Skin Conditions and Complementary Health Approaches: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
Skin Conditions and Complementary Health Approaches
The Evidence Base
- The evidence base on efficacy of complementary health approaches for atopic dermatitis consists of several randomized controlled trials on a variety of modalities and clinical practice guidelines from the American Academy of Dermatology.
Mind and Body Practices
There is some limited evidence that relaxation techniques may help improve symptoms of atopic dermatitis, particularly in the pediatric population, although most clinical studies are not methodologically rigorous. There is currently no evidence that acupuncture has any beneficial effects in the management of atopic dermatitis in adults or children.
- Acupuncture. A 2015 systematic review of acupuncture found no eligible studies to include in the review, although there were two studies that evaluated the antipruritic effects of acupuncture and one study that evaluated the effects of acupuncture on IgE-mediated allergy, a major characteristic of atopic dermatitis. The reviewers concluded that there is currently no evidence of the effects of acupuncture in the management of atopic dermatitis.
- Relaxation Techniques. A small 2012 study of 25 patients, mean age 23.5 years (range 12-40 years), with atopic dermatitis concluded that progressive muscle relaxation may be a useful adjunctive modality for the management of atopic dermatitis through the reduction of anxiety.
- Acupuncture appears to be safe when performed by appropriately trained practitioners, but a 2011 research review concluded that unwanted side effects can occur when acupuncture is done by poorly trained practitioners.
- Relaxation techniques are generally considered safe for healthy people, including children. However, there have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.
According to the American Academy of Dermatology’s clinical practice guidelines for the treatment of atopic dermatitis, there is inconsistent to no evidence to recommend the use of fish oils, evening primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, vitamin E, and vitamins B12 and B6 for the treatment of atopic dermatitis. Further, the guidelines state that the use of probiotics/prebiotics for the treatment of patients with established atopic dermatitis is not recommended because of inconsistent evidence.
- Dietary Supplements (Oral). A 2012 Cochrane review of 11 randomized controlled trials of dietary supplements (e.g., fish oil, vitamin D and vitamin E, vitamin B6, sea buckhorn oil, hempseed oil, sunflower oil, docosahexaenoic acid (DHA), selenium, and zinc sulfate) for atopic eczema found no convincing evidence of benefit for dietary supplements in atopic eczema. The American Academy of Dermatology’s clinical practice guidelines for the treatment of atopic dermatitis states that “there is inconsistent to no evidence to recommend the use of fish oils, evening primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, vitamin E, and vitamins B12 and B6 for the treatment of atopic dermatitis.”
- Probiotics (Oral). The American Academy of Dermatology’s clinical practice guidelines for treatment of atopic dermatitis state that “the use of probiotics/prebiotics for the treatment of patients with established atopic dermatitis is not recommended because of inconsistent evidence (Level of Evidence II; Strength of Recommendation B).
- There are conflicting data on the efficacy of probiotics for atopic dermatitis in children; overall, evidence suggests that probiotics may be effective for some, but not all, children with atopic dermatitis.
- A 2013 systematic review of 21 randomized controlled trials involving 6,859 participants, which included infants or mothers who were either pregnant or breastfeeding, investigated whether nutrient supplementation with probiotics, prebiotics, formula, or fatty acids prevents the development of atopic dermatitis or reduces the severity of the condition in newborns to children under 3 years of age. Data showed that certain types of nutrient supplementation may be an effective method in preventing atopic dermatitis or decreasing its severity. The best evidence, the reviewers found, lies with probiotics supplementation in mothers and infants in preventing the development and reducing the severity of atopic dermatitis.
- A 2008 Cochrane review of 12 trials found that probiotics do not reduce eczema symptoms such as itching, nor do they change the overall severity of eczema judged by their patients or their doctors.
- Primrose Oil and Borage Oil (Oral). A 2013 Cochrane review of 27 randomized controlled trials involving a total of 1,596 participants found that evening primrose oil and borage oil taken orally had no clinical benefit for the treatment of atopic eczema.
- Chinese Herbal Medicine (Oral and Topical). Another 2013 Cochrane review of 28 randomized controlled trials involving a total of 2,306 participants found no conclusive evidence that oral or topical Chinese herbal medicine could reduce the severity of atopic eczema in children or adults. A 2014 systematic review and meta-analysis of 10 studies involving 1,058 participants found no conclusive evidence demonstrating that topics Chinese herbal medicine for atopic eczema was superior to other control interventions.
- Patients considering the use of Chinese herbal medicine, especially for children, should use caution as they can be potentially hazardous. A 2013 review noted that these medications are easily accessed and not monitored by the U.S. Food and Drug Administration, and that some topical Chinese herbal medicines have been found to include high concentrations of dexamethasone.
There is some evidence that fish oil, Dead Sea climatotherapy, and the topical herbs Mahonia aquifolium and indigo naturalis may be beneficial for the treatment of psoriasis.
The Evidence Base
- The evidence base on efficacy of complementary health approaches for psoriasis consists of several small randomized controlled trials.
- Traditional Chinese medicine (Oral). There is some evidence that has shown that the combination of traditional Chinese medicine taken orally with conventional treatments for psoriasis is more efficacious than conventional treatment alone.
- Dietary Supplements (Oral). A 2015 review noted that there has been consistent evidence supporting the efficacy of fish oil supplementation in patients with psoriasis; however, there is conflicting evidence for vitamin D, B12, and selenium supplementation.
- Herbal Medicine (Topical). A 2015 review of complementary health approaches for psoriasis stated that the topical herbal therapies that have the most evidence for efficacy are Mahonia aquifolium and indigo naturalis, while there is a smaller amount of evidence for aloe vera, neem, and extracts of sweet whey. A 2013 systematic review and meta-analysis of plant extracts for the topical management of psoriasis concluded that there is limited but consistent clinical trial evidence for the efficacy of extracts of Mahonia aquifolium and indigo naturalis in plaque psoriasis when compared with the vehicle creams; however, the magnitude and duration of the effects are not assessable based on currently available evidence.
- Vitamin D (Topical). A 2013 Cochrane review of 177 studies involving a total of 34,808 people found that topical vitamin D products were superior to placebo, and had similar effects to topical corticosteroids when applied to the body. However, corticosteroids were superior to vitamin D for scalp psoriasis. Treatment that combined topical vitamin D with a corticosteroid was more effective than topical vitamin D alone and more effective than the topical corticosteroid alone.
- Climatotherapy. There is evidence from controlled trials that Dead Sea climatotherapy can improve psoriasis and induce lasting remissions; however, research on other locations of climatotherapy have provided little evidence.
- Light Therapy. Findings from a 2015 randomized controlled trial of 21 patients with plaque psoriasis suggest that moderate to severe plaque psoriasis should show a therapeutic response to orally administered Curcuma longa extract if activated with visible light phototherapy. A 2015 randomized controlled trial of 47 patients with mild psoriasis vulgaris evaluated the safety and efficacy of long-term UV-free blue light treatment and found that participants receiving blue light treatment had a significant improvement compared to the control.
- Some Chinese herbal medicines have been shown to be contaminated with heavy metals or corticosteroids. Other safety concerns include systemic toxicity or contact dermatitis from herbal supplements.
- Ultra-violet light exposure increases the risk of for both melanoma and non-melanoma skin cancers, so the benefits of climatotherapy should be carefully weighed against the risks for each patient.
- Vitamin D products may cause “local adverse events,” such as skin irritation and burning.
According to the American Academy of Dermatology’s clinical practice guidelines for the treatment of acne, there are currently very limited data regarding the safety and efficacy of herbal and other complementary therapies to recommend their use.
The Evidence Base
- The evidence base on efficacy of complementary health approaches for acne consists of a few randomized controlled trials and clinical practice guidelines issued by the American Academy of Dermatology.
- Tea Tree Oil, Bee Venom (Topical). A 2015 Cochrane review of 35 randomized controlled trials involving 3,227 participants concluded that there is some low-quality evidence from single trials that topical tea tree oil and bee venom may reduce total skin lesions in acne, but there is a lack of evidence from the review to support the use of other complementary health approaches, such as herbal medicine, acupuncture, or wet-cupping therapy. Another 2015 review of seven studies concluded that topical use of tea tree oil is an appropriate option for treating mild-to-moderate acne.
- Barberry Extract (Oral). Other herbal agents, such as oral barberry extract, showed some beneficial effects in a 2012 randomized controlled trial of 49 adolescents with moderate to severe acne.
- Biofeedback. There is weak evidence of the potential benefit of biofeedback-assisted relaxation and cognitive imagery in people with acne. A 1983 randomized controlled trial of 30 patients with acne evaluated the efficacy of biofeedback relaxation and cognitive imagery over 6 weeks and found that the treatment group had a significant reduction in acne severity compared to the control groups.
- In a 2012 study, oral aqueous extract of barberry was well tolerated, and no notable complications or side effects were reported.
- Tea tree oil contains varying amounts of 1,8–cineole, a skin irritant. Products with high amounts of this compound may cause skin irritation or contact dermatitis in some individuals. Oxidized tea tree oil may trigger allergies more than fresh tea tree oil.
- Tea tree oil should not be swallowed. Poisonings, mainly in children, have caused drowsiness, disorientation, rash, and ataxia. Topical use of diluted tea tree oil is generally considered safe for most adults. Pruritus, burning, stinging, scaling, itch, redness, and dryness have been reported.
- There is a potential for adverse effects from herbal medicines. Patients considering the use of Chinese herbal medicine, especially for children, should use caution as they can be potentially hazardous. A 2013 review noted that these medications are easily accessed and not monitored by the U.S. Food and Drug Administration, and that some topical Chinese herbal medicines have been found to include high concentrations of dexamethasone.
There is insufficient evidence to either recommend or dismiss herbal treatments for impetigo, including tea tree oil, garlic, coconut oils, tea effusions, and Manuka honey.
The Evidence Base
- The evidence base on efficacy of herbal extracts for impetigo consists of only a few controlled clinical trials, most of which are not methodologically rigorous.
- Herbal Medicine (Oral and Topical). A 2003 review of seven randomized and non-randomized studies examining both oral and topical herbal medicines for the treatment of bacterial infections, including impetigo, found some positive results reported for a topical ointment containing tea leaf extract. However, the reviewers concluded that the clinical efficacy of none of the herbal medicines has so far been demonstrated.
- There is a lack of safety data on herbal medicines for the treatment of impetigo.
- Patients should be encouraged to maintain proper wound care and hand washing and avoid contact with others as the infection can spread.
Although some natural products have shown promise for improving symptoms of rosacea, there is insufficient evidence to support the use of many of these products for rosacea.
The Evidence Base
- The evidence base on efficacy of natural products for rosacea consists of several clinical studies, but most of these studies are not methodologically rigorous.
- Plant Extracts (Oral and Topical). A 2015 systematic review of phytochemical and botanical therapies for rosacea found that several botanical therapies may be promising for rosacea symptoms, with several plant extracts and phytochemicals improving facial erythema and papule/pustule counts caused by rosacea. However, many of the studies included in the review were not methodologically rigorous.
- Azelaic Acid (Topical). A 2010 review of natural products had similar findings, but noted that based on two randomized trials, topical azelaic acid—a naturally occurring 9-carbon acid found in whole grain cereals and animal products—may provide some benefit for symptoms of rosacea.
- The 2015 systematic review of various phytochemical and botanical therapies found mild adverse reactions, such as transient burning or pruritus, and noted that several botanicals commonly used for rosacea have not been studied clinically and these may have more significant side effect profiles.
- A 2010 review of two studies found azelaic acid to be generally safe, with mild and transient local adverse reactions, and no difference between azelaic acid and placebo.
- American Academy of Dermatology. Atopic dermatitis clinical guideline. Available at: www.aad.org/practice-tools/quality-care/clinical-guidelines/atopic-dermatitis. Accessed on July 15, 2016.
- Bae BG, Oh SH, Park CO, et al. Progressive muscle relaxation therapy for atopic dermatitis: objective assessment of efficacy. Acta Derm Venereol. 2012;92(1):57–61.
- Bamford JT, Ray S, Musekiwa A, et al. Oral evening primrose oil and borage oil for eczema. Cochrane Database Syst Rev. 2013;4:CD004416.
- Bassett IB, Pannowitz DL, Barnetson RS. A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne. Med J Aust. 1990;153(8):455–458.
- Bath-Hextall FJ, Jenkinson C, Humphreys R, et al. Dietary supplements for established atopic eczema. Cochrane Database Syst Rev. 2012;2:CD005205.
- Boyle RJ, Bath-Hextall FJ, Leonardi-Bee J, et al. Probiotics for treating eczema. Cochrane Database of Systematic Reviews. 2008;4:CD006135.
- Cao H, Yang G, Wang Y, et al. Complementary therapies for acne vulgaris. Cochrane Database of Systematic Reviews. 2015;1:CD009436.
- Carrion-Gutierrez M, Ramirez-Bosca A, Navarro-Lopez V, et al. Effects of Curcuma extract and visible light on adults with plaque psoriasis. Eur J Dermatol. 2015;25(3):240–246.
- Deng S, May BH, Zhang Al, et al. Plant extracts for the topical management of psoriasis: a systematic review and meta-analysis. Br J Dermatol. 2013;169(4):769–782.
- DiNicola C, Kekevian A, Chang C. Integrative medicine as adjunct therapy in the treatment of atopic dermatitis–the role of traditional Chinese medicine, dietary supplements, and other modalities. Clin Rev Allergy Immunol. 2013;44(3):242–253.
- Fisk WA, Lev-Tov HA, Clark AK, et al. Phytochemical and botanical therapies for rosacea: a systematic review. Phytother Res. 2015;29(10):1439–1451.
- Foolad N, Brezinksi EA, Chase EP, et al. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013;149(3):350–355.
- Fouladi RF. Aqueous extract of dried fruit of Berberis vulgaris L. in acne vulgaris, a clinical trial. J Diet Suppl. 2012;9(4):253–261.
- Gu S, Yang AW, Li CG, et al. Topical application of Chinese herbal medicine for atopic eczema: a systematic review with a meta-analysis. Dermatology. 2014;228(4):294–302.
- Gu S, Yang AW, Xue CC, et al. Chinese herbal medicine for atopic eczema. Cochrane Database Syst Rev. 2013;9:CD008642.
- Hughes H, Brown BW, Lawlis GF, et al. Treatment of acne vulgaris by biofeedback relaxation and cognitive imagery. J Psychosom Res. 1983;27(3):185–191,
- Mason AR, Mason J, Cork M, et al. Topical treatments for chronic plaque psoriasis. Cochrane Database of Systematic Reviews. 2013;3:CD005028.
- Morelli V, Calmet E, Jhingade V. Alternative therapies for common dermatologic disorders, part 1. Prim Care. 2010;37(2):269–283.
- Pfaff S, Liebmann J, Born M, et al. Prospective randomized long-term study on the efficacy and safety of UV-free blue light for treating mild psoriasis vulgaris. Dermatology. 2015;231(1):24–34.
- Talbott W, Duffy N. Complementary and alternative medicine for psoriasis: what the dermatologist needs to know. Am J Clin Dermatol. 2015;16(3):147–165.
- Tan HY, Lenon GB, Zhang AL, et al. Efficacy of acupuncture in the management of atopic dermatitis: a systematic review. Clin Exp Dermatol. 2015;40(7):711–715.
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