Alternative Medicine and Eczema
Fellow of the American Academy of Dermatology
Affiliate of the American Academy of Medical Acupuncture
My disclaimer for this piece is that, like Fox Mulder from The X-Files, “I want to believe.” I am interested in all the healing arts and am more than willing to consider other traditions and approaches to understanding health and disease. I undertook formal acupuncture studies to learn more about Traditional Chinese Medicine and, specifically, to see how I could possibly use these to help understand and treat my eczema patients. That said, I feel strongly that part of my job as a board-certified dermatologist is to help guide people away from approaches that are untested, untrue, or too-good-to-be true.
Despite having access to some of the best healthcare in the world, an enormous number of patients with atopic dermatitis have tried alternative medicines. In one study, over half of the patients reported using one or more forms of alternative medicine for their disease (Jensen, 1990). Interestingly, in a companion study, the majority of patients reported no improvement or even worsening of their disease after using these alternative treatments (Jensen, 1990).
Part of the difficulty in understanding why people seek alternative medicine lies in defining “alternative medicine.” What is it?
Broadly speaking, it encompasses treatments and systems outside the cannon of “allopathic medicine” (the form of medicine taught in most U.S. medical schools), including things like acupuncture, homeopathy, and holistic medicine. But practically, people use the term for anything from chicken soup to any lotion or potion on the Internet to a new dietary supplement. What is concerning, then, is that beyond systematic approaches to health and disease that are at least time-tested, a great deal of snake oil can hide under the umbrella of “alternative medicine.” This situation is a bit reminiscent of allopathic medicine in its earliest days, before regulatory bodies like the Food and Drug Administration and certifying boards of medicine existed. And, despite the rocky road and numerous faults and flaws, so-called “allopathic medicine” has increasingly become “modern medicine” and continues to work at being “evidence-based medicine, meaning that diagnosis and treatment approaches are tested against each other and chosen not for their elegance or because of a theory, but truly because they are shown to work.
So, in one way of thinking, “alternative medicine” can be defined as things that are simply not based in evidence, either not having been tested sufficiently (for example, using borage oil to soothe eczema) or having been tested and found not to work as claimed when studied in a controlled setting (like homeopathy). I would take it a step farther and say that, at least for many of the physicians I know, any treatment that did pass a controlled test would immediately stop being “alternative” and enter into “modern medicine.” Examples here abound, including the use of Avena sativa (oatmeal baths) for dry, itchy skin, vitamin A derivatives (tretinoin) for acne, and vitamin D derivatives (calcitriol) for psoriasis.
The problem is that there are an overwhelming number of systems and non-systems, with an abundance of questionable anecdotal evidence, and wholly insufficient resources to test or study all of them. So, for diseases where we don't yet have all the answers (like eczema), modern medicine can be disappointing and offers only a list of what supposedly doesn’t cause it and treatments that, admittedly, only calm the symptoms without getting to the root of the problem. Indeed, for patients with severe diseases without good treatments or cures, modern medicine seems to offer little hope or encouragement in the meantime. It is also generally true that the more powerful the treatment, the more likely (and severe) the side effects. Modern medicine possesses a tremendous number of powerful therapies that carry with them many risks, another factor that can turn people away.
On my quest for learning everything I can about eczema, I have encountered many alternative theories of disease and many alternative treatment approaches. Sadly, I have not yet found a reliable cure. I usually reassure my patients by reminding them that if anybody actually finds a cure, we'll know about it because they will be on The Oprah Winfrey Show, not to mention they will win the Nobel Prize and be fabulously wealthy and famous!
Just because it hasn't been found yet, does not mean that a cure does not exist—or at least some really good and safe treatments. I want to highlight a few “alternatives” that I think have promise, especially for certain patients, alternatives that continue to give me (and my patients) a sense of hope.
Stress, either physical or emotional, can worsen atopic dermatitis. Stress has been shown to directly slow the healing of the skin barrier in one elegant study (Muizzuddin, 2003). Even more compelling, in another study, psychosocial stress and sleep deprivation were found to disrupt skin barrier function in healthy patients (Altemus, 2001). Thus, it is possible that some forms of alternative medicine could help atopic dermatitis by decreasing stress, something for which allopathic medicine offers very limited options.
Hypnosis is one such candidate for potential stress reduction. It is a relatively mainstream form of alternative medicine, but there is no doubt that some consider it outside of the cannon of usual eczema therapy. In one study, 18 adults with extensive atopic dermatitis, resistant to conventional treatment, and 20 children with severe, resistant atopic dermatitis were treated with hypnotherapy. A significant benefit was found both subjectively and objectively, and it was maintained at up to two years in some patients. Ten of 12 children surveyed at 18 months after the study reported continued improvement in itching and scratching, less sleep disturbance, and improvement in mood (Stewart, 1995). Other studies have focused on psychological and educational therapies, including relaxation therapies, biofeedback and behavioral interventions, with some promising but ultimately inconclusive results (Ersser, 2007).
Acupuncture can be very relaxing, and patients frequently report feeling energized and renewed after treatment. The traditional explanation for how acupuncture works is based on the idea that there are energy channels running through the body that can become blocked or unregulated and that by stimulating these channels with needles, energy flow can be restored. It is possible, however, that modulation of stress via the nervous system, with subsequent immune system alteration may explain some or all of the effects of acupuncture. There are very few studies of acupuncture for eczema. One study, however, found that when paired with Chinese herbal therapy, 100 percent of the patients improved at the end of 12 weeks; they were on average 63 percent better than when they started (Salameh, 2008). Because most of the data is anecdotal, it will be difficult to tease out a real effect for acupuncture until more work is done in this area.
There are many more studies focusing on Chinese herbs in atopic dermatitis, but there are several issues with the study of herbs in this context: 1) their purity and consistency are frequently uncertain and unverified; 2) many times for a given “disease” there are drastically different herbal concoctions that have to do with other symptoms and signs unrelated to the skin, thus making direct comparison across groups impossible; 3) there have been reports of contamination of herbs, which, though rare, can result in significant patient harm (Hsieh, 2008). One recent promising study led by Dr. Xiu-Min Li found that treating children with a combined approach consisting of an herbal tea, bath additives, creams, and acupuncture resulted in the improvement of 13 of 14 patients over three months (Wisniewski, 2009). Although the effect on eczema was fairly impressive in this study, the regimen was not simple by any means. It was also time consuming and expensive and thus ultimately must be compared to more standard therapies before it can be recommended.
An incredible number of plant-based materials have been suggested as being helpful for atopic dermatitis, but many have only one or two small reports to support them. Evening primrose oil has been studied in more depth but has had somewhat controversial results (Vender, 2002). The oil contains gamma-linolenic acid which is thought to posses anti-inflammatory properties and has been used in other inflammatory diseases. A meta-analysis of 26 studies of evening primrose oil found improvement in itch, crusting, and redness at one of two months of treatment (Morse, 2006). Adding to that literature, last year a randomized, placebo-controlled trial determined that the 96 percent of the patients who received evening primrose oil by mouth showed improvement versus only 32 percent of those in the placebo group (Senapati, 2008).
Finally, while there is no controversy that vitamin D is important to our overall health, the jury is out on whether or not it can be helpful for eczema. One small study performed in Boston suggested that vitamin D supplementation can improve eczema in patients who report that they are worse during the winter and better during the summer, with 80 percent of the vitamin D group improving versus only 17 percent of the control group (Sidbury, 2008). Though exciting, the effect was fairly modest and not universal; it is possible that vitamin D-responsive eczema represents a subset of patients.
On balance, my experiences with alternative medicines have been positive but not impressive. Most of the time my patients find that one or more alternative therapies can be helpful, but not curative or even able to stand on their own. Some may be critical of this and impugn such treatments immediately; I do not agree with this approach. Rather, I think that the fact that there are alternative and complementary treatments—an excellent term, indeed, and the one chosen by the National Institutes of Health (which includes the National Center for Complementary and Alternative Medicine)—is heartening. More gentle and more “natural” treatments open up the possibility for additional relief from eczema instead of or in addition to some of the more powerful standards of care. Above all, these treatments offer continued challenges and excitement as we discover more and learn more about them.
References:
Jensen P. Use of alternative medicine by patients with atopic dermatitis and psoriasis. Acta Derm Venereol. 1990; 70 (5): 421–4.
Jensen P. Alternative therapy for atopic dermatitis and psoriasis: patient-reported motivation, information source and effect. Acta Derm Venereol. 1990; 70 (5): 425–8.
Zhang W, Leonard T, Bath-Hextall F, Chambers CA, Lee C, Humphreys R, Williams HC. Chinese herbal medicine for atopic eczema. Cochrane Database Syst Rev. 2005 Apr 18; (2): CD002291.
Muizzuddin N, Matsui MS, Marenus KD, Maes DH. Impact of stress of marital dissolution on skin barrier recovery: tape stripping and measurement of trans-epidermal water loss (TEWL). Skin Res Technol. 2003 Feb; 9 (1): 34–8.
Altemus M, Rao B, Dhabhar FS, Ding W, Granstein RD. Stress-induced changes in skin barrier function in healthy women. J Invest Dermatol. 2001 Aug; 117 (2): 309–17.
Stewart AC, Thomas SE. Hypnotherapy as a treatment for atopic dermatitis in adults and children. Br J Dermatol. 1995 May; 132 (5): 778–83.
Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2007 Jul 18; (3): CD004054.
Salameh F, Perla D, Solomon M, Gamus D, Barzilai A, Greenberger S, Trau H. The effectiveness of combined Chinese herbal medicine and acupuncture in the treatment of atopic dermatitis. J Altern Complement Med. 2008 Oct; 14 (8): 1043–8.
Hsieh MJ, Yen ZS, Chen SC, Fang CC. Acute cholinergic syndrome following ingestion of contaminated herbal extract. Emerg Med J. 2008 Nov; 25 (11): 781–2.
Wisniewski J, Nowak-Wegrzyn A, Steenburgh-Thanik E, Sampson H, Li X. Efficacy and Safety of Traditional Chinese Medicine for Treatment of Atopic Dermatitis (AD). Abstract 131, 2009 American Academy of Asthma, Allergy and Immunology (AAAAI) Annual Meeting.
Vender RB. Alternative treatments for atopic dermatitis: a selected review. Skin Therapy Lett. 2002 Feb; 7 (2): 1–5.
Morse NL, Clough PM. A meta-analysis of randomized, placebo-controlled clinical trials of Efamol evening primrose oil in atopic eczema. Where do we go from here in light of more recent discoveries? Curr Pharm Biotechnol. 2006 Dec; 7 (6): 503–24.
Senapati S, Banerjee S, Gangopadhyay DN. Evening primrose oil is effective in atopic dermatitis: a randomized placebo-controlled trial. Indian J Dermatol Venereol Leprol. 2008 Sep–Oct; 74 (5): 447–52.
Sidbury R, Sullivan AF, Thadhani RI, Camargo CA Jr. Randomized controlled trial of vitamin D supplementation for winter-related atopic dermatitis in Boston: a pilot study. Br J Dermatol. 2008 Jul; 159 (1): 245–7.
National Center for Complementary and Alternative Medicine (www.nccam.nih.gov).
