Integrative Dermatology Addresses Unmet Need

NEW YORK, NY — Integrative care, a combination of conventional and complementary therapies, should not be marginalized if the goal is patient satisfaction, according to a dermatologist who offers alternative therapies as substitutes or adjuncts for patients with skin diseases. 

Clinicians antagonistic to integrative care are overlooking conventional evidence of benefit, including randomized trials, but more importantly, they are ignoring what many patients consider an unmet need, according to Peter Lio, MD, clinical assistant professor of dermatology and pediatrics, Northwestern University, Chicago, Illinois.

“Even if you think it is a bunch of bunk or hokum, the patients do not. Our patients are interested, so I do think it does pay to learn a little bit about it,” Lio said at the 27th Annual Winter Symposium – Advances in Medical and Surgical Dermatology (MSWS) 2024.

Surveys suggest that approximately 50% of patients with dermatologic diseases seek alternative medicines, whether first-line or in addition to conventional therapies, according to Lio, who cofounded the Chicago Integrative Eczema Center. He speculated that one reason is many chronic skin diseases are not completely controlled or cured with regulatory approved therapies, leaving a gap that sometimes alternative therapies can fill.

But he also said patients are drawn to the simpler and more digestible explanations for how alternative therapies may provide benefit.

“It can be difficult to compete against an alternative practitioner who says this is all in your gut or this comes from this particular food or this particular energy imbalance,” Lio said. Patients find reassurance in therapies that offer to “rebalance” or “tonify” a natural process that has gone awry relative to treatments that halt complex molecular processes they do not understand.

In his practice, Lio explains to patients that conventional medicines are often the best choice for a given dermatologic condition, but he said he is empathetic to patients who have an aversion to drugs such as steroids that are accompanied by annoying or potentially serious side effects.

For those patients very reluctant to take drugs with boxed warnings, such as many of the most potent anti-inflammatory drugs, he tries to address their concerns, and when possible, meet them halfway by using alternatives first and adding conventional treatments if needed or combining conventional and alternative therapies from the start.

Rather than avoiding effective conventional therapies, “my goal is to integrate conventional with some of the unconventional treatments together in a coordinated way,” he explained. He makes this goal clear to patients so that they can seek care elsewhere if they will not consider conventional therapies when alternative treatments are not adequate.

He also often uses the language common to alternative therapies to make conventional therapies more palatable. Moisturizers are an example. 

“I talk about moisturizers a lot. We all do, but I might use language like, ‘This will help strengthen your skin,'” he said. “It is not any kind of deception. It is just a reframing of how we think about it.”

But in offering alternative therapies, Lio does not rely on folk cures or strategies being circulated in the corners of the internet. He does employ standards.

“They have to have some clinical evidence. We have to have some sense that it is safe, and it has to be practical because our goal is to build a toolbox so that we can use these things,” he said. 

Lio acknowledged that the alternative options “are often not as good as we have with a true FDA [US Food and Drug Administration] -approved medication,” but he pushed back at claims that the therapies he offers are not backed by evidence.

“There is actually a lot of evidence,” he said. While the evidence might not involve thousands of patients in double-blind trials, much of it is controlled and in the context of benefit and adequate safety, Lio feels that a patient who wants to try an alternative treatment first or in addition to a conventional treatment can be accommodated.

Lio had many examples of evidence-backed alternatives. For dermatitis, he considers coconut oil, which he said has antimicrobial effects and has been shown to modify symptomatic dermatitis. In one controlled study, coconut oil was significantly more effective than mineral oil in lowering the Scoring Atopic Dermatitis (SCORAD) score, he said.

“I don’t think this is going to replace a biologic agent or a JAK [Janus kinase] inhibitor, but I often use coconut oil as an adjunctive topical,” Lio commented

Topical vitamin B12 is another example. Although Lio is excited about the numerous emerging nonsteroidal agents for inflammatory skin diseases, he said the anti-inflammatory effect and safety of topical vitamin B12 is supported by clinical evidence and it provides an option for those who want to avoid or employ newer agents in low doses. It might also be an option for children not eligible for a prescription drug. 

The list goes on, including indigo naturalis for mild psoriasis and black tea compresses for refractory uremic pruritus, according to Lio. 

And the list is also growing. Lio expressed particular interest in early studies with onion juice, a botanical with anti-inflammatory effects of sufficient degree that a company in Europe is pursuing studies to support a regulatory indication for skin disease.

“The FDA now has a botanical pathway. Only a few drugs are approved in that way, but these are coming,” Lio said. “I would love to see more of these botanicals approved.”

Lio emphasized that “modern medicine is incredible with so many breakthroughs, so many new ideas,” but also noted that adequate control is not achieved in every patient. While he acknowledged that not all patients want to pursue alternative therapies, he thinks they can be a big help for those open to this approach who are not achieving their goals with conventional medications alone.

Saakshi Khattri, MD, associate professor of dermatology and director of the Center for Connective Tissue Diseases at the Icahn School of Medicine at Mount Sinai, New York City, understands why many physicians do not want to get involved with alternative therapies. For many reasons, particularly lack of funding, alternative therapies seldom have the same level of evidence as drugs that go through the regulatory approval process.

However, she is not opposed to alternative therapies, particularly as adjuncts to approved therapies.

“I trained in India where alternative medicine is very well-accepted,” Khattri said. For the same reasons Lio cited, she agreed that clinicians should not dismiss patient preferences to incorporate these treatments into care. For some, adjunctive alternative treatments can be reassuring, which has its own value for patient satisfaction, a goal she thinks should not be overlooked.

Lio has reported no relevant financial relationships.Khattri has reported financial relationships with AbbVie, Arcutis, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Leo, MSD, Novartis, Pfizer, Regeneron, Sanofi, Takeda, and UCB. 

Ted Bosworth is a medical journalist based in New York City.