Complementary and alternative medicine (CAM) in dermatology encompasses a wide variety of methods of diagnosis and treatment that either supplement or substitute for conventional dermatologic practice. It is also referred to as holistic dermatology because it considers and addresses the entirety of the individual, including the physical, mental, emotional, and spiritual aspects of the individual’s life, as appropriate. Holistic dermatology draws on an expanded knowledge base that includes CAM, conventional practice, and the latest research findings. Its diagnostic and therapeutic choices are made by combining these three knowledge bases, in what might also be termed integrative dermatology.

The alternative healthcare systems considered by holistic dermatology may include time-honored practices such as ancient traditional Chinese medicine, Ayurvedic medicine, American folk medicine, homeopathy along with more recently developed techniques from chiropractic, energetic medicine, functional medicine, and psychosomatic modalities. Furthermore, holistic dermatology includes any other technique that works or makes sense based on science or observation.

Increasingly, patients are using CAM methods in addition to conventional dermatological treatment as cosmeceutical, nutraceutical, and even pharmacological manufacturers more routinely offer these products. CAM practitioners and dermatologists are being called upon to respond to their patients’ expectations, preferences and demands for therapeutic modalities and treatments that avoid or minimize use of prescription drugs, and are safe, natural, and effective.

Alternative medicine often embraces treatment that not only presages but also may ultimately be incorporated into conventional practice. Good CAM practice is rooted in basic science, clinical experience and good medicine, but it often lacks the sanctioned level of proof we have come to demand for scientific, allopathic dermatology. Further, CAM practices arise and are developed differently from conventional practices. For example, when a growing body of anecdotal experience is supported by the understanding of underlying mechanisms of pathology, particular CAM approaches to illness are employed, even before the methods are validated in the usual ways. Many of these methods are difficult to study or assess using conventional research methods because they relate to the individual rather than to the disease or condition itself.

Many CAM methods and practices have slowly been incorporated into more conventional practice and some have gained widespread acceptance and use. Examples include the increasing use of probiotics, which had its tentative beginnings in the 1980s, to counter Candida overgrowth in the gut, which was later shown to enhance barrier function in the intestines and skin. The CAM use of essential fatty acids (EFA) as anti-inflammatory agents preceded the growing literature on this subject.

CAM practice also identified trans-saturated fats as disrupters of cellular functioning, inhibiting the δ-6-desaturase and thus the production of anti-inflammatory prostaglandins. This tenet of CAM medicine was set forth by Horrobin and others in the 1980s, decades before products containing transfats were removed from the shelves and castigated as deleterious for health.1,2 Similarly, kitchen herbalists and small companies were producing herbal skin applications long before the current popularity of cosmeceuticals. And while historically CAM practices have gradually been adopted by mainstream practitioners, in dermatology, the pace of adoption has quickened in recent years. Perhaps most telling is that much of the herbal pharmacopoeia of CAM dermatology referenced in the last edition of this text is now described in the dermatologic literature or is available in products designed for the skin.

Eclectic practice and off-label use of pharmaceutical drugs has always been a part of dermatology, perhaps more so than in medicine in general. These practices provide novel and often effective approaches to disorders of uncertain etiology by incorporating methods from other spheres or from observed benefit. Many of the commonly used pharmacological agents used in conventional allopathic medicine are derived from herbal medicine.3 The American “herbal” tradition dates to the Eclectics, a school of physicians who, during the nineteenth and early twentieth century codified the use of Western herbs according to specific indications.4 Today a wide variety of herbs is used, and the methods of selecting specific herb combinations also originate in other traditions. For example, psoralens have been used in China and India for repigmentation of the skin for more than 4,000 years. Other herbs used in treating the skin include mayapple (podophyllin) for condyloma, horse chestnut for leg veins, bloodroot (sanguinaria) for skin tumors, and oatmeal (Avena sativa) to soothe rough, itchy, or inflamed skin.3

In addition to specific herbal remedies, some of the philosophical tenets of herbal medicine have been incorporated as key concepts in dermatology. For example, the principle of using a crude preparation as opposed to a purified single ingredient as tends to be used in a pharmaceutical product, was one of Sulzberger’s observations regarding the use of tar.5 It was the crude tar product from the distillery and not its purified derivative that had activity in treating psoriasis. In fact, variation in batch efficacy was assumed to be an indication of the heterogeneous nature of the preparation.

A virtual explosion in the availability of herbs in cosmeceuticals, herbal supplements, and new pharmaceuticals has occurred during the past 15 years. This growth has been accompanied by a substantial increase in peer-reviewed publications seeking to clarify the mechanism of action of herbs and their components and case studies detailing knowledge inferred from their traditional use. Each herb has a number of different activities and actions, which depend on growth conditions, the extent to which they have been challenged to fend off pathogens and predators, method of extraction, and the culture that utilized the herb or herbal preparation.

One of the advantages of knowing the traditional uses of herbs and their rich history of folk use is the ability to more fully appreciate their spectrums of action. For example, oats, A. sativa, are well known for their soothing anti-inflammatory effects on the skin as a topical soak. The milky white sap from green oats is known for its calming properties as a relaxant to the nervous system. In the context of its use as a folk and home remedy, it is easier and intuitively correct to seek out oat extracts for their calming effects on the nervous tissue in the skin, i.e., soothing and anti-pruritic actions as well.

Antioxidants

Antioxidants prevent damage from both exogenous and endogenous free radicals. Ultraviolet radiation from the sun is a major source of free radical damage to the skin, but is beneficial for the production of vitamin D. A symphony of antioxidants prevents excessive damage to either the somatic tissues or DNA of the cells. Plants also must develop their own complex of antioxidants in order to withstand excessive damage from the sun. A young sprout or a plant placed prematurely in full sun will wither and die. It is the complex of antioxidants and light absorbing pigments that plants develop which function to protect them from this damage. Therefore, some argue that eating whole plants, with their functional spectrum of antioxidants, is more protective than isolating the most active fraction, such as β-carotene, and administering it alone.

Nutritional supplementation can supply external antioxidants, or support the generation of endogenous antioxidants. Carotenoids and polyphenols (bioflavonoid) are two major classes of plant-derived antioxidants. Bioflavonoids are especially protective of the capillaries and blood vessels. Oxidative damage and glycation damage induce metalloprotease activity, which destroys the integrity of collagen and elastic tissue in both the skin and the vasculature, and antioxidant protection may slow this process.

The hallmark of CAM is a search for the elements in the causal chain of functional disturbances that lead to a skin disorder. For inflammatory disorders, an attempt is made to identify exposures, which could stimulate and/or disturb immune responses with secondary targeting of skin structures. CAM focuses on correcting probable underlying causes, often with treatments that are not proven in the traditional scientific method. The patient not only assumes the responsibility of making the necessary lifestyle changes but also the risk of using protocols that are neither conventional nor necessarily well researched.

Individual specificity is key to CAM dermatology. Long before knowledge of specific pathogens and genetic polymorphisms, other systems of healing such as Ayurvedic medicine developed classification and treatment paradigms that are still used today, and extend well beyond diagnosis. The long-awaited studies and meta-analyses of CAM in dermatologic disorders such as psoriasis6 will continue to be of very limited usefulness because they persist in classifying patients solely by disease and fail to choose herbs and supplements for time-tested indications in traditional systems, or based on CAM or individual-specific disease mechanism parameters. Appreciation of these distinctions will lead to the design of research studies that truly indicate how to integrate CAM into dermatology as well as how to accurately evaluate the efficacy of CAM practices.

Early Application of Medical Knowledge

 The application of medical, scientific, and folk information before it was either proven by double blind studies, incorporated by the majority of physicians as standard of practice, or justified as evidence-based medicine is part of the normal process of therapeutic innovation in dermatology. Advice to stop smoking would have been scientifically premature until a decade ago or so, but many physicians were bold enough to offer that advice to patients years before the dangers of smoking were definitively proven. An eclectic approach to treatment has historically been a mainstay in dermatology. Application of immune therapies, conformational chemical analysis, energy medicine, most food allergy testing, herbal and supplement therapies might all be considered premature if assessed using strict requirements for double blind proven or even evidence-based medical practice. When, however, these methods offer help where there has been none before, and their margin of safety is far greater than that offered by pharmacological interventions, it would seem quite sensible to consider the use of these “alternatives,” even before they are proven to work. The opportunity exists to integrate these alternative treatments into a comprehensive approach that offers a level of patient-specific safety and efficacy beyond what either CAM or conventional therapy alone can offer. A health system that promotes rather than forbids the flexibility necessary for this integrated care is crucial for the best health of the skin of our species.

Cross-Reaction and Molecular Mimicry

 In the CAM approach to dermatology, the environment is considered to play a fundamental diagnostic and therapeutic role. Cross-reactions with foods, chemicals, and infectious agents may be key precipitants or contributors to inflammation which itself may play a role in a range of dermatologic conditions. A mainstay of the CAM approach is to search for the inciting cause of an inflammatory response and once it is identified, to correct the ongoing memory response using natural means. Eliminating foods that exacerbate eczema, or enhancing food breakdown into smaller, less antigenic fragments by supplementing with digestive enzymes, is one example of how CAM acts to remove molecular mimics that stimulate skin inflammation.7

 There is individual specificity in antigen recognition,8 exposure history, and the type of tissue response to the resulting inflammatory cascade. It is therefore critical to look for the precipitating stimuli of disease onset for each individual. This concept is widely accepted for contact dermatitis but has not yet been adopted for eczema or psoriasis. At the same time, it is critical to consider the existence of factors that either neutralize or exacerbate the response to suspected or confirmed precipitating stimuli. An exhaustively detailed history is essential to understanding why a patient reacts at certain times and not others.

 Just as β-hemolytic Streptococcus can precipitate guttate psoriasis, molecular mimicry by microorganisms is associated with onset of autoimmune conditions. A corollary possibility that should be considered is that many inflammatory and autoimmune conditions of the skin involve cross-reactive initiation to food antigens, microbes, chemicals or other altered forms of self-antigens. This entire mechanism has been well described in celiac disease,9 a condition closely associated with the dermatologic condition, dermatitis herpetiformis.

 Autoimmune attack on tissues depends on a number of factors including recognition, molecular mimicry or identity, attack by lymphocytes with receptors that target a similar autoantigen, and propagation of this response by the phenomenon of bystander activation or epitope spreading.10 Normal mechanisms of tolerance and control by regulatory T cells must also fail for this to occur.

 Appearance of autoantibodies in the blood, once considered irrelevant in asymptomatic patients, may well be a warning sign to institute changes to prevent the gradual development of clinical autoimmune disease.

Heavy Metals

 Heavy metals and transition metals lead to autoimmunity because they bind to proteins, replace other metals in metalloproteins, and attach to sulfur groups altering molecular configuration. Crucial biotransformation metalloenzymes are inactivated by displacement. All of these actions affect the tertiary structure of proteins, creating neoantigens and altering function.

 Of interest to dermatologists is that increased reactivity to heavy metals has been reported in lupus erythematosis, oral lichen planus, oral burning and itching, eczema, and psoriasis, and Sjögren syndrome.11,12 Urticaria, eczema and other systemic conditions have been found to improve after removal of dental fillings and other treatment to facilitate removal of mercury from the body.8

Hepatic Factors

 Drug levels may be affected by foods or medications influencing specific P450 enzymes.13 Chemicals targeted by the liver for removal are first chemically converted by P450 isoenzymes in phase I to make them either more soluble or more chemically reactive for coupling to molecules in phase II for transport out via renal excretion. With insufficient transporters, these hyper-reactive drug metabolites, made more chemically reactive by the phase I liver P450 enzymes, may combine with molecules in skin tissue structures to create neoantigens or other molecular informational disturbances. Understanding how insufficient or incomplete biotransformation of accumulated toxic substances could trigger a skin reaction enables one to take a focused history, which includes not only the toxic substances, but also the change in hepatic ability to rid the body of molecular triggers.

Dietary Approaches

 Oral ingestion is one of the largest sources of foreign material entering the body. It has been established that large molecules, including horseradish peroxidase with a molecular weight over 1,000,000 daltons can be absorbed intact from the gut.14 Drugs are well known causes of skin eruptions.15 Foods have a variety of effects on skin disorders beyond a role as allergens.16 They can serve as informational molecules to incite eruption, direct or indirect hormonal aggravators, gut permeability modifiers, or influence the ecology of the gut flora. Certain nutrients can overcome the liver’s capacity to biotransform harmful antigens and toxic intermediates or aid in hepatic biotransformation. Foods can also have a wide variety of effects partially overlapping those of herbs and pharmaceuticals. Dietary effects on gene expression and individual specific food interaction are now known as neutragenomics.17

 Dietary treatment of acne was much more prevalent before the advent of antibiotics. In recent years, food triggers for acne had fallen out of favor and diet was widely assumed to be irrelevant. Recently, however, milk has once again been found to have an etiologic role in this disorder.18

“Food Allergy” Determination and Elimination

In addition to classic immunoglobulin E-mediated allergic response, the term food allergy also includes other types of allergy such as immune complex, delayed, and Toll-like receptor activation. There is also nonallergic sensitivity. Food allergies develop to the many common foods such as wheat, milk, soy, yeast, and corn. Some believe that a hallmark of food allergy is food craving with repetitive eating of the same food each day.19 A 5-day elimination and rechallenge on the sixth day is an effective way to determine if the food under consideration is the cause of the symptoms of concern.

Other symptoms beyond the skin could include digestive upset, nasal stuffiness, fatigue after eating, or even “brain fog.” Brain fog is a popular term for a sense of mental confusion, sluggishness, and slowness that may sometimes include a feeling of unreality or disorientation. Small peptides from casein digestion known as caseomorphins, which can also derive from gluten, rice, bovine albumin, and even spinach, have psychoactive properties.20 Treatment involves elimination, substitution with other foods, and food rotation. Enhancing digestion with digestive enzymes and adding metabolites to enhance the gut permeability barrier (and reduce the impact of leaky gut) helps to prevent sensitization to disease inducing cross-reactive antigens.21,22

Food Allergy Diagnosis

Diagnosing food allergy is best initiated by a careful history of the specific foods that preceded a reaction; these include foods consumed a few hours or even few days prior to the reaction. A food and reaction diary helps to reinforce memory and document instances of food consumption and reactions. Elimination and challenge is the gold standard for identifying food allergens. Intradermal testing can be helpful, and is far more useful than scratch tests because the latter detect IgE or immediate allergy only.