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Complementary therapies for the treatment of eczema

Edzard Ernst
MD PhD FRCP(Edin)
Professor
Complementary Medicine
Peninsula Medical School
Universities of Exeter and Plymouth
Exeter
E:Edzard.Ernst@pms.ac.uk

Eczema, or atopic dermatitis, is one of the most common inflammatory skin conditions. Its main manifestations are irritation, pruritus, erythema, scaling and thickening of the skin. As with most chronic conditions that significantly reduce wellbeing and quality of life, complementary therapies are extremely popular for eczema. A survey of German eczema patients reported homeopathy, acupuncture, dietary therapy, autogenic training and relaxation as the most frequently used forms of complementary/alternative medicine.(1) Many other forms of complementary medicines are also in use, and there are significant national differences, both in the prevalence of use and the type of therapies.
Given the present popularity of complementary medicine, it is pertinent to ask: what is the evidence is for or against these treatments, are they safe and effective? This article attempts to address these questions in a systematic way; it is largely based on a recent review of the evidence in complementary medicine in a wider context (for methodological details, see that review).(2)

Homeopathy
Homeopathy is a therapeutic method using (often highly diluted) preparations of substances whose effects, when administered to healthy subjects, correspond to the manifestations of the disorder in the unwell patient.(2) Intriguingly, there are no controlled clinical trials of homeopathy as a treatment for eczema,(3) even though homeopathy is (in Germany) the most popular complementary treatment for this condition.(1) This exemplifies the often stunning discrepancy between usage of and evidence for complementary therapies. In turn, this suggests that research into this sector is underdeveloped and urgently requires improving and intensifying.
As most homeopathic remedies are highly diluted, there are few safety concerns associated with it.(2)

Acupuncture
Acupuncture is the insertion of a needle into the skin and underlying tissues at special sites, known as points, for therapeutic or preventive purposes.(2) Again, no controlled clinical trials have tested the effectiveness of acupuncture for eczema - despite its popularity.(1)
Acupuncture has repeatedly been associated with severe adverse effects (eg, pneumothorax or infections).(4) A recent, large prospective study, however, showed that such complications are extreme rarities and that acupuncture, in the hands of well-trained professionals, is a very safe intervention.(5)

Diet
Several randomised clinical trials (RCTs) have investigated egg and cow's milk exclusion diets and their effects on eczema.(6-9) Some showed positive results,(3,6) including one on the effect of maternal antigen avoidance on breastfed infants.(9) RCTs on the prevention of eczema in high-risk infants by maternal antigen avoidance during pregnancy(7-10) and lactation(10) have been systematically reviewed. Based on only three trials each, it was concluded that the risk of the child developing eczema was likely to be reduced by exclusion diets during lactation, but not during pregnancy.

Autogenic training
Autogenic training (AT) refers to a particular technique of mental exercises involving relaxation and autosuggestion practised regularly, which aims to teach individuals to recognise the origin of certain mental and physical disorders within themselves, and to use that awareness for the self-treatment of those disturbances.(2)
In one study, 113 eczema patients were randomised to once-weekly AT or to cognitive behavioural therapy, or to a dermatological education programme.(11) Results at one-year follow-up showed that both psychological approaches yielded similar results in terms of skin condition and concomitant usage of topical steroids, and both were more successful than the educational programme.

Relaxation/hypnotherapy
There have been no controlled trials of relaxation therapy for eczema. An RCT with 31 children suffering from eczema compared the effects of hypnotherapy (four sessions over eight weeks) with biofeedback and an attention control condition where children discussed their eczema and kept a symptom diary.(12) After five months the hypnotherapy and biofeedback groups had improved significantly more than the control group with regards to severity of eczema, but not area of coverage.

Plant-based medicines
Two RCTs of borage (Borago officinalis) seed oil involving adult patients have produced conflicting results (see Table 1). A smaller crossover trial in 24 children with eczema using g-linolenic acid from borage seeds reported a strong placebo response and no difference between the interventions.(15)

[[NIP11_table1_29]]

A meta-analysis of nine placebo-controlled trials of oil of evening primrose (Oenothera biennis) demonstrated a significant positive effect.(16) However, the results of subsequent RCTs did not support this result, and recently evening primrose oil has been judged as not effective for eczema by the UK Medicines Control Agency.
A systematic review of Chinese herbs included only two RCTs from the same researchers, who reported positive results for a herbal combination in both adults and children.(17) A subsequent independent crossover RCT of the same preparation found it to be no different from placebo.(18)
An uncontrolled study showed that 63% of patients with recalcitrant atopic dermatitis who drank one litre of oolong tea daily seemed to be helped by it. The clinical improvement was first noticeable after one to two weeks and was still present six months later. The authors speculated that the positive effect was due to the antiallergic properties of tea polyphenols.(19)
None of the above plant-based medicines has been associated with significant adverse effects.

Autologous blood therapy
This therapy is widespread on the European continent. It involves drawing a patient's venous blood and reinjecting it intramuscularly following a particular dosage schedule. Thirty-one eczema patients were randomised to receive either autologous blood therapy or placebo once weekly for five weeks. After this treatment period the severity of the skin lesions had significantly decreased in the autologous blood therapy group compared with the placebo group.(20)
These promising yet preliminary results require replication in a larger trial before firm recommendations can be issued.

Comment
There is no convincing evidence for the effectiveness of any complementary therapy in treating or preventing eczema and no signs that conventional treatments can be matched. The therapies with the most promising evidence are those with a psychological component: autogenic training, biofeedback and hypnotherapy. These are relatively risk-free and may be worth considering as an adjunctive treatment.

References

  1. Augustin M, Zschocke I, Buhrke U. Attitudes and prior experience with respect to alternative medicine among dermatological patients. The Freiburg Questionnaire on Attitudes to Naturopathy (FAN). Forsch Komplementärmed 1999;6 Suppl:26-9.
  2. Ernst E, Pittler MH, Stevinson C, et al. The desktop guide to complementary and alternative medicine. Edinburgh: Mosby; 2001.
  3. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997;350:834-43.
  4. Ernst E, White A. Life-threatening adverse reactions after acupuncture? A systematic review. Pain 1997;71:123-6.
  5. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32000 consultations with doctors and physiotherapists. BMJ 2001;323:485-6.
  6. Lever R, MacDonald CWP, Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Allergy Immunol 1998;9:13-9.
  7. Atherton DJ, Sewall M, Soothill JF, et al. A double-blind controlled cross-over trial of an antigen-avoidance diet in atopic eczema. Lancet 1978;25:401-3.
  8. Neild VS, Marsden RA, Bailes JA, Bland JM. Egg and milk exclusion diets in atopic eczema. Br J Dermatol 1986;114:117-23.
  9. Cant AJ, Bailes JA, Marsden RA, Hewitt D. Effect of maternal dietary exclusion on breast fed infants with eczema: two controlled studies. Br Med J Clin Res Ed 1986;293:231-3.
  10. Kramer MS. Maternal antigen avoidance during lactation for preventing atopic disease in infants of women at high risk (Cochrane review). The Cochrane Library. Issue 4. Oxford: Update Software; 2002.
  11. Ehlers A, Strangier U, Gieler U. Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to relapse prevention. J Consult Clin Psychol 1995;63:624-35.
  12. Sokel B, Christie D, Kent A, et al. A comparison of hypnotherapy and biofeedback in the treatment of childhood atopic eczema. Contemp Hypnosis 1993;10:145-54.
  13. Buslau M, Thaci D. Atopische dermatitis: Borretschol zur systemischen therapie. Z Dermatol 1996;182:131-6.
  14. Henz BM, Jablonska S, Van de Kerkhof PCM, et al. Double-blind, multicentre analysis of the efficacy of borage oil in patients with atopic eczema. Br J Dermatol 1999;140:685-8.
  15. Borreck S, Hildebrandt A, Forster J. Borage seed oil and atopic dermatitis. Klin Paediatr 1997;209:100-4.
  16. Morse PF, Horrobin DF, Manku MS, et al. Meta-analysis of placebo-controlled studies of the efficacy of Epogam in the treatment of atopic eczema. Relationship between plasma essential fatty acid changes and responses. Br J Dermatol 1989;121:75-90.
  17. Armstrong NC, Ernst E. The treatment of eczema with Chinese herbs. A systematic review of randomized clinical trials. Br J Clin Pharmacol 1999;48:262-4.
  18. Fung AY, Look PC, Chong LY, But PP, Wong E. A controlled trial of traditional Chinese herbal medicine in Chinese patients with recalcitrant atopic dermatitis. Int J Dermatol 1999;38:387-92.
  19. Uehara M, Sugiura H, Sakurai K. A trial of Oolong tea in the management of recalcitrant atopic dermatitis. Arch Dermatol 2001;137:42-3.
  20. Pittler MH, Armstrong NC, Cox A, et al. Randomised, double-blind, placebo-controlled trial of autologous blood therapy for atopic dermatitis. Br J Dermatol In press 2003.