Evidence Grade B · Moderate-to-Good Clinical Evidence

Biological Overview

Black elderberry is a deciduous shrub native to Europe, Western Asia, and North Africa whose flowers and ripe berries are among the most clinically studied phytomedicinal preparations for viral respiratory infections. Berry extracts are standardised for anthocyanin content, chiefly cyanidin-3-glucoside, which accounts for the plant's antiviral, antioxidant, and immunomodulatory activity profile.

Key ActivesCyanidin-3-glucoside · Rutin · Chlorogenic acid
Primary TargetsInfluenza · Immune cytokines · Oxidative stress
Parts UsedDried flowers · Ripe berries
PharmacopoeiaFrench Pharmacopoeia List A
Botanical Classification

Taxonomy & Identification

Latin Name
Sambucus nigra L.
Synonym(s)
Sambucus nigra subsp. nigra
Family
Adoxaceae (formerly Caprifoliaceae)
Common Names
Black Elderberry, Elder, Sureau noir
English Name
Black Elderberry
Parts Used
Dried flower · Ripe berry (drupe)
Origin
Europe, W. Asia, N. Africa
Morphology & Distribution

Description & Habitat

Sambucus nigra is a fast-growing deciduous shrub reaching 4–5 metres in height, with large opposite pinnate leaves composed of 5 to 7 oval leaflets. Flowering occurs in late spring in wide, delicately scented umbel-like corymbs up to 20 cm in diameter. The ripe fruits are small, pendulous, jet-black drupes filled with deep violet-purple juice — a key visual distinction from the toxic dwarf elderberry (Sambucus ebulus), whose fruits point upward.

S. nigra is widespread across all of Europe, Western Asia, and North Africa, establishing itself in hedgerows, woodland edges, and disturbed ground, where it can become invasive. Drying the plant requires care as the material tends to blacken. Higher-altitude populations have been shown to produce berries with significantly elevated anthocyanin concentrations. [1]

Pharmacopoeia Note

The dried flower is official in the French Pharmacopoeia (List A) and must contain a minimum of 0.8% flavonoids expressed as isoquercitrin. Both flower and fruit are listed.

Morphological Profile
Height4–5 m at maturity
LeavesOpposite, pinnate; 5–7 oval leaflets
InflorescenceUmbel-like corymbs, Ø ~20 cm, delicately scented
FruitPendulous black drupes; dark violet juice
DistributionEurope, W. Asia, N. Africa; potentially invasive

Identification Caution

Do not confuse with dwarf elder (Sambucus ebulus), whose fruits are toxic and point upward. Black elderberry fruits hang pendulously downward when ripe.

Ethnobotany & Traditional Use

History & Tradition

Historically regarded as a veritable "country pharmacy," black elderberry has been employed across European folk medicine for centuries to treat a wide spectrum of ailments — from fevers and colds to joint complaints and skin conditions. Its flowers were traditionally used to prepare beignets (fritters), and its diaphoretic properties were exploited by physicians well before the age of clinical trials.

Ancient & Medieval

The Country Pharmacy

Elder was used across European folk traditions for feverish states, respiratory ailments, skin complaints, and rheumatism. Every part of the plant — bark, flower, berry, and leaf — had an assigned therapeutic role.

18th Century

Diaphoretic Use Documented

Boerhaave documented the flower's sudorific action in his 1766 treatise on intermittent fevers, noting a marked increase in perspiration — a finding echoed by Pichery in 1815. [6][7]

Hippocratic Tradition

Humoral Medicine

Elderflowers were once prescribed to purge "phlegm" — one of the four Hippocratic humours, nasal secretion believed to emanate from the brain. The phlegmatic temperament was considered susceptible to cold-damp diseases, which elder was meant to counteract.

Modern Era — 1995–Present

Randomised Clinical Trials

From the landmark 1995 Zakay-Rones influenza B trial to the 2019 meta-analysis by Hawkins et al., elderberry has accumulated the strongest RCT evidence base of any plant-derived antiviral preparation in phytomedicine. [28]

Traditional Epithet

"A veritable country pharmacy — every part of the elder tree was employed against some ill."

European Folk Medicine Tradition

Flowers were also traditionally used in cooking — the delicate blossoms are still battered and fried as elderflower fritters across Central Europe, illustrating the plant's deep integration into culinary and medicinal culture alike.

Pharmaceutical Preparations

Parts Used & Available Formulations

Both the dried flower (minimum 0.8% flavonoids as isoquercitrin) and the ripe berry are officinal under the French Pharmacopoeia List A. Multiple standardised preparations are commercially available.

Dried Flower (Infusion)

The dried elderflower is the primary pharmacopoeial part. Prepared as an infusion (tisane), it is used for its diaphoretic, diuretic, and bronchosecretory actions. Authorised for children and pregnant women.

Berry Extract (EPS / Élusane)

Standardised hydroalcoholic dry extracts (Élusanes®) and fresh plant extracts (EPS) of the ripe berry are the primary vehicles for antiviral and immunomodulatory applications. Sambucol® is the reference clinical preparation.

Berry Syrup & Tincture

Berry syrup is widely used in self-care for flu and colds. Mother tincture (TM) of the flowering top is also available. Raw berries should not be consumed without cooking due to residual cyanogenic glycoside content.

Clinical Dosing

Usual Dosages

Dosages as documented in the Wikiphyto monograph and corroborated by clinical trial and pharmacopoeial data. All doses refer to adults unless otherwise specified.

Formulation Indication Dose Frequency Notes
Mother Tincture (TM) General / flu / colds 50 drops 4× daily (adult) Flowering top
Berry Syrup Influenza / upper respiratory 15 ml (1 tbsp) 4× daily Standardised preparation preferred
Flower Infusion (Tisane) Fever / diaphoresis / colds 1 cup 4–6× daily 1 tsp dried flower per cup; steep 15 min; suitable for children
EPS (Fresh Plant Extract) — Berry Antiviral / immune support As per product labelling Varies Standardised hydroalcoholic extract
Biochemical Profile

Composition

The flower and berry have distinct but complementary phytochemical profiles. Berries are dominated by anthocyanins; flowers by flavonols and hydroxycinnamic acid derivatives.

Flower

Flavonoids (0.7–3.5%)Rutin (dominant), isoquercitroside, hyperoside, quercitroside; flavonols including 5,7,3',4'-tetra-O-methylquercetin and dihydromyricetin
Major class
Hydroxycinnamic Acids (5.1%)Chlorogenic, p-coumaric, caffeic, and ferulic acids
Antioxidant
Essential Oil (solid, butter-like)High free fatty acid content (~66%), predominantly palmitic acid; solid consistency at room temperature
Lipophilic
Triterpenic AcidsUrsolic acid and oleanolic acid
Anti-inflam.
Mucilages & TanninsDemulcent and astringent fractions
—
Sterols (0.11%)Minor phytosterol fraction
Minor

Berry (Ripe Drupe)

Cyanidin-3-glucoside794 mg/100 g fresh berry — dominant anthocyanin (Phenol-Explorer data)
Major
Cyanidin-3-sambubioside463 mg/100 g; potent antioxidant alongside cyanidin-3-glucoside
Major
Cyanidin-3-sambubioside-5-glucoside34 mg/100 g
Minor
Cyanidine-3,5-diglucoside17 mg/100 g
Minor
FlavonoidsRutin, isoquercitroside, hyperoside, quercetin (29–60 mg/100 g)
Antiviral
Organic Acids & VitaminsCitric, malic, shikimic, fumaric acids; vitamin B2 (65 mg), vitamin C (18 mg), folate (17 mg) per 100 g
Nutritional
Sambunigrin (trace)Cyanogenic glycoside — destroyed by cooking. [2][3]
Safety note

Anthocyanins — Key Active Class

Antiviral Action

Berry anthocyanins block viral glycoproteins and inhibit H1N1 and coronavirus entry. The whole extract outperforms isolated cyanidin-3-glucoside alone, indicating synergy. [25]

Antioxidant Potency

Cyanidin-3-glucoside and cyanidin-3-sambubioside are the most powerful antioxidants; they inhibit LDL oxidation and protect endothelial cells. [12][13]

Altitude Effect

Berries harvested at higher altitudes contain significantly greater anthocyanin concentrations, with important implications for raw material sourcing. [1]

Immune Cytokine Modulation

The berry extract markedly increases IL-1β and TNF-α, with moderate induction of IL-8 and IL-10 — an immunostimulant profile relevant to early-phase infection response. [20]

Plant Properties — Pharmacodynamics

Whole-plant biological activities with primary literature citations

14 Properties Flowers & Berries In Vitro · In Vivo · RCT

Diaphoretic (Flower)

Elderflower markedly increases perspiration — a property documented by Boerhaave (1766) and Pichery (1815) and still employed in feverish states today. [6][7]

Bronchosecretory (Flower)

The flower notably increases bronchial secretions, supporting mucociliary clearance in upper respiratory infections and dry coughs.

Diuretic (Flower)

Traditional diuretic action attributed to the flower, useful in oedematous states and as an adjunct in febrile illness management.

Insulin-Stimulating (Flower)

In vitro studies in mice showed significant stimulation of insulin secretion by elderflower preparations, corroborating traditional use in diabetic management. [8][9]

Neuroprotective (Flower)

A 2021 cell culture study found that Sambucus nigra preparations may inhibit neurodegeneration, establishing a new frontier for this traditional plant. [10]

Anti-Inflammatory (Berry)

Berry anthocyanins reduce pro-inflammatory cytokine levels and have demonstrated anti-inflammatory activity in human cytokine production assays. [11]

Antioxidant (Berry)

Cyanidin-3-glucoside and cyanidin-3-sambubioside are the dominant antioxidant compounds. The extract inhibits LDL oxidation and protects vascular endothelial cells against oxidative damage. [12][14]

Anti-Hyperlipidaemic (Berry)

At nutritional supplementation doses, elderberry juice significantly reduced fasting and postprandial serum lipids and LDL oxidation in a randomised double-blind placebo-controlled trial. [15]

Metabolic Syndrome Prevention (Berry)

Berry polyphenols reduce insulin resistance, decrease glycated haemoglobin, inhibit lipid peroxidation, and lower atherogenic risk in experimental diabetic models. [16][17]

Immunostimulant (Berry)

Berry extract markedly increases IL-1β and TNF-α and moderately induces IL-6, IL-8, and IL-10 in human peripheral blood mononuclear cells, demonstrating a broad immunomodulatory profile. [19][21][22]

Antiviral — Influenza (Berry)

Berry extract inhibits multiple influenza A and B strains in vitro and reduced symptom duration in RCTs. Flavonoids (5,7,3',4'-tetra-O-methylquercetin, dihydromyricetin) directly bind H1N1. A 2019 meta-analysis confirmed significant upper respiratory symptom reduction. [26][28][29][33]

Antiviral — Coronavirus (Berry)

Extract inhibits avian infectious bronchitis coronavirus (IBV) and demonstrates antiviral activity against human coronavirus NL63 (HCoV-NL63). [36][37]

Antidiabetic / Insulin-like (Berry)

Berry exhibits insulin-like and insulin-releasing actions in vitro, reduces glycated haemoglobin, and demonstrates hypoglycaemic and hypolipidaemic effects. Polyphenols protect against lipid peroxidation. [38][39]

Mildly Laxative (Berry)

The ripe berry exerts a mild laxative effect, consistent with its high fruit acid and flavonoid content.

Clinical Use

Clinical Indications

Principal therapeutic indications derived from the primary phytomedicinal literature and pharmacopoeial data.

Respiratory Infections
Phytotherapy — Whole Plant
  • Influenza A & B — Berry preparations are considered near-specific for influenza; multiple RCTs confirm symptomatic benefit including reduced fever, headache, and nasal congestion. [28][29][33]
  • Colds, rhinitis & sinusitis — Including allergic rhinitis; flower and berry preparations used for onset of febrile and catarrhal states. [40]
  • Rhinopharyngitis in children — Flower infusion (tisane) is safe for children; no adverse effects known for flowers.
  • Dry coughs — Flower preparations increase bronchial secretions and are indicated for dry, irritative coughs.
Fever & Diaphoresis
Phytotherapy — Flower
  • Febrile states — Elderflower tisane is a traditional diaphoretic, used at onset of febrile illness to support perspiration and reduce fever.
  • Eruptive infectious diseases — Historically indicated for measles, scarlatina and other eruptive fevers alongside standard management.
  • Gargling & fumigations — Flower preparations used topically as gargles, lotions, poultices, and fumigations for local ENT symptoms.
Metabolic & Cardiovascular
Phytotherapy — Berry
  • Dyslipidaemia — Elderberry juice at nutritional doses reduced fasting and postprandial serum lipids in a placebo-controlled RCT. [15]
  • Type 2 diabetes (adjunct) — Insulin-like and insulin-releasing actions documented in vitro; reduced glycated haemoglobin and lipid peroxidation in animal models. [38][39]
  • Metabolic syndrome prevention — Berry polyphenols reduce insulin resistance and protect against the atherogenic lipid profile. [17]
Rheumatism & General
Phytotherapy — Berry & Flower
  • Rheumatic complaints — Berries have been traditionally indicated in joint pain and rheumatism; anti-inflammatory anthocyanins provide mechanistic rationale.
  • Antalgic / analgesic — The systematic review by Vlachojannis et al. (2010) identified antalgic activity as part of the berry's documented efficacy profile. [18]
  • Immune support (general) — Berry extract used prophylactically and therapeutically in repeated or seasonal infections for its immunostimulant profile. [19]
Pharmacology

Known & Presumed Mode of Action

Mechanisms are derived from the primary cited literature. Mechanisms marked "preclinical" are not yet confirmed in human trials.

Viral Glycoprotein Blockade

Berry extract blocks viral surface glycoproteins required for host cell attachment and entry. This mechanism has been demonstrated for influenza A (H1N1) and is considered the primary antiviral mechanism. The whole extract is more potent than isolated cyanidin-3-glucoside alone, indicating phytochemical synergy. [25][26]

Cytokine Upregulation (Immunostimulant)

Berry extract markedly upregulates IL-1β and TNF-α production in peripheral blood mononuclear cells, with moderate induction of IL-6, IL-8, and IL-10. This cytokine profile supports rapid innate immune activation during early-phase viral infection. [20][21]

Free Radical Scavenging & LDL Protection

Cyanidin-3-glucoside and cyanidin-3-sambubioside are potent radical scavengers. They inhibit LDL oxidation in vitro and protect endothelial cells against oxidative damage — mechanisms relevant to both cardiovascular and anti-ageing applications. [13][14]

Insulin-Like & Insulin-Releasing Action

Both flower and berry preparations exhibit insulin-secretagogue and insulin-mimetic activity in vitro, reducing blood glucose and glycated haemoglobin in diabetic animal models. This is a preclinical mechanism requiring human trial confirmation. [9][38]

Neurodegeneration Inhibition (Preclinical)

A 2021 cell culture investigation demonstrated that S. nigra preparations can inhibit mechanisms of neurodegeneration. The polyphenol content, particularly anthocyanins, is considered responsible. This is an early-stage preclinical finding. [10]

Synergy with Echinacea

A 2013 study demonstrated synergistic inhibition of the influenza replication cycle when Echinacea purpurea and Sambucus nigra are combined, suggesting a complementary mechanism of action when used together. [31]

Preparation Guide

Common Formulations

01

Elderflower Infusion (Tisane)

Use 1 teaspoon of dried elderflower per cup of freshly boiled water. Steep for 15 minutes, covered. Drink 4 to 6 cups per day. Suitable for children and pregnant women. Preferred for diaphoretic and diuretic indications.

02

Berry Syrup

15 ml (one tablespoon) of standardised berry syrup, 4 times daily. Always use preparations made from properly cooked or processed berries. Do not use raw berry preparations — cooking destroys cyanogenic glycoside content.

03

Mother Tincture (TM) — Flowering Top

50 drops in water, 4 times daily for adults. The tincture is prepared from the flowering top of Sambucus nigra.

04

EPS & Standardised Dry Extract (Élusanes®)

Fresh plant extract (EPS) and standardised hydroalcoholic dry berry extracts (Élusanes®) provide the most consistent anthocyanin dosing for therapeutic antiviral and immunomodulatory applications. Follow product-specific dosing instructions.

Legal Status & Notes

Regulatory Status

French Pharmacopoeia — List A (Flower & Fruit)

Both the dried elderflower (Sambuci flos) and the elderberry fruit (Sambuci fructus) are official in the French Pharmacopoeia, List A. The flower monograph requires a minimum of 0.8% flavonoids expressed as isoquercitrin.

Natural Standard Research Collaboration — Safety Confirmed

An evidence-based systematic review by the Natural Standard Research Collaboration confirmed both the safety profile and the efficacy of elderberry and elderflower preparations, noting the absence of significant adverse events in the reviewed literature. [41]

European Medicines Agency (EMA/HMPC)

The EMA Committee on Herbal Medicinal Products (HMPC) has issued assessment reports on both Sambucus nigra flos (flowers, 2018) and fructus (berries, 2014), reviewing their traditional use and pharmacological evidence base.

Clinical Safety

Safety & Precautions

Flowers and ripe cooked berries carry an excellent safety record. Bark, stems, leaves, unripe berries, and raw berry preparations must be avoided.

⚠️

Adverse Effects & Toxicity

  • Flowers: No known adverse effects. Flower infusions are authorised for children and pregnant women. No contraindication identified in the literature.
  • Raw / undercooked berries: May cause nausea, vomiting, and stomach upset due to residual cyanogenic glycosides (sambunigrin). Cooking or standardised extraction eliminates this risk. [2][3]
  • Lectins: Seeds, leaves, bark, and stems contain lectins (SNA-III, SNA-IVf). Ripe berries and flowers do not contain lectins. [4]
  • Seeds: Contain cyanogenic glycosides (sambunigrin, prunasin, zierin, holocaline) — commercial preparations remove seeds or use extraction methods that eliminate these compounds.
🚫

Contraindications & Drug Interactions

  • Bark and bark-containing preparations: Must be strictly avoided. The bark contains active emetic and purgative constituents and is not considered safe for therapeutic use.
  • CYP3A4 Inhibition: An in vitro study reported inhibition of CYP3A4 for a commercial herbal combination of Echinacea purpurea and Sambucus nigra (Sambucus Force). This interaction has not been confirmed for elderberry preparations alone. Caution is warranted in patients on CYP3A4-metabolised drugs. [42]
  • Pregnancy and breastfeeding: Flowers and ripe berries are authorised for use in pregnancy (no lectins). Bark and leaf preparations are contraindicated.
  • No toxicological risk: Preparations based on properly cooked or standardised berry and dried flower carry no identified toxicological risk under normal conditions of use. [41]
Clinical Disclaimer: This monograph is for educational and professional reference only. It does not constitute medical advice, diagnosis, or treatment guidance. Sambucus nigra preparations should be used under the supervision of a qualified healthcare provider. The Health Reference reviews content against current primary literature.
Common Questions

Frequently Asked Questions

What is black elderberry used for medicinally?
Black elderberry (Sambucus nigra) is primarily used for upper respiratory infections, influenza A and B, colds, rhinitis, and sinusitis. The berry extract is also indicated for early-stage flu with fever, headache, and nasal congestion. Flowers are used as diaphoretics in febrile states and as bronchosecretory agents for dry coughs. In traditional medicine, berries have been used in rheumatic complaints. A secondary evidence base exists for antidiabetic and cardiovascular applications.
Is elderberry effective against influenza?
Yes, with Grade B evidence. Multiple randomised controlled trials — including the landmark Zakay-Rones 1995 and 2004 studies — demonstrated that elderberry extract reduces the duration and severity of influenza symptoms. A 2019 meta-analysis of RCTs by Hawkins et al. confirmed that black elderberry supplementation significantly reduces upper respiratory symptoms. Two systematic reviews note that the evidence is encouraging but further large-scale trials are required for confirmation. [32][33]
Are elderberries safe to eat raw?
Ripe, cooked elderberries are safe. Raw or undercooked elderberries may cause nausea, vomiting, and gastrointestinal upset due to residual cyanogenic glycosides — primarily sambunigrin. Cooking or proper extraction eliminates this compound. Bark, stems, and leaves must always be avoided as they contain higher concentrations of toxic lectins and cyanogenic glycosides. Dried flowers and properly processed berry preparations carry no known toxicological risk.
What are the main active compounds in black elderberry?
The primary active compounds in the berry are anthocyanins, led by cyanidin-3-glucoside (up to 794 mg/100 g), cyanidin-3-sambubioside (463 mg/100 g), and several related glycosides. Flowers are rich in flavonols (rutin, isoquercitroside, hyperoside), hydroxycinnamic acids (chlorogenic, caffeic, ferulic acids at 5.1%), and triterpenic acids (ursolic and oleanolic acids). These compound classes collectively account for the antiviral, antioxidant, anti-inflammatory, and immunomodulatory properties documented in the primary literature.
Can elderberry be used in pregnancy?
Yes, flower and ripe berry preparations are considered safe in pregnancy. The flowers and mature berries do not contain lectins, which are responsible for the toxicity of other plant parts. The flower infusion (tisane) is explicitly authorised for children and pregnant women. Bark-containing preparations must never be used in pregnancy. Always consult a qualified healthcare provider before using herbal preparations during pregnancy.
Does elderberry interact with medications?
An in vitro study reported that a combined Echinacea purpurea/Sambucus nigra product (Sambucus Force) inhibited CYP3A4, a key drug-metabolising enzyme. This interaction has not been confirmed for elderberry preparations used alone. However, caution is warranted in patients taking drugs metabolised by CYP3A4 — including many immunosuppressants, statins, and antiretrovirals. Consult a pharmacist or physician if taking prescription medications. [42]
Primary Literature

Bibliography

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↑ 39. Ciocoiu M et al. The effects of Sambucus nigra polyphenols on oxidative stress and metabolic disorders in experimental diabetes mellitus. J Physiol Biochem. 2009;65(3):297-304. PubMed PMID:20119824 →
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Additional Clinical & Reference Literature

Wichtl M, Anton R. Plantes thérapeutiques : Tradition, pratique officinale, science et thérapeutique. Tec & Doc, Cachan. 1999. p. 502.