1. Introduction: A Neglected Tropical Disease with a Heavy Nigerian Burden

Buruli ulcer (BU) is a chronic, debilitating skin disease caused by the bacterium Mycobacterium ulcerans. It is classified by the World Health Organization (WHO) as a Neglected Tropical Disease (NTD) and poses a significant public health challenge in West Africa, particularly in Nigeria. The disease manifests as severe skin ulcers, and without prompt and effective treatment, it can lead to extensive tissue destruction, permanent disfigurement, and long-term disability.

The challenge of managing Buruli ulcer in Nigeria is compounded by the fact that most cases occur in impoverished, rural communities where access to healthcare is limited. A key driver of the disease’s impact is the mycolactone toxin, produced by M. ulcerans, which causes tissue necrosis, suppresses the immune system, and is central to the disease’s severe skin damage. While WHO-recommended antibiotic regimens (rifampicin and streptomycin or clarithromycin) are effective, their cost, side effects, and the need for daily injections in remote settings often lead to poor compliance and treatment delays.

These realities have led many affected individuals to seek treatment from traditional healers, who use plant-based remedies, a practice deeply embedded in local culture. This review synthesises available literature on traditional and complementary management of Buruli ulcer, with a focus on Nigerian herbs and holistic therapies.

2. The Socio-Cultural and Economic Reality of Treatment-Seeking

A significant body of research, particularly from Imo State, Nigeria, highlights that traditional and spiritual therapies are not a fringe choice but the first line of defence for most patients. A 2025 mixed-methods investigation in Imo State found that 78% of 306 laboratory-confirmed BU patients initially consulted traditional healers before seeking biomedical care.

2.1 Factors Driving the Choice for Traditional Care

The preference for traditional care is driven by a complex interplay of factors:

Factor	Description	Key Finding
Cultural Attribution	Many communities attribute BU to supernatural causes like witchcraft or curses, making traditional healers the first choice.	65% of patients held strong cultural beliefs influencing treatment choice.
Economic Barriers	Direct and indirect costs of hospital care (consultation, transport, medication) are prohibitive for many rural families.	30% of patients cited financial constraints as a primary reason for not seeking orthodox care.
Trust and Accessibility	Traditional healers are perceived as empathetic, community-integrated, and more affordable, offering flexible payment systems.	64% of patients initially relied on traditional healing practices.

2.2 Clinical Consequences of Delayed Care

Delaying effective biomedical treatment has severe clinical consequences. The same study in Imo State found that the median delay before seeking orthodox care was 12 weeks. Crucially, 82% of patients who delayed treatment beyond 8 weeks presented with advanced (Category II or III) lesions. Logistic regression analysis showed that patients who delayed orthodox treatment for over 8 weeks had 4.3 times the odds of presenting with severe Category III lesions (p<0.001). In contrast, patients who promptly received evidence-based care had significantly higher healing rates (95%) and fewer complications.

3. Nigerian Herbal Remedies for Buruli Ulcer: Scientific Evidence

Despite the widespread use of traditional remedies, scientific validation is a relatively recent development. However, a growing body of evidence supports the potential of several West African and Nigerian plants against M. ulcerans.

3.1 Computational Discovery: Validating Indigenous Knowledge

A landmark 2025 study combined ethnopharmacology with advanced computational methods to identify promising anti-BU compounds from nine African medicinal plants, including several found in Nigeria. The selected plants were:

• Erythropheum suaveolens (stem bark)
• Newbouldia laevis (stem bark)
• Bryophyllum pinnatum (leaf)
• Ageratum conyzoides (leaf)
• Phyllanthus amarus (leaf)
• Psidium guajava (leaf)
• Allium sativum (bulb)
• Syzygium aromaticum (flower bud)
• Zanthoxylum zanthoxyloides (root)

Using virtual screening and machine learning, the study identified several hit compounds with strong binding affinities to essential M. ulcerans proteins. The most promising compound, AMPA (12-(acetyloxy)-17-(1-methyl-4-oxo-5-phenylpentyl)gonan-3-yl acetate) from Phyllanthus amarus, demonstrated a predicted Minimum Inhibitory Concentration (MIC) of 1.20 µg/mL, comparable to standard antibiotics . This validates the ethnopharmacological relevance of these plants and provides a foundation for future drug development.

3.2 Plants with Documented Activity

Several other plant species have been documented in scientific literature for their traditional use against BU or their demonstrated antimicrobial activity.

Ricinus communis (Castor Bean)

• Traditional Use: Widely used in Côte d’Ivoire and across West Africa for treating BU. The oil or leaf poultice is applied topically.
• Scientific Evidence: A therapeutic survey concluded that 80% of participants recovered from BU when treated with a preparation containing R. communis alongside other plants.
• Key Compound: Ricinine is considered a principal active alkaloid. The seeds also contain the highly toxic ricin, requiring careful preparation (using water as a solvent).
• Caution: The plant is classified as a poison plant due to ricin. Its LD50 is 20–30 mg/kg, and only water-based preparations are considered safe by traditional healers.

Nicotiana tabacum (Tobacco)

• Traditional Use: Powdered leaves are applied 2–3 times daily to BU lesions in Côte d’Ivoire
• Scientific Evidence: In the same survey, 80% (219) of patients treated with this powder healed.
• Key Compound: Nicotine is thought to be a primary active component.

Other Documented African Medicinal Plants

A review of African medicinal plants used for NTDs lists several others used for BU, including:

• Mangifera indica (Mango)
• Mariscus alternifolinus
• Solanum rugosum
• Carica papaya (Pawpaw)

3.3 In Vitro Activity and Bioassay-Guided Discovery

A 2016 study aimed to validate the use of medicinal plants for BU treatment by screening extracts against M. ulcerans. Key findings included:

• A total of 67 extracts were assessed from plants used in traditional medicine.
• 17 extracts showed significant antimycobacterial activity against M. ulcerans with MIC values ranging from 16 to 250 µg/mL.
• Most active extracts showed no significant cytotoxicity against normal human liver cells.
• Bio-guided fractionation led to the isolation of nine compounds with significant in vitro anti-M. ulcerans activity (MIC = 16–128 µg/mL).

This research provides critical support for the traditional use of these plants, demonstrating that they contain compounds with genuine antimycobacterial activity.

4. Traditional Preparation and Administration Methods

Traditional remedies are typically prepared and administered using methods that are often passed down through generations. The most common methods, as documented in literature, are:

Method	Description	Common Plants
Decoction	Boiling plant material (e.g., leaves, bark) in water to extract active compounds.	Mangifera indica, Carica papaya
Infusion	Steeping plant material in hot water, similar to making tea.	Leaves of various species
Trituration / Powder	Grinding dried plant material into a powder for topical application.	Nicotiana tabacum
Macerate / Poultice	Soaking plant material in water or oil, or creating a paste to apply directly to the wound.	Ricinus communis (oil)
Pomade	Mixing plant extracts with a fatty base for topical application.	Various species

Administration is predominantly topical, applied directly as a bandage or dressing, but some remedies are also administered orally.

5. A Path Forward: Integrating Indigenous Practices and Evidence-Based Care

The findings from Nigerian studies reveal a significant paradox: while traditional remedies are the first choice for many patients, there is a clear desire for integration. In one study, several traditional healers expressed a willingness to collaborate with mainstream healthcare institutions if properly engaged and trained. This offers a critical opportunity to improve early detection and treatment outcomes in endemic communities.

5.1 Recommendations

For Patients and Communities:

1. Seek Early Diagnosis: While traditional remedies may offer some benefit, the risk of disease progression and disability from delayed care is severe. Prompt diagnosis at a health facility is critical for successful treatment.
2. Disclose Herbal Use: Patients who do seek orthodox care should inform their healthcare provider about any traditional remedies they are using to avoid potential complications.
3. Use Herbal Products Cautiously: If using herbal remedies, ensure they are from a knowledgeable source and avoid plants with known toxicity (e.g., R. communis seeds).

For Healthcare Providers and Policymakers:

1. Acknowledge Traditional Knowledge: Recognize the central role of traditional healers in the community and the trust patients place in them.
2. Promote a Hybrid Care Model: Explore formal collaboration with traditional healers to encourage early referral. This could include training healers to recognize advanced lesions and to encourage patients to seek simultaneous or prompt biomedical care.
3. Investigate Active Compounds: Support rigorous, pre-clinical research and clinical trials on promising plants like Phyllanthus amarus and others identified through computational screening, aiming to develop standardised, safe, and effective phytotherapeutics.

6. Conclusion

Buruli ulcer remains a significant challenge in rural Nigeria, where traditional and herbal therapies are often the default treatment. Cultural beliefs, economic barriers, and deep community trust in traditional healers drive this preference, leading to significant treatment delays and more severe disease outcomes. While some herbs like Ricinus communis and Nicotiana tabacum show anecdotal and in vitro activity, their use remains unstandardized and potentially risky.

However, promising new research using advanced computational methods has validated the potential of Nigerian plants like Phyllanthus amarus as a source of powerful anti-BU compounds. The path forward lies in an integrated approach that respects indigenous knowledge while promoting evidence-based, timely care. By fostering collaboration between biomedical professionals and trusted traditional healers, and by investing in further research to unlock the therapeutic potential of Nigerian plants, there is an opportunity to significantly reduce the burden of this devastating disease.

7. References

1. Onwuka, C.D., & Tochi, O.E. (2025). Integrating Indigenous Practices with Evidence-Based Care: A Mixed-Methods Investigation of Buruli Ulcer Treatment Dynamics in Imo State, Nigeria. medRxiv.
2. Duru, C. E., Nwofor, C. N., Ikezu, U. J. M., & Enyoh, C. E. (2025). Virtual Screening and Machine Learning-Based Identification of Tropical Plant Metabolites with Multiple Mycobacterium ulcerans Protein Targeting Potential in Buruli Ulcer Management. Journal of Chemical Society of Nigeria, 50(4).
3. Tsouh Fokou, P. V., et al. (2015). Ethnopharmacological reports on anti-Buruli ulcer medicinal plants in three West African countries. Journal of Ethnopharmacology, 172, 297-311. (Cited in Heliyon review).
4. Onwuka, C.D., & Tochi, O.E. (2025). Understanding Buruli Ulcer in Imo State, Nigeria: Community Knowledge, Beliefs, and Treatment Compliance with WHO Guidelines. Asian Science Bulletin, 3(4), 274-287.
5. Adam G.O., et al. (2022). African Medicinal Plants for Neglected Tropical Diseases: A Review. Research Journal of Pharmacognosy, 9(4), 59-72.
6. Tsouh Fokou, P.V., et al. (2016). In Vitro Activity of Selected West African Medicinal Plants against Mycobacterium ulcerans Disease. Molecules, 21(4), 445. (Cited in CORE and Wiley).