Viewpoints on Integrative Dermatology, Part 1

We are so lucky to live in a time where we have an incredible array of treatments and more in the pipeline. You may be thinking, “Don’t we have all our needs met?” But it turns out that every patient is a little bit different. The more we dive in, the more we realize that there is no such thing as one size fits all in dermatology. There are many reasons why people might not want to go with a conventional treatment.

For example, patients for whom the conventional treatments have failed. I get a lot of referrals for patients who have tried first-, second-, and third-line treatments. They are stuck and asking, “Now what?” The evidence dries up after a certain point. If we think about the way clinical studies are done, researchers often indicate, “Sixty percent of the patients got to the end point.” But what about the other 40%? What happened to those people? Sometimes, they do okay, but maybe not quite as well; other times, they do not do well, and they run out of options. Or it might be the case that a patient has a problem with an option, such as an allergic reaction. I have many patients who are allergic to propylene glycol, and I have a whole cohort of patients who have had some damage from topical corticosteroid overuse. And then there are patients with a chronic condition who just prefer to take a different course. They say, “Listen, I hear you. I see that the data show this may help, but I would like to do something a little different. I would like to take a more natural path or try a different way.”

Integrative dermatology offers the ability to use evidence as much as we can and whenever we can, but also to think outside the box and be willing to push the boundaries a little bit along with the patient. In this article, I will answer frequently asked questions for those interested in learning more about integrative approaches.

Is There Evidence for Integrative Dermatology?
Some people may think that everything we talk about in integrative, or alternative, approaches is completely made up or just anecdotal. However, it turns out there is quite a bit of evidence, and it is fascinating to see things that are liminal, on the border or the edge of truly accepted treatments. For these treatments, there are enough studies and evidence to say, “Wait a minute. Why isn't this more accepted?” But sometimes, you do not need 15 different studies to conclude that a treatment may be helpful, especially when the stakes are lower. For example, we really did a complete about face in thinking about peanut allergy and food allergies. You can find guidelines from the ’80s and ’90s that advise to wait until the child gets older before giving them peanuts. And now we have flipped it completely around because of the LEAP study by Dr Gideon Lack. Obviously, if it is a life and death situation, such as a cancer drug or a cardiac procedure, we are going to need a lot more information. But if it is a topical oil that seems to be effective in a cohort of 20 patients across 2 or 3 studies, it might be enough to say we can try it.

I think the take-home point is that there is often more evidence than people are aware of. And, sometimes, there is even more evidence than people are willing to listen to. I have had skeptical audiences where I start presenting evidence for integrative approaches and they roll their eyes. If someone goes in with a bias that is already locked in, they may not be open to the evidence.

Are There Harms to Integrative Approaches?
There is honestly no such thing as a treatment that has no side effects. In fact, I tell my patients, “If somebody tells you it has no side effects and there are no risks, then they are lying, or they really do not know better.” Anything that does something has the potential to cause trouble, be it as simple as irritation or contact dermatitis or as serious as affecting the endocrine system. Sometimes we see patients who continue with a nonconventional path where things might not be enough to help them, even in the face of trusted advisors telling them that they need to go in a different direction. This is particularly acute when we are talking about cancer and life-threatening diseases. But even for skin problems, I have had many patients who suffer for a long time before they agree to come back to conventional medicine. I meet these patients who say, “I am not using any of it," but they are still miserable. And I say, "Listen, we have really tried our best. We have gone as far as we can go with some of these nonconventional treatments. I think we can give you some relief, and isn’t that what you are here for?" And, sometimes, there is a real moment where they say, "Okay, I am ready." However, in general, my patients are on at least some conventional therapy, and I am just bringing in other therapies. Shared decision-making is critical.

What Are Some of the Integrative Treatments to Consider?
For atopic dermatitis (AD), we use things like coconut oil, which has been shown to have some antibacterial effect, particularly an antistaphylococcal effect. We use sunflower oil, which seems to help not only strengthen the skin barrier but can also stimulate endogenous production of natural ceramides. We have patients take oral hemp seed oil, which has been shown to decrease disease severity in AD. There is a wonderful paper that came out of Germany a couple of years ago using black tea as a compress for severe AD on the face. It has changed my practice; I have seen things that I have not been able to do before with that treatment.

In psoriasis, there is some compelling literature that fish oil supplementation helps. Topical indigo naturalis cream can be used for psoriasis as well. The study on it is remarkable; it looks like a drug study. If I hid the name indigo naturalis and just put product X, you would think it was a study for a new pharmacologic agent. And in a way it is because this botanical is nature’s pharmacology. There is even scientific work showing histopathologic changes such as an eff ect on keratinocyte maturation.

For other conditions such as warts, there is interesting literature on using topical garlic by applying garlic extract or garlic itself to the warts. We have these different things that we can pull in from different areas to go hand in hand with some of the conventional treatments.

How Can I Best Discuss Integrative Approaches?
In my tenure offering integrative treatments to patients and speaking about them to colleagues, I have occasionally gotten pushback. Typically, though, my patients are excited about it. They will say, “Wait, really?” And I will even print out the study and show them. I want them to be involved and I want to explain about the evidence and what was seen and measured. I think that is a powerful connection we can make with our patients. Very rarely a patient will roll their eyes at me. Occasionally, I have misread the room and they will say, “I am not interested.” My answer is always, “Okay, no problem. We don’t have to go that way.”

More commonly, I will get pushback from colleagues and other health care professionals who say, “I don't think this is right. This is a bunch of baloney.” Then I will ask them for just a few minutes. I say, “Let me just tell you the story a little bit. Let me show you a little bit about what I am doing and share some of the data with you.” Usually, I can get people to at least come around to it. I often say to my colleagues, “Even if you think this is baloney, even if you hate this stuff, your patients are interested. We know that at least half of the patients who complete surveys are fascinated by these treatments and are exploring them. So, at the very least, to serve our role as a guide and someone who can teach and help, we must know a little bit about them.”

I think once you open that door, many people are interested. The truth is that many of our conventional treatments come from plants, and they come from observations. It is not even that revolutionary. Over the years, I have met great clinicians who would not admit to using things this way and they did not even like these terms. But this is really what they did. They thought outside the box, and they tried new things. They listened to their patient and really tried to connect with them. And that is ultimately the hidden agenda. We are trying to connect with people to get them better. This is just another avenue we can take on that journey together.

What Does the Future Hold for Integrative Treatments in Dermatology?
The future looks incredibly bright for integrative dermatology. There is an annual conference called the Integrative Dermatology Symposium for which I am one of the coordinators. There were so many people at the end of it who said, “It was just a weekend, and we need more.” As a result, 3 years ago we put together a 9-month certificate course for dermatologists, with just over 70 lectures and hundreds of hours of interaction with different types of providers and specialists. When we first did it, we thought we would have maybe 5 or 7 people, but we had over 30 people sign up for the first year, and each year it has gotten bigger.

I think we need to discuss integrative treatments in a way that is respectful, evidence-based, and humble. The number one thing I say is, “There is a lot of stuff I don’t know. And the more I learn, the more I realize I don’t know." If we go in with an excited and optimistic attitude to learn new things and solve problems that have not been solved yet, I think not only does it help our patients, but it helps us as clinicians. A lot of clinicians come into the course and say, “I am burned out from conventional medicine. I wanted to think outside the box. I wanted to learn and grow again.” That is what integrative dermatology has done for me; it has opened an entire new pathway.