea: stop it and see a doctor promptly.
A new rash in a child after echinacea: stop it and call the child's doctor.

Stop the supplement and contact a clinician or emergency service. In the US, Poison Control is 1-800-222-1222.

General information only, not medical advice. Ask a clinician or pharmacist before use, especially with medicines, in pregnancy or with a health condition. See the Natural Remedy Safety guide.

Frequently asked questions

Does echinacea prevent colds?

It might lower the chance a little. The independent Cochrane review found no single prevention trial that proved it, but a post hoc pooling suggested 10% to 20% fewer colds, and a 2019 pooled analysis found a risk ratio of 0.78, which the authors said might not matter much in daily life. Trials that were not clearly positive used other products. Many of the positive trials used one maker's fresh-plant extract. Certainty is low and reviews disagree.

^{57 18 55 92 79}

Does echinacea treat a cold once I have it?

Probably not much. Most of the best-designed trials found that taking it after symptoms start did not shorten the cold or make it clearly milder; the Cochrane review found only 1 of 7 treatment trials with a significant benefit. A few trials of specific standardised fresh-plant products found some benefit, so results depend heavily on the product. Certainty is low.

^{57 18 10 9 114 33 13}

How long should I take echinacea?

Keep courses short. The EU limit for the fresh-herb juice is no more than 10 days for a cold, and it advises seeing a doctor if symptoms last longer. In the trials, prevention blocks lasted about 2 to 4 months in a few maker-sponsored studies, and the longest ran about 6 months. Long-term safety beyond that is not established.

^{23 26 55 3}

Which species and plant part should I choose?

No species or part has been shown to be best. The three species (E. purpurea, E. angustifolia, E. pallida) differ chemically, and so do the herb, root and whole plant. The EU monograph for the fresh juice covers E. purpurea only, and E. angustifolia root extracts did not work in the large virus-challenge trial. Choose a product that names the species and the part used, and do not assume a result from one product applies to another.

^{105 8 116 23}

Is echinacea safe for children?

Be careful. The EU does not recommend it under 12 years for lack of data, and the US NIH says to ask the child's health care provider first. In one large trial of 407 children aged 2 to 11, rash occurred in 7.1% of infections treated with echinacea versus 2.7% with placebo. A 2025 pooled analysis found mild side effects moderately more common (risk ratio 1.38). Benefits in children are mixed and several trials were funded by the product maker.

^{101 84 26 73 80}

Can I take echinacea in pregnancy or while breastfeeding?

Ask a doctor first. The EU does not recommend it in pregnancy or breastfeeding unless a doctor advises. A Norwegian cohort of 363 pregnancies exposed to echinacea found no link to malformations or adverse outcomes, and the US NIH says up to 7 days in the first trimester is possibly safe, so a past exposure is not a reason for alarm. The data are too small to exclude rare problems. Breastfeeding data are very limited.

^{48 26 73 7}

Can I take echinacea if I have an autoimmune disease or take immune-suppressing medicine?

Ask your specialist first. The EU advises against it in autoimmune disease, immune deficiency and immune suppression because echinacea is described as an immune stimulant. This is a precaution based on theory: no trial showed flare-ups, and one 2016 review calls the contraindication questionable. A small pilot of 51 people with autoimmune uveitis reported no adverse reactions. Do not combine it with transplant medicines unless a specialist agrees.

^{26 27 3 77 73}

Does echinacea interact with medicines?

Possibly, but the findings are mixed. In small volunteer studies echinacea root changed how the body handles midazolam (a CYP3A medicine, in opposite directions in liver and gut) and slowed caffeine clearance by about a quarter in one study. Other studies found no change with lopinavir-ritonavir, docetaxel or warfarin (clotting did not change). One case report links it with low platelets during etoposide chemotherapy. The EU says no interactions have been reported and the NIH says the evidence is conflicting. Ask a pharmacist, especially with chemotherapy, transplant or narrow-margin medicines.

^{35 82 2 34 12 73}

Who should not use echinacea because of allergy?

Anyone allergic to echinacea or to other daisy-family (Asteraceae) plants such as ragweed, chrysanthemum, marigold or daisies should not use it. People with hay fever, allergic asthma, eczema or a past severe reaction should ask a doctor first. Reports describe hives, swelling, asthma attacks and anaphylaxis, some after the first dose. Stop and get emergency help for trouble breathing, throat swelling or fainting.

^{26 72 71 73}

What are the side effects?

Usually mild: stomach upset, nausea, abdominal pain and rash. In a 4-month trial of 755 healthy adults, 49.9% on a fresh-herb extract and 47.5% on placebo reported any adverse event, and stopping because of side effects was rare. Serious but rare reports include allergic reactions, a few severe skin reactions listed by the EU, and isolated liver injury cases. How often these happen is unknown.

^{53 55 57 89 26}

What is the best form of echinacea?

No form has been proven best. Trials of pressed juice and a maker's fresh-plant extract gave the most positive results, but those trials are mostly maker-linked, and a pressed-juice powder, root capsules and E. angustifolia root extracts found no benefit. For quality, look for the species and plant part, the extract type and amount, and independent testing. A 2018 DNA study of 53 European products found label fidelity of only 43%, so labels cannot be taken for granted.

^{13 114 9 105 86}

Does echinacea boost the immune system?

It changes some immune signals in lab dishes, animals and a few small human studies, but that has not been shown to make people healthier. In 80 adults, a 60% ethanol extract raised natural killer cell activity without changing cold or fatigue scores. Another small study found it kept saliva antibodies from falling after hard exercise. Boosting is not a measured medical outcome, and in autoimmune disease it is a reason for caution, not a benefit.

^{60 39 17 112 26}

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Editorial transparency

Written by: AlternativeMed editorial team. Research compiled with AI assistance, then checked against PubMed records.
Medical review: None. This page has not been reviewed by a physician or pharmacist.
First published: 2026-10-24
Last substantive update: 2026-10-24
How we research: We searched PubMed, NIH NCCIH, the EU herbal monographs and other regulators' pages, opened each source and recorded the study design, people, product, dose and result as reported. Most studies were read as abstracts only; the EU monographs and assessment reports were read in full. Some sources (the NIH LiverTox and LactMed entries and the Commission E and WHO monographs) could not be read directly, and nothing is claimed about them beyond what is marked. Facts about early Native American use and ancient history rest on the EU assessment report and encyclopedia summaries and are marked as not verified at source. No study is cited that we could not verify.
How we rate evidence: See "How we rate evidence" in the Evidence tab.
Independence: No product is promoted on this page. No affiliate links are shown. If one is added later it will be labelled and kept apart from the evidence.

Sources 119

Each source was opened and checked. Where we read only the abstract, it says so. The small numbers in the text point here.

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Deccy S, Bartkowiak C, Rodricks N, et al.. Echinacea Supplementation Does Not Impact Aerobic Capacity and Erythropoiesis in Athletes: A Meta-Analysis.. Nutrients. 2024. PMID 38999738. DOI 10.3390/nu16131991. (abstract)
Declerck K, Novo CP, Grielens L et al.. Echinacea purpurea (L.) Moench treatment of monocytes promotes tonic interferon signaling, increased innate immunity gene expression and DNA repeat hypermethylated silencing of endogenous retroviral sequences. BMC Complement Med Ther. 2021. PMID 33980308. DOI 10.1186/s12906-021-03310-5. (abstract)
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Haller J, Freund TF, Pelczer KG, et al.. The anxiolytic potential and psychotropic side effects of an echinacea preparation in laboratory animals and healthy volunteers.. Phytother Res. 2013. PMID 22451347. DOI 10.1002/ptr.4677. (abstract)
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. EMA/HMPC/557979/2013: Assessment report on Echinacea purpurea (L.) Moench, herba recens (final, 24 November 2014). . . (full-text)
. EMA/HMPC/424584/2016: Assessment report on Echinacea purpurea (L.) Moench, radix (DRAFT, 22 November 2016). . . (full-text)
. GBIF Backbone Taxonomy: Echinacea Moench (genus key 3150914), E. purpurea (3150935), E. angustifolia (3150933), E. pallida (3150919). . . (full-text)
. NCBI Taxonomy: Echinacea (TaxId 53747), E. purpurea (53751), E. angustifolia (308558), E. pallida (53749). . . (full-text)

Education, not medical advice. This page is for general information. It does not diagnose or treat any condition and is not a substitute for care from a qualified health professional. Natural does not automatically mean safe. Ask a clinician or pharmacist before changing your care, especially if you take medication, are pregnant or breastfeeding, or have a health condition.