Complementary, Holistic, and Integrative Medicine

Traditional Chinese Medicine (TCM) Herbs

A systematic review (n=159) that included three randomized, controlled trials (RCTs) (two from the United Kingdom [UK] and one from Hong Kong) and an open label trial (UK) investigated the short-term effects of a blend of 10 herbs (Potentilla chinensis, Tribulus terrestris, Rehmannia glutinosa, Lophatherum gracile, Clematis armandii, Ledebouriella saseloides, Dictamnus dasycarpus, Ponia lactiflora, Schizonepeta tenuifolia, and Glycyrrhiza glabrae) in treating patients who had AD. (4) The herbs were ground, placed in porous paper sachets, boiled into a thick concentrate, strained, and ingested orally as a drink for 8 weeks. Only one of the RCTs focused on efficacy in children (n=37); it found a median 51% decrease in erythema scores for the herbal group (95% confidence interval [CI] 34.5, 72.6) compared with 6.2% (95% CI −25.2, 30.7) for the placebo group. (5)

A subsequent 1-year follow-up study of 23 children found a persistent benefit from using the herbal blend in 18 children (78%), who had a 90% reduction in eczema activity score. (6) In this follow-up study, 14 of the original 37 children withdrew (10 due to lack of response, 2 because of unpalatability, and 2 due to difficulty in preparing the decoctions). The second RCT (UK) in the review also found the herbal blend to be more effective than placebo; (7) the third (Hong Kong) found no effectiveness. (8) The open-label trial found that both herbal and freeze-dried preparations reduced erythema and surface damage effectively. (9)

Due to the small number of participants in the studies (fewer than 50 in each trial), the reviewers could not conduct a meta-analysis of the data to provide a clearer indication of efficacy of TCM for AD. Other limitations of the trials included no allocation and concealment information and high dropout rates (more than 18% in three of the four trials). TCM herbs may be useful for the short-term treatment of AD, but additional evidence from larger trials is needed.

In the original RCT in children, unpalatability of herbs resulted in five dropouts (three in the intervention group, two in the placebo group). (5) In the follow-up study, two children in the intervention group developed liver function abnormalities (serum aspartate aminotransferase concentrations >1.5 times the upper limit of normal), which resolved after herbal treatment was discontinued. (6) Furthermore, one third of children in the intervention arm experienced diarrhea but continued with the trial. (6) Adverse effects reported in adults include mild dizziness, headaches, nausea, abdominal discomfort, and loose bowel movements or flatulence. (7)

An additional open-label case series from Hong Kong reported on nine children who had AD and took three capsules containing a blend of five TCM herbs (Flos lonicerae [Jinyinhua], Herba menthae [Bohe], Cortex moutan [anpi], Rhizoma atractylodis [Cangzhu], and Cortex phellodendri [Huangbai]) twice daily for 4 months. (2) AD improvements were measured by using a clinical scoring tool, the Severity Scoring of AD (SCORAD) index, which assesses the severity (ie, extent, intensity) of AD. The overall median SCORAD score decreased significantly from 60.3 (range, 20.0 to 82.6) at baseline to 40.0 (range, 11.4 to 56.5) at 3 months (P=0.008). (2) A subsequent RCT (n=85) by the same authors, in which children who had moderate-to-severe AD took the same capsules three times a day for 12 weeks, demonstrated improved quality of life and reduced topical corticosteroid usage. (10) Adverse events reported included upper respiratory tract infection, asthma, diarrhea, abdominal pain, and new rash.

Of concern, some herbal preparations from China have been found to be contaminated with toxins (ie, heavy metals such as mercury or arsenic) or adulterated with prescription medications such as glucocorticosteroids. Not surprisingly, the latter has been associated both with improvements in AD and cutaneous adverse effects similar to those caused by conventional corticosteroid creams. Reports of hypersensitivity reactions, liver toxicity, agranulocytosis, cardiomyopathy, and respiratory distress syndrome after ingestion of Chinese teas are well documented. (11) All TCM herbs used in the aforementioned trials were tested for heavy metals and residual pesticides to ensure that they met quality and safety requirements. Blood, renal, and liver function tests also were performed.

Honey Mixture

Honey is purported to reduce inflammation, promote healing, and stimulate tissue generation. It has been used in the treatment of respiratory, gastrointestinal, and skin diseases. A partially controlled single-blind study from Dubai assessed the effectiveness of a topical mixture containing honey, beeswax, and olive oil (1:1:1) in treating 21 children (ages 5 to 16 y) who had AD. (12) Children were divided into two groups based on topical corticosteroid use: Group A used topical corticosteroids (n=11); group B did not (n=10). The honey mixture was rubbed on lesions on the left part of the body and petroleum jelly (control) on the right side of the body three times daily for 2 weeks. In group B, AD symptoms and signs improved significantly (P=0.0129) in 8 of 10 children (80%) who used the honey mixture on the left part of the body and in 2 of 10 children (20%) who used petroleum jelly on the right part of the body. Furthermore, in 5 of 11 children in group A (45.4%), use of the honey mixture enabled steroid strength to be reduced by 75% without worsening of AD symptoms. The honey mixture was found to be useful in the management of AD.

Homeopathy

Homeopathy is based on the premise that “like cures like,” meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses actually causes those symptoms. Few studies have assessed the efficacy of homeopathic treatment for AD in children. A Japanese observational study assessed the effects of using different individualized homeopathic treatments (>20 types, including pulsatilia, sulfur, Lycopodium, Arsenicum, and Mercurius) in addition to conventional treatment in 45 patients (ages 14 to 77 y) who were followed for 3 months to 2 years and 7 months. (13) A total of 88.3% of patients reported having a greater than 50% improvement in their AD after homeopathic treatment. Such study findings may be biased due to the lack of a control group. No significant adverse effects were reported. An additional open-label trial that had positive findings was reported in abstract form (14) but is not included in this review because the original German article was not retrievable.

Although properly prepared homeopathic products are considered to be relatively safe, a few reports document that the chronic use of homeopathic remedies containing mercury, iron, or arsenic has caused exacerbation of AD. (11)

Essential Fatty Acids

AD may be associated with an abnormal ability to process essential fatty acids (EFAs). EFAs belong to the class of fatty acids called polyunsaturated fatty acids (PUFAs). They generally are necessary for stimulating skin and hair growth, maintaining bone health, regulating metabolism, and maintaining reproductive capability. There are two kinds of essential fats: omega 3 (n-3) and omega 6 (n-6, ie, gamma-linolenic acid [GLA]). Sources rich in GLA include borage oil (23% GLA), black currant seed (17% GLA), and evening primrose oil (EPO) (8% to 10% GLA). A primary source of omega-3 fatty acids is cold water fish such as salmon and sardines. (15)

A meta-analysis published in 2004 of 22 placebo-controlled trials examined the potential of oral EFA to alleviate symptoms of AD. (15) Nineteen trials involved GLA (in borage oil, EPO, and black currant seed), and five trials involved fish oil supplements (rich in n-3 EFAs) as the intervention (two studies involved both GLA and fish oils). The meta-analysis indicated a pooled effect size for GLA of 0.15 (95% CI −0.02, 0.32) from 11 trials. This finding corresponds to a 1.5 (95% CI −0.20, 3.3) reduction in the Costa score (a scale of AD severity) or a 5% decrease in severity, neither of which is considered to be clinically significant. The effect of fish oil from three trials was even smaller at 0.01 (95% CI −0.27, 0.21). From these findings, it appears that EFAs are not effective in the treatment of AD. However, small sample sizes in the pooled trial analysis may have prevented detection of any potential moderate effects of EFA supplementation. Furthermore, effectiveness in certain subgroups, such as young children who have severe AD, may be present. More evidence is required to substantiate or refute this conclusion.

Adverse effects reported with the use of borage oil in children include abdominal cramps and gastroesophageal reflux. (16) Adverse effects in adults included influenza-like symptoms, headache, nausea, diarrhea, and vomiting. (17) Adverse effects from taking EPO are rare and include nausea, stomach pain, loose stool, headaches, and seizures. (18)

Probiotics

Probiotics are nonpathogenic microbes, usually of the lactic acid-producing variety, that are used to improve or normalize the balance of gut microflora and are believed to have immune-regulating actions. (19) At least 10 RCTs have evaluated the use of probiotics as treatment for AD (Table 1); another 3 RCTs have evaluated probiotics for potential AD prophylaxis (Table 2). Both uses have contradictory findings: 6 of the 10 treatment trials reported positive effects, and 2 of the 3 prophylaxis trials reported positive findings. Some studies involved mothers taking probiotics prenatally and postnatally while nursing. Some positive results reflected primary outcomes; others represented secondary outcomes. Accordingly, study results should be interpreted cautiously.

In healthy individuals, the use of probiotics generally is safe. However, in severely debilitated and immunocompromised children, there have been case reports of aggravation of existing symptoms, pneumonia, septicemia, and meningitis. The safest sources of probiotic bacteria in the diet are fermented foods, such as buttermilk, yogurt, kefir, and sauerkraut. Higher doses are found in supplemental probiotic forms. When administered in appropriate doses, Lactobacillus acidophilus, Lactobacillus GG, and Saccharomyces sp appear to be safe for use in children (19).