Professional Documents
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Handbook of Inter Derm
Handbook of Inter Derm
Handbook of
Integrative
Dermatology
An Evidence-Based
Approach
123
Handbook of Integrative
Dermatology
Peter A. Lio Toral Patel
Neill T. Peters Sarah Kasprowicz
Handbook
of Integrative
Dermatology
An Evidence-Based Approach
Peter A. Lio, M.D. Toral Patel, M.D., M.S.
Assistant Professor of Clinical Instructor of Clinical
Dermatology & Pediatrics Dermatology
Northwestern University Northwestern University
Feinberg School of Medicine Feinberg School of Medicine
Chicago, IL, USA Chicago, IL, USA
Medical Dermatology D&A Dermatology
Associates of Chicago Chicago, IL, USA
Chicago, IL, USA
Sarah Kasprowicz, M.D.
Neill T. Peters, M.D. NorthShore University
Instructor of Clinical HealthSystem
Dermatology Clinical Assistant Professor
Northwestern University University of Chicago, Pritzker
Feinberg School of Medicine School of Medicine
Chicago, IL, USA Chicago, IL, USA
Medical Dermatology
Associates of Chicago
Chicago, IL, USA
To Neil, Alisha, Dilan, Mom, Dad, and Nilay: thank you for
your unwavering love and support.
T.P.
The fact that you are reading this means that you have at
least some interest in integrative, alternative, or complemen-
tary medicine. But why should you? Isnt it true thatpractically
by definitionthis approach to medicine is not evidence-based?
And, as rational and responsible healthcare practitioners,
isnt it our charge to focus on the evidence when treating
patients? Importantly, couldnt it even be dangerous to learn
about and discuss these treatments, since it could be per-
ceived as an endorsement of unaccepted therapies? We think
that the simple answer to all three questions is yes, but that
the real answer is far more complex. And, as difficult as it
may seem to reconcile these ideas, we feel that there are
several compelling reasons to read this book:
The first is that, like it or not, many of our patients are
interested in, using, or asking about alternative and comple-
mentary medicine. Indeed, the National Institutes of Healths
National Center for Complementary and Alternative
Medicine notes: many Americans, nearly 40%, use health
care approaches developed outside of mainstream Western,
or conventional medicine for specific conditions of overall
well-being (http://nccam.nih.gov/health/whatiscam). Part of
being informed and able to connect with ones patients
depends on understanding at least a little bit about this area,
since so many people are talking about it. If for no other rea-
son than to learn a little bit about some of these alternatives,
we feel that this book is necessary.
vii
viii Preface
References
http://nccam.nih.gov/health/whatiscam. Accessed 25 Mar 2014.
Spivack BS, Celsus AC. Roman medicus. J Hist Med Allied Sci.
1991;46:14357.
Contents
xi
xii Contents
Niacinamide.................................................................... 25
Evidence for Niacinomide ........................................ 26
Polyphenols .................................................................... 27
Evidence for Polyphenols ......................................... 27
Carotenoids .................................................................... 28
Evidence for carotene ............................................ 29
Polypodium Leucotomos .............................................. 30
Evidence for Polypodium Leucotomos .................. 31
Case 1 .............................................................................. 32
Case 2 .............................................................................. 33
References ...................................................................... 33
4 Skin Cancer .................................................................... 35
Introduction.................................................................... 35
Clinical Considerations ................................................. 36
Top Considerations ....................................................... 38
Ingenol Mebutate .......................................................... 39
Evidence for Ingenol Mebutate ............................... 40
Solasodine Glycosides (BEC) ...................................... 40
Evidence for Solasodine Glycosides (BEC) .......... 41
Vitamin D ....................................................................... 42
Evidence for Vitamin D ............................................ 43
Coenzyme Q10 ............................................................... 43
Evidence for CoQ10.................................................. 44
Escharotics...................................................................... 45
Evidence Against Escharotics .................................. 46
Gossypin ......................................................................... 47
Case 1 .............................................................................. 47
Case 2 .............................................................................. 48
References ...................................................................... 48
5 Acne ................................................................................ 53
Introduction.................................................................... 53
Clinical Considerations ................................................. 54
Top Considerations ....................................................... 56
Secondary Considerations ............................................ 56
Vitamin C ....................................................................... 57
Evidence for Topical Vitamin C............................... 57
Topical Nicotinamide .................................................... 58
Evidence for Topical Nicotinamide ......................... 59
Contents xiii
Cantharidin................................................................... 171
Evidence for Cantharidin ....................................... 171
Lemon Myrtle Solution (Backhousia citriodora) .... 171
Evidence for Lemon Myrtle Solution
(Backhousia citriodora) .......................................... 172
Tea Tree Oil (Melaleuca alternifolia)
and Iodine Preparation ............................................... 172
Evidence for Tea Tree Oil (Melaleuca
alternifolia) and Iodine Preparation...................... 172
Case 1 ............................................................................ 173
Case 2 ............................................................................ 174
References .................................................................... 174
13 Fungal and Bacterial Infections ................................. 177
Introduction to Fungi .................................................. 177
Clinical Considerations for Fungi.............................. 178
Top Considerations for Fungal Infections ................ 179
Topical Tea Tree Oil .................................................... 179
Evidence for Topical Tea Tree Oil ......................... 180
Secondary Considerations .......................................... 181
Coriander Oil ............................................................... 181
Evidence for Coriander Oil.................................... 181
Oil of Bitter Orange .................................................... 182
Evidence for Oil of Bitter Orange ........................ 182
Solanum chrysotrichum .............................................. 183
Evidence for Solanum chrysotrichum ................... 183
Garlic............................................................................. 185
Evidence for Garlic ................................................. 185
Ageratina pichinchensis .............................................. 186
Evidence for Ageratina pichinchensis .................. 186
Introduction to Bacteria ............................................. 187
Top Considerations for Bacterial Infections ............ 188
Tea Tree Oil .................................................................. 188
Evidence for Tea Tree Oil ....................................... 189
Honey ............................................................................ 189
Evidence for Honey ................................................ 190
Case 1 ............................................................................ 191
Case 2 ............................................................................ 191
References .................................................................... 192
xviii Contents
References
Jensen P. Use of alternative medicine by patients with atopic derma-
titis and psoriasis. Acta Derm Venereol. 1990;70(5):4214.
Introduction
Patients often inquire about what natural products they
might introduce into their routine to promote healthy skin
and prevent sun damage. While photoprotection through the
use of broad-spectrum sunscreen remains a mainstay of anti-
aging and preventive regimens, there are numerous botanical
agents and dietary supplements that claim to be effective
against aging skin and UV-induced damage. Many of these
claims are not substantiated by well-designed studies.
However, a few agents have been studied in small trials which
show some efficacy and are worth considering.
Common complaints from patients inquiring about anti-
aging skincare include lentigines (sun spots), uneven pig-
mentation, fine lines and wrinkles (rhytides), textural changes,
and increased laxity. Chronic, unprotected sun exposure leads
to these changes, which are collectively known as dermatohe-
liosis, or photoaging, This process occurs when ultraviolet
radiation triggers a cascade of signal transduction that ulti-
mately results in increased expression of matrix metallopro-
teinases, enzymes that degrade types I and III collagen in the
dermis. Dermal vasculature is directly injured by UV radia-
tion and indirect DNA damage occurs via the generation of
reactive oxygen species (ROS). While UVA rays are thought
Top Considerations
See Table 2.1.
Green Tea
Green tea is rich in plant polyphenols, compounds that
exhibit strong antioxidant, anti-inflammatory and immuno-
modulatory properties (Elmets et al. 2001; Katiyar et al.
2000). The primary antioxidants in green tea are epigallocat-
echin gallate (EGCG) and epicatechin gallate (ECG). The
Flavonoids
Flavonoids are secondary plant metabolites, found in many
fruits and vegetables as well as in red wine, tea and cocoa
(Heinrich et al. 2006). These compounds have been shown to
demonstrate anti-oxidant and anti-inflammatory effects
in vitro and as such have been investigated for their potential
benefits in cutaneous aging and repair of ultraviolet damage.
There are no large randomized controlled trials focusing on
the cutaneous effects of oral flavonoid consumption, and
there are no definitive recommendations on the doses of fla-
vonoids needed to achieve clinically significant improvement
in the skin. In the two studies listed below, the amount of
flavanols (a particular class of flavonoids) consumed by the
subjects was 100 g (3.5 oz) daily; this is approximately the
weight of a standard chocolate bar. Since dark chocolate con-
tains more cocoa than milk chocolate, dark chocolate is richer
Flavonoids 11
Vitamin C
Vitamin C is the most abundant water-soluble antioxidant in
human skin; it cannot be synthesized by the body and must be
obtained through oral or topical administration. Oral vitamin
C consumption does not significantly increase cutaneous con-
centration, so topical formulations of vitamin C have been
extensively studied for their role in treating photodamage
and cutaneous aging. In one split face study, improvement in
dyspigmentation, rhytides and skin texture was noted on side
of the face treated with vitamin C (Xu et al. 2012). The active
form of vitamin C, l-ascorbic acid, is very difficult to formu-
late as it easily oxidizes and becomes unstable in solution.
Vitamin C esters have been created that may be more stable.
Nevertheless, vitamin-C containing products should be care-
fully selected before use to ensure that they contain a stabi-
lized vehicle with an effective concentration and optimal pH
(Farris 2005).
Carotenoids
Carotenoids are pigments found in plants that protect them
from photooxidative stress. Beta-carotene and lycopene are
among the most abundant carotenoids found in human tissue,
and have been studied for their potential benefits in cutaneous
photoprotection and aging. Beta-carotene imparts the orange
color to fruits and vegetables such as carrots, cantaloupes and
mangoes. While the majority of lycopene consumption in the
United States is from tomatoes, this compound is also found in
other fruits such as watermelon and papaya. Beta-carotene can
either be converted to vitamin A after being ingested, or can be
used by cells as an antioxidant to combat free-radical induced
damage. Lycopene cannot be converted to vitamin A. Excessive
consumption of carotenoid-rich foods can lead to orange/yellow
discoloration of the skin known as carotenemia; this condition is
harmless but can be mistaken for jaundice, and can be cosmeti-
cally unappealing to the patient. Patients should be counseled to
consume these foods in moderation (Sale and Stratman 2004).
Soy
Soybeans, rich in protein and touted for their many potential
health benefits, are being increasingly studies for their use in
many diseases.
Soy 15
Licorice
Licorice root (glycyrrhiza glabra) has been shown to inhibit
tyrosinase (a rate limiting enzyme that controls the produc-
tion of melanin) and also possesses anti-oxidant and anti-
inflammatory properties (Adhikari et al. 2008). Licorice root
contains extracts known to affect melanin production: gla-
bridin has been found to be the constituent with the most
potent inhibitory effect on tyrosinase (Kim and Uyama
2005). Licorice extract is found in many over-the-counter skin
lightening preparations in varying concentrations, often com-
bined with other ingredients for a synergistic effect.
Niacinamide
Niacinamide is a form of vitamin B3. It has been shown
in vitro to inhibit the transfer of melanocytes to keratinocytes
(Hakozaki et al. 2002), and therefore has been studied for its
effect of cutaneous hyperpigmentation. Niacinamide also
functions as an anti-oxidant (Otte et al. 2005).
Case 1
A 39 year-old female comes to your office for a cosmetic
consultation. As she approaches her 40th birthday, she is
noticing more sun spots (lentigines), redness and overall dull-
ness of her complexion. She is worried that she looks tired
all the time and would like to establish an anti-aging skincare
regimen. She is confused by the plethora of over-the-counter
products and botanical ingredients and asks for your opinion
on effective products.
References 19
Discussion
This patient may benefit from a morning moisturizer contain-
ing soy extracts to aid with hyperpigmentation. Her evening
regimen could include a serum containing green tea polyphe-
nols, along with a niacinamide cream, to reduce erythema and
dyspigmentation. The patient should also be advised to incor-
porate foods rich in flavonoids (such as dark chocolate) and
carotenoids (such as tomatoes) into her diet.
Case 2
A 55 year-old female presents to you complaining of sagging
skin; as she has gotten older, she has noticed that her skin
seems to be more lax, and the texture has gotten rougher. While
she understands that neuromodulators and injectable fillers
may be needed for optimal correction, she is not ready to con-
sider these treatments yet, and would like to start by using topi-
cal products that improve skin elasticity and laxity. She has very
sensitive skin and cannot tolerate retinoids and alpha hydroxy
acids, so she is interested in more natural products.
Discussion
This patient would benefit from a soy-containing sunscreen in
the morning to improve skin tone, and twice daily application
of a vitamin C preparation to increase collagen production
and improve skin tone. She should also be advised to incorpo-
rate flavonoid and carotenoid-rich foods into her diet.
References
Adhikari A, Devkota H, Takano A, Masuda K, Nakane T, Basnet P,
Skalko-Basnet N. Screening of Nepalese crude drugs tradition-
ally used to treat hyperpigmentation: in vitro tyrosinase inhibi-
tion. Int J Cosmet Sci. 2008;30(5):35360.
20 2. General Skin Care
Ried K, Sullivan TR, Fakler P, Frank OR, Stocks NP. Effect of cocoa
on blood pressure. Cochrane Database Syst Rev. 2012;8:CD008893.
Introduction
Sun protection (photoprotection) is the process of defending
the skin from the harmful effects of Ultraviolet radiation
(UVR). UVR itself is a conundrum. Fun in the sun
describes the enjoyable experience of tanning and outdoor
activity. UVR is also an important natural source of Vitamin
D. Low levels of Vitamin D increase fracture risk and may
play a role in cardiovascular disease, auto-immunity and
malignancies (Kannan and Lim 2014). Thus, being in the sun
is desirable and appears to have health benefits. On the other
hand, UVR induces both skin cancer and photoaging. Some
of these cancers, such as melanoma, are life threatening.
Importantly, the incidence of melanoma is rising faster than
the incidence of any other cancer. Oral intake of vitamin
D-enriched foods or vitamin D supplements, therefore, is
recommended over seeking UVR to maintain proper serum
levels. Overall, the rising risk of skin cancer warrants imple-
mentation of comprehensive photoprotection strategies to
limit exposure to UVR.
UVR is comprised of UVB (290320 nm) and UVA (320
400 nm). UVB causes erythema and direct DNA damage
through the formation of pyrmidine dimers. It also can be a
source of oxidative stress. UVA penetrates more deeply into
the dermis and is the most powerful source of oxidative stress
Top Considerations
See Table 3.1.
Niacinamide
Niacinamide is the amide form of Vitamin B3. This water-
soluble vitamin, which is also referred to as nicotinomide, is
present in foods such as chicken, pork, beef and mushrooms.
Unlike niacin, niacinamide is not associated with flushing.
The disease model indicating the role of Vitamin B3 in pho-
toprotection is Pellagra. Extreme deficiency of Vitamin B3
26 3. Sun Protection
Polyphenols
Polyphenols are found in dry legumes, honey, red wine, green
tea, turmeric (curcurmin), milk thistle (silymarin), grape seed
proanthocyanidins and grape derived resveratrol, silibin, pome-
granate and chocolates (flavonoids). Polyphenols are powerful
antioxidants, anti-inflammatory agents and potentially anti-
carcinogenic. UV-induced skin inflammation, proliferation,
immunosuppression, DNA damage, and dysregulation of
important cellular signaling pathways all appear to be reduced
by consumption of polyphenols (Afaq and Katiyar 2011).
Carotenoids
Carotenoids include and carotenes, lutein and lycopenes.
Transported to the skin by lipoproteins, they accumulate
within the epidermis proportionate to dietary intake and with
variations based on body site. Higher levels are accumulated
Carotenoids 29
on the forehead, palms and soles with lower levels in the dorsal
hand and forearm regions. Carotenoids are amongst the most
powerful scavengers of oxygen singets (Stahl and Sies 2007).
Polypodium Leucotomos
Polypodium leucotomos (PLE) is a botanical product derived
from tropical ferns grown in Central and South America.
Used traditionally by Native Americans as an anti-
inflammatory agent, PLE looks very promising as an oral
agent capable of providing systemic photoprotection and
modulation of UV-induced immune responses. PLE may
achieve these effects via oral antioxidant and immunomodu-
latory effects. PLE prevents apoptosis and promotes DNA
repair via the p53 tumor suppressor gene and other pathways
(Bhatia 2015). Containing phenolic antioxidants such as caf-
feic and ferulic acids, PLE can diminish UV induced ery-
thema and inhibit UV induced immunosuppression. PLE also
has demonstrated efficacy in reducing angiogenesis, photo-
carcinogenesis, and solar elastosis.
PLE is a promising agent for systemic photoprotection
and may also offer chemoprevention of UV-induced cutane-
ous malignancies. Further research is needed to determine
optimized dosing, duration of effect, and the utility of using
PLE in combination with topically-applied sunscreens
(Bhatia 2015). Murine models suggest a potential for PLE as
a chemopreventative agent, however, to date, there are no
controlled trials in humans demonstrating this effect. This
may be an exciting area of future study.
Polypodium Leucotomos 31
Case 1
A 26 year-old healthy female presents with a history of
poorly-controlled polymorphous light eruption (PMLE).
Despite careful sunscreen use, she reports repeated flares. She
declines hydroxychloroquine and inquires about alternative
therapy options. She inquires about the use of Polypodium
leucotomos (PLE). Is there a basis for this therapy option?
Discussion
PLE could be discussed as an adjunct to therapy, but it should
be emphasized that systemic photoprotection does not replace
the need for conventional photoprotection with sunscreen and
protective clothing. Literature demonstrating reduced flaring
in PMLE patients pretreated with PLE prior to UV exposure
could be reviewed and PLE 7.5 mg/kg PO BID starting
2 weeks before planned sun exposure could be considered for
this patient.
References 33
Case 2
A 37 year old woman with a history of basal cell carcinoma
(BCC) presents looking to discuss using dietary modification
to replace topical sunscreens as her means of photoprotec-
tion. How would you counsel this patient?
Discussion
Literature supporting the potential benefits of lycopenes,
niacinamide, and polyphenols such as turmeric could be
reviewed as potentially providing some level of systemic pho-
toprotection. While in vivo and in vitro data exists for these
agents, it is important to stress that the literature does not fully
delineate optimized dosing for any of these items nor does it
specifically quantify efficacy individually or on a comparative
basis. While some of these items may indeed provide a degree
of adjunctive photoprotection, she should be advised to con-
tinue to use protective clothing and sunscreens to minimize her
risk of future BCC.
References
Afaq F, Katiyar SK. Polyphenols: skin photoprotection and inhibi-
tion of photocarcinogenesis. Mini Rev Med Chem. 2011;11(14):
120015.
Introduction
It is estimated that one in five Americans will develop skin
cancer in their lifetime and that up to 50% of Americans who
live to age 65 will develop either basal cell carcinoma (BCC) or
squamous cell carcinoma (SCC) at least once (http://
progressreport.cancer.gov). Treatment of non-melanoma skin
cancers has increased by 77% between 1992 and 2006 (Rogers
2010; http://cancer.org/acs/group/content/@epidemiologysur-
veilance/document036845.pdf), leading to continual reassess-
ment of treatment. Morbidity has been minimized with
techniques such as Mohs Micrographic surgery, and excellent
cure rates have been reported (Clark et al. 2014; Mostterd et al.
2008). For malignant melanoma, by far the most dangerous of
these three skin cancers, the outcomes are far less rosy, with
good cure rates for thin tumors, but poor rates for thicker, inva-
sive lesions. Importantly, options for metastatic melanoma are
limited, with modest life prolongation at best. In fact, patients
with visceral metastases have medial survival rates of only 4
months (Fox et al. 2013). Nonetheless, newer immunotherapies
such as ipilimumab and PD1 inhibitors now offer hope to mela-
noma patients with advanced disease (Fox et al. 2013).
Some skin cancer patients find the cost and/or resultant
excision scar unsatisfactory, or fear surgery altogether.
Perhaps surprisingly, complementary and alternative (CAM)
therapy options are being increasingly sought out and
Clinical Considerations
See Figs. 4.1, 4.2, 4.3, and 4.4.
Top Considerations
See Table 4.1.
Not Recommended
The escharotics (i.e., bloodroot, sanguinarine, and related
compounds) should be avoided for known malignancies as
they are unpredictable and have not reliably been shown
to be a viable treatment without concomitant surgery.
Gossypin (an extract from cotton and hibiscus plants)
has some promising data in mice and in vitro for mela-
noma, but is simply too experimental for clinical use at
this time.
Ingenol Mebutate
Actinic keratoses (AKs) are common scaling, epidermal
lesions occurring on sun exposed skin (Uhlenake 2013).
These lesions have the potential to transform into SCC, and
estimates of the annual rate of transformation range from
0.025 to 20% (Marks et al. 1988). Given the lack of clinical
features that allow clinicians to identify the lesions most
likely to progress, clinicians are obligated to treat AKs as a
preventative measure (Uhlenake 2013). These therapies
include cryotherapy, photodynamic therapy, topical chemo-
therapy, and topical field therapy with agents such as
imiquimod and ingenol mebutate (Uhlenake 2013). Ingenol
is a novel agent derived from Euphorbia peplus, a temperate
annual weed, known as radium weed, petty spurge, or milk-
weed (Rosen et al. 2012). The sap of E peplus is irritating and
has been used for centuries as a natural folk remedy for warts
and AK (Rosen et al. 2012). It was approved for the treat-
ment of AK in 2013 and is available in 0.05% gel for the body
(applied once daily for 2 days) and 0.015% for the face and
scalp (once daily for 3 days), Ingenol is thought to have sev-
eral mechanisms of action. These include disruption of
mitochondrial membranes resulting in cytotoxicity, activation
of proinflamatory cytokines, recruitment of neutrophils, and
generation of tumor specific antibodies (Rosen et al. 2012).
Complete clearance of facial lesions was 47% of individuals
at 57 days and mean reduction of lesions was 87% mean
reduction of lesions from baseline for face and scalp. Pooled
analysis of 4 trials (2 face and scalp, 2 body) concluded that
42.2% of face and scalp lesions cleared and 34.1% affected
body areas cleared. Adverse reactions include erythema,
scabbing and scaling and were mild to moderate in severity.
Unlike escharotics, randomized controlled trials have con-
firmed the efficacy of naturally occurring ingenol mebutate
for the topical field treatment of actinic keratoses. Ingenol is
presently being studied for therapy of BCC (Clark et al.
2014) and it has been recently reported to help pediatric mol-
luscum as an off label indication (Javed and Tyring 2014).
40 4. Skin Cancer
Vitamin D
The relationship of Vitamin D with melanoma continues to
be evaluated and remains complex. Some studies link low
levels of Vitamin D to melanomas with thicker Breslow
depths, positing antiproliferative and prodifferentiation
effects of the hormone (Berwick and Erdei 2013), while oth-
ers fail to show such a link. A study by Newton-Bishop et al.
demonstrated a survival advantage among melanoma patients
with higher Vitamin D levels at the time of diagnosis
(Newton-Bishop et al. 2009). Nurenberg et al. reported that
serum 25(OH)D levels were lower in patients with Stage IV
melanomas at the time of diagnosis compared to the levels in
patents with Stage I melanoma (Nurnberg et al. 2009). Data
on the role of dietary supplements of Vitamin D and mela-
noma risk have shown varying results. Weinstock and col-
leagues found no association between use of Vitamin D
supplementation and melanoma risk (Weinstock et al. 1992).
On the other hand, Vinceti et al. found an inverse association
between dietary intake of Vitamin D and melanoma risk
(Berwick and Erdei 2013). The VitaL cohort examined 68,611
participants who reported dietary and supplemental Vitamin
D intake (Asgari et al. 2009). Their review revealed no asso-
ciation between Vitamin D intake and melanoma risk for the
455 incident melanomas. In conclusion, there is inadequate
evidence to verify that Vitamin D supplementation decreases
melanoma risk (Berwick and Erdei 2013) even though some
studies suggest a survival benefit with Vitamin D supplemen-
tation. Results of ongoing studies will establish if supplemen-
tation is justified, and what the proper dosing should be.
Advising supplementation may be reasonable pending the
establishment of a final consensus, especially in light of the
fact that strict sun avoidance is generally recommended for
skin cancer prevention, which directly contributes to vitamin D
insufficiency.
Coenzyme Q10 43
Coenzyme Q10
Coenzyme Q10 (CoQ10) is a critical part of the electron
transport chain in mitochondria and is thought to plan an
important role in cellular regulation and function, as well as
immune system function. Historically, studies have found low
levels of CoQ10 in patients with various cancers (Rusciani
et al. 2006). Accordingly, CoQ10 levels have been found to be
44 4. Skin Cancer
Escharotics
Escharotic agents are frequently mentioned by patients and
alternative practitioners and warrant further discussion
beyond simply being not recommended. Escharotics con-
tain primarily zinc chloride and bloodroot (an alkaloid called
sanguinarine derived from the root of the plant, Sanguinaria
canadensis). In a notable reversal, these agents were used
initially as a tissue fixative in the conventional Mohs micro-
graphic surgery (MMS). This technique, pioneered by Dr.
Frederick Mohs in the early 1930s, involved fixation of
cancerous tissue with a version of this compoundreferred to
as Mohs pasteprior to excision. The disadvantages of the
initial technique included caustic destruction of adjacent
healthy tissue, pain, and prolonged surgical time. Over the
past 50 years, MMS has converted to fresh frozen tissue
analysis to achieve expedited, precise margin control with tis-
sue sparing. Overall, the Mohs technique routinely achieves
excellent cure rates and good cosmetic outcomes without the
use of escharotics.
At the same time that the Mohs technique was introduced,
Harry Hoxsey, a self-proclaimed cancer specialist with an
eighth grade education, touted an herbal tonic and paste
designed to treat both internal and external cancers (Elston
2005). Hoxseys paste resembled the original Mohs paste, con-
taining both zinc chloride and bloodroot. Hoxsey recom-
mended applying the paste to skin cancers and noted that
within days to weeks, the area would necrose and fall out. This
treatment was never scientifically tested or proven efficacious.
In the 1950s, the U.S. Food and Drug Administration (FDA)
condemned Hoxseys formulas. However, the use of escharot-
ics continues to be promoted by alternative practitioners as a
primary self-directed therapy for skin cancer. Via the internet,
patients searching for alternative skin cancer therapies can
purchase escharotics such as Black Salve (Cansema). The
content of these products and the purity of their ingredients
are not regulated, and, as such cannot be recommended.
46 4. Skin Cancer
Gossypin
Gossypin is extracted from cotton and hibiscus plants and has
been studied in vitro for melanoma. Gossypin reduced tumor
size and prolonged life in mice with melanoma tumors
(Bhaskaran 2013). Gossypin appears to inhibit melanoma cell
proliferation in human cel cultures as well. It is believed that
Gossypin inhibits kinase activities of BRAFV600E and
CDK4, in vitro, possibly through direct binding of gossypin
with these kinases. For cells harboring the BRAFV600E
mutation, gossypin inhibited cell proliferation through
abrogation of the MEK-ERK-cyclin D1 pathway (Bhaskaran
2013). Gossypin is a novel agent with dual inhibitory effects
for BRAFV600E kinase and CDK4 for treatment of mela-
noma. Although this may be a promising option in the future,
current research does not support a role for gossypin in
patient care at this time.
Case 1
A 58 year old male presents with a bleeding, erythematous
pearly papule on the nasal ala in the setting of severe sun
damage and multiple actinic keratoses on the face. Your skin
biopsy confirms a basal cell carcinoma, nodular type. You
advise the patient to proceed with Mohs micrographic exci-
sion of the lesion. Due to a fear of surgery and concerns
about scarring, the patient inquires regarding your opinion
on the use of the escharotic, black salve, to treat his BCC. How
would you advise the patient?
Discussion
It is important to stress to the patient that escharotics are
unsafe, unproven and seem to have poorer outcomes in terms
of scars, recurrence and even metastasis. While there may be a
role defined for them in the treatment of skin cancers in the
future, they simply cannot be recommended at this time and
48 4. Skin Cancer
Case 2
You diagnose a melanoma of the left leg (Breslow depth
1.01 mm) in a 43 year-old patient. She is scheduled for a wide
local excision of the primary tumor with a sentinel lymph
node dissection. Before proceeding with the advised surgery,
she inquires if there are any supplements that could be of
benefit in her care. How would you counsel this patient?
Discussion
Vitamin D supplementation could be recommended as there is
some evidence that it could be helpful in this context. Moreover,
given that strict sun protection is emphasized for melanoma
patients, Vitamin D supplementation of 5002,000 IU per day
is a safe and inexpensive adjunct that may be worthwhile.
While the data on Coenzyme Q10 is very limited, there may be
benefit in the setting of melanoma progression, so CoQ10
200 mg PO BID may be reasonable here.
References
Adler B, Freidman A. Closing a gap in clinical knowledge: analysis of
cases of self-treatment of moles and skin cancer with escharotic
and nonescharotic agents in the Internet age. Poster Abstract.
JAAD. 2014;70(5 (Suppl 1)):AB133.
Asgari MM, Maruti SS, Kushi LH, White E. A cohort study of vita-
min D intake and melanoma risk. J Inves Dermatol. 2009;129(7):
167580.
Eastman KL, McFarland LV, Raugi GJ. Buyer beware: a black save
caution. JAAD. 2011;65:e1545.
Fox MC, Lao CD, Schwartz JL, Frohm ML, Bichakjian CK, Johnson
TM. Management options for metastatic melanoma in the era of
novel therapies: a primer for the practicing dermatologist. Part II.
Management of Stage IV Disease. JAAD. 2013;68(1):13e.113.
http://www.antiaging-systems.com/23-bec5-curaderm?Aff=WRC1.
Accessed 26 May 2014.
Rogers H. Your new study of non melanoma skin cancers. New York:
Skin Cancer Foundation, Skin Cancer.org; 2010.
Smith N, Shin DB, Brauer JA, Mao J, Glefand JM. Use of comple-
mentary and alternative medicine among adults with skin dis-
ease: results from a national survey. JAAD. 2010;60(3):41925.
Weinstock MA, Stampfer MJ, Lew RA, Willett WC, Sober AJ. Case
control study of melanoma and dietary vitamin D: implications
for advocacy of sun protection and sunscreen use. J Invest
Dermatol. 1992;98(5):80911.
Chapter 5
Acne
Introduction
Common acne, or acne vulgaris, is one of the most common
skin conditions seen by practitioners; it can also be one of the
most frustrating conditions to treat. Acne is thought to affect
more than 80% of adolescents and will commonly persist into
adulthood (Bhate and Williams 2013). The clinical and histo-
logical features of acne are well described, with conventional
thinking that Propionibacterium acnes (P. acnes) bacteria
normally present on the skincolonizes the duct of the seba-
ceous gland, resulting in a non-inflammatory comedo or
inflammatory papule, pustule or nodule (Gollnick et al.
2003). However, in the last decade much has been written
about the pathophysiology of acne and many would argue
that an inflammatory state is present long before the clinical
formation of the acne lesion (Thiboutot et al. 2009). Evidence
now suggests a role for several inflammatory mediators such
as cytokines, defensins, peptidases, and sebum lipids (Tanghetti
2013), triggering the beginning of a paradigm shift in how
acne is viewed.
Despite decades of research and clinical trials, there
remains a surprisingly limited treatment armamentarium for
acne. Adding to the challenge is that acne can be classified
into numerous clinical categories: hormonal female acne,
Clinical Considerations
See Figs. 5.1 and 5.2.
Clinical Considerations 55
Top Considerations
Secondary Considerations
See Table 5.2.
Vitamin C
Vitamin C (ascorbic acid) is well known for the association of
its deficiency with scurvy. It was isolated in 1928 and is known
to be essential for the development and maintenance of con-
nective tissue. It supports the immune system, reduces the
severity of allergic reactions, and plays a role in fighting
infections (Chambial et al. 2013). Vitamin C is also a powerful
antioxidant and may be efficacious against P. acnes in the skin
(Klock et al. 2005). Several randomized, controlled trials have
found that topical application of a stable precursor of ascor-
bic acid is effective in reducing acne lesion counts, both alone,
or in combination with topical retinol (Ruamrak et al. 2009;
Woolery-Llyod et al. 2010). Vitamin C appears to be a very
safe and tolerable treatment but, depending on the concen-
tration and vehicle, irritation may occur. Ascorbic acid is also
notoriously unstable, so the proper formulation must be used.
Such a preparation, if in an appropriate vehicle, would likely
be considered pregnancy and lactation safe, as this water-
soluble vitamin is absorbed from many foods and could serve
as a helpful adjuvant option for acne treatment in this popu-
lation as well.
Topical Nicotinamide
Nicotinamide, also known as niacinamide, is a water-soluble
vitamin and is part of the vitamin B group. It is known that
nicotinamide is involved in numerous oxidation-reduction
reactions in mammalian biological systems. It also acts as an
antioxidant (Otte et al. 2005). Numerous studies have inves-
tigated the use of nicotinamide both topically and orally in
the role of acne vulgaris. Reasonable evidence exists for the
use of this agent in the treatment of acne, placing it on par
Topical Nicotinamide 59
Dietary Modifications
The relationship between diet and acne has been very contro-
versial. It is often one of the first questions a patient will ask:
Is it anything I am eating, or not eating? The answer to that
question has evolved with time. Historically, foods such as
chocolates, oils and sweets were implicated in exacerbating
acne. These associations have since been dispelled. But in the
last decade the question has re-emerged and new evidence
points to the possibility that dairy and carbohydrates may
indeed exacerbate acne (Bowe et al. 2010). In addition, peo-
ple are starting to consider what types of foods may have
therapeutic benefit for acne. Overall, evidence is surfacing to
more comprehensively answer this question for patients.
Oral Probiotics
Probiotics are live microorganisms that are associated with
beneficial effects. The probiotics most commonly used in over-
the-counter supplementation are lactobacilli and bifidobacte-
rium. With the exception of atopic dermatitis, there are not
many studies focused on the use of probiotics in dermatology.
One of the potential benefits that probiotics may offer is the
reduction of inflammation in acne by decreasing the release of
inflammatory cytokines and recruitment of CD8 cells, and by
activating regulatory T cells (Muizzuddin et al. 2012).
Probiotics may also decrease sebum content in the skin lead-
ing to decreased formation of acne lesions (Kim et al. 2010).
Additionally, probiotics have been shown to mitigate some of
the adverse effects of oral antibiotics, and may be useful as a
complementary treatment when administering oral antibiotics
for acne (Goldenberg et al. 2013). As our understanding of the
pathophysiology of acne evolves, there may be a role for the
use of probiotics, both oral and topically to treat acne.
Oral Zinc
Zinc is a metallic element that serves as an essential cofactor
in many biochemical reactions in the body. Zinc is also
thought to be bacteriostatic against P. acnes and to inhibit the
production of inflammatory cytokines. It has been shown that
the use of zinc is beneficial in the treatment of acne. In addi-
tion, there is discussion that newer preparations of zinc are
better dissolved by the stomach and more completely
absorbed, making it possible to administer lower doses of
zinc, with better gastrointestinal tolerability. Furthermore,
zinc is being looked at as beneficial in the treatment of resis-
tant strains of P. acnes to antibiotics (Sardana et al. 2014).
Case 1
A 15 year old male with a history of well controlled moderate
acne who has been on antibiotics for 6 months, once daily
benzoyl peroxide and once daily retinoid comes in with his
mother who is interested in stopping the oral antibiotic and
not pursuing additional oral therapies. What are some com-
plementary therapeutic options in this case?
Discussion
This is a tough and all too common clinical scenario. Diet is
often an easy and high-yield area to examine. Is there an exces-
sive dairy intake? Is there an abundance of sugar or
Case 2 69
Case 2
A 34 year old female with mild hormonal acne, well con-
trolled on a daily retinoid comes in wanting to start preg-
nancy planning and stop her retinoid. What are some
complementary therapeutic options in this case?
Discussion
This is another tough clinical scenario as there are so few topical
and oral products allowed in pregnancy planning and pregnancy
and this is a very common concern for patients. It is helpful to
look at all the topical products she is using to see if the program
can be re-worked to include products with vitamin C or niacina-
mide. Vitamin C serums can be used at night and sunscreens can
be found that include niacinamide for use during the day.
Increasing the intake of foods rich in probiotics such as probiotic
juices and yogurt is also a reasonable suggestion and examining
the diet for high levels of sugar or carbohydrate-rich foods and
encouraging more of a Mediterranean-focused diet may also be
useful. Starting the patient on prescription topical azelaic acid in
the pregnancy planning stage is an option as it is only of the only
FDA approved topical in pregnancy and considered more natu-
ral than many topical prescription acne products.
70 5. Acne
References
Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol.
2013;168(3):47485.
Sardana K, Chugh S, Garg VK. The role of zinc in acne and preven-
tion of resistance: have we missed the base effect? Int
J Dermatol. 2014;53(1):1257.
Introduction
It is estimated that rosacea affects 16 million people in the
US. Rosacea is a chronic inflammatory skin disorder charac-
terized by increased cutaneous sensitivity and inflammation
that is most commonly limited to the central part of the face.
Rosacea typically affects adults in the third decade and it is
predominantly seen in women. Clinical features may include:
erythema, papules and pustules, facial flushing, telangiecta-
sias and/or an associated ocular disease. Typically, rosacea is
classified into four sub-types: Erythematotelangiectatic, pap-
ulopustular, phymatous and ocular (Emer et al. 2011). Disease
exacerbation has been associated with a variety of triggers,
including but not limited to: caffeine, exercise, UV radiation,
stress, microbial colonization of the face, spicy food, alcohol,
and heat.
In the last decade it has become clear that little is known
about the pathophysiology of rosacea. Recent studies suggest
that rosacea initially occurs in individuals when inappropri-
ate innate immune responses to environmental stimuli lead
to inflammation and vascular abnormalities (Steinhoff et al.
2013). As the innate immune system plays a key role in the
immunologic skin barrier, agents that promote a competent
barrier are likely to be beneficial adjuncts in the treatment of
this disease.
Clinical Considerations
See Figs. 6.1 and 6.2.
Top Considerations
See Table 6.1.
Secondary Considerations
See Table 6.2.
Top Considerations
Nicotinamide
Nicotinamide is also known as niacinamide and nicotinic acid.
It is a water-soluble vitamin found in meat, fish and wheat.
It does not have the same pharmacologic effects of niacin, and
therefore it does not cause a flushing reaction. Nicotinamide
acts as an anti-oxidant and has anti-inflammatory properties,
skin-lightening properties, and can decrease the production of
sebum (Niren 2006). Topical application of nicotinamide has a
stabilizing effect on epidermal barrier function and reduces
transepidermal water loss (Draelos et al. 2005). In addition,
nicotinamide increases protein synthesis and potentiates the
differentiation of keratinocytes making it a natural alternative
to improve the skin integrity (Niren 2006).
Azelaic Acid
Azelaic acid is a saturated dicarboxylic acid produced natu-
rally by the yeast, Malassezia furfur that lives on the skin of
animals and humans. It is also found in plants such as wheat,
rye and barley (Draelos et al. 2013). Azelaic acid has signifi-
cant anti-inflammatory, anti-oxidative effects and is bacteri-
cidal against a range of gram-negative and gram-positive
micro-organisms as well including antibiotic-resistant bacte-
rial strains (Sieber and Hegel 2014). Although it is considered
conventional therapy for rosacea, we highlight it here because
it has been proven to be well tolerated in numerous clinical
trials and is considered a very safe topical.
78 6. Rosacea
Secondary Considerations
Chrysanthellum Indicum
Wild chrysanthemum (Chrysanthemum indicum) is tradi-
tionally used in Chinese folk medicine as an anti-inflammatory
agent. It has been shown to possess anti-inflammatory and
anticancer activities (Kim et al. 2013). It is also used in the
Chrysanthellum Indicum 79
Quassia Extract
Quassia extract comes from the Quassia amara tree, a small
tree that originates from South America. It is thought to have
anti-inflammatory properties as well as anti-parasitic activi-
ties (Toma et al. 2003). Quassia amara contains high levels of
active phytochemicals and has been shown to be effective
against facial seborrheic dermatitis as compared to topical
ketoconazole 2% (Diehl and Ferrari 2013).
Case 1
A 55-year-old female presents with a 15-year history of ery-
thematotelangiectatic rosacea. She has decided not to pursue
laser therapy and is not interested short-acting vasoconstric-
tors as she is concerned about the possibility of rebound. She
continues to cover the redness with green makeup, but asks
if there is anything natural and safe out there that she could
add to her facial regimen that could possibly help?
References 81
Discussion
This is a very common clinical situation and a challenge as
there are very few topical treatments that affect erythematotel-
angiectatic rosacea beyond topical brimonidine and lasers.
Topical niacinamide may be of some help here and is certainly
safe. It is present in some sunscreens and moisturizers, making
it very easy to integrate into a regimen.
Case 2
A 67 year old man presents with 1 year onset of papulopus-
tular lesions, in the malar cheek area. He has had multiple
medication allergies in the past and is on numerous medica-
tions currently so is not interested in an oral therapy. He also
notes a history of C. difficile colitis and is wary of topical
clindamycin that multiple doctors have suggested he use for
the rosacea.
Discussion
Topical azelaic acid once to twice daily is a safe medication
and most people tolerate it with out complication. It is impor-
tant to counsel patients that there may be an initial stinging
sensation that will likely dissipate. In addition, most patients do
well with once daily application but some appear to have
improved response to twice daily application. It is also helpful
to counsel patient to apply the cream to well dried (air dried
for 30 min) skin.
References
Diehl C, Ferrari M. Efficacy of topical quassia amara gel in facial
seborrheic dermatitis: a randomized, double-blind, comparative
study. J Drugs Dermatol. 2013;12(3):3125.
Introduction
Hair loss is a commonly encountered complaint in dermatology,
and it is a condition that can cause significant psychosocial
distress and decreased quality of life in affected patients
(Reid et al. 2012). Androgenetic alopecia and alopecia areata,
both nonscarring forms of hair loss, are perhaps the most
common types of alopecia encountered in practice. While a
number of complementary and alternative therapies have
been anecdotally reported to be effective in their treatment,
there remains a lack of robust evidence supporting any of
these modalities to be as effective as standard pharmacologic
therapies. Nevertheless, it is beneficial to be aware of the
small case reports in the literature, as patients often inquire
about natural remedies for their hair loss, and many times
the results of standard pharmacotherapy are suboptimal.
Additionally, as hair loss has few significant medical implica-
tionsthough clearly has tremendous psychological impact,
of coursethe risk-benefit calculation may be very different
than that of a more threatening condition.
Clinical Considerations
Top Considerations
See Tables 7.1 and 7.2.
Androgenetic Alopecia
Androgenetic alopecia (AGA) is a hereditary, nonscarring
form of hair loss mediated by the effects of dihydrotestoster-
one (DHT) on the hair follicle. Progressive miniaturization
of the hair follicle leads to hair loss in both male and female
pattern hair loss. Male pattern AGA classically manifests as
thinning over the vertex and fronto-temporal scalp; female
pattern AGA can manifest as thinning over the crown with
Raspberry Ketone 85
Raspberry Ketone
Raspberry ketone (RK) is an aromatic compound found in
red raspberries; it is similar in structure to capsaicin. The
mechanism of action for raspberry ketone in promoting hair
growth is thought to be due the increase of dermal insulin-
like growth factor-1 via the stimulation of sensory neurons
(Ulbricht et al. 2013). Applied topically, it may have some
effect on both AGA and alopecia areata (AA), perhaps via
induction of insulin-like growth factor-1.
86 7. Hair Loss
Procyanidins
Procyanidins are a class of flavonoids found in red wine,
chocolate, barley, grape seed and apples, among other sources.
They are increasingly being studied for their health benefits
due to their potent antioxidative properties (Hammerstone
et al. 2000; Chun et al. 2007). Procyanidin B-2, found in high
concentrations in apples, has been specifically studied as a
therapeutic agent for androgenetic alopecia.
Alopecia Areata
Alopecia areata is an autoimmune, nonscarring form of hair
loss mediated by lymphocytic infiltration of the hair follicle.
It is most commonly seen on the scalp but can also affect the
eyebrows, eyelashes and body hair. Multiple patterns of alo-
pecia areata exist, with the totalis (entire scalp) and universa-
lis (all hair on scalp and body) forms being the most severe
(Wasserman et al. 2007). The natural progression of alopecia
areata is unpredictable and highly variable; spontaneous
regrowth may occur in up to 50 % of patients after 1 year.
The extent and pattern of alopecia areata are the most
important prognostic factors (Alkhalifah et al. 2010).
Garlic
Garlic (Allium sativum) has been used worldwide for medici-
nal purposes due to its antimicrobial, anti-inflammatory and
immunomodulatory properties. While the mechanism of action
of garlic in many conditions has not been fully elucidated yet,
it has been hypothesized that it may be a useful treatment for
autoimmune forms of hair loss such as alopecia areata as an
88 7. Hair Loss
Onion Extract
Like garlic, onions (Allium cepa) contain alliin as well as
flavonoids including quercitin. It is thought that onion extract
may promote hair growth due to its induction of a contact
dermatitis and subsequent immune response (Sharquie and
Al-Obaidi 2002).
Aromatherapy
Aromatherapy refers to the medicinal use of essential oils and
essences derived from plants, flowers and wood resins; these
substances are typically massaged into the skin. Aromatherapy
has been studied for the treatment of hair loss, although the
mechanism of action for this treatment is unknown.
Hypnotherapy
Hypnosis as been defined as the agreement between a per-
son designated as the hypnotist and a person designated as
the client or patient to participate in a psychotherapeutic
technique based on the hypnotist providing suggestions for
changes in sensation, perception, cognition, affect, mood, or
behavior. (Montgomery et al. 2013). It has been utilized as
an alternative therapy in alopecia areata, although its mech-
anism of action for this disease has not been defined
(Willemsen et al. 2006).
Case 1
A 45 year-old female presents to your office complaining of
gradual thinning of her scalp hair. She has had to start parting
her hair in different ways to cover up balding areas on the
front of her scalp. She denies any itching, redness or irritation
of the scalp, and is not losing hair elsewhere on her face or
body. Her father and siblings also have thinning hair. The
patient has read about the potential side effects of topical
minoxidil and prefers not to use it. She is wondering if there
are alternative therapies for her form of hair loss.
Discussion
In addition to reviewing the relative safety of topical minoxidil
and perhaps discussing oral 5-alpha-reductase inhibitors such as
finasteride and anti-androgens such as spironolactone, a regimen
of raspberry ketone applied topically once daily and procyanidin
applied topically once daily may be beneficial for this patient. A
treatment period of at least 12 weeks should be recommended.
Case 2
A 24 year-old male comes to see you because he has noticed
bald patches on his scalp over the past few months. He is a law
student and has been under an increased amount of stress in
the past year. There is a family history of hypothyroidism but
the patient has no history of thyroid disease. The patient saw
another physician recently for his hair loss, who prescribed
topical steroids and topical minoxidil, but these treatments
were ineffective. The patient has read that steroid injections
can be helpful for some forms of hair loss, but he is very afraid
of needles and is hoping for less invasive treatment options.
Discussion
This patient may benefit from the essential oil mixture cited
above, applied to the affected areas in the morning. If he is able
to tolerate the smell of onion juice or garlic paste, he could also
try application of one of these substances to the affected areas
92 7. Hair Loss
References
Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia
areata update: part I. Clinical picture, histopathology, and patho-
genesis. J Am Acad Dermatol. 2010;62(2):17788.
Introduction
Psoriasis is a common dermatologic condition, affecting
approximately 23% of the population worldwide. The pres-
ence of large plaques on exposed areas of the body can cause
significant embarrassment and social anxiety for those with
psoriasis. There have been a number of exciting develop-
ments in the understanding of the pathogenesis of psoriasis,
and with those have come several new classes of medications
(Richard and Honigsmann 2014). Fortunately, there are mul-
tiple conventional options now that can manage psoriasis
very effectively, and many of these are appealing to patients
who prefer a more natural approach. From topical vitamin D
analogues (calcipotriene and calcipotriol), phototherapy uti-
lizing narrow band UVB light, and even a recently FDA-
approved blue light home treatment for psoriasis
(Kleinpenning et al. 2012), there are many potential choices
in the conventional armamentarium. Some of the most pow-
erful treatments, however, bring with them significant risks
such as hepatotoxicity for methotrexate, the possibility of
serious infections, malignancies, and autoimmune syndromes
from the biologic agents, and depression and suicidality from
a newer oral phosphodiasterase-4 inhibitor.
These risks, perhaps, as well as the chronic nature of the
disease remain frustrating for these individuals, and many
turn to complementary and alternative medicine (CAM) as an
Clinical Considerations
See Figs. 8.1 and 8.2.
Fig. 8.2. Psoriasis often affects the scalp, with erythematous scaly
plaques that may be pruritic.
Top Considerations
See Table 8.1.
Fish Oil
Oil from cold water fish such as salmon, cod, sardines and
herring are rich in the omega-3 essential fatty acids eicosa-
pentaenoic acid (EPA) and docosahexaenoic acid (DHA).
These fatty acids have been shown to possess anti-
inflammatory properties and have been studied for their use
in psoriasis (Nicolaou 2013). Other good sources of omega-3
fatty acids include walnuts, flax seed, and olive oil. There is no
standardized dosing for the use of omega-3 fatty acids in pso-
riasis; patients may be advised to increase intake via dietary
consumption or via oral supplements.
98 8. Psoriasis
Indigo Naturalis
Indigo naturalis is an herb that is commonly used in tradi-
tional Chinese medicine for the treatment of psoriasis and
other dermatologic conditions (Koo and Arain 1998). It has
been shown to regulate keratinocyte differentiation and
proliferation, aid in repair of the epidermal barrier and to
have anti-inflammatory properties, all of which are benefi-
cial in the treatment of psoriasis (Lin et al. 2009a, 2013).
Indirubin, found in indigo naturalis, is thought to be the
primary constituent that is helpful in treating psoriasis
(Lin et al. 2009b).
100 8. Psoriasis
Turmeric (Curcumin)
Turmeric (Curcuma longa) contains curcumin (diferuloylmeth-
ane), and has a long tradition of use orally and topically to treat
wounds, ulcers, dermatitis and pruritus. Curcumin has anti-
inflammatory, antioxidant, anticarcinogenic and antimicrobial
properties (Gupta et al. 2013). Curcumin has been shown to
block tumor necrosis factor (TNF), an inflammatory mediator
that is important in the pathogenesis of psoriasis (Aggarwal
et al. 2013). While a very appealing agent, inexpensive and
familiar as it is frequently used in cooking, its clinical literature
is in relative disarray. Of note, diets high in turmeric only cor-
respond to 60100 mg of curcumin, dosages much lower than
those used in the studies (Kurd et al. 2008). There are several
clinical trials, but with variability on the dosage and formula-
tion, and often used along with other agents, somewhat obscur-
ing the effect of curcumin. More work needs to be done, but
early reports are encouraging. It appears very safe, however: the
most common side effect is gastrointestinal upset; curcumin is
contraindicated in patients with gallbladder disease.
Aloe Vera
Aloe vera is a plant in the Liliaciae family. The gel of this
plant has been used for thousands of years to treat topical
conditions from sunburns to psoriasis. Aloe vera gel, obtained
from the inner portion of the leaves, has been shown to have
anti-inflammatory, anti-microbial and wound healing proper-
ties (Klein and Penneys 1998).
Mahonia Aquifolium
Mahonia aquifolium (Oregon grape) is an evergreen shrub that
is native to North America, and is the state flower of Oregon.
It has been used for the treatment of inflammatory skin dis-
eases including psoriasis; while its exact mechanism of action
has yet to be elucidated, its chemical constituents are thought to
have anti-inflammatory effects on the skin (Galle et al. 1994).
Balneotherapy
Balneotherapy refers to the practice of using baths (both hot
and cold) for the treatment of illnesses. In dermatology, this
practice is most commonly used for the treatment of psoriasis
and atopic dermatitis. High concentrations of salt, other
minerals and muds may be used in the baths. While the
mechanisms of action of balneotherapy have not been fully
elucidated, these baths are generally very low-risk treatments
that patients often find to be very soothing to the skin and
mentally comforting (Matz et al. 2003).
Case 1
A 35 year-old male with a many year history of plaque psoria-
sis comes to you to discuss treatment options. He has less than
5% body surface area involvement, with the largest plaques
108 8. Psoriasis
on his elbows and knees. The plaques are itchy and make the
patient very self-conscious; he has developed social anxiety
due to his condition. He has tried a number of topical steroids
over the years and prefers to avoid their use if possible. He has
no history of psoriatic arthritis and no joint pain currently.
Discussion
Since the patients body surface area in this case is small, he
may benefit from the use of bath soaks three times per week
coupled with the application of aloe vera gel to affected areas
twice daily. Cognitive behavioral therapy in the form of mind-
fulness based stress reduction should be encouraged, to help
decrease the psychosocial aspects of this patients condition.
Case 2
A 55 year old female with nail psoriasis is referred to you by
her primary care physician. She is tired of having to wear nail
polish to cover the pits and yellowing of her nails and is inter-
ested in a treatment with a low risk of side effects.
Discussion
The patient should be counseled that while nail psoriasis can
be very difficult to treat, indigo naturalis has shown some ben-
efit in the treatment of nail psoriasis. She could apply the
extract once daily for at least 12 weeks, and should be warned
about the risk of staining of the skin and clothing.
References
Aggarwal BB, Gupta SC, Sung B. Curcumin: an orally bioavailable
blocker of TNF and other pro-inflammatory biomarkers. Br J
Pharmacol. 2013;169(8):167292. doi:10.1111/bph.12131.
References 109
Introduction
Atopic dermatitis (AD) is often used interchangeably with
the term eczema, but perhaps is more accurately thought of
as a specific type (or, more likely, a collection of similar sub-
types) of eczema that often includes other allergic diseases
such as food allergies or asthma (Bos et al. 2010). Regardless
of its name, it represents a chronic, relapsing, itchy skin dis-
ease that often begins in the first years of life, but affects
patients of all ages. Its etiopathogenesis is complex and still
not fully elucidated, but is likely related to a combination of
skin barrier dysfunction, allergic/immunologic aberrations,
microflora abnormalities and pruritus (Kabashima 2013;
Kong et al. 2012).
AD affects up to 20% of children in developed countries,
and recent estimates are as high as 10% of adults having
some form of eczema as well (Silverberg and Hanifin 2013).
For such a common condition, however, a great number of
questions remain. As with other areas of alternative and
complementary therapies, scattered small and medium-sized
studies with fundamental differences in methodology defy
meaningful pooling of the evidence.
The conventional approach to management is multifaceted
and includes addressing the four main areas of dysfunction
with moisturization, anti-inflammatory agents, anti-microbials,
and anti-pruritic therapy. Allergen identification and
Clinical Considerations
There seem to be multiple subtypes of eczema, most of which
are poorly characterized. Of particular importance (Figs. 9.1
and 9.2):
Exudative and oozing lesions, wet pattern tends to
respond particularly well to antimicrobial therapies (such as
dilute bleach baths or compresses with aluminum acetate).
Eczema prominent on the head and neck area of young
adults seems to be intimately related to seborrheic dermatitis
and may share Malassezia yeast overgrowth and/or sensitiv-
ity as a contributing factor. Pulsing with oral anti-yeast agents
such as itraconazole can sometimes result in dramatic
improvement without immunosuppression.
Fig. 9.1. Oozing and crusting of facial eczema in an infant.
Top Considerations
See Tables 9.1 and 9.2.
2. Effect of olive and sunflower seed oil on the adult skin bar-
rier: implications for neonatal skin care. Danby SG, AlEnezi
T, Sultan A, Lavender T, Chittock J, Brown K, Cork MJ. Pediatr
Dermatol. 2013 JanFeb;30(1):4250. doi: 10.1111/j.1525-
1470.2012.01865.x.
19 adults were randomized to receive olive oil to one arm vs.
sunflower seed oil to the other for 4 weeks. The study found
that topical olive oil caused a worsening of the barrier function
and erythema in volunteers with and without a history of
AD. Sunflower seed oil, on the other hand, did not cause ery-
thema and preserved skin barrier function while actually
improving hydration.
Coconut Oil
Coconut oil (Cocos nucifera), particularly virgin coconut oil
(VCO),1 has been shown to be comparable with mineral oil
as an emollient (Agero and Verallo-Rowell 2004). In addi-
tion, it has also been shown to address another important
aspect of atopic dermatitis: staphylococcal colonization. In a
randomized controlled trial it was found to clear an impres-
sive 95% of staphyoloccal colonization in patients with AD
(Verallo-Rowell et al. 2008). And, similar to the findings of
sunflower seed oil, VCO has been shown to improve barrier
function in low birthweight babies (Nangia et al. 2008). When
put to a more clinical test, it actually outperformed mineral
oil in treating pediatric AD over 8 weeks in a randomized
trial (Evangelista et al. 2014), thus making it an important
alternative consideration.
1
N.B.: The term Virgin Coconut Oil is defined as coconut oil being
obtained from fresh, mature coconut kernels through mechanical or
natural means which do not lead to alteration of the oil [APCC
Standards]. This is in contrast to methods which use undesirable solvents
such as hexane to extract the oil.
118 9. Atopic Dermatitis (Eczema)
Acupuncture/Acupressure
While generally considered part of Traditional Chinese
Medicine, acupuncture and acupressure deserve independent
discussion as they have unique evidence in AD. It is based on
the idea that energy meridians in the body can become unbal-
anced and that by stimulating certain points (acupoints) with
needles, pressure, magnets, or even lasers, the flow can be
restored and rebalanced (Kampik 1976). From a conven-
tional standpoint, there are studies that show clear changes in
specific brain areas with acupuncture, and evidence that
there is endorphin production with acupuncture, suggesting a
neurocutaneous connection (Lu and Lu 2013). While formal
acupuncture would require a specially-trained practitioner,
more limited versions (including the single point study dis-
cussed below) could be performed by nearly anyone, includ-
ing patients themselves.
126 9. Atopic Dermatitis (Eczema)
Probiotics
Bacterial imbalance is clearly an important part of AD, and
beyond simply killing the bad bacteria, the concept of add-
ing back healthy bacteria has appeal. Probiotics are defined
as living microorganisms that are similar to those found on
the body in a healthy state and may be beneficial (NCCAM
website). Probiotics have proven benefit in diarrhea and irri-
table bowel syndrome (Ritchie and Romanuk 2012), and
there are some tantalizing studies which suggest an effect
may exist for AD, both in terms of prevention and possibly in
the treatment of existing disease (Kim et al. 2014). From a
clinical perspective, probiotics appear to be safe and may
have a modest effect, but many questions remain: dosage,
frequency of administration, timing, and strain type or types
all represent heterogeneity that makes coming to a final con-
clusion very difficult.
128 9. Atopic Dermatitis (Eczema)
Diet Modification
Perhaps the single most-asked question of new AD patients
and their families is: could it be something in the diet? This
notion, very appealing in its simplicity, has been heavily pro-
moted by healthcare practitioners and lay people as being a
fundamental root cause of AD (Gelmetti 2000). The truth,
however, appears to be more complex. Importantly, nearly a
third of patients with moderate or severe AD have true food
allergies; that is to say, they will develop urticaria and possi-
bly anaphylaxis within minutes of eating a food to which they
are allergic (Eigenmann et al. 1998). Undoubtedly, this type
of reaction could act as a trigger for an eczema flare, but it is
important to stress that this is not generally what people are
referring to when this topic is broached. Beyond causing an
eczematous reaction (which is difficult to test since it would
be expected to take many hours or even days to develop after
ingesting the offending food), the concept of food intoler-
ance which is sometimes described as a non-immunologic
reaction to certain foods, has further obfuscated this area
(Boettcher and Crowe 2013). While there is undoubtedly a
group for which avoiding certain foods leads to significant
improvement in eczema, this is overwhelmingly not the case
for most, and food avoidance without suggestive history or
testing has generally been found to be unhelpful.
Case 1
A 9-month-old girl presents with a long history of severe
atopic dermatitis. Since about 2 months of age, she has had
disrupted sleep, constant scratching, and open, oozing, and
bleeding skin. She has had multiple courses of oral antibiotics
and has used a number of topical corticosteroids, sometimes
132 9. Atopic Dermatitis (Eczema)
for months at a time. Despite this, she has had very little sus-
tained improvement. Her mother is very upset and explains
that she wants to get to the root of the problem rather than
just treat the symptoms. Moreover, she has read a great deal
on the internet about the dangers of topical steroids and
wants to avoid them completely, preferring to take a more
natural route.
Discussion
AD can cause a tremendous amount of misery for both the
patient and the family; the sleep disturbance alone can make for
unhappy, curt, and sometimes angry interactions. Unfortunately,
this case is not an uncommon scenario. Generally, from a con-
ventional standpoint, optimization of the four key areas would
likely result in significant improvement: aggressive moisturiza-
tion, optimized corticosteroid use with a more potent agent and
used with wet wrap therapy for up to 4-7 days until improved,
then resting the skin, and adding dilute bleach baths daily for
antimicrobial effects. Given the concerns about corticosteroids,
we must look to other agents for anti-pruritic and anti-inflam-
matory effects here, and we can use more natural agents to
cover several of these areas at once.
Topical sunflower seed oil offers anti-inflammatory, anti-
itch, and moisturizing properties and is safe and inexpensive;
perhaps integrating this with an infant massage once or twice
daily would also help relax the family and improve adherence.
A more occlusive moisturizer should be applied over the oil,
and this could be done after a dilute bleach bath, so that the
skin is clean and hydrated, then the oil is applied, and finally
an occlusive emollient seals everything in. Oral vitamin D
supplementation is also safe and inexpensive and could be
added, along with probiotics (which remain somewhat con-
troversial and walk the line between alternative and conven-
tional medicine). Finally, topical B12 cream or topical
cardiospermum plant extract cream could be used in lieu of a
corticosteroid for several weeks; close follow up might show
some significant improvement and perhaps more willingness
to try an appropriate corticosteroid for brief bursts in severe
areas. Looking forward, although such plans do not truly
Case 2 133
Case 2
A 29-year-old man with a history of sensitive skin presents
with widespread erythema, scaling, and multiple excoriations
over most of the body, including the head and neck area.
There is significant scaling on the scalp. The patient notes that
he has multiple food allergies, seasonal allergies, and that it
seems that nearly everything triggers a flare in the past several
years. He reports that the itch is maddening and that he can-
not stop rubbing his face some nights. He has used many topi-
cal corticosteroids, topical calcineurin inhibitors, and finds
that only oral prednisone gives him relief, albeit short-lived.
Discussion
This variant of AD is very difficult to treat and the head and
neck involvement suggests that there may be a component of
malassezia yeast, although this is not fully elucidated or agreed
upon. From a conventional medicine standpoint, a trial of a
systemic anti-yeast agent such as itraconazole could be very
helpful if malassezia is indeed playing a role. Failing that, this
patient is a candidate for systemic immunosuppression with an
agent such as cyclosporine, in addition to maximizing moistur-
ization and topical anti-inflammatory therapy.
From an integrative standpoint, topical coconut oil may be
helpful as it has antimicrobial effects and is soothing and mois-
turizing. Traditional Chinese Medicine may also be of help here;
herbal remedies seem to have an effect on these more allergic
variants and those with asthma, so might be worth exploring.
Finally, given that itch is such an important component, using
the large intestine 11 point for home acupressure or suggesting
formal acupuncture treatments may have significant benefits in
controlling the disease.
134 9. Atopic Dermatitis (Eczema)
References
Agero AL, Verallo-Rowell VM. A randomized double-blind con-
trolled trial comparing extra virgin coconut oil with mineral oil as
a moisturizer for mild to moderate xerosis. Dermatitis.
2004;15(3):10916.
Kim SO, Ah YM, Yu YM, Choi KH, Shin WG, Lee JY. Effects of
probiotics for the treatment of atopic dermatitis: a meta-analysis
of randomized controlled trials. Ann Allergy Asthma Immunol.
2014;113(2):21726.
Tyler VM, Premila MS. Ayurvedic herbs: a clinical guide to the heal-
ing plants of traditional Indian medicine (Google eBook)
Routledge, Oct 12, 2012, Health & Fitness, 404p.
Introduction
Urticaria, or hives, is a common condition with a lifetime
prevalence of approximately 25% (Williams and Sharma
2015). Transient dermal red pruritic papules and plaques
form due to the release of various mediators from mast cells.
These mediators include both histamine and prostaglandins
and cause increased vascular permeability leading to edema
and lesion progression. Urticaria may be difficult to treat and
can significantly impair quality of life. Angioedema is an
acute swelling of the dermis and subcutaneous tissue or the
mucosa and submucosal tissue. This rapid swelling can cause
emergent airway obstruction and may warrant urgent care.
Classification of urticaria is based on the duration of the epi-
sode. Urticaria of less than 6 weeks duration is considered
acute while episodes persisting more than 6 weeks are classi-
fied as chronic.
The pathogenesis of urticaria is poorly understood.
Potential triggers are identified in only 1020% of cases.
Triggers for urticaria are either allergic or non-allergic.
Allergic triggers include medications and food substances.
Non- allergic triggers include stress, infections (viral, bacterial,
Clinical Considerations
See Fig. 10.1.
Stress Reduction 139
Top Considerations
See Table 10.1.
Stress Reduction
Many authors suggest that psychological stress can exacer-
bate urticaria; however, the exact mechanism by which this
occurs is not well-understood (Spickett 2014 and Dave et al.
140 10. Urticaria and Angioedema
Vitamin D Supplementation
Vitamin D (cholecalciferol) is a fat-soluble hormone that
plays a number of roles in regulation of the immune system,
and thus may be relevant to allergic disease pathogenesis and
treatment (Benson et al. 2012). Importantly, patients with
chronic urticaria tend to have lower serum Vitamin D levels
compared to controls (Murzaku et al. 2014), but improve-
ment in urticaria has been reported in patients treated with
Vitamin D supplements with both low or normal baseline
levels of vitamin D. The optimized dosing and the mechanism
of action have yet to be determined, but this relatively safe
supplement is clearly worthy of consideration.
Dietary Modification
The relationship between diet and urticaria is complex and
controversial. Foods have been reported to both exacerbate
urticaria and ameloriate it, illustrating the conflicting infor-
Dietary Modification 143
Case 1
A 34 year-old healthy woman with an 8-month history of
urticaria but no other active medical problems is referred to
you by her allergist for a skin biopsy to exclude urticarial
vasculitis. Her lesions last up to 24 hours and fail to clear with
cetirizine 10 mg PO QAM and fexofenadine 180 mg PO
QHS. Prednisone has temporarily cleared the lesions, but the
hives relapse after discontinuing oral corticosteroid therapy.
The skin biopsy is negative for urticarial vasculitis and the
patient expresses her frustration. She indicates that she is
prepared to follow a gluten-free diet and asks if you believe
this will be of benefit.
References 145
Discussion
You review with the patient that there is little evidence that
gluten-free diets help chronic idiopathic urticaria in the
absence of celiac disease. You should discourage her from this
approach, but could suggest further workup if she has not been
adequately evaluated. You could also discuss the possible role
of a pseudoallergen-free diet, as some evidence exists that it
may be helpful in some cases, and discuss stress-reduction
approaches such as hypnosis, which may be of benefit.
Case 2
A 26-year-old male with a 2-year history of urticaria presents
with chronic idiopathic urticaria. While daily cetirizine has
given him fairly good control, he prefers an alternative approach
and wishes to try vitamin D supplementation. You check his
serum Vitamin D level and it is within the normal range. Is
there a role for Vitamin D supplementation in this setting?
Discussion
In this case, you could cite a recent RTC that found that high
dose Vitamin D supplementation (4,000 IU/day) improved
chronic urticaria independent of baseline vitamin D status. You
can support the use of this dose for up to 12 weeks and note
that this can be done in conjunction with cetirizine.
References
Benson AA, Toh JA, Vernon N, Jariwala SP. The role of vitamin D in
the immunopathogenesis of allergic skin diseases. Allergy.
2012;67(3):296301.
Dave ND, Xiang L, Rehm KE, Marshall Jr GD. Stress and allergic
diseases. Immunol Allergy Clin North Am. 2011;31(1):5568.
146 10. Urticaria and Angioedema
Introduction
A substantial area of general dermatology comprises
pigmentary complaintseither too much pigmentation or
too little. From lentigines (sun spots), melasma, and post-
inflammatory hyperpigmentation, to pityriasis alba and vitil-
igo, there is a spectrum of disorders that results in dark or
light areas on the skin. Some of these are addressed in other
sections more directly; here we will focus exclusively on the
aspect of color. While generally not possessing serious under-
lying medical implications, dyspigmentation can have devas-
tating psychological effects and a significant impact on the
quality of life of patients (Lieu and Pandya 2012).
From a scientific standpoint, alterations in melanocyte
density, melanin concentration, or both can result in anoma-
lies of skin pigmentation (Nicolaidou and Katsambas 2014).
Some diseases of hyperpigmentation such as melasma may
have an epidermal component (which often responds to topi-
cal therapies), a dermal component (which is very difficult to
treat), or may be mixed (Sanchez et al. 1981).
Melasma is the representative disease in the category of
hyperpigmentation, and its pathogenesis appears to be multi-
factorial: genetics, hormones and sun exposure all appear to
play a role (Grimes 1995). Patients with melasma, sometimes
called the mask of pregnancy, often give a history of
current or previous oral contraceptive use, and the signs of
Top Considerations
See Tables 11.1, 11.2, and 11.3.
Vitamin C
Vitamin C is the most abundant water-soluble antioxidant in
human skin; it cannot be synthesized by the body and must be
obtained through oral or topical consumption. Oral vitamin
C consumption does not significantly increase cutaneous
concentration, so topical formulations of vitamin C have
been extensively studied for their role in treating photodam-
age and cutaneous aging, but reports of improvement in
150 11. Disorders of Pigmentation
Soy
Soybeans, rich in protein and touted for their many potential
health benefits, are being increasingly studies for their use in
many diseases. Soy contains the serine protease inhibitors
soybean trypsin inhibitor (STI) & Bowman-Birk protease
inhibitor, both of which prevent melanosome transfer to
keratinocytes via inhibition of PAR-2 receptors present on
keratinocytes (Paine et al. 2001). Soy extracts have also been
shown to inhibit UVB-induced skin damage in vitro, making
them good candidates for consideration in treating increased
pigmentation (Chen et al. 2008). However, the actual clinical
evidence is somewhat sparse, underscoring the need for fur-
ther study.
Niacinamide
Niacinamide (also known as nicotinamide) is a form of vita-
min B3. It has been shown in vitro to inhibit the transfer of
melanocytes to keratinocytes (Hakozaki et al. 2002), and has
been studied for its effect of cutaneous hyperpigmentation.
Niacinamide also functions as an anti-oxidant, which may be
useful in prevention of further pigmentation (Otte et al.
2005). It is used in several other contexts safely (e.g., acne and
auto-immune bullous diseases), is inexpensive, and readily
available in a number of formulations making it an attractive
adjunctive therapy for pigmentation.
Licorice
Licorice root (glycyrrhiza glabra) has been shown to inhibit
tyrosinase (a rate-limiting enzyme that controls the produc-
tion of melanin) and also possesses anti-oxidant and anti-
inflammatory properties (Adhikari et al. 2008). Licorice
root contains several components known to affect melanin
production: glabridin has been found to the constituent with
the most potent inhibitory effect on tyrosinase (Kim and
Uyama 2005). Licorice extract is found in many over-the-
counter skin lightening preparations in varying concentra-
tions, often combined with other ingredients potentially for
a synergistic effect.
Ginkgo Biloba
Ginkgo biloba is a unique species of tree found in China,
widely cultivated and used in traditional medicines. Although
a specific mechanism of action is not known for ginkgo, it
appears to have anti-inflammatory, immunomodulatory, and
antioxidant properties all of which could potentially help in
vitiligo which may have an oxidative stress component
(Szczurko and Boon 2008). Interestingly, psychological stress
may play a role in vitiligo, and there is evidence that ginkgo can
have anxiolytic effects that may also be useful (Woelk et al.
2007). Indeed, this category of effect may in part by responsi-
ble for cognitive improvements in humans with dementia
(Szczurko and Boon 2008). In terms of safety, there is a litera-
ture that suggests it can increase risk of bleeding in some sce-
narios, particularly for patients on anticoagulants, but this does
not appear to be a major risk for otherwise healthy patients
(Mili et al. 2014). Its relative safety, low cost, and ease of
administration make it a very appealing option for vitiligo, but
it probably does not have pigment-stimulating effects directly
and is most likely limited to vitiligo because of this.
l-Phenylalanine 157
l-Phenylalanine
Phenylalanine is an essential amino acid involved in melanin
synthesis. It is widely available and is part of dietary proteins
and supplements. In vitiligo treatment, supplemental l-
phenylalanine is thought to provide a substrate for melanin
synthesis, and is generally used along with ultraviolet photo-
therapy to encourage repigmentation (Tamesis and Morelli
2010). While it appears very safe, the age of the studies and lack
of recent evidence is not reassuring. Larger well-designed trials
158 11. Disorders of Pigmentation
Vitamins
In the search for safe, effective alternatives to treat vitiligo, cer-
tain vitamins have been suggested as potentially being thera-
peutic. Specifically, vitamin B12 deficiency has been correlated
with vitiligo, possibly as part of multi-system autoimmunity
(Shankar et al. 2012). Patients often ask about vitamins for vit-
iligo, cementing their presence here. Unfortunately, there is
extremely limited data available, but the sparse evidence seems
to suggest that folate, B12, or vitamin E supplementation will
probably not make a significant difference for most.
Polypodium Leucotomos
Polypodium leucotomos (PL) is an extract from an indigenous
fern from Central and South America, used in traditional medi-
cine for inflammatory diseases of the skin (Palomino 2015).
When taken orally, there is a sizable body of evidence that PL
decreases sensitivity to ultraviolet radiation, blocking sunburn,
decreasing DNA damage and slowing tumor development, in
part due to its antioxidant properties (Middelkamp-Hup et al.
2004). Given the oxidative stress hypothesis for vitiligo, these
properties make PL a potential therapeutic candidate.
Case 1
A 42 year-old woman presents for melasma and some solar
lentigines on the face. She has tried hydroquinone in the past
and had some improvement, but is now concerned about the
side effects of this medication and is not interested in chemi-
cal peels or intense pulsed light therapy. What are some inte-
grative options for her?
Discussion
In addition to stressing strict, daily photoprotection with a
broad-spectrum sunscreen (perhaps containing soy as well), she
may benefit from a trial of a topical vitamin C preparation twice
daily, and perhaps a topical licorice formulation if available.
Case 2
A 17 year-old boy presents with a 3-year-history of general-
ized vitiligo that continues to worsen. He tried topical corti-
costeroids for many months and developed striae on the arms
162 11. Disorders of Pigmentation
which he and his family are very upset about. They are inter-
ested in safe, alternative options for his vitiligo.
Discussion
Phototherapy, preferably NB-UVB, two to three times weekly
would be an excellent start for him. It is relatively safe and prob-
ably has the best evidence of the conventional treatments. If the
family were open to this, Polypodium leucotomos taken daily
and 1 hour before phototherapy may enhance repigmentation
and may decrease some of the risks of UV irradiation to the skin.
If phototherapy were not possible (or perhaps in addition to
the above), Ginkgo biloba could be recommended twice daily
with the caveat about potentially increasing bleeding risk in
some settings.
References
Adhikari A, Devkota H, Takano A, Masuda K, Nakane T, Basnet P,
Skalko-Basnet N. Screening of Nepalese crude drugs tradition-
ally used to treat hyperpigmentation: in vitro tyrosinase inhibi-
tion. Int J Cosmet Sci. 2008;30(5):35360.
Introduction
Despite the fact that they are benign and generally self-
limited, warts and molluscum are responsible for an inordi-
nately high percentage of dermatology consultations: warts
alone constitute some 21% of all dermatology referrals
(Boull and Groth 2011), while molluscum has an estimated
prevalence in children of up to 11.5% (Olsen et al. 2014).
Warts are caused by the human papillomavirus (HPV) and
can infect epithelial and mucosal tissue throughout the body.
Certain strains have predilections for particular body areas,
such as HPV-2, HPV-27, and HPV-57 for warts on the hands
and feet (Tomson et al. 2011). Although warts often appear as
solitary, defined lesions, the virus may be present at distant
sites and may persist for many years. Conventional therapy is
focused on stimulating the innate immune response to the
virus via tissue destruction and irritation (Micali et al. 2004).
This comes to bear on the fact that over half of patients
report moderate-to-severe discomfort from their warts
(Ciconte et al. 2003), an aspect of warts that is often over-
looked, and is almost certainly exacerbated by destructive
and irritating therapies. Thus, it is possible that for this reason,
or perhaps because of the fact that even the best conventional
therapies rarely demonstrate efficacy above 60% that many
are drawn to alternative treatments.
Clinical Considerations
See Figs. 12.1 and 12.2.
Propolis
Propolis is a botanical, resinous mixture that serves as a seal-
ant in bee hives, and has been used since antiquity as a medi-
cine (Kuropatnicki et al. 2013). In more modern times, it has
shown promise as an immunomodulator, suggesting a mecha-
nism of action in this setting (Sforcin 2007).
Zinc
Zinc may play a role in immunity against viruses, and levels have
been found to be deficient in some patients with refractory warts
(Lazarczyk et al. 2008). There are data for both oral zinc with its
significant risk of nausea, as well as topical preparations that do
not share this unpleasant side effect in the treatment of warts.
Cantharidin
An extract of the blister beetle (family Meloidae), canthari-
din has a long history in medicine, but specifically has been
used to treat molluscum since the 1950s. It is classified as a
vesicant (blister-producing agent), and its mechanism of
action is thought to be by causing acantholysis via degenera-
tion of desmosomal plaques (Bertaux et al. 1988) in the skin.
Despite its fairly wide usage, it has never been FDA-approved
in the US, yet remains a very viable, natural alternative.
Case 1
A 14 year-old-boy with warts on the hands and elbow for 3
years presents for evaluation. He had tried various prepara-
tions of salicylic acid night for nearly 1 year, had tried and
failed home cryotherapy and then in-office cryotherapy for
over 6 months, oral cimetidine, topical imiquimod, topical
5-fluorouricil cream, and even had some lesions surgically
removed, to no avail. One of the warts treated with cryo-
therapy developed a large, painful blister and became a ring
wart: a larger, ring-shaped wart at the edge of the blister.
The patient and his family are upset and want a non-
destructive therapy today.
Discussion
While other conventional methods are still possiblethere
are many options for treating wartsoffering something
more gentle, at least initially, may be useful in this situation.
Oral propolis (as long as he does not have a known bee
allergy) along with topical zinc oxide could be an effective
yet mild initial approach. Should that fail after several
months, considering a trail of topical garlic to the lesions
could also be worthwhile.
174 12. Warts and Molluscum
Case 2
A 9-year-old girl with a history of moderate atopic dermatitis
presents with dozens of molluscum on the arms, legs, and
drunk. She has developed a severe eczema flare in the treated
areas after using imiquimod cream for several days for the
molluscum. They recount how they were told that the mol-
luscum were totally harmless and did not have to be treated,
but now are frustrated that nearly a year has gone by and the
lesions are still present. They would like a gentle but effective
approach.
Discussion
Offering destructive therapy such as cryotherapy or curettage
would be very reasonable here, but if the skin is inflamed and
the child is afraid of these approaches, they can be very diffi-
cult. A trial of cantharidin is generally very well-tolerated, even
in the setting of inflamed skin. At home application of lemon
myrtle could be a gentle adjunctive therapy in such a case.
References
Bertaux B, Prost C, Heslan M, et al. Cantharide acantholysis: endog-
enous protease activation leading to desmosome plaque dissolu-
tion. Br J Dermatol. 1988;118:15765.
Introduction to Fungi
Cutaneous fungal infections can be classified into infec-
tions that are limited to the stratum corneum, hair and nails
and, infections that are seen deeper in the skin, involving
the dermis and the subcutaneous tissues. Superficial myco-
ses include: tinea versicolor, tinea nigra, pityrosporum fol-
liculitis, tinea corporis, tinea cruris, tinea barbae, tinea
capitis, tinea pedis, and tinea unguium. Numerous genera
are responsible for superficial mycoses including, but not
limited to: Malassezia, Trichophyton, Microsporum and
Epidermophyton. Diagnosis and treatment of these infec-
tions can pose a challenge. Topical antifungals may be inef-
fective if the organism exhibits resistance to the antifungal
agent. Additionally, the topical antifungals themselves can
cause allergic and irritant skin reactions. Oral agents are
sometimes used when topical agents are not helpful and
these agents are associated with a high incidence of sys-
temic side effects. Many patients seek alternative
approaches to traditional therapy to avoid these potential
side effects. Worldwide, many plants are used to treat vari-
ous bacterial and fungal infections. While some have been
looked at in vitro, a minuscule percentage of these plants
have been subjected to controlled clinical trials (Martin
and Ernst 2004). Here we present primary and secondary
considerations for treatment of fungal infections with plant
Secondary Considerations
Coriander Oil
Coriander (Coriander sativum) is an annual herb in the family
Apiaceae. Although coriander is the seed of the cilantro
(Chinese parsley) plant, their flavors and properties are very
different and they cannot be substituted for each other.
Coriander has both culinary and medicinal applications. It is
common in South Asian, Southeast Asian, Middle Eastern and
Latin American cuisine, to name only a few. In addition to culi-
nary uses, coriander has been touted as having many medicinal
and pharmacological applications including: anti-microbial,
anti-oxidant and anti-inflammatory properties (Sahib et al.
2013). Essential coriander oil has shown antibacterial activity
towards many bacterial strains including Streptococcus pyo-
genes, and methicillin-resistant Staphylococcus aureus (MRSA)
in vitro (Casett et al. 2012). In addition, in vitro studies also
indicate that coriander essential oil shows promise in eradicat-
ing Candida (Freires et al. 2014).
Solanum chrysotrichum
Solanum is a diverse genus of flowering plants. Included in the
Solanum group are the tomato and the potato. The genus con-
tains both species used for food crops and ornamentals.
Solanum chrysotrichum is one species that is used in folk medi-
cine. A recent randomized controlled trial showed that saponin
SC-2 from Solanum chrysotrichum showed its effectiveness on
women with vulvovaginal candidiasis. It was shown to have a
similar clinical effectiveness to that of ketoconazole, but
obtained a smaller percentage of mycological effectiveness
and 100% tolerability (Herrera-Arellano et al. 2013). An addi-
tional study found the Saponin SC to be effective against can-
dida non-albicans species, or fluconazole and ketoconazole
resistant strains of yeast (Herrera-Arellano et al. 2007).
Garlic
Garlic (Allium sativum) is perennial blub most known for its
culinary uses. Folk uses of garlic have ranged from the treat-
ment of leprosy and tuberculosis to simple bacterial infections
(Bayan et al. 2014). Garlic is comprised of sulfur-containing
compounds, vinyldithiins, and ajoenes. The bulb also contains
an odorless, colorless, sulfur-containing amino acid called
alliin. When the bulb is ground, alliin is converted to
2-propenesulfenic acid which dimerizes to form allicin and
allicin is what gives the pungent odor of garlic. One study
looked at the effect of garlic and pure allicin on the growth of
hyphae in T. rubrum using electron microscopy and found that
allicin is more efficient in inhibition of the growth of hyphal
cells compared to garlic extract but that both were successful
in the treatment of dermatophytosis (Aala et al. 2014).
Ageratina pichinchensis
Ageratina pichinchensis is a perennial in the family Asteraceae.
In Mexican traditional medicine, the extract obtained from
this plant is utilized to treat skin injuries, such as wounds and
infections cause by fungi (Romero-Cerecero et al. 2013).
Clinical trials have supported the use of Ageratina pichinche-
nis for the use of onychomycosis and tinea pedis.
Introduction to Bacteria
It is thought that roughly 20% of outpatient dermatology
visits are for bacterial skin infections. Skin infections are
caused by both gram-positive (e.g., staphylococci and strepto-
cocci) and gram-negative (e.g., pseudomonas aeruginosa)
organisms. A rapidly increasing number of resistant organisms
are making these infections increasingly difficult to treat.
Costly drugs, decreased access to therapies and a global
increase in multi-drug resistance of pathogens has precipitated
188 13. Fungal and Bacterial Infections
Honey
Honey is a bee product made using the nectar from flowers.
It is a supersaturated solution composed of mainly fructose
and glucose, as well as proteins and amino acids, vitamins,
190 13. Fungal and Bacterial Infections
Case 1
A 29 year old man comes in with recurrent (culture positive)
Staphylococcus aureus skin infections. He works as a nurse in
the ICU and none of his cultures have ever shown resistant
strains. On physical exam he has a few erythematous follicu-
lar papules and a crusted area overlying a fissure on his lower
leg. He has taken numerous courses of antibiotics to treat
these infections including cephalosporins and tetracyclines.
He has a history of childhood eczema and notes that is skin is
always dry. He comes in very frustrated and worried about
antibiotic resistance especially in light of his professional
exposures. He is asking what other things can be done both
to prevent and treat these infections.
Discussion
This is a very common scenario, both in that in involves a
healthcare worker and an atopic dermatitis patient. In addition
to counseling this type of patient on the use of dilute bleach
baths, a very important consideration in this case, one could
also recommend washing with a tea tree oil cleanser. As the
irritant and contact dermatitis rate with tea tree oil is not insig-
nificant, using a suitable concentration is imperative. One
could recommend either a commercially available tea tree oil
wash, or consider adding 1012 drops of the essential oil to a
full bath tub. This regimen can be done every day for treatment
and once a week for prophylaxis or de-colonization.
Case 2
A 45 year old woman comes in with a long-standing history
of tinea versicolor. She notes it is worse in the summer with
the increase in humidity and she has done everything to
treat it including a dose of oral ketoconazole and recently an
application of baking soda that she read about on the
Internet. She is frustrated by the appearance and is looking
192 13. Fungal and Bacterial Infections
for additional options she could try. On physical exam she has
red brown round scaling on the chest and upper back that are
KOH positive for tinea versicolor.
Discussion
Tinea versicolor, albeit a benign and often asymptomatic erup-
tion for patients, tends to illicit frustration and may be challeng-
ing to treat. Topically, sulfur washes, ketoconazole, or selenium
sulfide are all commonly recommended and can be effective.
When a patient is looking for something in addition or in lieu
of these prescription options they could consider washing the
area with a tea tree oil product, either a commercially available
wash with tea tree oil in it or by adding 1012 drops of the
essential oil of tea tree to a full bath tub and using as a soak. In
addition, topical oil of bitter orange has been shown to be effec-
tive against fungal species and can be tried in the same dilution.
Note: neither product should be ingested orally.
References
Aala F, Yusuf UK, Nulit R, Rezaie S. Inhibitory effect of allicin and
garlic extracts on the growth of cultured hyphae. Iran J Basic
Med Sci. 2014;17(3):1504.
Knight TE, Hausen BM. Melaleuca oil (tea tree oil) dermatitis. J Am
Acad Dermatol. 1994;30:4237.
Maddocks SE, Lopex MS, Rowlands RS, Cooper RA. Manuka honey
inhibits the development of Streptococcus pyogenes biofilms and
causes reduced expression of two fibronectin binding proteins.
Microbiology. 2012;158(pt3):78190.
194 13. Fungal and Bacterial Infections
Malik KI, Malik MA, Aslam A. Honey compared with silver sulphad-
iazine in the treatment of superficial partial-thickness burns. Int
Wound J. 2010;7(5):4137.
Introduction
Seborrheic dermatitis (SD) is characterized by a scaly, inflam-
matory reaction pattern in typically oily areas of the face,
scalp, and occasionally chest. Although not completely under-
stood, the pathophysiology is intimately linked with the com-
mon skin commensal yeast Malassezia. An overgrowth of this
yeast, and/or an overzealous immune response to it appears
to lie at the heart of this chronic intermittent eruption
(Pedrosa et al. 2014).
Fittingly, there are two major categories of conventional
treatments available to address SD: those which calm the
aberrant immune response, including topical corticosteroids;
and those which putatively decrease the Malassezia on the
skin, including a number of anti-yeast agents. Several of the
alternative therapies discussed below appear to have fea-
tures of both of these categories, and are often used along-
side conventional agents with good effect (Dessinioti and
Katsambas 2013). Of note, SD is intimately related to scalp
psoriasis and can be difficult to distinguish; one paper below
is from the scalp psoriasis literature, but seems broadly
applicable to the matter at hand.
Clinical Considerations
See Figs. 14.1 and 14.2.
Fig. 14.1. Seborrheic dermatitis may affect the lower face, present-
ing as erythematous patches with a greasy appearing scale.
Tea Tree Oil 197
Top Considerations
See Table 14.1.
Honey
Honey has been used as a therapeutic skin treatment since
ancient times, and is still a mainstay of therapy in Eastern
medicine such as Ayurveda and Traditional Chinese medicine.
It has been shown to possess anti-inflammatory and antimi-
crobial properties (Burlando and Cornara 2013). Due to its
viscous nature, it is often diluted prior to use.
Sulfur
Sulfur is a yellow, non-metallic element with antifungal, anti-
bacterial and keratolytic properties. It is often used in combi-
nation with other agents, such as salicylic acid or sodium
sulfacetamide (a sulfonamide with antibacterial properties),
200 14. Seborrheic Dermatitis
Salicylic Acid
Salicylic acid, derived from bark of the willow tree, is best
known as the precursor to aspirin (acetylsalicylic acid), but is
also frequently used as a topical treatment for cutaneous
Case 1 201
Case 1
A 25 year old male presents with a few year history of dan-
druff of the scalp. He reports itching, flaking and irritation,
and sometimes also has redness and flaking of his eyebrows
and ears. He has tried a number of over-the-counter sham-
poos with minimal improvement, and has tried applying olive
oil to treat his dry scalp. The patient is concerned about
potential side effects of prescription shampoos and topical
steroids and is interested in natural treatment methods.
Discussion
This patient could be counseled to discontinue the use of olive
oil as a topical treatment for his scalp, as it may be worsening
his condition. He may benefit from the use of a tea tree oil
shampoo several times weekly, alternating with a salicylic acid
formulation to decrease scaling.
202 14. Seborrheic Dermatitis
Case 2
A 35 year old female presents with itching and flaking of the
scalp, which has persisted despite the use of prescription anti-
fungal shampoos. She is interested in alternative therapies for
her condition.
Discussion
This patient may benefit from a solution of dilute honey
applied to the scalp every other day for 1 month, along with the
use of a topical sulfur/sodium sulfacetamide preparation a few
times per week.
References
Burlando B, Cornara L. Honey in dermatology and skin care: a
review. J Cosmet Dermatol. 2013;12(4):30613.
Introduction
Pruritus (synonymous with itch) can be defined as an
unpleasant sensation that provokes the desire to scratch
(Pfab et al. 2013). It is a common feature of many inflam-
matory skin diseases such as atopic dermatitis, irritant and
allergic dermatitis, scabies, and lichen planus, but may also
be seen in a large number of systemic conditions, including
cholestasis, thyroid disorders, and kidney failure. Thus, it is
important to determine the cause of the itch before
attempting solely symptomatic treatment. Itch is classified
as either acute (<6 weeks in duration) or chronic (>6 weeks
in duration), and there is a significant psychosocial impact
to pruritus that should not be overlooked (Callahan and
Lio 2012). Beyond this, defining whether the itch is local-
ized or generalized is also important for both diagnosis and
therapy.
The pathophysiology of itch is nearly as diverse as its causes:
there are both central and peripheral mechanisms involved,
and a number of different pathways have been identified
Acupuncture/Acupressure
Acupuncture is based on the idea that energy meridians in
the body can become unbalanced and that by stimulating
certain points (acupoints) with needles, pressure, magnets,
or even lasers, the flow can be restored and rebalanced
(Kampik 1976). From a conventional standpoint, there are
studies that show clear changes in specific brain areas with
acupuncture, and evidence that there is endorphin produc-
tion with acupuncture, suggesting a neurocutaneous connec-
tion (Lu and Lu 2013). While formal acupuncture would
require a specially-trained practitioner, more limited ver-
sions (including the single point study discussed below)
could be performed by nearly anyone, including patients
themselves.
2. Effect of olive and sunflower seed oil on the adult skin bar-
rier: implications for neonatal skin care. Danby SG, AlEnezi
T, Sultan A, Lavender T, Chittock J, Brown K, Cork MJ. Pediatr
Dermatol. 2013 JanFeb;30(1):4250. doi:10.1111/j.1525-
1470.2012.01865.x.
19 adults were randomized to receive olive oil to one arm vs.
sunflower seed oil to the other for 4 weeks. The study found
that topical olive oil caused a worsening of the barrier function
and erythema in volunteers with and without a history of
atopic dermatitis. Sunflower seed oil, on the other hand, did
not cause erythema and preserved skin barrier function while
actually improving hydration. Dysfunctional barrier almost
certainly occurs after scratching or rubbing of the skin and
likely contributes to the itch-scratch cycle, regardless of the
underlying etiology.
Aromatherapy
Aromatherapy refers to the use of essential oils extracted
from botanical sources to treat diseases (Cooke and Ernst
2000). It is commonly administered by massaging into the
skin, although can be vaporized and inhaled, taken orally, or
212 15. Pruritus
Case 1
A 25-year-old woman presents with a 10 year history of itchy
skin. She feels it worsens during times of stress and she
admits to scratching and picking at her skin regularly. She has
had extensive evaluation by two internists in the past 2 years
which did not identify an underlying cause, and she has failed
a number of conventional topical and oral therapies. On
exam, she has multiple excoriated papules and nodules, espe-
cially on the arms and legs. She is asking for something safe
that will give her relief.
Case 2 213
Discussion
From the description, she may have prurigo nodularis, a
poorly-understood condition without a true primary skin issue
beyond itch. The hint that her itching worsens during times of
stress supports at least a behavioral component.
Beyond ensuring that her skin is well-moisturized and that
her barrier is as functional as possible, sunflower seed oil (ide-
ally followed by a more occlusive moisturizer) also has the
potential of being anti-inflammatory and thus may help with
the pruritus here. Asking her to massage it into the skin may
help in a fashion similar to that of the Aromatherapy study.
Discussing hypnosis, biofeedback, acupressure, or cognitive
behavioral therapy seems very appropriate in this case given
the long history and the exacerbation with stress.
Case 2
A 79-year-old man with a history of sensitive skin presents
with total body pruritus for 1 year without any rash. He com-
plains of inability to sleep at night due to the itch, and that he
is going crazy because of it. He tried several antihistamines
without relief, but is wary of starting antidepressants due to
side effects. Topical therapies have had almost no effect.
Discussion
Elderly patients present even more of a challenge, as there is
greater possibility of harm from conventional medications. In
this case, more powerful medications may not be the answer,
and so alternatives are more attractive. After a suitable evalua-
tion for the pruritus has been performed to exclude systemic
diseases, acupuncture is gentle and may provide significant
relief, especially if he is able to seek treatments with an experi-
enced practitioner. Aromatherapy with massage might also be
reasonable here as it could be done in the home, especially if
going to the acupuncturist is unfeasible.
214 15. Pruritus
References
Callahan SW, Lio PA. Current therapies and approaches to the treat-
ment of chronic itch. Int J Clin Rev. 2012. doi:10.5275/
ijcr.2012.02.01.
lycopene, 13 BCC, 33
sun protection, 2830 urticaria, 138, 142144
Chrysanthellum indicum, 7879 Docosahexaenoic acid (DHA), 97
Cobalamin. See Vitamin B12
Coenzyme Q10 (CoQ10)
cancers, 43 E
melanoma, 44 Eczema. See also Atopic
Cognitive behavioral therapy dermatitis (AD)
psychosocial aspects, 108 dyshidrotic, 113
skin and immune system, 107 exudative and oozing lesions,
Communityassociated 112
methicillin resistant facial eczema, 112, 113
Staphylococcus aureus itraconazole, 112
(CA-MRSA), 185 seborrheic dermatitis, 112
Complementary and alternative Eicosapentaenoic acid (EPA), 97
medicine (CAM), 9596 Epicatechin gallate (ECG), 9
conventional products safety, Epigallocatechin-3-gallate
215 (EGCG), 9, 2728, 188
dozen research centers, 215216 Erythema, 133
NCCIH, 215 Escharotics
Complementary medicine, 3, 119 BCC, 4546
Conventional medicine, 2, 3, 120, FDA and National Cancer
132, 133, 215 Institute, 45
Coriander (Coriander sativum) oil MMS, 45
antibacterial activity, 181
interdigital tinea pedis, 181
Curcumin. See Turmeric (curcumin) F
Fish oil
omega-3 fatty acids, 97
D PASI scores, 99
Dandruff psoriasis, 9799
honey, 199 Flavonols, 1011
sulfur, 199200 Food and Drug Administration
tea tree oil, 197198 (FDA), 45
Depigmentation Food intolerance, 129
ginkgo biloba, 156157 Fungal infections
l-phenylalanine, 157158 ageratina pichinchensis, 186187
polypodium leucotomos, coriander oil, 181182
160161 garlic, 185186
vitamins, 159160 oil of bitter orange, 182183
Dermatoheliosis, 7 solan chrysotrichum, 183185
Dermatology Life Quality Index superficial mycoses, 177
(DLQI) score, 103 tea tree oil, 179, 181
Dietary modifications tinea corporis (ringworm), 178
acne, 6163 tinea pedis + onychomycosis, 178
angioedema, 138 topical antifungals, 177
atopic dermatitis (AD), 129130 treatment, 179
220 Index
G Medihoney, 190
Garlic (Allium sativum) Staphylococcus aureus skin
antiviral effects, 169 infections, 191
fungal infections, 185186 therapeutic and prophylactic
hair loss, 8788 effects, 199
tinea pedis, 185186 tinea versicolor, 192
warts, 169170 Traditional Chinese medicine,
Gingko biloba 199
anxiolytic effects, 156 Hoxsey, H., 45
repigmentation, 157 Human papillomavirus (HPV).
vitiligo, 156157, 160 See Warts
Vitiligo Area Scoring Index Hyperpigmentation
(VASI), 157 hydroquinone, 148
Gossypin, 47 lentigines, 148
Green tea licorice, 155156
acne, 6364 melasma, 147148
EGCG and ECG, 8 niacinamide, 1718, 153154
GTPs, 9 soy, 152153
UVA & UVB induced sunscreen vs. control
erythema, 910 moisturizer, 154
Green tea polyphenols (GTPs), 9 treatment, 150
vitamin C, 149, 151152
Hypnosis
H alopecia areata, 90
Hair loss atopic dermatitis, 130131
alopecia areata, 87 definition, 90
androgenetic alopecia (AGA), itch-scratch cycle, 130
8385 stress, 130
aromatherapy, 89 stress-relieving techniques,
garlic (Allium sativum), 8788 131
hypnotherapy, 9092 Verbally Active Distraction,
onion extract, 8889 141
procyanidins, 8687 Hypnotherapy. See also Hypnosis
raspberry ketone (RK), 8586 AD, 130, 207
Hanifin, J.M., 2 hair regrowth, 90
Heinrich, U., 11
Hives. See Urticaria
Honey I
antimicrobial properties, 190 Indigo naturalis
Ayurveda, 199 Chinese medicine, 99
burns, 190 Nail Psoriasis Severity Index
CA-MRSA, 190 (NAPSI), 100101
inhibines, 190 plaque psoriasis, 99
itching and hair loss, reduction, Ingenol mebutate
201 AKs, 39, 40
manuka honey, 190 ingenol, 3940
Index 221
W Z
Warts Zemaphyte. See Traditional
garlic, 170 Chinese Medicine (TCM)
human papillomavirus, 165 Zinc
oral propolis, 173 acne, 68
treatment, 165, 168 oral zinc sulfate, 168, 169
verrucous papules, 166 warts, 168169
zinc, 168169
Weinstock, M.A., 42
Winter eczema, 120
Woods lamp examination, 156