- Email: [email protected]
Community perceptions about the use of black salve
J AM ACAD DERMATOL VOLUME 74, NUMBER 5
Arizona,f and Society Hill Dermatology and Cosmetic Center, Philadelphia, Pennsylvaniag Funding sources: None. Conflicts of interest: None declared. Correspondence to: James A. Solomon, MD, PhD, Director of Ameriderm Research, 725 West Granada Blvd, Suite 44, Ormond Beach, FL 32174 E-mail: [email protected] REFERENCES 1. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014;70:748-762. 2. Cormier JN, Xing Y, Ding M, et al. Ethnic differences among patients with cutaneous melanoma. Arch Intern Med. 2006;166: 1907-1914. 3. Robinson KA, Saldanha IJ, McKoy NA. AHRQ Methods for Effective Health Care. Frameworks for Determining Research Gaps During Systematic Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011. 4. Thong HY, Jee SH, Sun CC, Boissy RE. The patterns of melanosome distribution in keratinocytes of human skin as one determining factor of skin colour. Br J Dermatol. 2003;149:498-505. 5. Kim M, Boone SL, West DP, Rademaker AW, Liu D, Kundu RV. Perception of skin cancer risk by those with ethnic skin. Arch Dermatol. 2009;145:207-208. http://dx.doi.org/10.1016/j.jaad.2015.11.028
Community perceptions about the use of black salve To the Editor: Black salve describes a group of products that contain the escharotic agents zinc chloride and sanguinarine.1 Despite numerous side effects and a lack of predictable response, individuals continue to choose self-treatment of benign and cancerous skin lesions with black salve in the place of conventional medical therapy.2-4 To understand the factors that patients consider when choosing black salve, we surveyed 340 adult patients in primary care and dermatology clinics. Follow-up interviews were performed with 18 of 23 subjects who reported using black salve. The interviews were conducted in a semistructured format, which allowed the exploration of interesting and unexpected themes raised by participants. The generalizability of our study is limited as our population was predominantly from rural ZIP codes and from a Department of Veterans Affairs medical center. Survey results were analyzed with descriptive statistics and univariate comparisons were made using the 1-way analysis of variance and the 2
Letters 1021
test. Black salve users were significantly more likely than nonusers to be female, live in a rural area, and have a household income greater than $30,000/y (P \ .05 for all). Data on participants’ experience and satisfaction with black salve are presented in Table I. We transcribed and coded interviews from 18 black salve users with NVivo qualitative data analysis software (QSR International, Melbourne, Australia) for experimental themes and patterns.5 We report these themes in Table II. Among our black salve users, the perceived success of treatment had a greater contribution to the overall experience of using black salve than pain or scarring. This insight, that the desire to be effectively treated often outweighs potential harmful side effects, can aid physicians when discussing black salve use with their patients. Participants’ most commonly cited motivation to use black salve was a desire to avoid surgical treatment. Their specific fears of surgery included potential surgical failure, scarring, pain, cost, convenience, and efficacy. These are issues that can often be moderated or allayed through education. We unexpectedly found out that 17 of 23 black save users were unaware of the potential side effects of black salve treatment. Nine of our 18 black salve interviewees reported barriers to communication with their physician. These barriers include fear of being judged, or a lack of receptiveness by physicians to field questions about black salve treatment. This supports our finding that a majority (70%) of black salve users did not visit a dermatologist before treatment and rather relied on personal experience of friends and family members. Educating patients about alternative therapies can require significant time from a physician. If, however, health care providers avoid questions about nonbiomedical therapies, other sources, including online anecdotal narratives can fill that void and become the de facto expert source. Our investigation demonstrated significant opportunities for clinicians to build on common ground with black salve users to educate them on potential side effects and other more predictably effective therapy. Joshua J. Clark, BS,a Alexandra Woodcock, BS,a Sarah D. Cipriano, MD, MPH, MS,a Mark A. Hyde, MMSc, PA-C,a Sandra L. Edwards, MA,b Caren J. Frost, PhD,c and Mark J. Eliason, MDa Department of Dermatology,a Division of Epidemiology,b and College Of Social Work,c University of Utah, Salt Lake City Supported by American Skin Association medical student grants targeting melanoma and skin
1022 Letters
J AM ACAD DERMATOL
MAY 2016
Table I. Participants experience and satisfaction with black salve (n ¼ 23) % (n)
What type of spot or lesion was most recently treated with this salve? Cancerous lesions Precancer Benign growths (eg, wart, skin tag) Wounds Did not know Did a doctor or other health care professional evaluate the spot or lesion before it was treated with this salve? Lesion was not evaluated Dermatologist Other health care professional How did you learn about black salve? (multiple answers possible) Doctor Internet Friend Family Other Were you aware of potential side effects of black salve? (multiple answers possible) Not aware Scarring Damage to normal-appearing skin Skin cancer may remain Did you have any symptoms during treatment with black salve? (multiple answers possible) Pain Bleeding or scab Skin damage None What was the result of treatment with black salve? (multiple answers possible) Scar present Lesion or spot still present Lesion or spot no longer present Satisfaction with treatment Very satisfied Satisfied Neither satisfied or unsatisfied Unsatisfied Very unsatisfied Likelihood of recommending black salve Very likely Likely Not sure Unlikely Very unlikely Likelihood of using on skin cancer Very likely Likely Not sure Unlikely Very unlikely Personal history of skin cancer
30.4 17.4 30.4 13.0 8.7
(7) (4) (7) (3) (2)
52.2 (12) 30.4 (7) 17.4 (4) 13.0 13.0 43.5 52.2 8.7
(3) (3) (10) (12) (2)
73.9 17.4 21.7 8.7
(17) (4) (5) (2)
30.4 43.5 17.4 56.5
(7) (10) (4) (13)
34.8 (8) 13.0 (3) 52.2 (12) 26.1 34.8 30.4 0.0 8.7
(6) (8) (7) (0) (2)
43.5 26.1 13.0 8.7 8.7
(10) (6) (3) (2) (2)
30.4 13.0 26.1 17.4 13.0 56.5
(7) (3) (6) (4) (3) (13)
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J AM ACAD DERMATOL VOLUME 74, NUMBER 5
Table II. Representative quotes Experiential theme
Frequency of theme
Motivation for use: concern of surgery
8 of 18
Motivation for use: convenience
4 of 18
Understanding of black salve: selectivity
5 of 18
Positive experience with black salve: successful treatment
11 of 18
Positive experience with black salve: repeated use
11 of 18
Positive experience with black salve: recommend to others
10 of 18
Physician interaction: inefficient or lack of communication
6 of 18
Physician interaction: fear of being judged
5 of 18
Exemplary quotes
Participant information
‘‘Every time they cut into them, those cancer cells are going all throughout your body, which I don’t really care for. If I had a spot that I knew was something like that, I would definitely try the black salve again first before I had something like that biopsied and cut.’’ ‘‘I don’t have time to sit there and be sick like this all the time. One day of extreme pain, to me, is worth it, rather than have 2 weeks of feeling really sick and looking like a nightmare.’’ ‘‘Yeah, so the black salve was kind of nice in the sense that it only tended to stay localized to where the cancer was.’’ ‘‘What about it did I like? Well, it caused this to clear up, myeif it was cancer, the cancer on my face.’’ ‘‘I wouldn’t hesitate if I had a little bit of black salve. I’d put it on there because I know what it would do and it would be off in a while. Then I wouldn’t have to go see a doctor.’’ ‘‘I recommended to my sister and father had cancer, but it didn’t work for him. He was a different type of cancer, but for skin cancers, absolutely I would recommend it.’’ ‘‘The doctor wouldn’t eveneand I knew him from childhoodeand he wouldn’t even discuss it. I felt bad about that.’’
Participant 13 62-year-old man who applied black salve to a skin cancer and ingested black salve to treat leukemia
‘‘This was quite a while ago, and of course I got put down for these hocus-pocus snake-oil remedies.’’
cancer and the Department of Dermatology, University of Utah. Conflicts of interest: None declared. Presented in part as a poster at the University of Utah’s Medical Student Research Symposium, March 11, 2015. Correspondence to: Mark J. Eliason, MD, Department of Dermatology, University of Utah, 30 North 1900 East, 4A330, Salt Lake City, UT 84132 E-mail: [email protected]
Participant 16 49-year-old woman who used black salve on a skin cancer
Participant 17 54-year-old man who applied black salve on a skin cancer Participant 3 83-year-old man who used black salve on a skin cancer Participant 2 73-year-old man who used black salve on a skin cancer
Participant 14 59-year-old woman who used black salve on a skin cancer
Participant 11 76-year-old woman who used black salve on a mole and treated a skin cancer on her husband’s scalp Participant 1 65-year-old man who applied black salve to cutaneous T-cell lymphoma
REFERENCES 1. Eastman KL, McFarland LV, Raugi GJ. A review of topical corrosive black salve. J Altern Complement Med. 2014;20: 284-289. 2. Osswald SS, Elston DM, Farley MF, Alberti JG, Cordero SC, Kalasinsky VF. Self-treatment of a basal cell carcinoma with ‘‘black and yellow salve.’’ J Am Acad Dermatol. 2005;53: 508-510. 3. Ma L, Dharamsi JW, Vandergriff T. Black salve as self-treatment for cutaneous squamous cell carcinoma. Dermatitis. 2012;23:239-240. 4. Payne CE. ‘‘Black salve’’ and melanomas. J Plast Reconstr Aesthet Surg. 2011;64:422. 5. NVivo. Available from: URL: http://www.qsrinternational.com/ products_nvivo.aspx. Accessed February 23, 2016. http://dx.doi.org/10.1016/j.jaad.2015.10.016
Arizona,f and Society Hill Dermatology and Cosmetic Center, Philadelphia, Pennsylvaniag Funding sources: None. Conflicts of interest: None declared. Correspondence to: James A. Solomon, MD, PhD, Director of Ameriderm Research, 725 West Granada Blvd, Suite 44, Ormond Beach, FL 32174 E-mail: [email protected] REFERENCES 1. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014;70:748-762. 2. Cormier JN, Xing Y, Ding M, et al. Ethnic differences among patients with cutaneous melanoma. Arch Intern Med. 2006;166: 1907-1914. 3. Robinson KA, Saldanha IJ, McKoy NA. AHRQ Methods for Effective Health Care. Frameworks for Determining Research Gaps During Systematic Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011. 4. Thong HY, Jee SH, Sun CC, Boissy RE. The patterns of melanosome distribution in keratinocytes of human skin as one determining factor of skin colour. Br J Dermatol. 2003;149:498-505. 5. Kim M, Boone SL, West DP, Rademaker AW, Liu D, Kundu RV. Perception of skin cancer risk by those with ethnic skin. Arch Dermatol. 2009;145:207-208. http://dx.doi.org/10.1016/j.jaad.2015.11.028
Community perceptions about the use of black salve To the Editor: Black salve describes a group of products that contain the escharotic agents zinc chloride and sanguinarine.1 Despite numerous side effects and a lack of predictable response, individuals continue to choose self-treatment of benign and cancerous skin lesions with black salve in the place of conventional medical therapy.2-4 To understand the factors that patients consider when choosing black salve, we surveyed 340 adult patients in primary care and dermatology clinics. Follow-up interviews were performed with 18 of 23 subjects who reported using black salve. The interviews were conducted in a semistructured format, which allowed the exploration of interesting and unexpected themes raised by participants. The generalizability of our study is limited as our population was predominantly from rural ZIP codes and from a Department of Veterans Affairs medical center. Survey results were analyzed with descriptive statistics and univariate comparisons were made using the 1-way analysis of variance and the 2
Letters 1021
test. Black salve users were significantly more likely than nonusers to be female, live in a rural area, and have a household income greater than $30,000/y (P \ .05 for all). Data on participants’ experience and satisfaction with black salve are presented in Table I. We transcribed and coded interviews from 18 black salve users with NVivo qualitative data analysis software (QSR International, Melbourne, Australia) for experimental themes and patterns.5 We report these themes in Table II. Among our black salve users, the perceived success of treatment had a greater contribution to the overall experience of using black salve than pain or scarring. This insight, that the desire to be effectively treated often outweighs potential harmful side effects, can aid physicians when discussing black salve use with their patients. Participants’ most commonly cited motivation to use black salve was a desire to avoid surgical treatment. Their specific fears of surgery included potential surgical failure, scarring, pain, cost, convenience, and efficacy. These are issues that can often be moderated or allayed through education. We unexpectedly found out that 17 of 23 black save users were unaware of the potential side effects of black salve treatment. Nine of our 18 black salve interviewees reported barriers to communication with their physician. These barriers include fear of being judged, or a lack of receptiveness by physicians to field questions about black salve treatment. This supports our finding that a majority (70%) of black salve users did not visit a dermatologist before treatment and rather relied on personal experience of friends and family members. Educating patients about alternative therapies can require significant time from a physician. If, however, health care providers avoid questions about nonbiomedical therapies, other sources, including online anecdotal narratives can fill that void and become the de facto expert source. Our investigation demonstrated significant opportunities for clinicians to build on common ground with black salve users to educate them on potential side effects and other more predictably effective therapy. Joshua J. Clark, BS,a Alexandra Woodcock, BS,a Sarah D. Cipriano, MD, MPH, MS,a Mark A. Hyde, MMSc, PA-C,a Sandra L. Edwards, MA,b Caren J. Frost, PhD,c and Mark J. Eliason, MDa Department of Dermatology,a Division of Epidemiology,b and College Of Social Work,c University of Utah, Salt Lake City Supported by American Skin Association medical student grants targeting melanoma and skin
1022 Letters
J AM ACAD DERMATOL
MAY 2016
Table I. Participants experience and satisfaction with black salve (n ¼ 23) % (n)
What type of spot or lesion was most recently treated with this salve? Cancerous lesions Precancer Benign growths (eg, wart, skin tag) Wounds Did not know Did a doctor or other health care professional evaluate the spot or lesion before it was treated with this salve? Lesion was not evaluated Dermatologist Other health care professional How did you learn about black salve? (multiple answers possible) Doctor Internet Friend Family Other Were you aware of potential side effects of black salve? (multiple answers possible) Not aware Scarring Damage to normal-appearing skin Skin cancer may remain Did you have any symptoms during treatment with black salve? (multiple answers possible) Pain Bleeding or scab Skin damage None What was the result of treatment with black salve? (multiple answers possible) Scar present Lesion or spot still present Lesion or spot no longer present Satisfaction with treatment Very satisfied Satisfied Neither satisfied or unsatisfied Unsatisfied Very unsatisfied Likelihood of recommending black salve Very likely Likely Not sure Unlikely Very unlikely Likelihood of using on skin cancer Very likely Likely Not sure Unlikely Very unlikely Personal history of skin cancer
30.4 17.4 30.4 13.0 8.7
(7) (4) (7) (3) (2)
52.2 (12) 30.4 (7) 17.4 (4) 13.0 13.0 43.5 52.2 8.7
(3) (3) (10) (12) (2)
73.9 17.4 21.7 8.7
(17) (4) (5) (2)
30.4 43.5 17.4 56.5
(7) (10) (4) (13)
34.8 (8) 13.0 (3) 52.2 (12) 26.1 34.8 30.4 0.0 8.7
(6) (8) (7) (0) (2)
43.5 26.1 13.0 8.7 8.7
(10) (6) (3) (2) (2)
30.4 13.0 26.1 17.4 13.0 56.5
(7) (3) (6) (4) (3) (13)
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J AM ACAD DERMATOL VOLUME 74, NUMBER 5
Table II. Representative quotes Experiential theme
Frequency of theme
Motivation for use: concern of surgery
8 of 18
Motivation for use: convenience
4 of 18
Understanding of black salve: selectivity
5 of 18
Positive experience with black salve: successful treatment
11 of 18
Positive experience with black salve: repeated use
11 of 18
Positive experience with black salve: recommend to others
10 of 18
Physician interaction: inefficient or lack of communication
6 of 18
Physician interaction: fear of being judged
5 of 18
Exemplary quotes
Participant information
‘‘Every time they cut into them, those cancer cells are going all throughout your body, which I don’t really care for. If I had a spot that I knew was something like that, I would definitely try the black salve again first before I had something like that biopsied and cut.’’ ‘‘I don’t have time to sit there and be sick like this all the time. One day of extreme pain, to me, is worth it, rather than have 2 weeks of feeling really sick and looking like a nightmare.’’ ‘‘Yeah, so the black salve was kind of nice in the sense that it only tended to stay localized to where the cancer was.’’ ‘‘What about it did I like? Well, it caused this to clear up, myeif it was cancer, the cancer on my face.’’ ‘‘I wouldn’t hesitate if I had a little bit of black salve. I’d put it on there because I know what it would do and it would be off in a while. Then I wouldn’t have to go see a doctor.’’ ‘‘I recommended to my sister and father had cancer, but it didn’t work for him. He was a different type of cancer, but for skin cancers, absolutely I would recommend it.’’ ‘‘The doctor wouldn’t eveneand I knew him from childhoodeand he wouldn’t even discuss it. I felt bad about that.’’
Participant 13 62-year-old man who applied black salve to a skin cancer and ingested black salve to treat leukemia
‘‘This was quite a while ago, and of course I got put down for these hocus-pocus snake-oil remedies.’’
cancer and the Department of Dermatology, University of Utah. Conflicts of interest: None declared. Presented in part as a poster at the University of Utah’s Medical Student Research Symposium, March 11, 2015. Correspondence to: Mark J. Eliason, MD, Department of Dermatology, University of Utah, 30 North 1900 East, 4A330, Salt Lake City, UT 84132 E-mail: [email protected]
Participant 16 49-year-old woman who used black salve on a skin cancer
Participant 17 54-year-old man who applied black salve on a skin cancer Participant 3 83-year-old man who used black salve on a skin cancer Participant 2 73-year-old man who used black salve on a skin cancer
Participant 14 59-year-old woman who used black salve on a skin cancer
Participant 11 76-year-old woman who used black salve on a mole and treated a skin cancer on her husband’s scalp Participant 1 65-year-old man who applied black salve to cutaneous T-cell lymphoma
REFERENCES 1. Eastman KL, McFarland LV, Raugi GJ. A review of topical corrosive black salve. J Altern Complement Med. 2014;20: 284-289. 2. Osswald SS, Elston DM, Farley MF, Alberti JG, Cordero SC, Kalasinsky VF. Self-treatment of a basal cell carcinoma with ‘‘black and yellow salve.’’ J Am Acad Dermatol. 2005;53: 508-510. 3. Ma L, Dharamsi JW, Vandergriff T. Black salve as self-treatment for cutaneous squamous cell carcinoma. Dermatitis. 2012;23:239-240. 4. Payne CE. ‘‘Black salve’’ and melanomas. J Plast Reconstr Aesthet Surg. 2011;64:422. 5. NVivo. Available from: URL: http://www.qsrinternational.com/ products_nvivo.aspx. Accessed February 23, 2016. http://dx.doi.org/10.1016/j.jaad.2015.10.016