Takeaway: Considering alternatives

January 15, 2015

Dermatology Times editorial advisor, Elaine Siegfried, M.D., talks with Peter Lio, M.D., assistant professor of clinical dermatology and pediatrics at Northwestern University’s Feinberg School of Medicine, and private practice, Dermatology and Aesthetics of Wicker Park, Wicker Park, Chicago, about his interest in alternative medicine and the legitimacy and usefulness of certain techniques and therapies.

Dermatology Times editorial advisor, Elaine Siegfried, M.D., talks with Peter Lio, M.D., assistant professor of clinical dermatology and pediatrics at Northwestern University’s Feinberg School of Medicine, and private practice, Dermatology and Aesthetics of Wicker Park, Wicker Park, Chicago, about his interest in alternative medicine and the legitimacy and usefulness of certain techniques and therapies.

Dr. Siegfried: When and how did you become interested in alternative medicine?

Peter Lio, M.D.Dr. Lio: I think the first memory I have about alternative medicine was being a boy, maybe in high school, and seeing a show on PBS about acupuncture. Watching the acupuncturists’ healing techniques and seeing the patients before and after really affected me. I think that actually shaped part of the reason I wanted to go into medicine. When I got to medical school I was lucky enough to be able to spend a summer with Ted Kaptchuk, O.M.D., author, researcher, professor of medicine at Harvard Medical School and director of the Harvard-wide Program in Placebo Studies and the Therapeutic Encounter (PiPS) at Beth Israel Deaconess Medical Center in Boston, and David M. Eisenberg, M.D., who was then the director of the Center for Alternative Medicine and Education at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School. They were both doing some really interesting research and some deep thinking about alternative medicine, which was during the lead up to the development of the National Center for Complementary and Alternative Medicine. So I felt like I was brought into the cutting edge at that point.

Elaine Siegfried, M.D.Dr. Siegfried: And I think it’s nice to mention that David Eisenberg was the first western-trained medical student to have a foreign exchange with China right after Nixon opened relations in the early 1970’s. He wrote a wonderful book called “Adventures with Chi” for anyone that’s interested. What year was that that you had the opportunity to work with him?

Dr. Lio: That would have been the summer of 1998. And, once I finished medical school, I did my preliminary year of dermatology residency in pediatrics at Boston Children’s Hospital, which also shaped me greatly. They recognized my interest in complementary medicine and any time there was a patient interested in alternatives or perhaps something that was a little out of the ordinary, they would call me in. When I finished training, I heard about a course offered through Harvard called Structural Acupuncture for Physicians. I think it’s now hosted by Brigham and Women’s Hospital in Boston. It’s a year-long course with people from all over the world, as it is designed to be taken remotely. Once you complete it, you get enough CME hours to be able to practice acupuncture as a physician in almost every state, and you have both the theoretical foundation as well as some practical experience to do so.

Dr. Siegfried: If it’s designed to be a remote course, how do you actually learn acupuncture without hands-on training?

Dr. Lio: It’s brilliantly done. I can’t say enough good things about it. You have your reading, you have your lectures that you watch either remotely or in person in you’re in the Boston area, and then basically there are weekends during the course that you go in person and spend the entire weekend doing hands-on practical sessions. When I finished, I actually spent a second year working with some of the teachers in the course and working with a friend doing acupuncture on the weekends. Just like with medical school and residency: you learn a lot, but you don’t really learn it all until you’re seeing patients on your own, you get the opportunity to practice it, and you have patients come back and say “Hey that didn’t help,” or “Boy that was wonderful.” That was the year I felt like I really grew.

Dr. Siegfried: And during that period of time, I imagine you were the only dermatologist among those peers?

Dr. Lio:  I was. Most people were pain specialists and family practice doctors who really wanted to expand their practice; so I was a little bit different.

Dr. Siegfried: While you were with those people would they funnel to you the skin-related cases?

Dr. Lio: Absolutely. And, for all my practical sessions on those weekends, I would bring all of my tough cases because I had direct access to amazing teachers: Kiiko Matsumoto, Lic.Ac., a world renowned Japanese acupuncture practitioner and teacher, and David Euler, L.Ac., Dip.Ac. (NCCA). They would have a look, we’d talk about them, and they would tell me their approach and their thoughts. What I really loved and respected about them is that they were very humble and they were very clear about their limitations. I’d brought case in which the patient had alopecia universalis that had been going on for 10 years and they were happy to try but made it clear that there couldn’t be any promises in such a tough case. Kiiko Matsumoto, in particular, was really good with chronic regional pain syndrome, which is one of these terrible things that I think that a lot of doctors are afraid to treat, but she would engage these patients and work with them. Patients that had neurogenic itch would often respond beautifully to her treatment. I felt like that was really helpful to see that kind of mind-body connection really playing out in a very practical way.

NEXT: A variety of alternatives

 

 

A variety of alternatives

Dr. Siegfried: So, we’ve talked about acupuncture but of course there are a lot of other alternative approaches. How do you decide which patient’s conditions are more well-suited to first, acupuncture, and then, second, to other forms of alternative therapy?

Dr. Lio: One of the things I try to do is really listen to the patient when he or she comes in and really try to read them. My general default is going to be Western medicine. My training is in Western medicine; so if a patient doesn’t say anything then that is how I’ll approach treatment. But if a patient says he doesn’t really want topical steroids or antibiotics, for example - and I’ve been surprised by people who didn’t strike me as folks who would want alternative treatments - then I talk about what other options we have. I am honest and upfront about the idea that we’re really trying to pick the best treatments that have the best evidence. So even if it seems alternative, it has at least some evidence. There are a lot of treatments we use and we don’t really understand why they work, but we have enough data; and then the opposite is also true. If I feel like the alternative is not going to help them, I’m going to tell the patient that I think he’s wasting his time. That’s how I try to manage expectations.

Dr. Siegfried: So are there any conditions that you tend to gravitate toward a homeopathic or alternative approach from the start?

Dr. Lio: My area of interest and my passion is atopic dermatitis. I think it’s really well-suited for this in a lot of ways. I think many of those patients, in particular, are curious about or have tried alternative therapies, and so that’s a great place to experiment with some of these. We’re going to use them much more as complimentary therapies - meaning things that will be supporting our more conventional approaches. So even if you’re recommending a fairly mainstream treatment plan, patients love that there can be some natural or herbal components playing a role. Other diseases I think are much harder. For example, I find that with acne I really don’t have great luck with some of the alternatives. We have a couple of things we keep in our back pocket, but the data on them is not so great and our regular treatments are so good that you have to be really motivated not to want to use regular treatments.

NEXT: Seeking advice

 

Seeking evidence

Dr. Siegfried: I know that you’ve had special training in acupuncture, but where do you get the amount of information on everything that you’ve put together in your excellent talks? Are you compiling that from the Western literature, PubMed, or are there other sources that you go to?

Dr. Lio: I really do try to focus mostly on things that have some evidence, so PubMed is my friend. The big problem, of course, is that most of the studies we look at are small, they often have flaws, and many of them are not randomized or placebo controlled, so you end up with really poor levels of data to base decisions on. I start there though, because I like to have at least something. You also know that when there’s been a peer reviewed study, you have some sense that somebody thinks it may help and has looked at it in a more formalized setting. So then I’ll look at other sources too, and I have to confess some of the places I look are on chat forums on the Internet to see what people are interested in, what they talking about. For example, for keratosis pilaris - the bane of my existence - so many frustrated patients come in looking for an answer and a cure and of course we have a very limited armamentarium. So I tell the patients what some of the groups recommend, so we can get a little alternative with things where I really feel like our western treatments aren’t very helpful. I also have a number of books on various topics in alternative medicine such as natural herbs and Traditional Chinese Medicine in dermatology. The problem there is that you end up really using “eminence-based” medicine, and so it’s not very helpful when you are considering whether there is really good evidence. Although, many of the things we do have to begin somewhere, and it often begins with a clinician saying ‘Hey! You know what? This worked!” We would never have known that propranolol helped for hemangiomas if it wasn’t for somebody proposing the idea that it was the propranolol rather than the prednisone that was making the difference. So I feel like a lot of things have to begin there.

Dr. Siegfried: So in general and I noticed that the name of your practice doesn’t have anything about alternatives. With that in mind, what percentage of patients do you think employ some alternative approach in the treatments that you offer?

Dr. Lio: Well, over half of my patients are trying it, interested, or come to me asking about it. The piece that is a little bit more alternative is that I have created an eczema center called The Chicago Integrative Eczema Center. We have a free meeting every other month. We have families come on a Saturday morning and we talk really in depth about eczema, and focus on or emphasize some of the alternative treatments. That’s been a big success. While we see some of those folks as patients, we have a lot of people coming from all over the country for the weekend just for the information. We usually have speakers from different areas of alternative medicine come and lecture to the doctors and the patients who attend. That’s another place that I feel like I get to keep learning from practitioners who are really in the field seeing patients.

Dr. Siegfried: How do you find those practitioners to invite?

Dr. Lio: A lot of it is word of mouth. I did all of my training in Boston, so it took me a while to find acupuncturists here, meet them, refer patients to them, and get feedback. I’ve been able to extend that network by asking those practitioners I’ve come to know and trust, who they really trust. So little by little, I’ve built relationships and each one of those is very important to me because I don’t want to send patients to somebody who is going to sell them snake oil; I think that hurts all of us.

NEXT: Educating patients

 

Educating patients

Dr. Siegfried: I had a patient who was a very difficult, a 4-month old with infantile eczema/seborrheic dermatitis who was seeing me for a second visit. When I first saw her, I recommended what I always do: stop using complex products, take a bleach bath every day and use fluticasone every day for seven days and then every other day and come back and see me in a month. On this visit, I find they hadn’t used anything or maybe used the treatment for a day or two, but were very much opposed to anything having to do with the idea of bleach, and of course didn’t want to use any topical corticosteroids. So, do you recommend bleach baths?

Dr. Lio: I do. I think that’s one of the most powerful things that has come into our armamentarium in the past nine years that I’ve been in practice. I feel like that’s changed everything.

Dr. Siegfried: People don’t like that, they would rather do apple cider vinegar, dead sea salts, or Epsom salts, etc. First, what do you think of those? Second, how do you handle the patients like mine who just don’t want to follow that regimen? Is there a way that you help patients recognize the safety and efficacy of sodium hypochlorite baths?

Dr. Lio:  First of all, I feel like each of those can be helpful for some patients, but in my opinion it’s underwhelming compared to the power of the bleach. I’ve been talking with a friend of mine at the National Institutes for Health about doing a study to compare bleach versus vinegar, because I think it would be interesting to see what it does to the microflora on the skin. But, I agree. I think a lot of patients do react negatively, perhaps becasue it sounds like a toxic, nasty thing to put on your skin. My general approach is to compare it with swimming: I ask them if they’ve ever been in a swimming pool, and say that’s all I’m asking you to do is go swimming a little more often. Sometimes I can’t convince them. But the cool thing is that I’ve had good luck with a lot of patients that really have closed the doors to other doctors, and I think that’s because I am open to talking about these other therapies. With many patients I will start talking about sunflower seed oil[i] or coconut oil [ii] (my two favorites) or even if they want to engage in the diet realm, which is one of the tougher parts for me, we can do that at first. I’ll engage it honestly, and a lot of times, by the end of the visit, they’re using fluticasone and the bleach baths. I’m able to convince them to try conventional treatments, but I think it’s because we connected on the alternatives and  regain their trust. Oftentimes, it is a fully conventional regimen, but with alternatives added; an integrative approach.

NEXT: What about warts?

 

What about warts?

Dr. Siegfried: In my mind skin problems that are really well-suited to alternative treatments are ones that are common, may linger, don’t have a good Western treatment approach, have a high rate of spontaneous resolution, and have a high rate of placebo response. Warts is kind of at the top of mind. Would you agree with that? What is your standard approach to refractory warts and then what are the other alternatives?

Dr. Lio: I think that you hit it on the head with the things that are best suited for alternatives, and warts are a big one. So I want to make a disclaimer first that most of the patients that I see for warts that I’m going to talk about, they’ve already tried conventional treatments. Many of them have had a few rounds of cryotherapy, they have used some form of salicylic acid at home. They have waited and waited, and they are still being bothered by these warts, so much so that they are seeking other opinions. Once you’ve tried the basics, then you really do become stuck, because then the conventional evidence starts to fail us.

One of the things that I’ve been interested in is supplementing some of these patients with zinc. There’s an interesting suggestion in the literature that may be a subgroup of patients with refractory warts are a little bit zinc deficient.[iii] So, supplementing with oral zinc may help some patients. The caveat is that a fair number of people get sick to their stomachs on it, but I’ve had some patients really respond.

The other one is propolis, which is a natural glue that bees make to seal their hives. There was an interesting double blinded, randomized, controlled study that showed that people taking oral propolis actually cleared their refractory warts better than the control group.[iv] So I’ll try that when the warts are really refractory; the only issue there would be caution in patients who are allergic to bees. There may be bee fragments or bee proteins in it and you don’t want to cause a serious allergy. It’s something that can be found in a health food store, relatively safe and inexpensive.

Another therapy I’ve been interested in is topical garlic. There was a small case-controlled study and then there was a larger study that looked at a broader group taking some garlic and sort of slicing off a fresh piece of it from the clove and then just gently rubbing it on the warts at bed time and then applying a bandage over them. [v],[vi] The disclaimer is that you should not tape the piece of garlic to the wart or to the skin, because that can actually cause a pretty nasty chemical burn. There probably are some anti-viral properties to the garlic, and also, it seems to be a pretty good natural irritant. Patients love that it’s simple, it’s at home, it’s inexpensive, and it buys them time away from the office and from more expensive, potentially damaging treatments.

If all those things fail, however, then we go right back to more conventional things. Although certainly not for everyone, I also use intralesional candida albicans antigen and even intralesional bleomycin, off label of course, in those situations.

Dr. Siegfried: Do you have any alternatives for vitiligo?

Dr. Lio: I think it’s interesting. None of the things that I’ve really tried or read about seemed convincing enough to me. Pseudocatalase has been around for a while, and there were some provocative studies with it a few years back; [vii]then a paper came out a year or two ago kind of re-igniting interest in it, but I just have not had much luck at all with it.[viii]

Supplements in general have not been that helpful; however, the one I do use is a ginkgo. There have been a couple of studies from around the world showing that oral supplementation with gingko can decrease the formation of new areas of vitiligo. [ix],[x] I don’t know if it works. If it does, it’s pretty subtle, but if patients really want to do something more natural I think ginkgo is a reasonable thing to consider. It does have some potential side effects: it can increase your risk for bleeding, so we have to keep an eye on that, but in a healthy patient it’s probably okay at the doses we’re talking about.

Dr. Siegfried: So you just provide anticipatory guidance about bruising or petechiae or something like that?

Dr. Lio: Exactly, and asking about a history of bleeding disorders and upcoming surgeries.

Dr. Siegfried: Are there any other alternative approaches that you use the most often?

Dr. Lio: Something I’ll put out there because there is no evidence on this and I want someone to study this: There was a paper that came out a few years ago looking at spearmint tea. The paper showed that drinking spearmint tea had measurable effects on free and total testosterone levels and on FSH and LH in women with polycystic ovarian syndrome.[xi] They also noticed that their hirsutism decreased when they drank spearmint tea. So it seems to be affecting androgen levels in patients with PCOS, in particular, but potentially in anybody, and the question is: Could this help with hormonal acne? We see it in so many young adult women, and often benzoyl peroxide and retinoids can be irritating to them. So I’ve had a number of patients with this hormonal micronodulocystic mandibular acne that have tried drinking a few cups per day of spearmint tea and they do well on it.  So I feel like this is an area that has a scientific rationale but no clinical data. I do use it all the time, because a lot of my patients for whom I recommend spironolactone will blanch - they’ve read about the risks of certain types of cancers and they get nervous. I feel like this is a more natural approach that potentially can really help.

Dr. Siegfried: In any of the books that you have, is this something that’s been recognized in Traditional Chinese herbal formularies before?

Dr. Lio: Surprisingly not to my knowledge. I’ve looked it up, and you will see it listed sometimes in this context, but usually they’re listing it as a topical preparation like a spearmint oil. So this is neat. The patients can go to the grocery store and get plain old spearmint tea, brew it up, drink it, and there really is an effect on testosterone - at least from that one study.

NEXT: Chronic itch

 

Chronic itch

Dr. Siegfried: Ok, what about itch?

Dr. Lio: One of the toughest problems we face, and of course being pediatric focused, we see a lot of itch in multiple contexts. And of course, we have the other end of the population: elderly patients with terrible itch, sometimes without any rash, so just this generalized pruritus. One of my favorite things-we did a study about because it really made such an impression on me-there was a study a few years ago looking at patients with uremic pruritus, the terrible itch associated with kidney failure.[xii] We don’t really get why this happens of course, but it’s intractable and they had tried everything all the way through the list up to naltrexone and failed. This acupuncture group stimulated one point called the large intestinal eleven (LI 11), which is at the lateral aspect of the antecubital fossa, and they compared that to a sham placebo point. The experimental group did amazingly well compared to the sham group in terms of itch reduction.

And I thought, what if we could harness this for eczema? So we did a study a couple of years ago for the itch of eczema and instead of using needles, we tried acupressure. We had the patients massage that same point three times a week for three minutes. We compared that to a control group, and it really did significantly reduce itch.[xiii] Their visual analog scales for their itch report was significantly improved by just rubbing one little point on your arm. So now that’s one of my favorite things for itch. If they are not able to see an acupuncturist (which can be expensive and time consuming), then they can just literally do this at home whenever they’re feeling itchy.

There a number of reasons why this could work. There is probably a distraction and placebo effect, but there actually may be a neurologic effect - this gate control theory of pain and itch may somehow be deeply related to the underlying pathophysiology in the way that acupuncture and acupressure works.

Dr. Siegfried: For some of those patients or other patients, do you ever personally use acupuncture in your practice now?

Dr. Lio:  I don’t so much anymore. I usually will refer out to a full-time acupuncturist. I find that one of the nicest things is that there are folks who do community-style acupuncture, where one acupuncturist can treat multiple patients simultaneously at a much reduced cost. Many of these sessions will be $20 to $50 a session as opposed to $150 to $200 per session, so patients can really actually take advantage of it without feeling like it’s too expensive.

Dr. Siegfried: That is in David Eisenberg’s book; the way they do it in China?

Dr. Lio: Yes, and I feel like many places in Asia, that’s the general approach. We have a little bit of a more personal and private obsession in the United States, and so this is a nice way, I think, to get back to the roots.

NEXT: Flawed alternatives

 

Flawed alternatives

Dr. Siegfried: Are there any alternative treatments that you have tried in the past and then after a while you decided not to recommend anymore?

Dr. Lio: Absolutely. One is evening primrose oil for atopic dermatitis. I used to recommend it a fair amount; there were a few studies that really seemed great, and I tried it and tried it, but it just didn’t seem to make much of a difference. Recently, I think just last year, the Cochrane Review came down on both borage oil and evening primrose oil and said there is sufficient evidence to say they don’t work and no further resources or time should be put into these.[xiv]

The other one I’ve stopped-although I have mixed feelings about it-is probiotics. I was so excited about probiotics and we had some really exciting data, first, that they can be preventive for eczema and then second, they could potentially mitigate some of the active eczema symptoms; but, it has not panned out for me clinically. I’m still waiting to see if there are more variables or different sub strains or different sub types of patients that may respond better. I still do use them when I am giving oral antibiotics, but feel like I need to know more about them before just recommending them widely for eczema patients.

Dr. Siegfried: It seems like a lot of the recommendations that you make are based on herbal supplements, but you haven’t mentioned anything about the traditional decoctions or combinations that are custom made. I know that takes a lot of training. Do you ever recommend those kinds of combinations, or do you have plans for additional training in doing that sort of treatment?

Dr. Lio: True herbal medicine is pretty intense, and we touched upon it in my course, but it was made very clear to us you really need several years of devoted training to know what you’re doing with herbs.

The other hard part about herbs is that the safety of the herbs and their sourcing is really confusing. I think even a good experienced practitioner can run into this problem, so I won’t dabble with them directly. I do know that there are a couple of herbal preparations that are currently being reviewed by the FDA. There are people trying to get more properly formulated herbs with good sourcing, that are tested and are FDA compliant out there -one of which is for asthma and one of which is for eczema. In the meantime, I refer patients to practitioners who specialize in that. Again, I think often times its part of a bigger picture: the herbs are playing one part, acupuncture may be playing another part, and then some of our western therapies are also playing a role. Together we get this messy but in-its-own-way beautiful integrative care that I think patients really like and answers a lot of questions that maybe we can’t all do individually.

 

[i] Eichenfield LF, McCollum A, Msika P. The Benefits of Sunflower Oleodistillate (SOD) in Pediatric Dermatology. Pediatr Dermatol. 2009 Nov;26(6):669-75.

[ii] Verallo-Rowell VM, Dillague KM, Syah-Tjundawan BS. Novel antibacterial and emollient effects of coconut and virgin olive oils in adult atopic dermatitis. Dermatitis. 2008 Nov- Dec;19(6):308-15.

[iii] Mun J-H, Kim S-H, Jung D-S, et al. Oral zinc sulfate treatment for viral warts: an open-label study. J Dermatol. 2011;38(6):541–5.

[iv]Propolis as an alternative treatment for cutaneous warts. Zedan H, Hofny ER, Ismail SA.

Int J Dermatol. 2009 Nov;48(11):1246-9.

[v] Silverberg NB. Garlic cloves for verruca vulgaris. Pediatr Dermatol. 2002;19(2):183.


[vi] Dehghani F, Merat A, Panjehshahin MR, Handjani F. Healing effect of garlic extract on warts and corns. Int J Dermatol. 2005;44(7): 612–5.


[vii] Schallreuter KU, Wood JM, Lemke KR, Levenig C. Treatment of vitiligo with a topical application of pseudocatalase and calcium in combination with short-term UVB exposure: a case study on 33 patients. Dermatology (Basel). 1995;190(3):223-9.

[viii] Schallreuter KU, Salem MA, Holtz S, Panske A. Basic evidence for epidermal H2O2/ONOO(-)-mediated oxidation/nitration in segmental vitiligo is supported by repigmentation of skin and eyelashes after reduction of epidermal H2O2 with topical NB-UVB-activated pseudocatalase PC-KUS. FASEB J. 2013;27(8):3113-22.

[ix] Szczurko O, Shear N, Taddio A, Boon H. Ginkgo biloba for the treatment of vitilgo vulgaris: an open label pilot clinical trial. BMC Complement Altern Med. 2011;11:21.

[x] Parsad D, Pandhi R, Juneja A. Effectiveness of oral Ginkgo biloba in treating limited, slowly spreading vitiligo. Clin Exp Dermatol. 2003;28(3):285-7.

[xi] Grant P. Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. A randomized controlled trial. Phytother Res. 2010;24(2):186-8.

[xii] Che-yi C, Wen CY, Min-tsung K, Chiu-ching H. Acupuncture in haemodialysis patients at the Quchi (LI11) acupoint for refractory uraemic pruritus. Nephrol Dial Transplant. 2005;20(9):1912-5.

[xiii] Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunct Med. 2012;30(1):8-11.

[xiv] Bamford JT, Ray S, Musekiwa A, Van gool C, Humphreys R, Ernst E. Oral evening primrose oil and borage oil for eczema. Cochrane Database Syst Rev. 2013;4:CD004416.

 

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