Advances in Integrative Dermatology

Advances in Integrative Dermatology: Modifying the Concepts from the Past to Change the Future of Dermatology

Katlein França1,2 and Torello Lotti1

1 Centro Studi per la Ricerca Multidisciplinare e Rigenerativa, Università degli Studi Guglielmo Marconi, Rome, Italy

2 Department of Dermatology & Cutaneous Surgery; Department of Psychiatry & Behavioral Sciences; Institute for Bioethics & Health Policy, University of Miami Miller School of Medicine, Miami, FL, USA

“Every writer creates his own precursors. His work modifies our conception of the past, as it will modify the future.”

Jorge Luis Borges


Medical practices that reside outside the mainstream medical structures have existed for centuries. [1] The origins of medicine are deeply rooted in civilization’s cultural beliefs, experiences, and observations, and those practicing medicine believed that the body and the mind were not two separate entities. In the 1600s Rene Descartes, in an attempt to protect the body from spirits, separated the body from the mind. This was the beginning of evidence‐based medicine where the understanding of parts would lead to an understanding of the whole [2]. Subsequent developments such as antibiotics, other pharmaceuticals, anesthetics, and sterile surgical procedures gave a different perspective to medicine [3]. In particular, the discovery of antibiotics in 1928 boosted the pharmaceutical model we have today which emphasizes drugs as a primary means to treat disease. In Western civilizations, complementary and alternative medicines (CAMs) only began to re‐emerge after the 1960s with the awareness that chronic diseases were replacing acute diseases as the predominant health problem, and that a reductionist pharmaceutical model alone could not be sufficient for the prevention or treatment of these chronic diseases [4].

Different concepts and terms were given to describe the Integrative Medicine field: holistic medicine, alternative or complementary medicine, and then complementary and alternative medicine(CAM) [5]. The authors of this chapter understand that Integrative Medicine encompasses the coordination of conventional medicine with complementary therapies. The same concept applies to the Integrative Dermatology field. The skin is the largest organ of the human body interacting with other organs and responding to psychological, endocrines, and nervous stimuli through the Psycho‐Neuro‐Endocrine‐Immune system [6]. The integrative approach consists of a comprehensive evaluation of the physical, biological, psychological, social, and environmental overlapping aspects that affect the patient’s life, offering them conventional and complementary therapies with scientific basis. The integrative approach is based on the concept that every human being has a “diffuse brain” that commands a cross‐talk of messengers (cytokines, neuropeptides, hormones, grow factors, etc.) involved in the Psycho‐Neuro‐Endocrine‐Immune system.

This book explores a new kind of dermatological healthcare. It is patient centered, and considers the physical, biological, psychological, social, and environmental aspects of the patient’s life. It is based on dermatological healthcare promotion and skin diseases prevention, and embraces evidence‐based conventional and complementary therapies.

Integrative Dermatology: Conventional and Complementary Dermatology

Conventional Dermatology

Also called allopathic dermatology, mainstream dermatology, orthodox dermatology, or Western dermatology, this healthcare model of dermatology is generally taught in traditional medical schools and dermatology specialization programs. It uses evidence‐based knowledge and uses drugs, surgery, and minimally invasive procedures as a form of treatment.

Complementary Dermatology

Complementary dermatology refers to a group of diagnostic and therapeutic disciplines that are used together with conventional dermatology. Complementary dermatology is different from alternative dermatology. Whereas complementary dermatology is used together with conventional dermatology, alternative dermatology is used in place of conventional dermatology [7, 8] (Figures 1.1 and 1.2).

A circle labeled conventional dermatology added to a circle labeled complementary dermatology equal to a circle labeled integrative dermatology.

Figure 1.1 Integrative dermatology: combination of conventional dermatology and complementary dermatology.

Top: continuous cycle from physical to biological to psychological to social to environmental. Bottom: flow from dermatological health promotion and diseases prevention to incorporation of concepts of quality….

Figure 1.2 Pillars and principles of integrative dermatology by França and Lotti.

Pillars of the Integrative Approach

Physical Findings

What does the patient present, and is visible to the physician?

Greeting the patient is the first step to establish rapport between the healthcare provider and the patient. In general, a handshake seems to be the most appropriate way to start a consultation. However, religious and cultural aspects may interfere in this process, so the healthcare professional should remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. The physicians should introduce themselves using their first and last names and also call the patients by their first and last names, at least in the initial contact, following the national patient safety recommendations concerning patient identification. [9, 10]

The physician should ask the reason for the visit. The interview should address the duration and location of the patient’s cutaneous diseases (if any), other diseases, family medical history, use of and allergy to medications, sun exposure, current and previous skincare regimens, daily habits including exercise and diet, and the patient’s emotional state [11]. More questions should be asked during the physical examination as needed.

A complete skin examination is essential in the assessment of patients. All healthcare professionals should have a fundamental knowledge of the structures and functions of the skin in order to assess any changes to normal skin [12]. The ideal physical examination includes a systematic exam of the entire skin and its appendages. It is important to examine the skin for lesions that are directly related to the chief complaint as well as for incidental findings, especially for lesions that may be skin cancer [13].

A study published in the British Journal of Dermatology showed that in a nine‐month period, in a sample of 483 new patients, three patients (0.6%) had potentially lethal skin malignancies identified that would not have been diagnosed without a complete skin examination. Sixteen (3.3%) patients had basal cell carcinomas that would have been missed without a complete skin examination. This study confirms the traditional teaching that complete skin examination has the potential to reduce morbidity and mortality from cutaneous malignancy [14].

Dermatological equipment should be available during the physical examination, including: magnifying lens, dermatoscope, Wood’s light, a microscope, and a camera to document the findings. França performed a study in Brazil with 307 patients and found that 57% of that sample considered that the use of devices (magnifying lens, dermatoscope) by the physician during the physical examination would be fundamental for the correct diagnosis of the disease. Although not always true, these patients may believe that the technology helps their physician to make their diagnosis [15].

This physical findings session emphasizes the need for a complete physical assessment to find the physical manifestations of the disease or complaint, and the findings that are visible to the physician.

Biological Factors: The Psycho‐Neuro‐Endocrine‐Immune System

What is the identity of the patient?

Biological factors refer to anything that could affect the function and behavior of a living organism. These factors could be physiological, chemical, neurological, endocrinological, and immunological, or a genetic condition which causes a psychological effect. Biological factors are seen as the primary determinants of human behavior [16]. The psychobiological concept involving the Psycho‐Neuro‐Endocrine‐Immune System is particularly useful for the study of dermatological diseases. The Psycho‐Neuro‐Endocrine‐Immunology (PNEI) is a scientific field of study that investigates the link between multidirectional communications among the nervous system, the endocrine system, and the immune system, and the correlations of this cross‐talk with physical health of the skin. The authors emphasize that this innovative medical approach represents a paradigm shift from a strictly biomedical view of health and disease taken as hermetically sealed compartments to a more interdisciplinary and integrative one [17].

Psychological Aspects: Psychodermatology and Quality of Life

How does the patient think, feel, and behave?

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Aug 10, 2020 | Posted by in Dermatology | Comments Off on Advances in Integrative Dermatology
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