A Mixed Bag: Traditional Medicine Meets Evidence-Based Alternatives

Allison Evans

Dermatology World

As a child, Peter Lio, MD, FAAD, was an enthusiast for all things mysterious -- telepathy, Bigfoot, the Loch Ness Monster. Despite this fascination, Lio, the founding director of the Chicago Integrative Eczema Center and clinical assistant professor of dermatology and pediatrics at Northwestern University, found himself in the evidence-based world of medicine.

"I loved my dermatology residency and was taught by brilliant scientists and master clinicians," he said. "However, even with that knowledge and training, we still faced difficult situations. Some patients didn't respond to the treatments, and some had side effects that were as bad as or even worse than the disease we were treating."

A growing number of patients who fail to respond to traditional Western medical approaches to their skin conditions are clamoring for alternative or "natural" approaches to healthcare, including diet and lifestyle modifications, vitamins, herbs, and botanicals, among others. This demand can align with a naturopathic approach, which has placed licensed naturopaths (NDs) on the map in a new way.

As a result, some dermatologists are using an integrative approach to care that combines traditional medicine with evidenced-based alternatives. Experts explore the clinical and evidence-based approaches to naturally based skin care treatments.

Naturopathic approach to skin health

For Trevor Cates, ND, a naturopathic approach to care seeks to determine the root cause of a problem.

"What's the underlying cause of our patients' skin or health problems? Usually, when patients come to us with acne, eczema, or rosacea, it's something they have been struggling with for some time," Cates said. "Often, they have tried many things that haven't worked. Because naturopathy uses a whole-systems approach, practitioners typically spend between 60 and 90 minutes with a patient at an initial appointment."

"In daily practice, our goal is to address the patient's main concerns but also take into account the totality of the symptoms they are experiencing," said Shayna Peter, ND, LDN, a functional ND and licensed dietitian and nutritionist. "If you can identify connections between other symptoms that point to a common root cause, then you can improve more than one condition."

For example, when looking at root causes with skin conditions, the microbiome is often an essential piece of the puzzle, Cates said. "We know from the research and also from clinical experience that the gut microbiome impacts the skin, so often we look at whether there is something going on internally with the gut that could be impacting the skin microbiome."

DeJarra Sims, ND, a licensed naturopathic practitioner in California, also sees clinical evidence of the gut-skin connection in practice. However, "You have to know when to refer and when to use conventional treatments," Sims said. "We look at natural medicine as the least-invasive thing to do as a first step. However, you still have to understand the disease progression and when a higher-level intervention is needed."

What is integrative dermatology?

According to the National Center for Complementary and Integrative Health, "there are many definitions of 'integrative' health care, but all involve bringing conventional and complementary approaches together in a coordinated way."

In 2020, Lio -- along with Raja Sivamani, MD, FAAD, and Apple Bodemer, MD, FAAD -- launched the Integrative Dermatology Certificate Program (IDCP).

"The IDCP is a nine-month program for board-certified dermatologists to do a deep dive into integrative dermatology," said Lio.

The program is designed to provide hands-on, practical solutions for dermatologists looking to start an integrative practice, expand their offerings, or advance their knowledge of integrative medicine within dermatology.

California dermatologist Elizabeth Grossman, MD, MBA, FAAD, a recent graduate of the IDCP, explained how the lectures began with an in-depth dive into the pathophysiology of a disease and moved on to review Western therapies. "Then we would shift to integrative therapies including Ayurvedic medicine, nutrition, herbs and botanicals, the microbiome, and mindfulness," she said.

Lecturers explained the biochemistry behind why an herb or botanical may help a condition, she said. "Looking at itch, for example: We learned how the flavonoid quercetin may affect itch because it is a mast cell stabilizer. We learned how anxiety can exacerbate itch, and that mindfulness techniques can help provide relief from itch as well."

One of the greatest benefits of the program, Grossman said, was that it incorporates many aspects of medicine, including Western medicine. If alternative medicine means using, quite literally, an alternative approach to the conventional, then integrative means bringing the best from many traditions, Lio said. "To some extent, good clinicians have always been willing to be creative and think outside the box, particularly when a patient has exhausted conventional, mainstream approaches."

Patient demand for integrative dermatology

"Our patients are demanding it. If we cannot meet their needs, they will go elsewhere," Lio explained. "Dermatology is a small specialty, making up only about 1% of practicing MD physicians. Many patients are seeking integrative approaches, so they are clearly willing to look outside of our specialty and, indeed, outside of mainstream medicine to find them."

Lio explained three major areas of focus that lie at the root of the integrative dermatology movement: Diseases that are not curable; explanations that are unsatisfying; and treatments that are thought to be unsafe and/or only symptomatic.

"For dermatology in particular, many of our diseases are chronic and incurable, much of our understanding of the pathophysiology is incomplete, and many of our treatments offer only a temporary reprieve with many potential side effects," Lio said.

For Grossman, interest in integrative dermatology grew out of conversations with her patients. "I fielded a lot of questions about ingredients in sunscreens, natural oils, diet and skin, stress and skin, and I just didn't have a lot of answers." These questions motivated her to complete the IDCP.

Integrative dermatology in practice

When treating patients, Lio always starts with conventional medicine. "I like to use the most evidence-based, up-to-date, and modern approaches for my patients, and I like to explain those options carefully."

"I then try to integrate other, often less evidence-based modalities, but with clear reasons," he said. "Perhaps it is to minimize the use of a topical steroid or avoid exposure to an oral antibiotic. Perhaps it is to mitigate against a potential side effect. This is very different than, for example, seeing an alternative medicine provider who may not even be able to use prescription medications, let alone be highly experienced with them."

He has three guiding principles when thinking about integrating natural approaches into clinical practice: Some evidence of efficacy; reasonable assurance of safety; and accessibility to patients and physicians.

"With many inflammatory skin conditions, I recommend an anti-inflammatory supplement," Grossman said. "I recommend zinc and niacinamide for my hidradenitis patients, and turmeric for my rosacea patients. Many of my patients also want to discuss the microbiome of the gut and skin. I will recommend a variety of probiotics for my patients, particularly those with acne or atopic dermatitis, as there are studies showing which strains of bacteria may benefit patients with these conditions."

There are two large studies that show a clinically relevant effect of fish oil on psoriasis as well as evidence that shows indigo naturalis may have benefit for psoriasis patients, Lio said.

Atopic dermatitis

"For my atopic dermatitis patients who are very hesitant to use steroids, I can recommend sunflower oil," Grossman said. "I discuss why I am recommending it. I review how sunflower oil has been shown to increase the synthesis of ceramides and help repair the skin barrier. I reference studies because I want my patients to know that there are data behind my natural recommendations. Offering alternatives has increased the trust between myself and my patients because they feel heard and that their concerns or beliefs are not being dismissed."

Colloidal oatmeal (Avena sativa) has a long history of use in atopic dermatitis and chronic pruritus. Oats contain hydrophilic carbohydrates that enhance moisture uptake and retention as well as unsaturated triglycerides, flavonoids, tocols, alkaloids, and sterols that further exert barrier repair and anti-inflammatory effects, Lio said.

Virgin coconut oil has also demonstrated both emollient and antibacterial properties. It has been shown to address another related issue in atopic dermatitis: Staphylococcus colonization. In a randomized controlled trial, it was found to clear an impressive 95% of Staphylococcus colonization in patients with atopic dermatitis compared to only a 50% reduction in a control group. When put to a more clinical test, it outperformed mineral oil in treating pediatric atopic dermatitis over eight weeks in a randomized trial.

Acne

Massachusetts dermatologist and nutritionist Valori Treloar, MD, CNS, FAAD, has relied on teaching her patients about the role of diet in conditions such as acne for many years -- long before the more recent evidence of the correlation of dairy consumption and a high glycemic diet with onset or exacerbation of acne. While nutritional counseling once may have been deemed an "alternative" approach, it is now supported by the canon of evidence-based research.

Treloar referenced a study in the American Journal of Clinical Nutrition that showed when obese patients who had moderate-to-severe chronic plaque psoriasis lost weight through a calorie-controlled diet, they increased their response to low-dose cyclosporine. Counseling patients about lifestyle factors may not prevent them from needing conventional treatments, but it may alleviate the need for a particular drug, she explained.

For a patient with severe nodulocystic acne, there's nothing that is going to work like isotretinoin, Grossman said. "When starting a patient on isotretinoin, I may now recommend also starting pantothenic acid or L-carnitine, both of which can help with side effects from isotretinoin."

Dermatology, functional medicine, naturopathy

As an integrative dermatologist and certified practitioner of functional medicine, Treloar has witnessed how poor diet, sedentary lifestyle, high stress, and inadequate sleep all wreak havoc on patients. "A huge part of functional medicine is helping people change how they eat, how they sleep, how they exercise, and teaching them why that's important."

In functional medicine, health is viewed as a continuum and not just the absence of disease. "There is an emphasis on optimizing wellness and, when possible, catching imbalances early before they progress to a full-blown disease state," said Peter.

McKenzie Mescon, ND, a licensed ND in Montana, and Treloar's daughter, finds that her training overlaps with functional medicine and integrative medicine. "I aim to treat the cause of the disease. It's a lot of getting the story and understanding the root cause of why patients feel the way they do. Naturopathic medicine relies on another philosophy, which is the idea that we're all meant to be well and that the body has an innate ability to heal itself."

There are times, however, when patients need conventional care, Mescon said, and she spends a remarkable amount of time convincing some patients to get that care. Treloar has established a solid referral network with other dermatologists who work with patients exasperated by the failure of conventional medicine or want a physician with experience in naturally based approaches.

"By the same token, if somebody happens to find their way into my office and wants me to prescribe them a biologic as a first-line treatment for psoriasis, I will refer them to one of my colleagues who excel at that approach," Treloar said.

The evidence

The body of evidence for integrative approaches is obviously smaller, said Grossman, and the data have not been centrally located (there is no JAAD on integrative dermatologic approaches). There is data in peer-reviewed journals to support treatments that she recommends.

"Understanding the pathophysiology of a condition and the biochemistry behind an integrative approach is critical," Grossman said. "While there isn't a huge body of evidence, it is growing."

Particularly for patients with eczema, there is now research to accompany the use of probiotics. There's also a lot more research coming out on fish oils and omega-3s, which NDs have been using for years, Sims noted.

There has also been more research on things like aloe, niacinamide, green tea, CoQ10, vitamin E, vitamin A, and other supplements, Cates said.

"But the challenge with these studies is funding," Cates said. "A company that grows calendula may not necessarily have the same kind of budget that a pharmaceutical company would have to pay for a study. As naturopathic physicians, we would love to see research done either way to prove or disprove that a natural substance works or doesn't work. The question is who's going to pay for it and is it going to be biased?"

A new approach?

Board-certified dermatologists are trained to be much more reductionistic and targeted than NDs, Lio said.

"We know that the average acne visit with a dermatologist is very brief and, while there are outliers, the typical visit would not really discuss gut health, sleep, or even diet," Lio said. "Maybe one or two prescriptions would be written, and the patient would be on their way. This isn't to impugn that approach -- it is highly effective and extremely efficient for both patient and doctor -- but it does allow us to imagine a different approach that is more encompassing."

"Because my toolbox for treating a dermatologic condition is so much broader, I feel that I am able to connect more with my patients," Grossman said. "Not every patient wants a supplement or natural remedy, so I absolutely do not push them on all patients. On the other hand, some of my patients have a real hesitancy about therapies -- especially steroids."

While incorporating elements of alternative medicine in daily clinical practice is a path less traveled for many dermatologists, its value may extend beyond treatment.

"For many patients, the openness and willingness to go with them on a journey, and the actual experience with different forms of medicine -- all of this -- is often enough to make them feel at ease and allows us to build the therapeutic alliance that is critical to get people better," Lio said.

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