Atopic dermatitis (AD) is a chronic, itchy, and relapsing inflammatory disease that affects a large number of children and adults.1 Its morbidity is not limited to the skin. AD patients also have increased rates of attention-deficit/hyperactivity disorder, depression, and anxiety.2 Eczematous skin may also lead to the development of systemic food allergies.3
Today we have an impressive armamentarium of conventional therapies that give most AD patients excellent relief, but some are not well-served by these treatments. Side effects, co-morbidities, personal preference, and the fear of side effects can be insurmountable obstacles. For some patients, an integrative approach to treating AD may be necessary, and creativity and ingenuity can help find alternatives.4
Integrative medicine aims to marry conventional, evidence-based treatments with those that are perhaps less conventional and may not have widespread acceptance among all physicians and healthcare practitioners. Sometimes called “alternative” or “complementary” medicine, integrative medicine seeks to address physiological abnormalities as well as the emotional, social, and spiritual aspects of a patient’s life.5 AD is a popular target for integrative medicine because it is often resistant to conventional treatments, has no cure, and continues to defy easy explanation. Roughly half of all patients with AD have tried at least one form of alternative medicine.6 It is beneficial to know at least a little about these treatment options as many patients may ask. In this article, we will touch upon some conventional and alternative therapeutic options that can be used to treat AD.
The Conventional Approach
Conventional AD treatment takes a multi-pronged approach to enhance the barrier function of the skin as well as reduce inflammation and itch. Additional steps include avoiding factors that trigger flare-ups and decreasing bacterial colonization. AD triggers may include contact allergens, detergents, and extreme temperatures.7
A primary goal of treating AD is to maintain adequate skin moisture. This can be addressed by the use of moisturizers, which provide the skin with lipids and humectants, form a barrier to the outside world, and improve moisture retention. Generally, fragrance-free moisturizers with few ingredients are preferred to minimize allergic sensitization. Lotions, creams, and ointments may all be used in atopic dermatitis, although ointments tend to have a higher lipid content leading to a more effective barrier.7 The use of emollients decreases the need for topical steroids in infants with AD,8 and data suggest that early use of moisturizers can actually prevent the development in AD in high-risk populations.9,10
Topical corticosteroids remain the mainstay of treatment for AD for better or for worse.11 While they have a rapid and powerful effect on AD, prolonged use of topical corticosteroids can cause side effects including skin atrophy, hypopigmentation, and even topical corticosteroid withdrawal in some settings.12,13 Increasing recognition of these adverse effects has led to widespread ‘corticosteroidphobia’, which may also contribute to the desire for more integrative approaches to the treatment of AD.14
Tacrolimus and pimecrolimus, non-steroidal topical calcineurin inhibitors, approximate moderate-to-potent topical steroids in their anti-inflammatory effect, and can be used in lieu of steroids or as a complement if needed.15 Application of corticosteroids or calcineurin inhibitors to skin previously affected by AD may decrease future flares, although this “proactive approach” may be more difficult to deploy in practice.16
Patients who have more severe disease may require additional techniques including “wet wrapping” and “soak and smear.”17,18 Phototherapy, particularly with narrow band UVB, is relatively safe and can stave off the need for more potent systemic agents.19
If all of the above treatment options fail, patients may require systemic immunosuppressants such as cyclosporin. Off-label studies in AD have demonstrated that six to eight weeks of treatment with cyclosporin results in a roughly 50 percent decrease in the mean disease severity of AD,20 providing much-needed relief and a chance to heal and recover. However, these drugs are not curative and while they may induce a remission, their cessation generally results in relapse.21
While there is currently great enthusiasm about the AD pipeline, some of these medications may be years away, and others may become held up during the development process. Our patients don’t want to and shouldn’t have to wait for relief.
The Alternative Approach
Moisturizing oils are commonly used in the treatment of AD, and those that are plant-based have a place in alternative medicine. Sunflower seed oil has been found to induce the production of endogenous ceramides.22 It also directly enhances the skin barrier and decreasing inflammation via activation of peroxisome proliferative-activated receptor-alpha.11
Coconut oil can be used to combat the symptoms of atopic dermatitis. In addition to serving as a moisturizer, it also possesses anti-microbial properties. One study demonstrated a 95 percent reduction in staphylococcus in AD patients compared with only a 50 percent reduction in a control group.23 This is promising given that the skin of AD patients is often colonized by Staphylococcus aureus which may be playing a direct role in fueling inflammation.24,25
Both acupuncture and acupressure have the potential to alleviate the pruritus associated with AD. Acupuncture can reduce Type I hypersensitivity itch reactions,26 and acupressure has been shown to significantly reduce the itch of AD in a clinical setting.27 Stimulation at these specific “acupoints” results in vasodilation, stimulation of inflammatory mediators, and activation of C fibers, which alter neurotransmitter levels.26 These effects may explain how acupuncture and acupressure relieve some of the symptoms of AD.
Stress-reducing methods such as hypnosis, massage, and relaxation therapies may also provide benefit to AD patients.28 Stress has been implicated in weakening the barrier function of the skin in healthy individuals, and delaying skin healing in patients with AD.6 One study demonstrated that 10 of 12 children had decreased itching and scratching 18 months after hypnotherapy treatment. These patients also had improved mood and sleep.29 Another study showed that interventions geared toward reducing stress levels in patients with AD were associated with significantly less itching.30
Although the effects are generally modest, there may be a role for these approaches in some patients. The lack of significant side effects and the relatively low cost associated with most of these modalities makes them that much more appealing.
The Best of Both Worlds
If conventional medicine incompletely alleviates symptoms or leads to undesirable side effects, it may be time to consider alternative and complementary approaches. This can mean a trial of phototherapy while using sunflower and coconut oils to help moisturize and decrease staphylococcal colonization, or identifying a patient who reports flaring with stress and encouraging a trial of a stress-relieving behavioral approach in addition to soak and smear. It can even mean using acupressure as an adjunct to systemic methotrexate or cyclosporine. Sometimes just bringing up these ideas may be of great value for those unresponsive to or unwilling to consider the conventional approach. n
Fatima Lakhani is a medical student at the Northwestern University Feinberg School of Medicine in Chicago. She is originally from Miami, Florida and graduated from the University of Florida with bachelor degrees in Biology and Psychology in 2015.
Peter Lio, MD is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine and a partner of Medical Dermatology Associates of Chicago. He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. Dr. Lio is the founding director of the Chicago Integrative Eczema Center, and has spoken nationally and internationally about atopic dermatitis as well as alternative medicine. He is also a Practical Dermatology® contributor and Editorial Board member.
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