Integrative Medicine for Atopic Dermatitis: Q&A With Vivian Shi, MD, Part 1

The Dermatologist spoke with Vivian Shi, MD, assistant professor of dermatology in the Department of Medicine at the University of Arizona and Banner University Medical Center and director of the Eczema and Skin Barrier Clinic and Follicular Disorder Clinic in Tucson, Arizona, about skin care and the use of integrative medicine for patients with AD. Dr Shi has extensive clinical and research experience in AD, and the repair of the skin’s natural protective barrier. She presented on complementary and alternative treatments in AD on June 23 at the Eczema Expo 2018, hosted by the National Eczema Association.

Q. What nonpharmacological treatment options do you recommend for patients with AD and why?

A. Nonpharmacological means any treatment that I do not need to write a prescription for and I typically maximize these options before I write on my prescription pad. Holistic treatment without a prescription is a big portion of the work, in my opinion, of AD treatment and that includes a good bathing and moisturizing regimen, along with lifestyle modifications.

Often, when people are thinking about nonpharmacologic treatments they are really thinking about what kind of alternative things can they do other than using moisturizers. What I recommend the most to my patients is using natural oils with potent antimicrobial and anti-inflammatory properties, such as coconut and sunflower seed oil, in addition to their daily moisturizers. Coconut oil has antimicrobial properties and has been shown to decrease the bacteria that flares AD, Staphylococcus aureus. Sunflower seed oil can decrease inflammation. I ask patients to avoid using products that are irritating even though some are natural oils, such as olive oil and essential oils. Studies have shown that olive oil contains irritating fatty acids, such as oleic acid, that can worsen the skin barrier and AD. Essentials oils are often extracted through steam-distillation of the aromatic parts of the plants such as flowers and leaves, which require adding heat and chemicals. This process may create irritating compounds that may flare AD.

If patients have AD in a more diffuse area, I recommend bleach baths. Previously, we thought bleach baths improved AD by decreasing the surface bacteria colonization. However, we recently found evidence showing that bleach baths are more than just antimicrobial. In a review paper I recently published with Melody Maarouf, MHS, current evidence suggest that bleach baths have direct anti-inflammatory affects and modulate the neurosensory transmission to decrease itch.¹

Usually, I ask my patients to take daily vitamin D supplementation. While there is some conflicting evidence, the majority of data shows that vitamin D is helpful for AD and some studies have shown that not enough vitamin D in the blood is associated with more severe disease.

Additionally, acupuncture and acupressure has been shown to be effective for decreasing itch in AD. Acupuncture has been done in Eastern medicine for centuries. Essentially, the body has meridians that help calm neurosensory transmission and inflammation. It has been shown that certain acupoints can help relieve itch in patients with AD and decrease hives in AD-prone patients, and it is generally safe. If patients are afraid of the acupuncture needles, they can do acupressure, which involves either a tiny titanium bead device or massage to the acupoint. A paper published by Lee and colleagues² examined the use of acupuncture to treat itch and AD. The study showed that performing acupuncture on the large intestine 11, which is 1 of the acupressure points, decreased itching and hives compared to a sham acupuncture treatment. Additionally, it has been shown that acupuncture combined with cetirizine, a non-drowsy antihistamine, can decrease itch in AD patients compared to placebo or no treatment alone.

I recommend acupuncture for patients who are interested, but especially to patients who are refractory to other treatment options. For example, they have maximized their pharmacologic treatment options, or they do not want to go to the next step of their immunosuppressive, or they do not want an injection. For patients like this, I start talking about acupuncture because it is really helpful with itch.

Q. How do you discuss skin care with patients?

A. Often, when patients come in, they will either prefer Western, conventional medicine alone at first, or want to avoid Western medicine and start with alternative medicine first. As a “Western Medicine”-trained, board-certified dermatologist who practices integrative medicine, I often start by exploring where the patient and their family stand in their healthcare beliefs. I do not impose my beliefs onto them, but instead, work closely with them to design a mutual treatment plan that works for both sides. This is called shared-decision making, which fosters open, and honest communication between the physician, patients and their families. Shared-decision making has been shown to improve clinical outcomes.

I discuss with my patients the best way to use a home-based AD regimen, and how we can incorporate a prescription medicine. We select a regimen that will actually work for them and their families. Some of my patients have heard or read that bathing is bad for AD and they haven’t bathed themselves or their child for a whole week, which is not the thing to do. Typically, I ask my patients to shower or bath once a day for a short period of time, about 10 minutes with lukewarm water not hot water, and to gently pad dry, then apply a moisturizer right away. Bathing gets rid of the dirt, sweat and irritants that are coating the skin, which can worsen AD, and it also washes away the natural oil that normally functions to protect our skin. I ask that my patients choose a gentle, non-fragranced soap, and only use it on select areas such as the face, armpits or private areas. Patients do not need to use soap all over the body because soap itself is a compound that can worsen AD and strip the natural oil and protection of the skin.

I have patients choose a moisturizer for sensitive skin with ceramide, which is the fat that is naturally lacking in the skin of individuals with AD. There are now bioactive lipids called endocannabinoids that act on cannabinoid receptors in the skin to decrease inflammation and itch, which are good compounds for AD skin. An example of a topical endocannabinoid that has been shown to be helpful in AD is palmitoylethanolamide (PEA).

Reference

1. Maarouf M, Shi VY. Bleach for atopic dermatitis: beyond antimicrobials [published online before print April 3, 2018]. Dermatitis. doi:10.1097/DER.0000000000000358.

2. Lee KC, Keyes A, Hensley JR, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunt Med. 2012;30(1):8-11. doi:10.1136/acupmed-2011-010088.