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Integrative Skin Care: Dermatology and Traditional and Complementary Medicine

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Abstract

Skin problems and diseases are extremely common globally and, due to their visibility, often result in severe distress and stigma for sufferers. Traditional (i.e., indigenous or local) and complementary health systems are widely used and incorporate many treatment modalities suitable for skin care, and a body of evidence for their efficacy and safety has built up over many decades. These approaches are often used as part of a broader "integrative medicine" (IM) approach that may also include, for example, nutrition and mind-body approaches. This article presents an overview of current knowledge about traditional and complementary medicine (T&CM) and IM principles and practices for skin health; reviews published epidemiologic studies, clinical trials, and wider literature; and discusses the challenges of conducting research into T&CM and IM. It also highlights the need for an innovative research agenda-one which is congruent with the principles of IM, as well as taking policy and public health dimensions into consideration.
ORIGINAL ARTICLE
Integrative Skin Care:
Dermatology and Traditional
and Complementary Medicine
Gerard Bodeker, PhD,
1–3
Terence J. Ryan, DM, Drhc,
1,2,4,5
Adva Volk, ND, ClH, MIHA,
2
Jahnavi Harris, BS,
2
and Gemma Burford Mbiochem, MSc
2,5
Abstract
Skin problems and diseases are extremely common globally and, due to their visibility, often result in severe
distress and stigma for sufferers. Traditional (i.e., indigenous or local) and complementary health systems are
widely used and incorporate many treatment modalities suitable for skin care, and a body of evidence for their
efficacy and safety has built up over many decades. These approaches are often used as part of a broader
‘‘integrative medicine’ (IM) approach that may also include, for example, nutrition and mind–body ap-
proaches. This article presents an overview of current knowledge about traditional and complementary medi-
cine (T&CM) and IM principles and practices for skin health; reviews published epidemiologic studies, clinical
trials, and wider literature; and discusses the challenges of conducting research into T&CM and IM. It also
highlights the need for an innovative research agenda—one which is congruent with the principles of IM, as
well as taking policy and public health dimensions into consideration.
Keywords: skin care, policy and public health, dermatology, ayurveda
Introduction
The skin is the body’s largest organ, and the impact of
skin conditions on well-being is increased by their visi-
bility. Throughout history, traditional (i.e., indigenous and
local) healthcare systems have evolved diverse responses to
skin conditions, and it has been estimated that skin and
wound treatments account for approximately a third of all
traditional medicines.
1
This figure may not include the nat-
ural products applied regularly to healthy skin in many parts
of the world to promote hygiene, such as ‘‘soap plants’’ and
emollients.
Formerly ‘traditional’ approaches to the treatment of skin
conditions have now become popular in many industrialized
countries, either as health systems in their own right (e.g.,
Traditional Chinese Medicine and Ayurveda) or within the
realm of ‘‘complementary and alternative’’ medicine (e.g.,
Naturopathy and Functional Medicine). With the recent
emergence of integrative dermatology,
2
professional der-
matologists have also begun to explore diverse approaches
for treating skin conditions holistically and systemically
rather than focusing only on topical applications. These
include, for example, nutrition-based interventions, Tradi-
tional Chinese Medicine, Ayurveda, ‘‘Western’’ herbal
medicine, mind–body approaches, and energy medicine.
The growing interest in integrative dermatology may be
attributable, in part, to scientific advances highlighting the in-
terconnectedness of the skin, the nervous system, the gut and
skin microbiome, the emotions, and the endocrine system,
3,4
but public expectations are another important driving factor.
A cross-sectional study conducted in Singapore found, for
example, that more than 60% of patients (n=855) expected
dermatologists to provide at least basic advice on comple-
mentary and alternative medicine (CAM).
5
In another study
from 2012, 78% (n=235) of patients with dermatologic con-
ditions stated that incorporating CAM approaches into their
treatment recommendations should be considered by physi-
cians and 89% stated that CAM approaches should be studied
1
Green Templeton College, University of Oxford, Oxford, United Kingdom.
2
Global Initiative for Traditional Systems of Health, Oxford, United Kingdom.
3
Department of Epidemiology, Columbia University, New York, New York.
4
Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom.
5
Centre for Biocultural Diversity, University of Kent, Canterbury, United Kingdom.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 00, Number 00, 2017, pp. 1–8
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2016.0405
1
in research by the dermatology department where the survey
was taken.
6
In a cross-sectional survey for dermatologists
(n=61) from 2009, 88% reported that patients asked them for
advice or information about CAM (most frequently for psori-
asis, eczema/dermatitis, allergies, acne, and hair loss), 26%
of dermatologists were using CAM themselves, and 50% of
participants expressed interest in learning more about CAM.
7
To strengthen bridges between conventional allopathic
therapies and the utilization of traditional and complemen-
tary medicine (T&CM) or integrative medicine (IM) for skin
conditions, a better understanding of the principles and ap-
proaches of these therapies is needed. Such systems of
medicine seek equilibrium and well-being of the whole
person and view the appearance of skin pathology as an
indicator of psychologic, as well as physiologic, dimensions.
In this review, the authors do not presume to do justice to
such a vast topic from the perspective of clinical practice.
The recent book Integrative Dermatology, edited by Nor-
man et al.,
2
addresses the subject rigorously by presenting
overviews of diverse therapeutic perspectives and offering
recommendations for the integrative management of specific
skin conditions. The aim of the study is to provide an
overview of the existing research base and the challenges of
research in this area, on the one hand, and to broaden the
scope of Integrative Dermatology to encompass wounds,
burns, and preventative skin care, especially in developing
countries, on the other.
Principles of T&CM and IM
T&CM treatments include a wide spectrum of systems.
Among those, the most widely utilized and studied are
Chinese Medicine, Ayurveda, and Naturopathy. The main
therapeutic principle which they share in common is the
view of the person as a whole:
Ayurveda aims to preserve youth, prevent disease, nurture
natural and inner beauty, and delay aging. It recognizes
the importance of confidence in one’s presentation to
others. It finds skin luster and radiance desirable and uses
various techniques to achieve this. Ayurveda’s basic
principles include inductive learning, whole system
thinking, and individually optimized therapy: techniques
such as removal of toxins, herbal and dietary regimens,
and behavioral advice are an integral part of the treatment
protocol. The three main constitutional types or doshas are
understood to present as differing skin pathologies and
demand different Ayurvedic prescriptions.
8
Chinese Medicine also takes the body as a whole and
views the diseased state as a reflection of imbalance of
the whole body. Chinese herbal medicines (CHMs)
contain ingredients that treat diseases from multiple
targets, mobilizing the whole body rather than regu-
lating just a single factor.
9
One of the principles of Naturopathic medicine is the
removal of underlying factors causing the disease. For
skin diseases, treatment will be different for a skin
condition that is a manifestation of an allergic reaction
(e.g., contact dermatitis) or one that is related to in-
flammation and hormonal imbalance (e.g., acne). Other
principles are that the patient’s intrinsic self-healing
capacity is a key driver, the whole body is treated, and
the treatment is personalized—that is for the patient
and not the disease. The focus of the treatment is on
tailoring a unique treatment protocol for each individ-
ual, strengthening energy levels (referred to as ‘‘life
force’’), and drawing on nutrition and other modalities
for a therapeutic outcome.
10
Researching T&CM and IM
The principles of T&CM run into a conflict with the re-
search methods that have come to be accepted as a gold
standard in biomedicine, namely preclinical studies and ran-
domized double-blind clinical trials. There are two main
difficulties: first, that different treatments would typically be
offered for different individuals or subsets of people suffering
from the same skin condition, and second, that a treatment
protocol might include different techniques that would work
together as a whole, for example, nutrition combined with
herbs and oils. Randomized controlled clinical studies, by
contrast, are typically carried out with a standardized for-
mulation, or in some cases even a single ‘‘active ingredient’’.
On this note, it should be emphasized that clinical re-
search remains fundamentally important in establishing an
evidence base for T&CM, evaluating efficacy and safety of
particular treatments, and most importantly evaluating in-
teractions between drugs and natural products as part of the
process of safe integration acceptable for doctors, as well as
natural medicine practitioners. Preclinical studies also pro-
vide important clues about the mechanisms of action of such
therapies. Nevertheless, such studies may not give a full
picture of efficacy of holistic treatments. Treatment proto-
cols that would typically include nutrition, systemic and
topical herbal treatments, and lifestyle recommendations
(such as mindfulness or relaxation techniques) may not be
adequately assessed through clinical research. Clinical
studies may lead to some false negatives, suggesting that a
treatment is ineffective when in fact only one element of the
treatment protocol has been studied. It would be important,
therefore, to supplement clinical research with case series
analyses that report on personalized holistic treatment pro-
tocols as they are designed for, and administered to, indi-
viduals and focus the efforts on evaluating the underlying
process of personalization of the treatment and the clinical
benefit of the ‘‘whole-person’ treatment model. Recent re-
search on Ayurvedic combination therapy has moved in this
direction by applying a combination of biomedical and
psychosocial measures to evaluate treatment outcomes.
11
Narahari et al. also have moved to a whole systems ap-
proach with a study aimed at developing IM treatment
protocols for the long-standing skin diseases vitiligo and
lymphedema.
12
In this study, a team of medical doctors
along with therapists from multiple disciplines (homeopa-
thy, yoga, and Ayurveda) developed guidelines for pre-
scription of their therapies and a patient care algorithm
despite the different interpretation of the pathologic basis of
the disease by each of the systems.
An important article by Dattner,
13
a clinician, describes
how complementary medicine has been integrated into the
practice of dermatology over a period of two decades, il-
lustrating in depth other ways that skin disorders can be
understood and treated. Topics covered include proantho-
cyanidins for capillary leakage, intestinal Candida over-
growth and skin inflammation, and leaky gut and food
2 BODEKER ET AL.
allergy. Dattner identifies herbs that enhance or inhibit in-
flammation and offers the view that the skin is an organ of
elimination that can be supported by herbs, for example,
milk thistle, for supporting the liver in inflammation. A
number of the approaches discussed have been subsequently
studied and incorporated into clinical practice. This report is
important in presenting a framework for understanding the
thinking process involved in diagnosing and treating skin
disease from an integrative perspective.
While currently there is very little clinical research using
methodologies congruent with the principles of T&CM and
IM, some studies exist which demonstrate the connection
among diet, digestion, the microbiome, and the skin. These
studies form the basis for further research on whole-person
orientated medicine systems and for understanding the
foundations on which the diagnosis and treatments they
offer are constituted. One such article by Melnik
14
describes
how two metabolism regulators, FoxO1 and mTORC1,
promote acne when their signaling process becomes unbal-
anced due to consumption of western diet (specifically milk
and sugar). A review from 2014
15
discusses probiotics and
the gut–brain–skin axis and the role they play in acne. The
importance of the microbiome in skin disorders is slowly
gaining more recognition and paving the way for more
studies incorporating nutritional approaches. Another study
from 2005
16
examined data from the Nurses Health Study II
to evaluate whether there is an association between dairy
intake during high school and severe teenage acne and found
a positive association for intake of milk and skimmed milk.
The authors hypothesize that these results may be due to
presence of hormones and bioactive molecules in the milk.
This study highlights the importance of dietary modifica-
tions in managing certain skin disorders toward a more
complete resolution.
Research into T&CM for Treating Skin Diseases
Epidemiology
There have been few studies of the epidemiology of tra-
ditional or IM use for skin conditions. Most existing epide-
miologic studies are framed in terms of ‘CAM’ utilization.
A systematic review of CAM utilization surveys among
dermatologic patients in industrialized countries
17
identified
seven studies that met the inclusion criteria: lifetime prev-
alence of CAM utilization was high but variable, ranging
from 35% to 69%. More recent research includes a 2009
study based on results from a national survey in the United
States which showed that among people reporting on skin
disease 49.4% had used CAM and 6% of this group used it
specifically for skin disease. Moreover, those reporting on
skin problems were more likely to use CAM than those who
did not report any skin condition.
18
Another survey from the
United States was conducted in a dermatology department in
a tertiary care center and showed that 82% of respondents
used CAM.
5
Baron et al.
19
conducted a survey in the United
Kingdom to investigate the use of CAM for dermatologic
conditions in Yorkshire and South Wales and found that
over a third of participants (n=1037) were using CAM and
that more than 45% of them were using it for their derma-
tologic condition. Results from a survey conducted in 2014
in eastern Turkey revealed that 43.7% used at least one
CAM method for their dermatologic condition and 20.8%
used two or more.
20
A secondary analysis of data from the
Oxford Healthy Lifestyle Survey
21
showed that about one in
ten (9.8%) of respondents with a chronic skin condition had
visited a complementary practitioner within 3 months of the
survey.
Findings from a study in Korea
22
follow the same trend of
high utilization levels with 67.2% of respondents using
CAM for androgenetic alopecia, 68.9% for atopic dermati-
tis, and 46.6% for psoriasis. There are also epidemiologic
studies on use of CAM for specific skin disorders such as
atopic dermatitis, psoriasis, and eczema.
23,24
Clinical trials
Reviews of the literature on T&CM treatments for in-
flammatory skin conditions such as eczema, psoriasis, and
acne indicate promising initial results, but a disappointing
lack of ‘‘gold standard’ research, when judged against the
criteria of biomedicine. The continuing difficulty of building
up an acceptable evidence base is largely due to under-
funding. In the global South, the large participant numbers
and full-time staff required to fulfill randomized controlled
trial (RCT) criteria are often far too costly. In the global
North on the other hand, there is a lack of feedback from
patients, constraints on clinical research due to privacy
regulations, and insurance funding bias against the evalua-
tion efforts needed for understanding T&CM outcomes. An
equal concern is the attempt to evaluate T&CM and IM
practices using methodologies which do not encompass the
full breadth of these practices.
While published clinical studies do exist, many of them
are very small and/or methodologically flawed, and the di-
versity of T&CM treatments leads to difficulties in com-
parison. This is well illustrated by a systematic review of
both biomedical and T&CM treatments for atopic eczema,
24
which identified a total of 1,165 eligible RCTs. Of these,
893 (77%) were eliminated because of a lack of appropriate
data, leaving 272 trials that covered at least 47 different
interventions, broadly categorized into 10 main groups. Of
the T&CM treatments, only psychologic approaches were
classed as having ‘‘reasonable RCT evidence to support
use.’’ There was insufficient evidence to make recommen-
dations on Chinese herbs, homeopathy, massage therapy,
hypnotherapy, or evening primrose oil. This review further
highlights the limitations in the current methodology used
for evaluating T&CM as so little evidence was gathered
from such a large number of studies.
A systematic review focusing specifically on RCTs of
orally administered Chinese herbal preparations for treating
atopic dermatitis/atopic eczema
25
identified seven such
studies. Six compared CHM with placebo, and the seventh
compared the combination of Chinese and allopathic
(‘‘Western’’/biomedical) treatment with allopathic medica-
tion alone. The meta-analysis revealed significant im-
provement in quality of life and symptom severity, but
called for the findings to be treated with caution because
most of the studies were of poor quality—describing all but
two as showing as having a high risk of attrition bias, re-
porting bias, or both. The two studies described as meth-
odologically sound are as follows:
- Hon et al.
26
have described a RCT of ‘‘PentaHerbs’’, a
standardized capsule containing 2 g of Flos lonicerae
INTEGRATIVE SKIN CARE 3
(Jinyinhua), 1 g of Herbamenthae (Bohe), 2 g of Cortex
moutan (Danpi), 2 g of Rhizoma atractylodis (Cangzhu), and
2g of Cortex phellodendri (Huang bai), in children with
moderate-to-severe atopic dermatitis. While both groups
showed a similar decrease in the disease severity score, the
treatment group (n=42) showed a significantly greater im-
provement in the Children’s Dermatology Life Quality Index in
comparison to those receiving placebo (n=43). Topical corti-
costeroid use was reduced by a third in the treatment group.
- Cheng et al.
27
conducted a randomized, double-blind
placebo-controlled trial of Xiao-Feng-San, a widely used
Chinese traditional preparation consisting of 12 herbs. They
observed that after 8 weeks, the treatment group (n=47) had
a significantly higher decrease in total clinical lesion score,
as well as statistically significant differences in erythema,
surface damage, pruritus, and sleep scores, than the placebo
group (n=24).
A Cochrane review covering both oral and topical Chinese
herbal preparations for the treatment of atopic eczema
28
echoed
this note of cautious optimism. It reported that the total effec-
tiveness rate in the CHM groups was superior to placebo
(risk ratio [RR] 1.43, 95% confidence interval: 1.27–1.61)
across 21 studies, representing a total of 1,868 patients; yet
it too described the evidence as ‘‘very low quality,’’ high-
lighting the risk of bias in most published studies and calling
for large well-designed RCTs to be conducted.
A 2016 review
29
illustrates the importance of diet and
nutrition for psoriatic patients based on current knowledge.
After introducing the relationship among obesity, low-grade
inflammation, and psoriasis, the review then details a
number of nutritional regimens that have been found to be
beneficial in the treatment of psoriasis. These include low-
energy diets and vegetarian diets, formula diet weight loss
programs, gluten-free diet, very low calorie carbohydrate-
free (ketogenic), fasting periods, and diets rich in omega-3
polyunsaturated fatty acids from fish oil.
A systematic review and meta-analysis from 2015 exam-
ined the effect of lifestyle weight loss intervention on disease
severity of psoriatic patients. It reviewed seven RCTs with a
total of 878 participants, of which five were included in the
meta-analysis. In patients receiving weight loss intervention
of various types, a greater reduction (of up to 75%) in
Psoriasis Area Severity Index score was exhibited.
30
Alow-
energy diet has also been found to significantly improve the
outcomes of conventional topical therapy for pustular psori-
asis, in comparison with the standard hospital diet.
31
These
findings are consistent with the principles of T&CM and the
use of IM, highlighting the value of treating the whole system
when managing skin disorders.
A recent study from 2016 reviewed RCTs of CAM
therapies for atopic dermatitis. Out of the 70 included arti-
cles, the reviewers found sufficient evidence of efficacy for
acupuncture, acupressure, stress-reducing techniques such
as hypnosis, massage, biofeedback, balneotherapy, herbal
preparations, particular botanical oils, oral evening primrose
oil, Vitamin D supplements, and topical vitamin B12.
32
This
type of evidence highlights the multitude of treatment op-
tions available and the potential for further studies to inte-
grate a number of these treatments together.
Isolated RCTs have been conducted on non-Asian poly-
herbal preparations for the treatment of skin conditions.
Zerehsaz et al.
33
carried out a double-blind randomized
clinical trial of a topical herbal preparation, containing ex-
tract of Althaea rosea,Althaea officinalis, and a number of
other plants, versus systemic meglumine antimoniate for the
treatment of cutaneous leishmaniasis in 171 patients in Iran.
It was found that the herbal preparation achieved a 74% cure
rate, compared with only 24% for the conventional treatment.
Beltrami et al.
34
conducted a clinical trial on a topical herbal
formulation for the treatment of acne vulgaris, incorporating
a lipophilic extract of Krameria triandra (antibacterial),
Serenoa repens (which inhibits 5- _
areductase), and Centella
asiatica (which stimulates collagen production). The find-
ings included a significant increase in skin hydration, de-
creased transepidermal water loss, and decreased sebum
production in comparison with placebo. For herpes simplex,
a topical preparation containing copper sulfate pentahydrate
and Hypericum perforatum was found to be more effective
than the standard treatment, 5% acyclovir cream, at treating
active skin lesions and reducing acute pain, erythema, and
vesiculation after a single application in contrast to the
acyclovir, which required repeat application.
35
Using skin care as the objective, rather than named der-
matologic conditions, wound healing, burns management,
lymphedema, and Neglected Tropical Diseases may offer an
easier and more available testing ground for T&CM treat-
ments. A double-blind RCT studied the effect of topical
application of Hypericum perforatum on the wound healing
and scar of cesarean in 144 women with surgical childbirth.
Participants were assigned to three groups—treatment, pla-
cebo, and a control group with no intervention. Results show
significant differences in wound healing and scar formation
in the treatment group compared to placebo and control
groups. Pain and pruritus reported by treatment group were
also significantly lower.
36
An RCT on topical use of Calendula officinalis found it to
be significantly more effective than trolamine for preventing
acute dermatitis of grade 2 or higher during irradiation for
breast cancer. Acute dermatitis among the 254 patients who
participated in the study was only 41% with application of
calendula versus 63% with trolamine. There was greater
self-assessed satisfaction in patients using calendula, even
though its application was considered more difficult.
37
Narahari et al.
38
conducted a nonrandomized interven-
tional study that reflects the ‘‘whole-system thinking’’
principle of T&CM and IM therapies. The aim of the study
was to determine the efficacy of an integrative treatment
protocol for morbidity control of lymphedema in two lym-
phatic filariasis endemic districts of South India. The treat-
ment included skin wash, phanta soaking (an Ayurvedic
infusion of Rubia cordifolia in hot water), yoga and
breathing exercises, Indian manual lymph drainage (limb
massage against the direction of hair growth using an oil
specially prepared for lymph drainage), compression ther-
apy, and bacterial entry points care using pharmaceutical
medicines. Seven hundred and thirty patients completed the
three and a half months follow-up. The results demonstrate a
statistically significant reduction in limb volume measure-
ments, a decrease in inflammatory episodes (from 37.6% to
10.2% in one of the districts), and an overall improvement
in all life quality dimensions on a lymphatic filariasis spe-
cific quality-of-life questionnaire.
Due to the magnitude of placebo effects and the nature of
certain therapies, it is evident that placebo-controlled RCTs
4 BODEKER ET AL.
are not the only valid means of evaluating the clinical effi-
cacy of T&CM and IM treatments. To cite just a few ex-
amples, case reports for acupuncture in the treatment of
psoriasis
39
and facial skin diseases
40
have shown good re-
sults; regular practice of Tai Chi Chuan has been associated
with improved endothelial function in the skin vasculature of
older men
41
; and even listening to music by Mozart has been
shown to reduce allergic skin wheal responses in atopic
dermatitis patients with latex allergy.
42
Mind–body therapies
have been demonstrated to be helpful in a wide variety of
skin conditions.
Toxicologic studies
Use of herbal and traditional medicine as a basis for pri-
mary healthcare is common among the majority of the world
population, making research into toxicity of herbs and tra-
ditional medicines a crucial task. The main problems that
arise when discussing toxicity involve botanical misidentifi-
cation or mislabeling of plant material, changes in old plant
descriptions, contamination of herbs with microorganisms,
fungal toxins such as aflatoxin, pesticides, and heavy metals.
Another potential for herbal poisoning stems from the
difference between traditional preparation and modern un-
professional processing. Interactions between herbal prod-
ucts and conventional drugs can also lead to undesired
effects.
43
The Aristolochia disaster in Belgium, in which
over 100 women developed kidney failure and some died
after consuming a Chinese herbal slimming preparation in
which Aristolochia fangchi had been accidentally sub-
stituted for Stephania spp.,
44
is probably the most extreme
example, but even in the case of skin treatments, various
side-effects have been reported among users of Chinese
medicines in industrialized countries. The commonest is
contact dermatitis,
45
but more serious reactions have also
been reported, such as cardiomyopathy and liver damage.
43
There is an urgent need for improved standards of toxi-
cologic assessment, quality control, and postmarket surveil-
lance for all T&CM therapies and practices, but particularly
those that are widely used outside the communities in which
they evolved. Research into toxicology may also include
ways of mitigating or abolishing the side-effects of T&CM
therapies, as in the example of Ginkgo biloba seed pulp,
which induces severe contact dermatitis: some causative
constituents can be removed, and the protective effects
against sunburn enhanced by chemical manipulation.
46
It is important to note as well that biomedicine may carry
greater risks of adverse reactions than T&CM. For example,
a U.S. study reported that one in four older patients admitted
to hospitals is prescribed at least one inappropriate medi-
cation and up to 20% of all inpatient deaths are attributable
to potentially preventable adverse drug reactions.
47
While dermatology’s most studied adverse reaction is
contact dermatitis, its textbooks report little on reactions
from herbals and the essential oils used, for example, in
aromatherapy.
Preclinical research
There is a large body of preclinical research relevant to
the use of traditional herbal preparations to maintain or
improve the health of the skin, using both in vitro and
in vivo models. The scope of this article does not permit us
to review them in depth, but only to highlight some
emerging lines of research.
Dermatologists have developed a number of distinctive
preclinical research methodologies for studying the skin,
many of which are useful in the evaluation of T&CM
therapies. Transepidermal water loss is often used as a tool
for studying barrier function.
48
The blood supply of the skin
has been especially well studied in China, using noninvasive
techniques such as nailfold video microscopy and laser
Doppler flowmetry.
49
These seek to distinguish a healthy
system from a disordered system and restore the latter to
health using oral CHMs, acupuncture, and other Chinese
traditional systems.
The preclinical study of essential oils for skin care has
recently been the subject of research attention. Patchouli
(Pogostemon cabli) oil has been found to be useful in the
prevention of cutaneous photoaging induced by UV irradia-
tion in mice,
50
while lemon grass (Cymbopogon citratus)
essential oil may be very valuable for the treatment of fungal
infections and skin inflammation. The oil was tested on mice
and demonstrated significant effects against Candida albi-
cans,Ctropicalis,andAspergillus niger. Dose-dependent
anti-inflammatory activity in response to oral administration
and topical administration was exhibited as well.
51
Traditional Medicine in the Treatment
of Wounds and Burns
Traditional systems of healthcare are widely used in the
global South as immediate ‘‘first aid’ for wounds, preventing
excessive blood loss, microbial infection, and oxidative dam-
age. A great many traditional wound treatments have antimi-
crobial properties. Indeed, the very existence of secondary
metabolites in plants is an adaptive response to microbial at-
tack: as Ryan
52
has pointed out: ‘plants have learned to deal
with bacteriaand viruses probably long before the human being
did so.’ The antiseptic properties of plant preparations can be
studied very easily without the use of sophisticated equipment,
and there is a wide literature on the subject.
The authors have identified three randomized clinical
trials of traditional or complementary medicines for wound
and burn healing. First, Chen et al.
53
studied the effect of
intravenous Salvia miltiorrhiza on wound complications
after mastectomy for breast cancer and found a significant
improvement in ischemia and necrosis in skin flaps on the
fourth ( p=0.002) and eighth ( p<0.001) days after surgery,
in comparison with a control group receiving routine wound
care. Second, in an RCT by Chuangsuwanich et al.,
54
the
proprietary polyherbal gel ‘‘Cybele
Scagel’’ (including
among other ingredients Allium cepa extract, Centella
asiatica extract, and Aloe vera extract) was found to lead to
a significant reduction in scar development according to the
Vancouver Scar Scale ( p=0.003 at 4 weeks; p<0.001 at 12
weeks) and an increase in patient satisfaction in 15 patients
undergoing a split-thickness skin graft operation. Third,
Lewis et al.
55
carried out a randomized placebo-controlled
study of a cream containing beeswax and herbal oils for the
reduction of postburn itching and found it to reduce itch
significantly more frequently than placebo ( p=0.001). Pa-
tients in the treatment group also reported a longer delay
before itch recurrence (p£0.001) and lower use of antipru-
ritic medications ( p=0.023) than those in the placebo group.
INTEGRATIVE SKIN CARE 5
A review of complementary medicine use after derma-
tologic surgery identified therapies that appear to have
evidence of benefit not only in wound healing itself but
also for their anti-inflammatory and antipurpuric properties.
These include bromelain, honey, propolis, arnica, vitamin C
and bioflavonoids, chamomile, Aloe vera gel, grape seed
extract, zinc, turmeric, calendula, chlorella, lavender oil,
and Centella asiatica.
56
There is a growing body of evidence from in vitro and
in vivo experiments suggesting that many of the traditional
preparations applied to wounds play an active role in tissue
repair. A wide variety of mechanisms have been cited, in-
cluding the stimulation of fibroblast proliferation, protein
precipitation (as part of the process of crusting), granulation
tissue formation, and reepithelialization. Bodeker et al.
57
have reviewed many of these mechanisms.
T&CM Therapies and Practices for Maintenance
of Skin Health
There are a number of traditional practices throughout the
world that contribute to skin hygiene and the maintenance of
skin health. One of the most widespread, but least studied,
practices is the use of plants for washing the skin, hair, and
clothes. While some plants provide one of two substances—
oil and ash—which are mixed together to produce the
soap,
58
other plants can be applied directly to the skin as
affordable and readily available soap substitutes.
59
Emollients (moisturizers) are widely used, often on a
daily basis, to promote skin health and suppleness: Ryan
60
states that ‘‘in dermatology, the first commandment is the
use of emollients.’’ In particular, the practice of oil massage
of neonates is extremely widespread throughout the Indian
subcontinent, with a study in Bangladesh
61
showing that oil
massage was practised by over 96% of surveyed caretakers
of newborns (n=352), irrespective of socioeconomic status
or place of residence. A RCT of sunflower seed oil massage
for premature infants in Bangladesh
62
found that infants
treated with sunflower seed oil were 41% less likely to de-
velop nosocomial infections (i.e., hospital-acquired infec-
tions) than untreated controls.
Another important consideration in relation to T&CM
preparations is skin tanning and skin lightening. A very
large number of products can be purchased in Africa and
Asia to make the light-skinned darker or the dark-skinned
lighter. While many of these products include strong allo-
pathic medications such as topical steroids and even
mercury-based products, which have been associated with
significant toxicity, there are also herbal products that in-
fluence pigmentation, and can be harmful. Some, including
those containing furanocoumarins, toxic compounds found
primarily in species of the Apiaceae and Rutacea are known
to be phototoxic. Two case reports from 2001, for example,
revealed severe sun-related burns caused by fig leaf decoc-
tion produced as a homemade tanning lotion and hemolytic
anemia and retinal hemorrhages as systemic complications
from the furanocoumarins in the decoction.
63
Defining a Research Agenda for the Future
The evaluation of T&CM and IM approaches relevant to
the care of the skin requires a flexible and interdisciplinary
approach to research. It is essential to develop new research
methodologies that are congruent with the principles of
T&CM therapies, yet will still be seen to provide valid
evidence of efficacy and safety. Using skin care as the ob-
jective, rather than named dermatologic conditions, wound
healing, burns management, lymphedema, and Neglected
Tropical Diseases may offer an easier and more available
testing ground for T&CM treatments.
One important strategy is to develop an agenda for re-
search at the level of full treatment protocols, encompassing
all the techniques offered for each individual. These could
include, for example, individual case series, surveys, and
modulated questionnaires for patients using T&CM and IM
and well-monitored and long-term mixed method research.
An exploration of theoretical, as well as pragmatic, aspects
of T&CM/IM treatment is often necessary, as exemplified
by a recent study of correspondences between Ayurvedic
and biomedical understandings of lichen planus.
64
The role
of patient satisfaction and placebo effects also deserves
special attention.
There is also value in including qualitative studies in
future research agendas, with the focus being on the quality
of treatments given within the context of the system, in-
cluding diagnosis, personalization of the treatment, and use
of either one or several treatment modalities in accordance
with the individual needs of the patient. With this intention,
the focus of such studies would be on evaluating whether a
specific treatment platform (e.g., a program of multiple
Ayurvedic, TCM etc., skin therapies) is effective, rather
than a specific product, technique, or herb.
There is an urgent need to update the research base with
new epidemiologic studies on the prevalence of T&CM/IM
in preventative and curative skin care and to explore its
importance within the context of public health. It is im-
portant to note that the integration of different approaches
may be performed by patients themselves, sometimes
without their healthcare provider’s knowledge, with im-
portant implications for safety (e.g., herb–drug interactions).
Policy and regulation of traditional, complementary, and IM
also constitute important areas for research, as does the
conservation of medicinal plants in the global South.
65
Conclusions
There have been many positive developments within
clinical dermatology and dermatology nursing worldwide,
with respect to integrating T&CM into mainstream care and
collaborating with or referring patients to T&CM providers.
These developments are the rational response to patient de-
mand; given the high prevalence of utilization in all settings
studied to date, T&CM is a reality that dermatologists cannot
afford to ignore. Moreover, it constitutes a sizeable human
resource in the field of skin care. The challenge that remains is
for this high level of interest to be translated into a systematic
research agenda and body of evidence, enabling skin-care
providers at all levelsfrom the rural mother in India or
Bangladesh, massaging her newborn infant, to the consultant
dermatologist practicing in a private clinic in London or New
York—to maintain or adopt beneficial practices and modify
or eliminate potentially harmful ones.
Author Disclosure Statement
No competing financial interests exist.
6 BODEKER ET AL.
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8 BODEKER ET AL.
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Chapter
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This is the first book to address public health issues in traditional, complementary and alternative medicine (TCAM). It presents state-of-the-art reviews of TCAM research in a range of priority public health areas such as malaria and HIV and in such common ailments as skin conditions and orthopedic injury in developing countries. Contributions analyze policy trends in areas such as financing of TCAM and education and training in this field as well as selected case studies of model TCAM projects. Important chapters on research methodology, ethical and safety issues, and intellectual property rights pertaining to traditional medicine are also presented. Public financing for TCAM is a test of the commitment of governments, and the book includes an analysis from the World Health Organization's (WHO) Global Atlas data of the worldwide trends in this area. With safety concerns foremost in the minds of both policy makers and the public, the book offers a global overview of policy and legislative trends in this field as well as an important set of guidelines for pharmacovigilance and TCAM products.
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Psoriasis is a chronic inflammatory disease of the skin with joint manifestations. Greater psoriasis severity and lower response to treatment have been linked to obesity. However, the effect of weight reduction by non-pharmacologic intervention on disease severity is still questionable. This is a systematic review and meta-analysis of randomized controlled trials (RCT) of the effect of dietary and lifestyle weight loss interventions on psoriasis severity. We comprehensively searched PubMed/MEDLINE, EMBASE, and CENTRAL from their inception to August 2014. Inclusion criteria were RCT that examined lifestyle intervention by diet or exercise in overweight or obese patients with psoriasis and measured the severity of psoriasis as an outcome compared with controls. Two authors independently assessed article quality and extracted the data. Of 12 full-text articles, 7 RCT involving 878 participants met our inclusion criteria. Five of these RCT were included in the meta-analysis, which was based on the random-effects model. There was a greater reduction in the Psoriasis Area Severity Index (PASI) score in patients receiving weight loss intervention than in controls, with a pooled mean difference of -2.49 (95% CI, -3.90 to -1.08; P=0.004). More participants in the intervention group than in the control group achieved a 75% reduction in the PASI score, with a pooled odds ratio of 2.92 (95% CI, 1.39-6.13; P=0.005). Nonpharmacologic, nonsurgical weight loss intervention is associated with reduction in the severity of psoriasis in overweight or obese patients. However, more RCT with more participants are needed to provide better quality of evidence.International Journal of Obesity accepted article preview online, 29 April 2015. doi:10.1038/ijo.2015.64.
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The prevalence of complementary and alternative medicine (CAM) use in US children with eczema is unknown. Furthermore, it is unknown whether CAM use in the United States is associated with higher eczema prevalence. We sought to determine the eczema prevalence in association with CAM usage. We analyzed data from the 2007 National Health Interview Survey that included a nationally representative sample of 9417 children ages 0 to 17 years. Overall, 46.9% (95% confidence interval, 45.6%-48.2%) of children in the United States used 1 or more CAM, of which 0.99% (0.28%-1.71%) used CAM specifically to treat their eczema, including herbal therapy (0.46%), vitamins (0.33%), Ayurveda (0.28%), naturopathy (0.24%), homeopathy (0.20%), and traditional healing (0.12%). Several CAMs used for other purposes were associated with increased eczema prevalence, including herbal therapy (survey logistic regression; adjusted odds ratio [95% confidence interval], 2.07 [1.40-3.06]), vitamins (1.45 [1.21-1.74]), homeopathic therapy (2.94 [1.43-6.00]), movement techniques (3.66 [1.62-8.30]), and diet (2.24 [1.10-4.58]), particularly vegan diet (2.53 [1.17-5.51]). In conclusion, multiple CAMs are commonly used for the treatment of eczema in US children. However, some CAMs may actually be harmful to the skin and be associated with higher eczema prevalence in the United States.