Lay Summary

Eczema and CAM

What is Eczema?
Eczema is also known as atopic dermatitis or atopic eczema. It is a chronic inflammatory skin condition that runs in some families and is related to other allergic (atopic) conditions such as asthma and hay fever. It causes red, itchy and flaky rashes in response to a variety of triggers, including allergens and irritants. Uncomplicated AD is not infectious, so touching the rash will not make it spread.

How is Eczema treated conventionally?
The best treatment is prevention by staying away from known allergens and irritants, as well as avoiding extreme dry/moist and cold/hot conditions. Allergens may include some foods and pets. Irritants such as soaps, shampoos and other detergents are common. Frequent itching and rubbing of the skin will also irritate it, and stress can contribute to severity of rash. While poor hygiene may contribute to eczema, excessive washing can also dry out and irritate sensitive skin. Bland moisturizers for dry skin can help prevent eczema, and they can also help treat it.

Medications are prescribed for eczema if it persists or worsens. The commonest treatment is anti-inflammatory steroids such as hydrocortisone, in the form of creams or ointments. Higher potency topical steroids and non-steroidal immunomodulators are also available, but have potentially more side effects, and should be used with medical supervision. Eczema complicated by bacterial infection requires the addition of antibiotics.

What is Complementary and Alternative Medicine (CAM)?
Complementary and alternative medicine (CAM) is a group of diverse health care systems, practices and products that are not presently considered to be part of conventional medicine. (NCCAM. What is Complementary and Alternative Medicine. Health Information. 2002) Examples of CAM practices include massage therapy and acupuncture. Examples of CAM products (also known as natural health products) include Echinacea and St. John's wort.

What kinds of CAM are used to treat Eczema?
There are many CAM therapies used to treat eczema. Many treatments have not been well studied in children, especially regarding effectiveness and safety. There are very few high-quality studies, and this can make it difficult to give good evidence-based advice. The information presented here is based on published research. In particular, randomized, controlled trials of commonly used CAM and studies involving children were searched. For AD, the focus will be on 5 kinds of CAM:
- Traditional Chinese Medicine (TCM)
- Natural health products (NHPs)
- Homeopathy
- Massage therapy
- Mind-body interventions

Traditional Chinese Medicine (TCM):
TCM is an ancient Chinese system of medicine that includes meditation, herbal and nutritional therapy, restorative physical exercises, and acupuncture. Studies of 2 different herbal preparations used to treat eczema are described.

The first product was a proprietary blend of 10 Chinese medicinal herbs that is no longer being manufactured. A 2006 Cochrane systematic review of 4 studies found that, overall, this product was helpful in reducing symptoms and signs of eczema, but there were some concerns about the quality of the studies. One of the studies involved 47 children, and also found that the beneficial effect lasted up to one year in half the children.

Safety of 10-Chinese-herbs blend:
Two children developed temporary changes in their liver function tests during one trial, suggesting potential liver toxicity. The commonest problem with this blend was its bad taste, which caused several subjects to drop out of the trial. Other side effects included dizziness, headaches, nausea, stomach-aches, and diarrhea.

The second product was a capsule containing 5 TCM herbs: Flos lonicerae (Jinyinhua), Herba menthae (Bohe), Cortex moutan (Danpi), Rhizoma atractylodis (Cangzhu) and Cortex phellodendri (Huangbaig). Two small studies involving children with eczema found that the capsules were beneficial in decreasing disease severity.

Safety of 5-herb capsules:
These studies reported side effects of colds, asthma, diarrhea, stomach-aches and new rash.

Safety of TCM herbs - general:
Some herbal preparations from China have been found to be contaminated with toxins (i.e. heavy metals such as mercury or arsenic) and/or adulterated with prescription medications such as steroids. Reports of allergic reactions, and side effects involving blood, liver, heart and lungs after drinking Chinese teas are well documented.

Natural Health Products (NHPs):
NHPs are widely used for prevention and treatment of various conditions and to maintain health. Examples include herbals, homeopathic remedies, vitamins, minerals, probiotics, amino acids, and traditional medicines. Dosing and quality of products can vary significantly. NHPs commonly to treat eczema include honey, essential fatty acids (including borage seed oil, evening primrose oil) and probiotics.

Honey:
Honey is claimed to have anti-inflammatory effects and to enhance healing.

A 2003 study from Dubai used a mixture of honey, beeswax and olive oil on 21 children with eczema. Compared to petroleum jelly, the mixture improved the rash, and allowed those on topical steroids to decrease the dose.

Safety of honey:
Honey is safe, especially when pasteurized. Infants under 12 months old should not eat honey since they are particularly vulnerable to botulism, an uncommon but potential contaminant of honey.

Essential Fatty Acids (EFA):
EFAs include such polyunsaturated fatty acids as omega-3 and omega-6 fatty acids. A major source of omega-3 fatty acids is fish oils. Gamma-linolenic acid (GLA) is an omega-6 fatty acid that is thought to be deficient in people with eczema. GLA is found in plants such as borage seed, evening primrose and black currant seeds.

A 2004 meta-analysis of 22 trials involving omega-3 and omega-6 fatty acids found that they were not significantly helpful in treatment of eczema.

Borage seed oil:
Borage oil (Borago officinalis), also called starflower oil, contains at least 23% GLA, making it a rich source of omega-6 fatty acids. Results of a 2003 UK study and a smaller 1997 German pediatric study found no difference between Borage oil and placebo in treating eczema. However, a 2003 Dutch study looked at prevention of eczema in the first year of life by giving Borage oil for 6 months to formula-fed infants of atopic mothers. Borage oil was found to be better than placebo in decreasing the severity of eczema.

Safety of borage oil:
Many of the side effects in these studies were found in both borage oil and placebo groups: stomach-aches, reflux (heartburn), flu-like symptoms, headache, nausea, diarrhea and vomiting.

Evening primrose oil (EPO):
Evening primrose oil, Oenthera biennis L., contains 8-10% GLA. Results of pediatric studies are conflicting. A Swedish study published in 1994 found that EPO was no different than placebo, but a 1996 UK study found that high dose, but not low dose, EPO was effective compared with placebo.

Safety of Evening primrose oil:
None of the studies reported side effects, which seem to be rare. Side effects may include nausea, stomach-aches, diarrhea, headaches and seizures.

Probiotics:
Probiotics are live microorganisms, usually bacteria, which are consumed as dietary supplements or added to foods such as yogurt. There are many different types (species or strains) of bacteria used, and they are thought to promote a healthy combination of bacteria in the gut (large intestines) that can help prevent or treat certain conditions and maintain general wellness. Evidence in children for treatment and prevention of eczema is conflicting.

Several studies published between 1997 and 2006 looked at treatment of AD using probiotics in children. The results were contradictory and difficult to interpret accurately when taken together.

Two larger studies investigated the potential to prevent infant eczema by giving probiotics to pregnant or breastfeeding women or their newborns for up to 6 months. The Finnish study published in 2001 and followed up in 2003 found that probiotics were effective, but a 2007 Australian study concluded that probiotics were no better than placebo in preventing the development of eczema.

Safety of probiotics:
While probiotics are likely safe in healthy people, consumers should be mindful that they are ingesting live organisms. There are a few case reports of severe and potentially life-threatening bacterial infections in children and adults with underlying medical problems including weakened immune systems.

Homeopathy:
The principle that "like cures like" means that substances that cause symptoms at normal or high doses can cure them when given in small, highly diluted amounts.

A Japanese study from 2003 observed patients on individualized homeopathic preparations for up to 2 ½ years, and reported that most of them had improved by at least 50%. There were no side effects.

A homeopathic herbal ointment was used in a small German pediatric open-label trial published in 2005. 82% of the children's symptoms improved after 2-4 weeks of treatment. No information about side effects was available.

Safety of homeopathy:
Homeopathy, when taken internally rather than topically, is considered to be very safe since the preparations are very dilute, but it may be possible to trigger a reaction in an allergic person. Temporary worsening of symptoms, called "aggravation", can last a few hours and happens in 10-20% of patients.

Massage therapy:
Stress can contribute to severity of eczema. Also, stimulation of the skin is felt to enhance circulation and healing. Short-term massage therapy has been used successfully to manage both stress and treat eczema.

A small American trial published in 2000 compared standard eczema treatment with and without massage therapy given by parents to their children for one month. There were improvements in the rashes, in the children's behaviour and in the parents' anxiety level. A small 1998 UK study compared 8 weeks of massage by a trained therapist with and without essential oils. Both types of massage helped eczema symptoms in children to a similar degree. However, additional treatments with essential oils caused worsening of rash. The essential oils were a combination of sweet marjoram, frankincense, German chamomile, myrrh, thyme, benzoin, spike lavender and Litsea cubeba.

Safety of massage therapy:
Some essential oils, such as tea tree oil and verbena, are known to cause rashes in susceptible people. Massage therapy is generally very safe. However, 2 cases of stroke have been reported in adults after shiatsu-type neck massage.

Mind-Body techniques:
Mind-body medicine focuses on connections between the mind, including emotional, mental, social, spiritual and behavioural aspects, and the body. These interactions are considered to affect health directly. Examples of mind-body interventions include hypnotherapy, relaxation therapy, and biofeedback. Patients with eczema can use these techniques to help control symptoms such as itching. Susceptibility to hypnotherapy is age-specific; children tend to respond well.

Three studies, from the UK (1993 and 1995) and from Germany (1995), found that various mind-body techniques helped symptoms of eczema, and there were no reported side effects.

Safety of mind-body techniques:
There are no well-established tools to assess side effects of mind-body therapies, but studies suggest that 5-54% of people may experience some forms of anxiety, unpleasant sensations or thoughts, or muscle spasms. Factors associated with such experiences include fear of letting go or losing control, restlessness, and feelings of vulnerability. These side effects may cause some people to stop therapy. In other cases, the feelings are used to therapeutically to explore and cope with these fears. Adequate preparation and supervision of therapy may help minimize and prevent such effects.

Conclusions:
There is research showing that CAM may help children with eczema. However, many of the studies have significant limitations that make it difficult to offer advice with confidence based on their conclusions, whether positive or negative. These limitations include lack of safety information (especially long-term side effects), flaws in methodology, and small numbers of patients recruited. Evidence from a single trial of any specific CAM should encourage further study and confirmation of conclusions, and the use of such therapies should be supervised with caution by health care providers. Pediatric dosing is often unknown and the quality of some natural health products is unreliable, making safety a further concern. Adults respond to therapies in ways that children may not, therefore assumptions based on adult experience can be inaccurate or even harmful. Products given to prevent illness, rather than for treatment, are often taken every day during susceptible periods. For eczema, this means that infants may be taking NHPs for many weeks or months at a time. Some therapies and products can be costly and add financial stress for families.

The natural course of eczema is that it is chronic, but the severity often improves over time, depending on exposure to triggers. Each child is unique, and families must weigh the risks and benefits of all interventions as objectively as possible. This is especially important for therapies and products in which good evidence is limited or unknown. The information provided here is intended to promote discussion among parents and health care providers of children with eczema and is not meant to replace medical advice. More high-quality studies are needed to guide recommendations about effectiveness and safety of CAM for treatment of AD, and to assist caregivers and families in making informed decisions about treatment options.

The following figure shows how the evidence for each CAM can be organized according to safety and effectiveness.

Green
Massage therapy
Mind-body interventions

Blue
Honey
Probiotics
Borage oil
Evening primrose oil
Homeopathy

Yellow
Chinese herbal preparations

The CAM therapies are organized into colour-coded categories for clarity. Conventional medications can also be categorized similarly. For instance, many over-the-counter medications would fall into the blue area, and many prescription medications would fall into the yellow area. Some pediatric health issues can be potentially serious, especially if the condition is chronic, or multiple therapies, NHPs and medications are used together. The decision to use CAM should be based on each child's health and include discussion with the child's physician.

Each child is unique, and families must weigh the risks and benefits of all interventions as objectively as possible. This is especially important for therapies and products in which good evidence is limited or unknown. The information provided here is intended to promote discussion among parents and health care providers of children with asthma and is not meant to replace medical advice. More rigorous studies are needed to guide recommendations about effectiveness and safety of CAM for treatment of asthma, and to assist caregivers and families in making informed decisions about treatment options.

Funding: Partial funding support for this review was received from Passeport Santé.

Lay summaries: For more information in French, please see Passeport Santé.

Clinician summaries: Full scientific review article will be published in Pediatrics in Review. To review a copy of the abstract click here.

Disclaimer: The information available on this website is intended to provide general information about complementary and alternative medicine (CAM). This website does not provide specific medical advice and the information provided should not be used as a substitute for seeking medical advice from a registered health practitioner. The opinions expressed on this website are not necessarily reflective of the opinion of the Stollery Children's Hospital, Capital Health Authority,Passeport Santé or Pediatrics in Review.