Key points
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A review of a variety of alternative therapies for atopic dermatitis (AD) is the focus of this chapter. Among those reviewed are acupuncture, cupping, and herbal therapies, which are common traditional Chinese therapies used by AD patients.
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We discuss the limited, but compelling research surrounding acupuncture and its subtypes’ success in treating AD symptoms such as itch.
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Cupping has less clear evidence for its use. We review the positive as well as the negative effects it may produce.
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We consider ancient Chinese herbal remedies, as well as teas and caffeine, their efficacy, and how their use translates into modern treatment of AD.
Introduction
According to some experts in traditional Chinese medicine, atopic dermatitis (AD) is caused by “a congenitally weak constitution, resulting in a predisposition toward atopic diseases and susceptibility toward external or internal pathogenic factors, such as wind, dampness, and heat. Its recurrent and chronic nature can injure Yin (as in Yin/Yang) and blood and generate dryness” ( ). Traditional Chinese medicine is an alternative medicine practice that includes using many herbs that are specifically formulated for the needs of each individual patient ( ). Since this ancient definition of AD, science has come a long way in understanding the mechanism behind AD. As research moves to unveil the mechanisms responsible for the pathogenesis of AD, there will be more opportunity to understand the reasons for different treatment modalities’ efficacy or lack thereof. Until a comprehensive pathophysiology is uncovered about AD, patients may continue to seek other nonconventional practices that have succeeded in managing symptoms of many diseases for centuries. Thus patients may look to those ancient Chinese remedies such as herbal extracts for healing their diseased skin.
The current data suggest that approximately one-third of AD patients will use complementary or alternative therapies in the lifetime of their disease. This is at least in part due to the chronicity of AD, its predilection for development in pediatric populations, and treatment resistance ( ).
In the instances where patients look for alternative therapies for management of their AD, the goal should be to confirm safety of the treatment rather than move to stop its practice. The high level of patients seeking to use complementary and alternative treatment therapies may suggest that conventional health treatments are not providing high levels of satisfactory results ( ).
This chapter focuses on existing evidence and gaps in research for complementary therapies in AD, including acupuncture, cupping, and herbal therapies. We explore the human and animal trials that are starting to uncover evidence for therapies that in some cultures have been used for centuries for the treatment of dermatologic disease. Additional complementary and alternative therapies, including supplementary oils, bathing additives, topical endocannabinoids, and fabric selection, are discussed in Chapter 26 .
Physical treatments
Acupuncture
In acupuncture, thin caliber (20-40 gauge) needles are placed at specific target locations on the body to modulate neurosensory transmission. A randomized, sham-controlled, single-blinded preliminary trial with 30 adult participants with mild to moderate AD administered verum acupuncture three times weekly for 4 weeks, twice weekly for 4 weeks, and sham acupuncture twice weekly for 4 weeks. Both acupuncture groups had a significant reduction in eczema severity when compared to sham. However, there were no significant improvements in insomnia, pruritus, or EASI scoring of eczema severity ( ). A randomized, double-blinded, placebo-controlled, crossover trial with 20 adult patients with AD found higher reductions in itch intensity between acupuncture and antihistamine itch therapy and significantly higher reductions of itch when compared to placebo ( ). A 2016 review stated that acupuncture treatment for symptoms of itch seems promising, but larger, randomized, placebo-controlled studies needed to be done before conclusions can be made ( ).
Electroacupuncture
An alternative form of acupuncture is electroacupuncture in which an electrical current is passed between acupuncture needles. There are no studies on electroacupuncture treatment in human patients with AD. A study on a model of AD in rats suggests high-frequency electroacupuncture alleviates pruritus through causing dynorphin neurotransmitter release, which acts on opioid receptors to decrease itch. Paradoxically, there was no significant difference in pain scores in rats even though pain and itch share many of the same neurologic pathways ( ). Lack of human clinical trials precludes the possibility of concluding electroacupuncture can be used to treat AD until further studies are completed.
Acupressure
Acupressure uses a small titanium bead to massage an acupoint on the skin. Most promising is a randomized, controlled pilot study of 15 adults with AD by Lio et al., which applies acupressure for 3 minutes three times per week for 4 weeks. They found significant improvements in pruritus and lichenification in the treatment group but also conclude that larger scale studies will be needed to confirm efficacy ( ). Current treatment guidelines for AD by Sidbury et al. state that there is insufficient evidence to support acupressure in the management of AD ( ). Acupressure may be a good alternative for pediatric patients who are less likely to tolerate traditional acupuncture.
Cupping therapy
Cupping therapy is an ancient Chinese modality in which partial, local suctioning is created on the skin by placing inverted cups and sealing with heat or suction. Cupping creates temporary bruises and microtrauma and is believed to dispel stagnation of blood and lymph and therefore improve energy (qi) flow ( ). There is very little published on the subject of cupping and AD.
One study of 88 patients compared blood-letting puncturing and cupping with a placebo of Claritin and Pairuisong Ointment. The study concluded there was a definite therapeutic effect on acute eczema, which is better than Western medicine. However, this study has limited scientific data included in its references and was not able to be examined in detail because it is written in Chinese ( ). Notably, the only other literature referencing cupping and AD is a case report of an 11-year-old girl with AD who developed blisters and oozing after cupping therapy, which rapidly evolved into purulent ulcerations ( ).
Currently there is very limited evidence that supports the use of cupping for treating AD, and there is concern for patient harm. Therefore more data on the safety and efficacy of cupping in patients with AD are needed before it can be recommended.
Herbal therapy
Traditional Chinese medicine is historically a popular complementary medicine in many Asian societies. PentaHerbs Formula (PHF) is based on a widely used ancestral Chinese concoction of five herbs: Flos Lonicerae (Jinyinhua), Herba Menthae (Bohe), Cortex Moutan (Mudanpi), Rhizoma Atractylodis (Cangzhu), and Cortex Phellodendri (Huangbai). In a randomized, double-blind, placebo-controlled study in children with AD, oral PHF was well tolerated and significantly improved symptoms and quality of life; there was also a reduction in topical corticosteroid requirement ( ).
Cardiospermum (balloon vine) extract contains flavonoids with antiinflammatory and antipruritic effects. Balloon vine was a minor ingredient in an open-label, forearm-controlled pilot study, which found that balloon vine-containing ointment applied twice daily led to significant improvements in transepidermal water loss (TEWL), hydration, skin elasticity and firmness, erythema. Skin roughness and smoothness were assessed via Visioscan VC98 which uses special illumination to capture high-resolution images of the skin ( ). However, balloon vine was among many ingredients contained in the ointment, therefore efficacy of balloon vine extract cannot be discerned. A review article described a double-blind, placebo-controlled study of an ointment containing balloon vine leaf extract and found it to be slightly superior when compared to placebo in patients with mild eczema. We cannot confirm the study design, ingredients, or any other details due to the study being written in German ( ). At this time there is insufficient evidence for the use of balloon vine extract in AD.
Tea and caffeine
Black tea
Black tea compresses have anecdotally been used by German dermatologists to treat eczema and dermatitis for decades. The mechanism for black tea’s efficacy in skin disorders has not been fully elucidated. Some researchers theorize that tannins, polyphenol organic molecules, and flavonoids act as astringents and antiinflammatories. In a prospective, open, uncontrolled study of 22 patients with atopic or contact facial dermatitis, black tea dressings and an emollient cream were administered four to five times daily to the face for 6 days. A significant reduction of eczema severity occurred within the first 3 days of treatment, with continued improvement through day 6. The study suggests that black tea is not only rapidly effective for the treatment of facial dermatitis, but it is also easy to use and low cost compared to many typically prescribed medication options. Of note, the process of the applications does require a patient willing to follow a strict compress regiment in order to see results ( ).
Animal models have shown efficacy in using tea to suppress type I and type IV allergic skin reactions ( ). In a study of 121 patients with recalcitrant AD, a 10-g oolong teabag placed in 1000 mL of boiling water steeped for 5 minutes was divided into three equal servings, and one serving was consumed daily after three regular meals. The study assessed severity of pruritus using a 6-point Likert-like scale and assessed visual morphology and observed marked to moderate improvement of AD severity. Benefits were first after 1 to 2 weeks of treatment. There were no reported clinical side effects found during the study ( ). Due to a lack of adverse effects, treatment of AD with regularly ingested tea appears to be a safe and reasonable addition to a patient’s current regiment.
Green tea
Oral green tea efficacy for AD-like lesions has been recently studied in a murine model, and significant reductions in skin inflammation and TEWL were observed ( ). A nonblinded, nonrandomized pilot study of green tea extract bathing additive treatment three times weekly for 4 weeks in four patients found improvement in eczema severity, visual lesion severity, and decreased mean serum eosinophil counts in four patients with Malassezia -associated AD ( ). Larger, randomized, and blinded trials of topical and oral tea in AD need to be conducted before formal, evidence-based recommendations can be delineated. However, due to safety and affordability, black tea compresses, oral oolong tea, and oral green tea may be useful adjunctive therapies in AD.
Caffeine
Caffeine’s action is thought to be due to elevation of local cyclic adenosine monophosphate (cAMP) by inhibiting phosphodiesterase (PDE). PDE4 is an important regulator for inflammatory cytokine production in AD. Its mechanism of action depends on degrading cAMP. The inhibition of PDE4 has been shown to reduce the release of proinflammatory cytokines ( ). This similar mechanism has thought to suppress histamine release during acute inflammatory skin reactions ( ). There have been oral medications such as apremilast (a PDE inhibitor), used for other dermatologic conditions such as psoriasis ( ). A topical version of such a drug may help limit its effect on nontarget tissue. In theory, topical caffeine application could provide this desired effect.
A double-blind trial of 83 patients with AD found that topically applied caffeine 30%-hydrocortisone 0.5% in hydrophilic ointment and betamethasone valerate 0.1% cream performed significantly better than a control of hydrocortisone 0.5% in hydrophilic ointment when looking at metrics such as lichenification, excoriation, and global impression. The study results suggest that caffeine-hydrocortisone combinations could be useful in the treatment of AD and could reduce the need for topical steroids and associated cutaneous side effects such as hypopigmentation or cutaneous atrophy ( ).
Summary
As patients look to complementary and alternative therapies for the management of AD, it is important that the dermatologic community moves to understand the evidence behind these therapies’ efficacy as well as their limitations, including their potentially harmful side effects. Although there are few studies with limited trial sizes, given the available evidence we believe that evidence-based complementary and alternative treatment modalities may be integrated into conventional treatment plans for AD to improve overall patient treatment outcomes.
A few randomized controlled trials investigating the use of acupuncture and acupressure have shown promising results with regard to eczema severity in AD ( ). Current evidence supports that these practices are likely safe adjunct or supplementary treatments for patients seeking alternative therapy for AD. Acupressure may be particularly well suited for nervous or pediatric patients who prefer to avoid traditional acupuncture. Electroacupuncture has only been studied in rats thus far and should not be recommended to patients.
Therapies adapted from ancient Chinese medicine, including herbal therapies and teas, have sparse but positive evidence. Oral PHF, balloon vine-containing ointment, and caffeine have been shown to improve AD symptoms ( ). However, these studies are very small with confounding variables (e.g., other ingredients tested simultaneously), and the results need to be interpreted accordingly. Due to the lack of negative side effects reported, these herbal remedies can be used cautiously if requested by the patient. However, patients should be made aware that there is limited evidence for efficacy.
Tea modalities have limited clinical trials supporting their use; nevertheless, they have been studied more closely than other herbal supplements. Black tea dressings, oral administration of oolong, as well as green tea bathing additives have shown promise in improving eczema severity ( ). To our knowledge no major adverse reactions were associated with using tea orally and topically, and its use may be recommended in clinical practice.
Overall, the data for traditional Chinese medicine in AD is sparse. The existing research is limited by small sample size, confounding variables, language barriers, and study design flaws. However, there continues to be a large interest among patients for these supplementary treatment methods, which should serve as an impetus to test their safety and efficacy. Several modalities are safe and may be trialed on a case-by-case basis. As the evidence evolves, physicians will likely begin to integrate alternative therapies into everyday practice.
Table 27.1 summarizes alternative treatments for AD discussed in this chapter.
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