It's been one year since NEA, in collaboration with four peer patient advocacy organizations, hosted the landmark patient-focused drug development (PFDD) meeting dedicated to eczema.
Published On: Mar 10, 2015
Last Updated On: Mar 10, 2015
There seem to be three major reasons why patients seek alternative medicine for atopic dermatitis. First, we simply don’t yet have a cure for this disease. Second, we can’t yet clearly explain why this disease occurs. While doctors try hard to describe factors that play a role in atopic dermatitis, such as cytokines and inflammatory cells, we still can’t pinpoint the root of the disease. Third, the outcomes of conventional atopic dermatitis treatments are not always consistent, and sometimes they are perceived as being unsafe.
Those perceived risks can be real (as with long-term use of powerful immunosuppressive medicines) or magnified (as when patients are reluctant to use topical corticosteroids or topical calcineurin inhibitors, due in part to black box warnings containing scary words like “cancer”). We are also amid a movement against preservatives and other chemicals found in the environment—and we wonder whether we should be putting these ingredients on our skin. All of the warnings, whether perceived or real, create lots of landmines to negotiate around when prescribing treatments to patients.
A beautiful figure from a paper last year called “The Listing Tree of Science” really struck a chord with me. It illustrates atopic dermatitis research, and it shows a terrible imbalance. One side of the tree depicting basic science research is lush, showing knowledge in areas such as cytokines, neuropeptides, ceramides, IgE, mast cells and eosinophils. The other side of the tree, representing clinically-relevant understanding, is sparse, showing just a couple of little rootlets. I’d say we know even less about alternative treatments, so little is being done.
We still have a lot of big questions to answer about atopic dermatitis—like how common it is, what causes it, and whether it can be prevented. It seems that people are more likely to turn to alternative medicine when we don’t have the answers to big questions like these.
My hope for atopic dermatitis is that the conversation about alternative treatments will become useless one day because we will have safe and effective medicines and there will be no need to seek alternative options. But until we find a cure, doctors and patients need to work to find the best treatments—and to understand and mitigate the risks and perceived risks associated with different medicines.
Alternative treatments can have a wide reach. Studies show that about 50 percent of the time, patients have used or considered using alternative medicine. Those who don’t think of using alternative treatments themselves are often introduced to the idea by someone in their lives—a neighbor or relative perhaps—who tells them, “You’ve got to try this thing I saw on TV (or online)!”
The label “alternative medicine” has become a catch-all that includes everything from Traditional Chinese Medicine to an item that sells for $19.95 and is marketed as a magical eczema cure.
In general, we can define alternative medicine as treatments for which we don’t have enough evidence to specify whether they will work in an intended way. Some alternative treatments are those that people talk about and use—even though they have been found not to work in studies.
One such treatment is homeopathy. I have a lot of patients who swear by it and love it—and in one way or another, it has certainly helped some people. But when you look at all the data from studies, it doesn’t seem to work in a consistent, reliable way to pass muster.
Other treatments are categorized as alternative by the medical community because they haven’t yet completed enough tests to know whether their use will provide an intended outcome.
The key to making sense of the alternative treatment category is to narrow the scope to treatments that are backed by at least some evidence, are generally thought to be safe, and are practical (the treatment should not be more difficult than the disease, because part of our job as doctors and researchers, is to give people their life back).
A practical way to look at alternative approaches is to think about ways to use nature to support, enhance, augment, and heal the patient. We use these terms in alternative medicine in place of more aggressive terms like “attack,” “cut out,” and “strike down,” and I think they can have a positive psychological effect on both the patient and doctor when approaching a disease with no known cure.
While we try to work with nature, we have to remind ourselves that natural doesn’t necessarily mean safe. After all, poison ivy, arsenic, and bacteria are all natural things, but we don’t want them on our skin. We also have to be aware that people tend to “greenwash” things; they throw the concept of “natural” around even when it doesn’t fit, or isn’t entirely honest.
It’s a slippery slope; things can quickly go from natural to unnatural. Turmeric, for example, is an amazing herb with anti-inflammatory properties. But is it really natural to take 10 pills of turmeric a day—especially if the source of that pill is a manufacturing plant in New Jersey?
Finally, it’s helpful to remember that even though some emerging natural treatments show promise, discussions of their benefit is speculative in the grand scheme of things. Alternative treatments are generally supported by some — but not overwhelming — evidence. Just like drugs that have been approved by the FDA, natural treatments may have hidden side effects that may not be exposed for years to come. These considerations can help a person keep perspective when considering alternative remedies.
Ceramides are skin barrier bolstering fats that are naturally produced in our bodies. Many cosmetic companies enhance their moisturizers with ceramides as a way to replenish the level of these fats via topical absorption. Sunflower seed oil can stimulate our bodies’ natural ceramide production internally, which, in turn, can help improve the skin barrier. The natural oil also serves as an anti-inflammatory, which can be beneficial for patients suffering from the inflammation of eczema.
A few small studies have looked at how we harness the power of nature to help improve inflamed skin. One study examined sunflower oil distillate. Researchers fractionated the oil and found that patients who used the sunflower oil along with a topical steroid for three weeks had significantly less lichenification (skin that becomes thick and rough from rubbing and scratching). Presumably, this meant they were less itchy, because they weren’t scratching as much. While more studies are needed, this small trial demonstrated a beneficial outcome for a treatment that is safe for many patients to try.
How safe is it? Because we often don’t have large numbers of eczema patients for studies in alternative medicine, we look to indirectly related studies to connect the dots. To explore the safety of sunflower seed oil, we reviewed a study of premature babies with poor barrier function (similar in some ways to that of eczema patients). These babies also lived in a place that put them at high risk for getting a blood infection, sepsis, and dying. The babies were given sunflower seed oil topically three times a day and had a 41 percent reduction of bacterial infection in the blood and a 26 percent reduction in death when compared to other babies who did not have the oil applied.
The study suggests that sunflower seed oil could enhance skin-barrier function and help heal the skin, thus protecting it from bacterial invasion. Since the study subjects were babies who have more absorbent skin than adults and they did fine, it strongly suggests that sunflower seed oil is safe for skin. As a result, I’ve incorporated the use of sunflower seed oil into some of my patients’ skin care regimens. I recommend that patients apply the lightweight oil when the skin is still wet.
Another fascinating natural ingredient that has become popular for skin and hair care is coconut oil. One study with atopic dermatitis patients showed staph bacteria on the skin decreased by 95 percent after coconut oil was applied to the skin (as compared to a reduction of about 50 percent in patients who applied olive oil instead).
This is astounding considering that most patients with moderate to severe atopic dermatitis have skin that’s colonized with staph bacteria—even if they don’t have an infection. This treatment is safe for most people and is frequently used in other countries.
One caveat to consider when thinking about incorporating food-based products into a treatment routine is the development of allergies; we know that putting food proteins onto open skin can increase the risk of a person becoming allergic to that food. Fortunately, I haven’t seen this happen with coconut oil or sunflower seed oil. As long as a patient is not allergic, these oils seem to be a good thing. I suggest mixing a little bit of sunflower seed oil and coconut oil into a moisturizer before applying them to the skin.
We know stress plays a huge role in atopic dermatitis; when patients of all ages are stressed out, they get itchy and experience flare-ups. So it makes sense that a stress reliever like massage could help atopic dermatitis sufferers.
In one study, a massage therapist taught the parents of 20 atopic dermatitis patients, ages two to eight, how to give a massage to their children. Parents then gave their children a massage for 20 minutes a day. At the one-month mark, when the children’s skin was compared to that of children with atopic dermatitis who did not receive massage, researchers found a significant improvement in all critical measures of eczema. Researchers also found that the kids and parents in the massage group showed less signs of anxiety.
For parents of younger children with eczema, the massage becomes a great time to apply moisturizer to the skin; this is not only a gentle and safe way to help treat your children, but a great time to bond as well.
Acupuncture is a beautiful, complicated system that I have studied and trained in.
One of the studies that came to my attention while learning acupuncture examined patients suffering from a disease that triggers failure of the kidneys (organs that filter out toxins in the body). When the kidneys aren’t functioning correctly, people get itchy to the point of wishing themselves dead.
Acupuncture was used to stimulate one point on the arm called Large Intestine 11 in one group of patients. A placebo treatment, which did not stimulate a significant point on the body, was used in another group. The researchers found that the patients who underwent the acupuncture treatment reported a significant reduction in itch, while the placebo group reported no significant change.
We wanted to try this technique with eczema patients, but since many of my patients are needle-phobic, we decided to try acupressure instead.
We directed 15 patients with moderate to severe eczema to massage the Large Intestine 11 spot using small titanium beads for three-minute sessions three times a week for four weeks. We found that four of the patients who performed acupressure got significantly better whereas no one in the non-acupressure group saw improvements.
When we looked at whether itchy sensations decreased, along with the severity of overall eczema, two of the people who did not receive the acupressure treatment got worse, whereas no one in the acupressure group got worse — and five of the people getting the acupressure treatment got better versus only two in the other group. These results were enough to be statistically significant even though the study was small.
We have discovered that beads aren’t required of this treatment: many of my patients have reported beneficial results from massaging with their fingers.
Robert Sidbury, M.D., a Seattle-based pediatric dermatologist and member of the NEA Scientific Advisory Committee, studied 11 children with severe eczema whose condition worsened in the winter, giving them either 1,000 IU of vitamin D or a placebo.
Eighty percent of those who took vitamin D improved and none reported worsening, whereas everyone in the placebo group essentially stayed the same. Other studies show people who have low vitamin D levels tend to have worse eczema than those with higher levels, supporting this idea.
In the Western world, many people are slightly vitamin D deficient due to the amount of time spent indoors and because of the sun protection we use to help prevent skin cancer. I usually suggest that my patients take a vitamin D supplement to help maintain a normal level.
There is a lot of spotty data out there for hypnosis as it relates to atopic dermatitis patients. But I think there’s a role for hypnosis in eczema patients, particularly when it comes to stress. Think of it as a relaxation technique that helps you go to a quiet space and calm things down. It can help create a powerful connection to mind, body, and skin as well.
Of course, hypnosis as eczema therapy has its own obstacles: patients must find a therapist who can perform the treatment, it’s expensive, and it’s often not covered by insurance. Those interested in trying hypnosis without the cost can access Skin Deep, a free book online from Massachusetts-based dermatologist Ted Grossbart, Ph.D. The book shows readers how to perform some simple self- hypnosis.
For those with atopic dermatitis, the concept of bathing can be really confusing. Some doctors say that taking too many baths will dry out skin, while others suggest bathing twice a day to help prevent water loss. You’ll sometimes hear doctors say it’s best to apply a moisturizer while the skin is still damp—or within 10 seconds or three minutes or seven minutes of emerging from the bath.
Bath therapy has been recommended for a long time, but we don’t have much evidence about best practices and many of the numbers that get tossed around aren’t rooted in research. In fact, when I was part of the Joint Task Force in Allergy and we wrote the recent treatment guidelines, we realized there was only one study upon which we could actually base any recommendations!
In that study patients were instructed to take a bath or not take a bath, and then put on moisturizer either right away or after waiting awhile. The research showed that if moisturizer is applied while skin is still damp, then it locks water into the skin and ultimately, hydrates better. It’s still very important to apply lotion on dry skin, too, in order to achieve sustained hydration.
Taking a bath at least once a day (rather than less frequently), then moisturizing immediately after, is helpful for most of my patients; it washes allergens, pollutants, and other irritants from the skin and keeps it hydrated.
Can bathing in special water at a spa be more therapeutic than simply bathing at home? There’s actually a lot of good evidence that spa time can help. The problem is, it’s hard to pinpoint what aspect of the spa experience is helping; it may be a little misleading to declare that the water itself is the healing part of the experience.
Thermal spas in the south of France have served as a healing destination for people with terrible eczema and psoriasis. While there, people get sunlight and warm weather (which is sometimes called climatotherapy) in a vacation setting. It’s a spa! You’re in France! How could you not be relaxed and happy? The problem, of course, is that it’s expensive and time consuming to go to France. And for most of us, it’s a temporary solution. That being said, some studies show sustained improvement in patients with atopic dermatitis for up to two years.
A paper released last year showed that certain types of Staph bacteria makes a toxin, and when that toxin is placed on the skin of a mouse, it can create eczema—even in normal skin. We are still learning what this means for us, but the concept of maintaining a community of healthy normal bacteria on your body, called the microbiome, is an emerging area of scientific study.
Some studies show that newborn babies who have a limited number of bacteria in their guts also have an association with eczema at one year of age. Babies with a more diverse flora of healthy bacteria in their guts have a decreased risk of eczema at one year of age. We don’t know exactly what that means yet — but it’s compelling in its connection between bacteria in the skin and gut.
In regard to bacteria and the skin, the number of healthy bacteria decreases around the time one experiences an eczema flare. After treating the eczema — even if using topical steroids — the bacteria diversifies again and the skin looks better. By working to restore the skin’s natural environment — even using things that are thought to be un- natural, like topical steroids — you help lay the groundwork for beneficial bacteria to grow again.
In short, when your skin’s bacteria become imbalanced and staph goes up, then the flare on your skin follows. But when the staph goes down, your healthy bacteria come up and then the flare ends. So this raises the question: can we force the growth of beneficial bacterial populations outside of what naturally happens on our skin and in our bodies?
As with many alternative treatments, the answer is: we don’t know.
A study in 2001 showed that when expectant mothers, and then babies, were given a lactobacillus probiotic, it cut the development of atopic dermatitis in half. This got people very excited, thinking that this would be the key to preventing the disease. But the studies that followed weren’t as striking, and the research since then has gone back and forth.
A study in 2005 showed that giving probiotics to older children with established eczema helped them get much better, and that created another wave of excitement. This too was followed by studies with mixed results. We need to learn a lot more about what probiotics can and can’t do, which ones to give, and when to give them.
Garments with a built-in antibacterial agent provide an- other way to address the growth of the problem bacteria. A few studies have shown that wearing these garments can be helpful to patients, but many of these studies have been small, quirky, or underpowered, and we’ve got to be careful about making sweeping generalizations when more study is needed. Occasionally, I’ve had patients benefit from using silk clothing wraps, which can be very light, breathable and cooling to the skin.
There has also been some discussion of using silver, a natural antibacterial treatment, in clothing. But silver can leach out into the environment and negatively impact aquatic ecosystems when it is laundered. Silk and silver in clothing are also very expensive weapons of choice—especially where growing kids are concerned.
There is some suggestion that yeast may play a role in atopic dermatitis, particularly in young adults with severe eczema on the head and neck. A type of yeast called malassezia that composes a normal part of our microbiome can overgrow and trigger the immune system.
A few studies have shown that taking the anti-yeast pill itraconazole, can improve the skin, but in my experience, the medicine can be a little hit or miss. Even so, I’ll sometimes have patients try it because it can be taken once a week and is pretty safe since it’s not an immunosuppressive, and it offers another approach.
Apple cider vinegar may provide a more natural way to address the yeast, as it has some anti-yeast properties and could help restore the skin’s natural healthy state in that it is slightly acidic. When our skin is a little more acidic (pH around 5), it stays strong and bacteria can’t grow well.
Conversely, if skin is more alkaline, or basic, then it begins to break down and bacteria levels increase. Patients who don’t like the concept of bleach baths can try apple cider vinegar baths as a safe and gentle possible treatment.
Topical steroids are known anti-inflammatory drugs, but they can’t be used all the time. To supplement topical steroids, some of my patients benefit from using Florasone, an inexpensive cream that contains a Cardiospermum plant extract and serves as a gentle treatment. Because its active ingredient is derived from a plant, the cream may trigger allergies or sting the skin.
Clearly, there are many alternative treatments that can be tried and it can be overwhelming. I generally have patients try them one or two at a time and provide honest feed- back about the outcome after a set period of usually just a few weeks. With care and effort, many patients can find helpful alternatives and complementary treatments that keep the eczema in check.
Until we find a safe and inexpensive cure, keeping an open mind about some of the lesser-known alternative treatments can provide some people with much-needed relief.