Ask your patients about their use of alternative/complementary therapies, which are often helpful but can cause or worsen skin problems.
Alternative and complementary therapies may be best known in medical fields other than dermatology, but patients concerned about their skin turn to these treatments too. Some can actually cause harm, like pure tea tree oil, which can be very irritating in its undiluted form. But dermatologists say others are helpful complements to pharmaceutical treatments and may even be preferable to traditional medications in certain situations.
“It’s important for the clinician to be open-minded to something that may not necessarily be a mainstream conventional treatment,” says Sarah Kasprowicz, M.D., one of several dermatologists who spoke about alternative and complementary treatments during a session at the 73rd annual meeting of the American Academy of Dermatology in San Francisco earlier this year.
It’s especially crucial to ask patients whether they’re taking any alternative treatments, she says, because they can contribute to potentially dangerous interactions just like mainstream medications. In some cases, she says, there’s actually more potential for risk because “we have few data on these compounds and how they interact with other compounds.”
Dr. Kasprowicz, based in Skokie, Ill., cautioned that if patients aren’t asked directly, they will “very rarely disclose what they are using that may be considered ‘alternative.’”
“Patients will often assume that because something is over the counter it doesn't count as a medicine,” she says. “However, when asked the question they will offer up things they have tried, or therapies they’ve read about and considered trying.”
At the AAD conference, Dr. Kasprowicz discussed alternative treatments for two specific conditions: acne and rosacea. “Is the panacea for acne and rosacea found at the health food store? As of present day, no. But there are adjunct treatments that can be used safely that have been shown to have a positive effect.”
READ: It's rosacea, not acne
Indeed, “one compound that has evidence for both acne and rosacea is niacinamide, a water-soluble B vitamin,” she says. “This has been looked at both orally and topically. It has been shown to be equal or superior to topical clindamycin in some studies. In addition, it has been shown to be anti-inflammatory in the skin through inhibition of IL-8." 1,2,3
Niacinamide is a form of vitamin B3 and available over-the-counter via B complex vitamins and as niacinamide vitamins.
It is also available as a topical treatment and is found in many over-the-counter sunscreens, serums and moisturizers, Dr. Kasprowicz says. “Incorporating one of these products into a patient’s routine will likely not be the magic elixir, but it may help.”
There’s also evidence to support the use of Vitamin C4,5, tea tree oil6,7 and green tea8,9,10 extract when used safely, she says. However, “there are many things that I have seen people use that are harmful. I have seen a number of patients apply compounds directly to the skin like toothpaste, pure ascorbic acid and pure tea tree oil, causing anything from a mild contact dermatitis to a burn.”
Peter A. Lio, M.D., FAAD, the director of the AAD session, says he’s developed a reputation among patients as being especially open to alternative treatments. “More than half of my patients bring these types of treatments up and want to talk about them,” says Dr. Lio, assistant professor of Clinical Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine.
Dr. Lio often supports the use of alternative and complementary therapies for atopic dermatitis, the topic of his talk at the AAD conference. While Western medicine offers valuable treatments, he says, they can have downsides. In addition, he says, some patients prefer more natural or gentle treatments.
“Alternatives work best as part of an integrative plan,” he says, featuring “a strong backbone of conventional therapy but with complements or adjuncts from the alternative world to minimize the need for stronger therapies and help support the body and the skin.”
Specifically, he says, “there are alternative treatments that do a great job helping moisturize the skin (such as sunflower seed oil), control staphylococcus on the skin (such as coconut oil), and sooth inflammation (such as topical vitamin B12).”
Dr. Lio says other favorites include topical cardiospermum extract and diluted apple cider vinegar soaks. He adds: “Some of the things I like are on the border of alternative and conventional, such as vitamin D supplementation and probiotics.”
What about support for these products from clinical research? “This is tricky because, to some extent, as soon as there is enough evidence that something works, then it ceases being an alternative and becomes conventional or mainstream,” he says. “We're left with a lot of small studies, many of which are of questionable quality. But we've focused on the ones for which there really seems to be something going on.”
One challenge for dermatologists is the fact that alternative treatments generally “have much more subtle improvements than we might see with a conventional drug, and as physicians this can be disorienting.” Still, he says, “every bit could help” with a condition like atopic dermatitis, “and possibly prevent the need for going on a more serious therapy such as cyclosporine.”
Toral Patel, M.D., MS, a dermatologist in Chicago, spoke at the AAD conference session about alternative and complementary therapy to combat aging. She says patients often ask about natural treatments to reduce fine lines and wrinkles and repair lentigines, melasma and post-inflammatory hyperpigmentation from conditions like acne.
Vitamin C, flavanol-rich foods such as cocoa, and lycopene-rich foods such as tomatoes offer potent anti-inflammatory and anti-oxidant properties, Dr. Patel says. “Many natural ingredients also inhibit melanin production and help improve hyperpigmentation, such as soy, licorice and arbutin.”
In terms of topical applications, Vitamin C serums are “excellent for overall aging,” Dr. Patel says, since they’re “a very effective topical treatment for numerous skin concerns including fine lines and wrinkles and disorders of pigmentation.”
Dr. Patel especially recommends combining a topical Vitamin C serum with sun protection in the morning. As for other treatments for hyperpigmentation, she says she’s seen “good improvement with products containing licorice root extract or soy as active ingredients.”
Echoing the concerns of Dr. Kasprowicz, Dr. Patel warns her patients to be cautious. “Many botanical products found on the market today do not have sufficient evidence to demonstrate their efficacy,” she says. “I tell patients to only use products that have some science behind them to support their use. In the anti-aging realm, products may be harmful if patients develop an allergy to them such as a contact dermatitis or if they are applied or ingested in excess.”
Disclosures: Dr. Farris is a consultant to L’Oreal. Dr. Lio and Dr. Patel report no relevant disclosures.
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