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Navigating "natural" medicine

How to meet patients' desire for alternative medicine with evidence-based care

Dermatology World abstract illustration of mortar and pestle

Navigating "natural" medicine

How to meet patients' desire for alternative medicine with evidence-based care

Dermatology World abstract illustration of mortar and pestle

By Emily Margosian, assistant editor

“We are clearly past the ‘golden age’ where, by and large, physicians experienced something of a monopoly on the knowledge of medicine,” said Peter Lio, MD, a dermatologist in private practice in Chicago and clinical assistant professor of dermatology and pediatrics at Northwestern University. Considered a niche market several decades ago, complementary and alternative medicine (CAM), a term that broadly encompasses a wide range of practices including yoga, traditional Chinese medicine (TCM), acupuncture, naturopathy, and beyond — has now become a billion-dollar global industry. “Twenty years ago, there wasn’t as much discourse surrounding this, but now social media information is shared more quickly and freely, and I think that has had a lot to do with the rise of public interest in complementary and integrative approaches,” said Raja Sivamani, MD, MS, AP, adjunct associate professor of clinical dermatology at University of California, Davis.

Dermatology has not remained untouched by this trend, with research suggesting that patients with skin disease are more likely to use CAM compared to the baseline population (J Am Acad Dermatol. 2018;79(1):1-16). As patients increasingly turn to natural and alternative solutions for their dermatologic needs, dermatologists may be more likely to find themselves on the defensive with a patient who has decided that topical steroids don’t fit their vision of wellness. “From ‘instant experts’ via the internet, to a panoply of different health care practitioners competing for the same patients, I think we have our work cut out for us more than ever before,” said Dr. Lio. “Fortunately, dermatologists remain an incredibly talented, passionate, and well-trained group who are uniquely suited to thrive in such a melee.”

This month, Dermatology World consults with five physicians — each with their own take on this burgeoning area in health care — to address:

  • The evolution and expansion of alternative medicine

  • Practical strategies for negotiating treatment plans with alternative-minded patients

  • What to watch for on the horizon, while keeping a focus on evidence-based care 

The evolution and impact of alternative medicine

In order to understand how alternative medicine gained such a foothold in American culture, it’s necessary to look backward. Early signs of a major tone shift in the country’s consumption of health care appeared in 1976, when the American Medical Association (AMA) was sued by a chiropractor for antitrust violations. It was forced to change the language of its Principles of Medical Ethics, ultimately removing the phrase, “A physician should practice a method of healing founded on a scientific basis and he should not voluntarily associate professionally with anyone who violates this principle.” While the victory was at the time largely symbolic, the incident nevertheless foreshadowed a more intersectional future between physicians and alternative providers.

Roughly 20 years later in 1994, Congress would pass the DSHEA (Dietary Supplement Health and Education Act), which differentiated supplements from food and drugs — thereby absolving them from having to meet the pre-market efficacy and safety standards of drugs.

Since then, CAM has become widely adopted by the public, with approximately four in 10 adults using some form of it, according to NIH survey data. This has created a steady cash flow for the CAM industry, with an estimated $30.2 billion spent out-of-pocket in 2016 — $12.8 billion of which was spent on supplements alone, as per a 2016 NIH report. Fueled in part by broad endorsement by both A-list celebrities and social media influencers (actress Gwyneth Paltrow’s Goop “wellness” empire was recently valued at $250 million as per the New York Times), patients’ appetites for alternative health care are projected to further expand. Market research firm Grand View Research estimates that by 2025 the global market for CAM will reach a collective value of $196.9 billion.

Furthermore, data from the CDC indicates that one-third of adults (33.2%) reported using some form of CAM in the previous 12 months, and the number of annual visits to alternative providers has been estimated at 629 million — higher than the number of yearly primary care visits (J Am Acad Dermatol. 2018;79(1):1-16).

Who are the primary users of CAM? CDC data reveal that women are more likely to use CAM than men, as are persons with higher levels of education. CAM usage also varies according to race and ethnicity; “non-Hispanic whites have the highest reported usage at 37.9%, whereas non-Hispanic blacks (19.3%) and Hispanics (22%) had the lowest usage” (J Am Acad Dermatol. 2018;79(1):1-16).

Naturopathic scope of practice

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ENTER THE DERMATOLOGIST

How then should physicians expect to navigate this brave new world? “We dermatologists pride ourselves on being up to date on the most effective, evidence-based therapies, and sometimes it can seem like an affront when a patient wants to take a different path,” said Dr. Lio. “That is why I tend to advocate for an integrative dermatology approach, where we take the best conventional evidence and understanding and pair it with some of the complementary treatments that have at least some positive evidence or sound basis.” According to Dr. Lio, the most viable integrative approaches should demonstrate a reasonable assurance of safety, some positive evidence, and practicality within a conventional dermatology setting. 

Hadar Lev-Tov, MD, assistant professor of dermatology and cutaneous surgery at the University of Miami, also agrees that there’s room within dermatology for other approaches. “I’ll give an example — often we see people with venous insufficiency and leg swelling that can lead to leg ulcers, and one treatment that can help with that is horse chestnut seed extract. It’s something I’ve been using in my practice, and believe it or not, there’s currently a Cochrane review showing efficacy.” For other natural treatments, however, Dr. Lev-Tov notes that “there is an enormous shortage of evidence about CAM interventions. At some point, dermatologists and other physicians should ask themselves, ‘Why is that? Are we failing our patients?’”

Additionally, what happens when the two worlds don’t meet so harmoniously? “Not everything natural is good,” said Vivian Shi, MD, assistant professor of dermatology and director of the eczema and skin barrier research program at the University of Arizona. “I had a patient who used a probiotic sample from a company, and within a week she was hospitalized because this particular supplement caused an overwhelming drug reaction in the form of pustules all over her body.” 

While there are undoubtedly both possibilities and pitfalls associated with patient demand for alternative care, in the meantime there are several strategies dermatologists can employ during visits to come to a treatment consensus amenable to both patient and physician. 

1. Make it a part of your routine to ask when taking patient histories. 

As some patients may not volunteer their CAM use out of anticipated judgment or dismissal, dermatologists may want to consider including questions about alternative therapies as part of the history-taking process for a clearer picture of their patients’ health. “I think it’s sensible to ask those kinds of questions, particularly if it’s a chronic condition like psoriasis or atopic dermatitis, where the patient has been frustrated for a while,” said Dr. Sivamani. “Whether you agree or disagree with what they’re using, I think the first step is to be open to listening and get them talking about what they’re using,” he said. 

Asking questions about CAM can also have value from a safety standpoint, suggests Dr. Lio. “Some alternative practices can have very real interactions with conventional therapies. Additionally, sometimes the alternatives are potentially dangerous and very likely to be unhelpful — such as extreme exclusion diets for children with atopic dermatitis. By not asking, some things can be easy to miss in our short and very densely packed visits.” 

To streamline the process, Dr. Shi found it helpful to create a written questionnaire for patients to complete during visits. “If they’re here for acne, I have an acne dietary and practice questionnaire, and you could do the same for other conditions like psoriasis,” she said. “I think it’s really important to take CAM as part of the history, especially when you’re suspecting a systemic or topical allergic reaction, or drug reaction.”

2. Be prepared to provide evidence-based information and education.

When patients arrive at a visit with incomplete information, dermatologists should be prepared to present them with the right facts to make the most informed decision possible. “If someone is using essential oils, you don’t want to give an absolute like ‘essential oils are all good,’ or ‘essential oils are all bad,’” said Dr. Sivamani. “You have to have a better working knowledge of normal, safe ways of using them, and be open about a lack of evidence where there is none. Engaging in that discourse is important.” 

Dr. Shi agrees. “In the case of essential oils, you should note that they are constructed very differently than the cold-pressed oils, and the manufacturing process can create chemicals that may cause allergic reactions. Part of it is explaining, ‘while I’m open to your options, let’s think through why it may not be good for this particular condition.’”

Ultimately, however, the final choice over a patient’s health lies with them. “You should accept that some people are going to have a different mindset than yours, and if they’re perfectly happy with a little bit of psoriasis on their body but not using a biologic, then that’s fine. Our goal as a physician is to make sure they’re adequately informed and being safe, but ultimately we can’t make them do something they don’t want to do,” said Dr. Lev-Tov. 

3. Reframe your language. 

Sometimes reaching a treatment consensus with patients is as simple as a change of phrase. “For example, we commonly use birth control pills for acne, but a lot of times in the exam room, if I say, ‘birth control pills’ you see the dad or the mom of the teenager shut down,” said Dr. Shi. “So, language can be very important. I’m mindful of not using that word in the office — instead I call them ‘hormone modulators.’ Strategically changing the term and describing what you’re doing is so important. When I say, ‘let’s start a pill that will regulate your hormones,’ I get a much different response than ‘let’s start you on contraception.’” 

4. Find a middle ground. 

To avoid a treatment stalemate — or a patient who simply never returns, patient and physician must work together to find a way forward. “You know a lot of times in the exam room, it’s a negotiation,” said Dr. Shi. “I go in with an agenda hoping that I can at least put them onto prescription medicine, but I’m also open to hearing what they have in mind. You typically only have 10 to 15 minutes with them, and you have to negotiate down to a plan that works for both of you.” 

One strategy is to identify the root cause of the patient’s desire for alternative treatment and work from there, suggests Dr. Lev-Tov. “One of the claims of alternative medicine is that western medicine doesn’t treat the cause, it just treats the symptoms. For example, if I have a patient come in with the worst psoriasis you can imagine and I know that they’re a real candidate for a biologic, but they want to treat it with alternative medicine, most dermatologists are going to tell them flat out it’s not going to happen,” he said. “What I try to do is I listen to what they’ve tried so far, and offer alternative suggestions that have shown some efficacy. After we have that discussion, I say, ‘look I gotta tell you though — just from looking at the evidence, you’re welcome to use some of these, but I want you to know that biologics are actually very specific medications that allow us more targeted therapy.’ When you explain it like that, half of the time people who come to me looking for an alternative solution may still utilize something alternative — but will also accept the biologic.” 

Zoe Draelos, MD, a dermatologist in private practice and consulting professor of dermatology at Duke University, agrees that often physicians and their alternative-minded patients can strike a balance that incorporates the best of both worlds. “So many times, if someone has a complementary medicine product that they really like, you can just use that alongside other topical medications and they’ll be able to use both. Maybe there’s an essential oil moisturizer they just love, so they can put their topical medication on first, then they can use their complementary medicine product right on top of that,” she said. “The worst thing is to totally dismiss the patient and say, ‘oh that doesn’t work,’ or ‘that’s not good medicine,’ or ‘that’s going to hurt you.’ In most cases, the dermatologist can prescribe skin therapy and just let the patients keep using their alternative treatment along with it.”

5. Know what’s out there. 

It’s hard to win an argument without all the facts, and dermatologists may likewise want to do a little research into what their patients are researching. By building familiarity — and an opinion on what works and what doesn’t — dermatologists can be prepared to offer patients some safe alternative options when asked. “There are a variety of formulations out there that do incorporate herbals and it’d be good for the dermatologist to develop a list of products where they are comfortable with the quality, the reproducibility, and the stability of the product, so if a patient does ask — is there anything natural I can use in addition to this prescription product? — the dermatologist could make a recommendation,” said Dr. Draelos. “The two worlds are not mutually exclusive, and they could very much coexist.”

Dr. Lev-Tov agrees that dermatologists shouldn’t be afraid to expand their thinking around CAM. “If you have a particular interest — some people like nutrition, some people like Ayurvedic practices — one of the things you can do is develop your own internal referral network. Just like you have a relationship with your dermatopathologist, by the same token you should have an open channel with a nutritionist. Same goes for acupuncture. There’s decent evidence for acupuncture as it relates to itch. So, you find the licensed acupuncturist in your neighborhood, and you can try to work with them on certain aspects of dermatologic disease.” 

According to Dr. Shi, “We are — believe it or not — in a service industry even though we’re clinicians. Patients are coming and asking for it, so we have to keep up in a sense. Our knowledge base is often driven by patient interest and curiosity, so it’s important we become familiar with certain CAM modalities in order to be prepared to counsel our patients.”

6. Stay respectful. 

Patients often turn to alternative care after feeling alienated by their physicians, and dermatologists should work to avoid exacerbating that feeling. “As with so many things in medicine, I think the answer lies in communication and good rapport. Connecting with the patient and explaining your approach and your limitations allows everyone to be on the same page,” said Dr. Lio. “When offered with sincerity and a willingness to help, I think it allows for the therapeutic alliance to form, even when across very different traditions. Sometimes I will identify that what the patient seeks is beyond me or not part of my expertise. In these cases, knowing when to refer to a trusted practitioner can also make a big impact on the patient. That changes the narrative from, ‘That doctor didn’t understand me and dismissed what I needed,’ to ‘The doctor understood what I wanted and was able to send me to the right place.’ Not that this is always easy. It can be somewhat treacherous to try to explain that what the patient wants or thinks they need is probably not going to help and that you really do have their best interest in mind. In these situations, I try to think about the wisdom of one of my medical school teachers, Dr. Daniel Federman who said, ‘Think out loud. Keep it simple. Be kind.’”

In some cases, consistently maintaining a level of respect when a patient brings up alternative treatments can build the trust necessary for the patient to ultimately go with the dermatologist’s original preferred treatment plan. “I have not felt any erosion in authority at all,” said Dr. Sivamani. “By having these conversations, I feel like they have more trust in me, and are more willing to use their steroids. Personally, I find that it empowers my patients a bit more, and while I can see how at first blush that might seem more time-consuming, ultimately long-term outcomes tend to be better when there is more interest and buy-in from the patient regarding their health.” 

According to Dr. Shi, while answering patient questions about CAM can be frustrating at times, those conversations can also potentially spark new areas of investigation. “Definitely patients are coming in with more questions and information that they extract from social media — I’m sure you’ve heard of the charcoal topical remedy for skin detoxification; I get asked about that almost every other hour — and it can be hard to keep up with these questions when there is no evidence behind them," she said. "But scientific breakthrough doesn't happen without complicated discussions with our patients. I just love it because they ask very stimulating questions, and it's possible we'll end up with something maybe 10 years from now that has become standard practice."