Complementary, Holistic, and Integrative Medicine: Atopic Dermatitis Cecilia Bukutu, Janjeevan Deol, Larissa Shamseer and Sunita

Vohra Pediatr. Rev. 2007;28;e87-e94 DOI: 10.1542/pir.28-12-e87

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/cgi/content/full/28/12/e87

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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Article

complementary medicine

Complementary, Holistic, and Integrative Medicine:

Atopic Dermatitis
Cecilia Bukutu, PhD,* Janjeevan Deol, BSc,* Larissa Shamseer, BSc,* Sunita Vohra, MD, MSc*

Introduction
Atopic dermatitis (AD), or atopic eczema, has been increasing worldwide; the lifetime prevalence is estimated to be between 10% and 20%. (1) In 90% of patients, the onset of AD occurs before 5 years of age. Despite a wide range of conventional treatments, including corticosteroids, symptoms may not always improve. Furthermore, because some therapies are associated with serious adverse effects, patients may consider using complementary and alternative medicine (CAM) to prevent, cure, or relieve symptoms. (2) The lifetime prevalence of CAM use by patients who have dermatologic diseases (including AD) ranges from 35% to 69%. (3) This review of published scientic literature assesses the efcacy and safety of some common CAM therapies in treating pediatric AD.

Author Disclosure: Dr Bukutu, Ms Deol, and Ms Shamseer did not disclose any nancial relationships relevant to this article. Dr Vohra disclosed that she receives salary support from the Alberta Heritage Foundation for Medical Research and Canadian Institutes of Health Research.

Natural Health Products

Traditional Chinese Medicine (TCM) Herbs
A systematic review (n 159) that included three randomized, controlled trials (RCTs) (two from the United Kingdom [UK] and one from Hong Kong) and an open label trial (UK) investigated the short-term effects of a blend of 10 herbs (Potentilla chinensis, Tribulus terrestris, Rehmannia glutinosa, Lophatherum gracile, Clematis armandii, Ledebouriella saseloides, Dictamnus dasycarpus, Ponia lactiora, Schizonepeta tenuifolia, and Glycyrrhiza glabrae) in treating patients who had AD. (4) The herbs were ground, placed in porous paper sachets, boiled into a thick concentrate, strained, and ingested orally as a drink for 8 weeks. Only one of the RCTs focused on efcacy in children (n 37); it found a median 51% decrease in erythema scores for the herbal group (95% condence interval [CI] 34.5, 72.6) compared with 6.2% (95% CI 25.2, 30.7) for the placebo group. (5) A subsequent 1-year follow-up study of 23 children found a persistent benet from using the herbal blend in 18 children (78%), who had a 90% reduction in eczema activity score. (6) In this follow-up study, 14 of the original 37 children withdrew (10 due to lack of response, 2 because of unpalatability, and 2 due to difculty in preparing the decoctions). The second RCT (UK) in the review also found the herbal blend to be more effective than placebo; (7) the third (Hong Kong) found no effectiveness. (8) The open-label trial found that both herbal and freeze-dried preparations reduced erythema and surface damage effectively. (9) Due to the small number of participants in the studies (fewer than 50 in each trial), the reviewers could not conduct a meta-analysis of the data to provide a clearer indication of efcacy of TCM for AD. Other limitations of the trials included no allocation and concealment information and high dropout rates (more than 18% in three of the four trials). TCM herbs may be useful for the short-term treatment of AD, but additional evidence from larger trials is needed. In the original RCT in children, unpalatability of herbs resulted in ve dropouts (three in the intervention group, two in the placebo group). (5) In the follow-up study, two children in the intervention group developed liver function abnormalities (serum aspartate aminotransferase concentrations 1.5 times the upper limit of normal), which resolved after herbal treatment was discontinued. (6) Furthermore, one third of children in the

*Complementary and Alternative Research and Education (CARE) Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada. On behalf of the American Academy of Pediatrics Provisional Section on Complementary, Holistic, and Integrative Medicine. Note: The agents discussed in this series are designated as dietary supplements rather than drugs. Although dietary supplements are regulated by the United States Food and Drug Administration (FDA), their manufacturers may make claims with little evidence and need not prove safety prior to marketing. The burden is on the FDA to monitor safety after the product is on the market. Readers are referred to the 1994 Dietary Supplement Health and Education Act (www.cfsan.fda.gov/dms/dietsupp.html). Pediatrics in Review Vol.28 No.12 December 2007 e87

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intervention arm experienced diarrhea but continued with the trial. (6) Adverse effects reported in adults include mild dizziness, headaches, nausea, abdominal discomfort, and loose bowel movements or atulence. (7) An additional open-label case series from Hong Kong reported on nine children who had AD and took three capsules containing a blend of ve TCM herbs (Flos lonicerae [Jinyinhua], Herba menthae [Bohe], Cortex moutan [anpi], Rhizoma atractylodis [Cangzhu], and Cortex phellodendri [Huangbai]) twice daily for 4 months. (2) AD improvements were measured by using a clinical scoring tool, the Severity Scoring of AD (SCORAD) index, which assesses the severity (ie, extent, intensity) of AD. The overall median SCORAD score decreased signicantly from 60.3 (range, 20.0 to 82.6) at baseline to 40.0 (range, 11.4 to 56.5) at 3 months (P 0.008). (2) A subsequent RCT (n 85) by the same authors, in which children who had moderate-to-severe AD took the same capsules three times a day for 12 weeks, demonstrated improved quality of life and reduced topical corticosteroid usage. (10) Adverse events reported included upper respiratory tract infection, asthma, diarrhea, abdominal pain, and new rash. Of concern, some herbal preparations from China have been found to be contaminated with toxins (ie, heavy metals such as mercury or arsenic) or adulterated with prescription medications such as glucocorticosteroids. Not surprisingly, the latter has been associated both with improvements in AD and cutaneous adverse effects similar to those caused by conventional corticosteroid creams. Reports of hypersensitivity reactions, liver toxicity, agranulocytosis, cardiomyopathy, and respiratory distress syndrome after ingestion of Chinese teas are well documented. (11) All TCM herbs used in the aforementioned trials were tested for heavy metals and residual pesticides to ensure that they met quality and safety requirements. Blood, renal, and liver function tests also were performed.

was rubbed on lesions on the left part of the body and petroleum jelly (control) on the right side of the body three times daily for 2 weeks. In group B, AD symptoms and signs improved signicantly (P 0.0129) in 8 of 10 children (80%) who used the honey mixture on the left part of the body and in 2 of 10 children (20%) who used petroleum jelly on the right part of the body. Furthermore, in 5 of 11 children in group A (45.4%), use of the honey mixture enabled steroid strength to be reduced by 75% without worsening of AD symptoms. The honey mixture was found to be useful in the management of AD.

Homeopathy
Homeopathy is based on the premise that like cures like, meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses actually causes those symptoms. Few studies have assessed the efcacy of homeopathic treatment for AD in children. A Japanese observational study assessed the effects of using different individualized homeopathic treatments ( 20 types, including pulsatilia, sulfur, Lycopodium, Arsenicum, and Mercurius) in addition to conventional treatment in 45 patients (ages 14 to 77 y) who were followed for 3 months to 2 years and 7 months. (13) A total of 88.3% of patients reported having a greater than 50% improvement in their AD after homeopathic treatment. Such study ndings may be biased due to the lack of a control group. No signicant adverse effects were reported. An additional open-label trial that had positive ndings was reported in abstract form (14) but is not included in this review because the original German article was not retrievable. Although properly prepared homeopathic products are considered to be relatively safe, a few reports document that the chronic use of homeopathic remedies containing mercury, iron, or arsenic has caused exacerbation of AD. (11)

Honey Mixture
Honey is purported to reduce inammation, promote healing, and stimulate tissue generation. It has been used in the treatment of respiratory, gastrointestinal, and skin diseases. A partially controlled single-blind study from Dubai assessed the effectiveness of a topical mixture containing honey, beeswax, and olive oil (1:1:1) in treating 21 children (ages 5 to 16 y) who had AD. (12) Children were divided into two groups based on topical corticosteroid use: Group A used topical corticosteroids (n 11); group B did not (n 10). The honey mixture
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Nutritional Supplements
Essential Fatty Acids
AD may be associated with an abnormal ability to process essential fatty acids (EFAs). EFAs belong to the class of fatty acids called polyunsaturated fatty acids (PUFAs). They generally are necessary for stimulating skin and hair growth, maintaining bone health, regulating metabolism, and maintaining reproductive capability. There are two kinds of essential fats: omega 3 (n-3) and omega 6 (n-6, ie, gamma-linolenic acid [GLA]). Sources rich in GLA include borage oil (23% GLA), black currant seed

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Summary of Studies Assessing Probiotic Effectiveness in the Treatment of Atopic Dermatitis in Children
Table 1.

Author

Design

Population

Intervention
9

Findings

Comments

Brouwer Double-blind 53 children (<5 mo) 3 10 CFU/d of: 2006 (20) RCT who had AD and Group A: suspected CMA Lactobacillus (Netherlands) rhamnosus Group B: LGG Group C: Placebo for 3 mo Folster-Holst Double-blind 54 infants (1 to Group A: 5 109 CFU LGG 2006 (21) RCT 55 mo) who had Group B: Placebo AD (England) twice daily for 2 mo

SCORAD and immunologic 6% dropout rate effects of improvements among groups not signicantly different (P values not given) No signicant difference in SCORAD between groups (P value not provided) High dropout rate (22%). Mild adverse effects reported: diarrhea (4 Group A, 4 Group B), nausea/vomiting (3 Group A, 4 Group B), fever (1 Group A, 1 Group B), urticaria (1 Group B) No comment on withdrawals, dropouts, or adverse effects

Isolauri 2000 Double-blind 27 infants (mean (22) RCT age: 4.6 mo) who had early-onset AD (Finland)

Group A: 3 108 CFU/g LGG Group B: 1 109 CFU/g Bidobacterium lactis Group C: Placebo EHF for 6 mo Kirjavainen Double-blind 35 infants (mean Group A: 1 109 2003 (23) RCT age: 5.5 mo) who CFU/g viable LGG had AD and Group B: 1 109 suspected CMA heat-killed LGG (Finland) Group C: Placebo EHF for 7.5 wk Majamaa and Double-blind 31 infants (2.5 to Group A: 5 108 Isolauri RCT 15.7 mo) who had CFU/g LGG 1997 AD (Finland) Group B: Placebo (Part 1) for 1 mo (24) Majamaa and Cohort study 11 nursing mothers 2 1010 CFU/g LGG Isolauri and their infants twice daily to 1997 (mean age: breastfeeding (Part 2) 4.4 mo) who had mothers for (24) AD (Finland) 1 mo Passeron Double-blind 48 children (mean Group A: Synbiotics 2006 RCT age: 5.85 y) who 1.2 109 CFU (25) had moderate-toL rhamnosus severe AD (France) prebiotic preparation Group B: Prebiotic preparation three times/d for 3 mo Weston 2005 Double-blind 56 infants (6 to 18 Group A: 1x109 CFU L fermentum (26) RCT mo) who had Group B: Placebo moderate-tomaltodextrin (1-g severe AD sachets in 5 to 10 (Australia) mL water) twice daily for 8 wk

At 2 mo, signicant difference in SCORAD improvement between Groups A and B compared with Group C (P 0.002); at 6 mo, all groups had the same SCORAD score (0) Signicantly greater Five children in Group B decrease in SCORAD in had diarrhea several Group A versus Group C days to weeks after (P 0.02) study start Signicant improvement in SCORAD for those in Group A, not Group B Signicantly decreased SCORAD after 1 mo of treatment (P 0.007) No signicant difference in SCORAD changes between groups (P 0.535) No between-group signicance test reported One dropout; no reason stated

19% dropout rate. Mild abdominal pain (2 Group A, 1 Group B)

No signicant difference in SCORAD improvement between groups (P 0.06)

No comment on withdrawals, dropouts, or adverse effects

(continued)
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Summary of Studies Assessing Probiotic Effectiveness in the Treatment of Atopic Dermatitis in Children (Contd)
Table 1.

Author Rosenfeldt 2003 (27)

Design

Population

Intervention
10

Findings

Comments

Sistek 2006 (28)

Viljanen 2005 (29)

Nonsignicant difference High dropout rate (26%) Double-blind 58 children (mean 1 10 CFU in SCORAD between crossover age: 5.1 y) who L rhamnosus and groups (P 0.09) RCT had AD (Denmark) L reuteri versus identical placebo twice daily for 6 wk (6-wk washout between treatments) Nonsignicant difference High dropout rate (21%) Double-blind 62 children who had Group A: 2 1010 in SCORAD between CFU/g L rhamnoRCT AD (New Zealand) groups (P 0.18) sus and B lactis Group B: Identical Signicant difference in placebo once daily SCORAD improvement for 12 wk between groups in food-sensitized children (P 0.01) 7% dropouts In all groups, mean Double-blind 230 infants (mean Group A: 5 109 SCORAD decreased by RCT age: 6.4 mo) CFU/g viable LGG 65%, but no signicant who had AD and Group B: Mixture differences among suspected CMA of 5 109 CFU/g treatment groups (Finland) viable LGG immediately or 4 wk 5 109 CFU/g after treatment viable LLC No treatment differences 2 108 CFU/g observed in infants who viable Bbi99 had CMA 2 109 CFU/g In IgE-sensitized infants, viable PJS group A showed a Group C: Placebo greater decrease in for 4 wk SCORAD than did the placebo group (P 0.014)

AD atopic dermatitis, Bbi99 Bidobacterium breve, CMA cow milk allergy, CFU colony-forming units, EHF extensively hydrolyzed formula, LGG Lactobacillus GG, LLC Lactobacillus rhamnosus LC705, PJS Propionibacterium freudenreichii subsp shermanii JS, RCT randomized controlled trial, SCORAD Severity Scoring of Atopic Dermatitis, synbiotics probiotics prebiotics formula.

(17% GLA), and evening primrose oil (EPO) (8% to 10% GLA). A primary source of omega-3 fatty acids is cold water sh such as salmon and sardines. (15) A meta-analysis published in 2004 of 22 placebocontrolled trials examined the potential of oral EFA to alleviate symptoms of AD. (15) Nineteen trials involved GLA (in borage oil, EPO, and black currant seed), and ve trials involved sh oil supplements (rich in n-3 EFAs) as the intervention (two studies involved both GLA and sh oils). The meta-analysis indicated a pooled effect size for GLA of 0.15 (95% CI 0.02, 0.32) from 11 trials. This nding corresponds to a 1.5 (95% CI 0.20, 3.3) reduction in the Costa score (a scale of AD severity) or a 5% decrease in severity, neither of which is considered to
e90 Pediatrics in Review Vol.28 No.12 December 2007

be clinically signicant. The effect of sh oil from three trials was even smaller at 0.01 (95% CI 0.27, 0.21). From these ndings, it appears that EFAs are not effective in the treatment of AD. However, small sample sizes in the pooled trial analysis may have prevented detection of any potential moderate effects of EFA supplementation. Furthermore, effectiveness in certain subgroups, such as young children who have severe AD, may be present. More evidence is required to substantiate or refute this conclusion. Adverse effects reported with the use of borage oil in children include abdominal cramps and gastroesophageal reux. (16) Adverse effects in adults included inuenza-like symptoms, headache, nausea, diarrhea,

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Summary of Studies Assessing Probiotic Effectiveness in the Prevention of Atopic Dermatitis in Children
Table 2.

Author

Design

Population

Intervention
10

Findings

Comments 17% dropout rate due to noncompliance (13 LGG, 14 placebo) No dropouts had AD before dropping out

Kalliomaki Double-blind 159 prenatal mothers Group A: 1x10 CFU/g Frequency of AD in Group A (23%) was 2001 RCT who had one rstLGG half that of Group B (30) degree relative (or Group B: Identical (46%) partner) who had placebo daily for 2 to AD (Finland) 4 wk (two capsules) 56% LGG and 57% placebo mothers chose to give treatment to child Signicantly fewer on Kalliomaki 4-y follow 107 children from Comparisons between LGG (14/53) developed 2003 up of RCT previous study placebo and LGG AD than did placebo (31) (Kalliomaki group in AD (25/54) (RR 0.57, 2001) (Finland) development by 95% CI 0.330.97) questionnaire, clinical Preventive effect examination of LGG extends beyond infancy Pessi Cohort study 9 children (mean 1 1010 CFU LGG twice Concentration of anti2000 age: 21 mo) who daily for 4 wk inammatory mediator (32) had AD (Finland) (interleukin-10) was signicantly different after treatment (P<0.001), thus substantiating the anti-inammatory properties of probiotics Rate of AD at 6 mo not Taylor Double-blind 231 pregnant women Group A: 3 109 signicantly different 2007 RCT who had diagnosed Lactobacillus between groups (33) allergic disease acidophilus (P 0.629) (Australia) Group B: Placebo (maltodextrin) daily At 1 y, still no signicant for rst 6 postnatal difference in rate mo (P 0.58) or severity (P 0.995)

No comments on withdrawals, dropouts, or adverse effects

Adverse effects not reported

AD atopic dermatitis, CI condence interval, CFU colony-forming units, LGG Lactobacillus GG, RCT randomized controlled trial, RR relative risk.

and vomiting. (17) Adverse effects from taking EPO are rare and include nausea, stomach pain, loose stool, headaches, and seizures. (18)

Probiotics
Probiotics are nonpathogenic microbes, usually of the lactic acid-producing variety, that are used to improve or normalize the balance of gut microora and are believed to have immune-regulating actions. (19) At least 10 RCTs have evaluated the use of probiotics as treatment for AD (Table 1); another 3 RCTs have evaluated probiotics for potential AD prophylaxis (Table 2). Both uses have contradictory ndings: 6 of the 10 treatment trials reported positive effects, and 2 of the 3 prophylaxis trials

reported positive ndings. Some studies involved mothers taking probiotics prenatally and postnatally while nursing. Some positive results reected primary outcomes; others represented secondary outcomes. Accordingly, study results should be interpreted cautiously. In healthy individuals, the use of probiotics generally is safe. However, in severely debilitated and immunocompromised children, there have been case reports of aggravation of existing symptoms, pneumonia, septicemia, and meningitis. The safest sources of probiotic bacteria in the diet are fermented foods, such as buttermilk, yogurt, ker, and sauerkraut. Higher doses are found in supplemental probiotic forms. When administered in appropriate doses, Lactobacillus acidophilus,
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Summary of Mind-Body Therapies Used to Treat Atopic Dermatitis Symptoms in Children

Table 3.

Author Sokel 1993 (36)

Design Cross-over study

Population 44 children (UK)

Intervention

Findings

Comments

Stewart and Thomas Observational 20 children 1995 (38) study (ages 2 to 15 y) (UK)

Ehlers 1995 (39)

RCT

113 patients (ages 17 to 52 y) (Germany)

Comparison of hypnotherapy Lichenication and surface 30% dropouts, but reasons damage was signicantly (relaxation-focused, were not reduced in the reducing itching), provided biofeedback and biofeedback (relaxation No blinding hypnotherapy groups with no direct imagery), No adverse effects compared with the and discussion only reported discussion group (discussion of AD but not Girls in the hypnotherapy of symptoms) group obtained the best results No controls Based on subjective Children listened to a measures, 19 children magic music tape showed immediate AD involving relaxation and improvement (itching hypnotherapy techniques and scratching), which every night for up to was maintained at the 6 mo. Questionnaires follow-up clinics assessing change in itching, scratching, sleep 18 mo after treatment, 10 children had disturbance, and mood maintained AD were completed by improvements children or parents at weeks 4, 8, 16, and 26 At 1 y, follow-up Compared autogenic psychological treatments relaxation therapy (AT) (AT, BT, and DEBT) led with three therapies: a to signicantly larger cognitive behavioral improvement in skin treatment (BT), a standard lesions (as assessed by dermatologic educational a dermatologist) than program (DEP), and did intensive (DEP) combined DEP and BT or standard (SMT) (DEBT) dermatologic treatment All therapies were compared Signicant reduction in with standard medical use of topical steroids in treatment (SMT) DEBT patients (P<0.05) Intervention lasted for 3 mo, and patients were followed for a year

AD atopic dermatitis, RCT randomized controlled trial, UK United Kingdom.

Lactobacillus GG, and Saccharomyces sp appear to be safe for use in children (19).

Biomechanical Therapies: Massage Therapy

Massage therapy may affect dermal blood ow, provide a mechanism for emollient delivery, and offer social support. (34) A United States RCT assessed the efcacy of massage therapy on AD in 20 children who received either standard care (emollients and topical corticosteroids) or standard care plus daily 20-minute massages administered by trained parents for a 1-month period. (35) Mood, activity levels, and all measures of skin cone92 Pediatrics in Review Vol.28 No.12 December 2007

ditions (redness, lichenication, excoriation, pruritus) improved (P 0.05) in children in the massage group. Furthermore, parental anxiety levels were reduced and parental ability to cope with their childs illness increased. An 8-week UK single-case, experimental design, across-subject study examined whether massage with or without essential oils (EOs) was benecial in treating AD in 16 children (ages 3 to 7 y). (34) The control group received counseling and massage therapy only. The treatment group was given counseling and a weekly massage from a therapist using a mixture of preferred EOs (sweet marjoram, frankincense, German chamomile, myrrh,

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thyme, benzoin, spike lavender, and Litsea cubeba) chosen by the mother. Using daytime irritation and night disturbance scores as measures, AD improved in both groups, but a potential benet of EOs was not observed. Of concern, the AD of the children who were exposed to two additional 8-week periods of therapy with EOs worsened, even compared with baseline. From both studies, it appears that short-term massage therapy without EO may be effective, but long-term effects are not understood. The topical use of some pure EOs is known to cause allergic AD (tea tree oil) or photosensitization (verbena). (15) Although massage is believed to carry a low risk of complications, larger studies that have longer observation times are needed to gauge its long-term effects on AD.

Mind-Body Therapies (MBT)

Stress worsens itching, a common symptom of AD, often resulting in persistent scratching and impaired sleep. MBT, such as hypnosis or biofeedback, may help promote relaxation, thereby assisting in the management of AD. (36) Children between the ages of 7 and 12 years are reported to be the best subjects for hypnosis. (37) We identied three studies that have investigated the efcacy of MBT in treating pediatric cases of AD, all of which reported MBT to be effective in reducing AD symptoms (Table 3). No adverse effects were reported. MBT may enhance existing treatments by reducing itching, scratching, and subsequent skin damage.

Conclusion
Preliminary evidence from small RCTs suggests that the use of TCM herbs, massage, and MBT may be benecial in treating pediatric AD. Potential contamination of herbs from China is a cause for concern. Although many studies have investigated probiotics and EFAs, the ndings are conicting. Before routine use can be recommended, more denitive research into the safety, efcacy, and cost-effectiveness of these CAM therapies is needed. Given their favorable safety prole, the use of MBT may be considered as adjuvant therapy.

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Complementary, Holistic, and Integrative Medicine: Atopic Dermatitis Cecilia Bukutu, Janjeevan Deol, Larissa Shamseer and Sunita Vohra Pediatr. Rev. 2007;28;e87-e94 DOI: 10.1542/pir.28-12-e87

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