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Use of complementary and alternative medicine by patients seen at the dermatology department of a tertiary care center
Complementary Therapies in Clinical Practice 18 (2012) 49e53
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Use of complementary and alternative medicine by patients seen at the dermatology department of a tertiary care center Amer N. Kalaaji a, *, Dietlind L. Wahner-Roedler b, Amit Sood b, Tony Y. Chon b, Laura L. Loehrer b, Stephen S. Cha c, Brent A. Bauer b a b c
Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
a b s t r a c t Keywords: CAM Complementary and alternative medicine Dietary supplements Herbs Vitamins
The use of complementary and alternative medicine (CAM) among patients with dermatologic conditions has not been well studied. The aim of this study was to evaluate the frequency and pattern of CAM use in patients referred to the dermatology department of a tertiary care center. Patients referred to the dermatology department of an academic tertiary referral center between February 2, 2010, and February 10, 2010, were invited to participate in an 86-question survey regarding CAM use during the previous year. A total of 300 patients completed the survey, of whom 154 (51%) were women. Eighty-two percent (n ¼ 247) of the respondents had used some type of CAM during the previous year. The most frequently used treatment and technique was massage therapy (33%), and the most commonly used vitamin was vitamin C (31%). Herbs or other dietary supplements were used by 58% (n ¼ 173) of patients. Seventyeight percent (n ¼ 235) of patients stated that physicians should consider incorporating CAM approaches into their treatment recommendations, and 89% of patients (n ¼ 267) stated that our dermatology department should study CAM approaches in research studies. CAM utilization is high among patients at a large academic dermatology department. Patients indicated a strong preference for having CAM approaches incorporated into their treatment recommendations and believed in the value of clinical studies to further refine the role of CAM. Ó 2011 Elsevier Ltd. All rights reserved.
Complementary and alternative medicine (CAM) refers to a group of medical and health care practices that are not generally considered part of conventional therapy.1 Traditionally, alternative medicine refers to the use of CAM in place of conventional medicine. Complementary medicine refers to the use of CAM along with conventional medicine. Examples of CAM therapies include herbs and dietary supplements, vitamins, mind/body practices, and hands-on treatments or techniques (eg, acupuncture, massage, or chiropractic). Today, however, there is a growing shift toward integrative medicine that combines conventional and CAM therapies that have been proved safe and effective. This movement toward an increasing presence of CAM in conventional medicine settings has been driven in part by strong interest in CAM by patients, with the use of CAM continuing to increase in the United States.2 According to a survey conducted in 2007 by the Centers for Abbreviation: CAM, complementary and alternative medicine. * Corresponding author. E-mail address: [email protected] (A.N. Kalaaji). 1744-3881/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2011.05.003
Disease Control and Prevention, approximately 38% of adults and 12% of children had used some type of CAM in the past 12 months.3 As interest in and use of CAM continues to grow, it is imperative that clinicians be able to help patients make informed decisions regarding the safety and efficacy of the various therapies they encounter.4 Use of CAM by dermatology patients might be expected to be higher than in the general public because of the chronic nature of many dermatologic conditions (eg, psoriasis and eczema). This supposition appears to be borne out by a 2000 systematic review of surveys of CAM use by dermatologic patients, which found that 35%e69% of dermatology patients used CAM at some point in their lifetime.5 Since the use of CAM has continued to grow in the past decade, we wished to determine how CAM was being used currently by dermatology patients in a tertiary care setting. Therefore, we conducted a new survey regarding use of CAM by patients at our dermatology department. We aimed to help focus ongoing and new research and education efforts to ensure that patients and clinicians are optimally informed about the risks and benefits of CAM.
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A.N. Kalaaji et al. / Complementary Therapies in Clinical Practice 18 (2012) 49e53
1. Patients and methods This study was approved by our institutional review board. Adult patients with appointments in the department of dermatology at an academic tertiary referral center between February 2 and February 10, 2010, were approached in person and asked to complete a survey regarding their use of CAM therapies during the previous year. The survey was conducted by 2 study coordinators of the complementary and integrative medicine group at our institution who remained available for questions. The surveys were collected within 30 minutes of distribution. 1.1. Survey instrument The survey instrument has been described in detail previously.6,7 It was modified for this study to fit patients seen in the department of dermatology. The survey addressed the use of different CAM domains, including treatments or techniques, vitamins, and herbs or other dietary supplements during the previous year. The survey also addressed the types of skin conditions for which CAM was being used and patients’ feelings about our department conducting research on CAM and incorporating CAM approaches into our treatment recommendations. 1.2. Statistical analysis Frequency and percentage were used to evaluate the frequency and pattern of CAM use in our dermatology patients. 2. Results A total of 300 patients completed the survey: 154 (51%) women, 143 (48%) men, and 3 did not report their sex. The respondents were divided into categories by age: 138 (46%) older than 60 years, 115 (38%) aged 40e59-years, 41 (14%) aged 20e39 years, 5 (2%) younger than 20 years, and 1 did not report age. Of the 300 respondents, 247 (82%) had used some type of CAM therapy during the previous year.
frequently were massage therapy (n ¼ 100, 33%), chiropractic therapy (n ¼ 65, 22%), relaxation therapy (n ¼ 45, 15%), yoga (n ¼ 41, 14%), and meditation (n ¼ 40, 13%). Use of the most common treatment or technique, massage therapy, was highest in the 40e59-year age group (n ¼ 49, 43%), and it was used by 46% of women vs 20% of men. 2.1.2. Vitamins Eighty-one percent (n ¼ 243) of patients used 1 or more vitamins (Table 2). The most frequently used vitamins were multiple vitamins and vitamin D, used by 70% (n ¼ 209) and 40% (n ¼ 119) of patients, respectively. However, it should be noted that these vitamins have been incorporated into conventional medicine and are no longer considered CAM by the National Center for Complementary and Alternative Medicine. Therefore, excluding these, vitamin C was used most commonly by all patients (n ¼ 93, 31%) (Table 2). Its use was most common in the 40e59-year age group (n ¼ 43, 37%), followed by those 60 years and older (n ¼ 38, 28%). Slightly more women than men used vitamin C (34% vs 28%). 2.1.3. Herbs and other dietary supplements One or more herbs or other dietary supplements were used by 58% (n ¼ 173) of our patients (Table 3). The 5 most commonly used oral herbs or other dietary supplements were green tea (n ¼ 104, 35%), fish oil (n ¼ 91, 30%), flaxseed (n ¼ 62, 21%), glucosamine (n ¼ 50, 17%), and garlic (n ¼ 49, 16%). Aloe was the most commonly used topical herb (n ¼ 52, 17%), which was used by 25% (n ¼ 39) of women. Overall, herbs or other dietary supplements were most commonly used by patients 60 years and older (n ¼ 85, 62%) followed by the 40e59-year age group (n ¼ 68, 59%). Only 7% of patients using this CAM modality were younger than 40 years. 2.1.4. Use of herbs and other dietary supplements for specific dermatologic problems As shown in Table 4, 112 patients (37%) reported having at least 1 skin condition. The 3 most common dermatologic problems for which herbs and other dietary supplements were used included dry skin (n ¼ 86, 29%), pruritus (n ¼ 43, 14%), and wrinkles (n ¼ 22, 7%).
2.1. CAM use by modality 2.1.1. Treatments and techniques One or more treatments or techniques were used by 160 patients (53%) (Table 1). The 5 treatments or techniques used most
2.1.5. Patients’ attitudes toward CAM When asked whether our Department of Dermatology should consider incorporating CAM approaches into treatment recommendations, a significant majority of patients (n ¼ 235, 78%) felt we
Table 1 Treatments and techniques used by patients separated by sex and age groupa. Treatment or technique
Sex Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
Massage Chiropractic Relaxation Yoga Meditation Music therapy Homeopathy Aromatherapy Acupuncture Energy healing Tai chi Hypnosis Biofeedback Magnetic therapies Qigong Chelation therapy At least 1 treatment/technique
100 (33) 65 (22) 45 (15) 41 (14) 40 (13) 35 (12) 33 (11) 31 (10) 27 (9) 19 (6) 12 (4) 10 (3) 8 (3) 7 (2) 5 (2) 4 (1) 160 (53)
28 (20) 29 (20) 11 (8) 7 (5) 12 (8) 8 (6) 11 (8) 3 (2) 8 (6) 6 (4) 1 (1) 1 (1) 1 (1) 2 (1) 0 (0) 2 (1) 57 (40)
71 (46) 35 (23) 34 (22) 34 (22) 28 (18) 27 (18) 22 (14) 28 (18) 18 (12) 13 (8) 10 (6) 9 (6) 7 (5) 5 (3) 5 (3) 2 (1) 102 (66)
1 2 1 0 1 0 0 0 0 1 0 0 0 0 0 0 2
16 (39) 10 (24) 5 (12) 13 (32) 10 (24) 6 (15) 8 (20) 12 (29) 3 (7) 4 (10) 3 (7) 0 (0) 0 (0) 0 (0) 3 (7) 0 (0) 27 (66)
49 (43) 25 (22) 24 (21) 16 (14) 15 (13) 18 (16) 12 (10) 13 (11) 13 (11) 7 (6) 3 (3) 4 (3) 3 (3) 3 (3) 0 (0) 1 (1) 74 (64)
34 (25) 28 (20) 15 (11) 12 (9) 14 (10) 11 (8) 13 (9) 6 (4) 11 (8) 7 (5) 6 (4) 6 (4) 5 (4) 4 (3) 2 (1) 3 (2) 57 (41)
a
Values are No. of patients (%).
Age, y
(20) (40) (20) (0) (20) (0) (0) (0) (0) (20) (0) (0) (0) (0) (0) (0) (40)
A.N. Kalaaji et al. / Complementary Therapies in Clinical Practice 18 (2012) 49e53
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Table 2 Vitamins used by patients separated by sex and age groupa. Vitamin
Vitamin C Vitamin B Vitamin E Vitamin A Beta-Carotene At least 1 vitamin a
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
93 48 47 14 6 243
40 15 18 4 2 102
52 32 29 10 4 140
1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 4 (80)
11 (27) 5 (12) 5 (12) 4 (10) 0 (0) 32 (78)
43 22 24 7 5 96
38 21 18 3 1 111
(31) (16) (16) (5) (2) (81)
(28) (10) (13) (3) (1) (71)
(34) (21) (19) (6) (3) (91)
(37) (19) (21) (6) (4) (83)
(28) (15) (13) (2) (1) (80)
Values are No. of patients (%).
conditions including psoriasis,10e12 atopic dermatitis,13 warts,14 wound healing,15 and cutaneous ulcers.16 The protective effects of green tea extracts on photoaging is also a growing area of investigation,17,18 as is the role of natural antioxidants in dermatology.19 Furthermore, specific CAM therapies aimed at reducing stress levelsdsuch as massage, relaxation therapy, meditation, and yogadmay benefit patients for whom stress aggravates their skin condition (reported by 31% [n ¼ 92] of patients in our study). Several studies have demonstrated enormous popularity of CAM use among patients with inflammatory skin diseases in France (49%), Germany (46%), Australia (48.5%), and the United States (34%).20,21 CAM use among patients with psoriasis is common, with a prevalence of 43%e69%.22e27 Herbs, special diets, and dietary supplements are the most commonly used modalities. In a systematic review of the clinical trial literature regarding CAM use for psoriasis, Smith et al12 concluded that the most promising CAM modalities for psoriasis were fish oil, climatotherapy, and mind/ body approaches. Overall, they concluded that both the results and the quality of the clinical trials varied, and there is significant need for high-quality, controlled clinical trials regarding CAM use in dermatology.
should offer CAM therapy (Table 5). Furthermore, an overwhelming 89% (n ¼ 267) of patients felt that our dermatology department should include CAM approaches in our research activities. 3. Discussion The use of CAM is increasing in the United States. Patients seen in tertiary care centers are usually physician referred and accept conventional medical treatment. Therefore, the use of CAM by this patient population could be considered more complementary than alternative. One of the landmark studies examining complementary medicine in the United States was conducted by Eisenberg and colleagues in 1993.4 Other surveys have concentrated on trends in CAM2,8 or compared the use of CAM among different specialty clinics in a tertiary care center and in a fibromyalgia clinic.6,7 One recent review examining the use of botanicals in various dermatologic conditions, including acne, atopic dermatitis, psoriasis, and skin infections, highlighted that certain plant-derived compounds such as dithranol (anthralin), methoxsalen (8-methoxypsoralen), podophyllin, salicylates, and tannins are already well used in dermatology.9 CAM has also been used for other dermatologic
Table 3 Herbs and other dietary supplements used by patients separated by sex and age groupa. Herb or other dietary supplementb
Green tea Fish oil Flaxseed Aloe Glucosamine Garlic Soy Ginger Probiotics Chondroitin Echinacea Acai berry Coenzyme Q10 Ginseng Lutein Melatonin Cayenne pepper MSM Ginkgo biloba Turmeric Milk thistle Mangosteen Saw palmetto Evening primrose oil At least 1 herb or other dietary supplement listed above or in footnoteb
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
104 (35) 91 (30) 62 (21) 52 (17) 50 (17) 49 (16) 46 (15) 44 (15) 44 (15) 37 (12) 28 (9) 22 (7) 20 (7) 18 (6) 16 (5) 16 (5) 15 (5) 14 (5) 13 (4) 13 (4) 10 (3) 9 (3) 9 (3) 8 (3) 173 (58)
40 (28) 39 (27) 23 (16) 13 (9) 23 (16) 21 (15) 17 (12) 14 (10) 15 (10) 17 (12) 8 (6) 4 (3) 6 (4) 3 (2) 8 (6) 3 (2) 6 (4) 7 (5) 5 (3) 5 (3) 4 (3) 4 (3) 8 (6) 0 (0) 69 (48)
63 (41) 51 (33) 39 (25) 39 (25) 27 (18) 27 (18) 28 (18) 29 (19) 28 (18) 20 (13) 20 (13) 18 (12) 13 (8) 14 (9) 8 (5) 13 (8) 9 (6) 7 (5) 8 (5) 7 (5) 6 (4) 5 (3) 1 (1) 8 (5) 102 (66)
1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 1 (20) 1 (20) 1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (20)
13 (32) 10 (24) 9 (22) 11 (27) 4 (10) 5 (12) 7 (17) 9 (22) 7 (17) 2 (5) 5 (12) 6 (15) 0 (0) 4 (10) 0 (0) 1 (2) 3 (7) 2 (5) 2 (5) 2 (5) 0 (0) 1 (2) 1 (2) 1 (2) 19 (46)
46 (40) 29 (25) 26 (23) 26 (23) 18 (16) 24 (21) 18 (16) 21 (18) 21 (18) 14 (12) 14 (12) 10 (9) 5 (4) 9 (8) 9 (8) 11 (10) 6 (5) 4 (3) 3 (3) 4 (3) 5 (4) 4 (3) 3 (3) 4 (3) 68 (59)
44 (32) 52 (38) 27 (20) 15 (11) 28 (20) 19 (14) 20 (14) 13 (9) 16 (12) 21 (15) 9 (7) 6 (4) 15 (11) 5 (4) 7 (5) 4 (3) 6 (4) 8 (6) 8 (6) 7 (5) 5 (4) 4 (3) 5 (4) 3 (2) 85 (62)
Abbreviation: MSM, methylsulfonylmethane. a Values are No. of patients (%). b Herbs and other dietary supplements used by 2% of patients (listed in decreasing order): goji berry, black cohosh, red yeast rice, St. John’s wort, cat’s claw, feverfew, bilberry, S-adenosyl methionine, stinging nettle, valerian, bitter orange, devil’s claw, hawthorn, and kava.
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Table 4 Skin conditions treated with herbal supplements by patient sex and age groupa. Skin condition
Dry skin Itch Wrinkles Skin cancers Toenail fungus Psoriasis Eczema/dermatitis Acne Warts Hair loss Hyperpigmentation Rosacea Lupus At least 1 skin condition a
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
86 43 22 16 14 12 9 8 8 6 5 5 4 112
30 16 3 9 7 4 5 3 4 3 3 3 2 38
55 27 19 7 7 8 4 5 4 3 2 2 2 73
3 (60) 0 (0) 0 (0) 0 (0) 1 (20) 0 (0) 1 (20) 1 (20) 1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 3 (60)
10 (24) 5 (12) 2 (5) 2 (5) 0 (0) 2 (5) 2 (5) 2 (5) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 14 (34)
33 14 12 4 2 5 3 4 2 1 2 1 2 44
39 23 8 9 11 5 3 1 4 5 3 4 2 50
(29) (14) (7) (5) (5) (4) (3) (3) (3) (2) (2) (2) (1) (37)
(21) (11) (2) (6) (5) (3) (3) (2) (3) (2) (2) (2) (1) (27)
(36) (18) (12) (5) (5) (5) (3) (3) (3) (2) (1) (1) (1) (47)
(29) (12) (10) (3) (2) (4) (3) (3) (2) (1) (2) (1) (2) (38)
(28) (17) (6) (7) (8) (4) (2) (1) (3) (4) (2) (3) (1) (36)
Values are No. of patients (%).
Table 5 Patients’ attitudes toward CAM by sex and age groupa. Patients’ attitudes toward CAM
Incorporate CAM treatments Research CAM treatments
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
235 (78) 267 (89)
106 (74) 127 (89)
127 (82) 138 (90)
5 (100) 5 (100)
36 (88) 35 (85)
96 (83) 107 (93)
98 (71) 120 (87)
Abbreviation: CAM, complementary and alternative medicine. a Values are No. of patients (%).
Our current study was designed to evaluate the frequency and pattern of CAM use in patients referred to our Department of Dermatology. It is clear from our study that dermatology patients seen in our clinic do indeed use CAM. A total of 82% of patients had used at least 1 form of CAM therapy during the previous year. The use of CAM to treat skin conditions was highest among patients 40 years and older. Fifty-three percent of our patients used treatments or techniques, with massage therapy being the most common. Excluding multivitamins and vitamin D, which are now considered part of conventional medicine, vitamin C was the most commonly used vitamin (31% of patients), with higher usage among women and those age 40 years and older. Vitamin C was also the most commonly used vitamin in a previous survey study by WahnerRoedler and colleagues.7 Fifty-eight percent of our patients used one or more herbs or other dietary supplements. This finding is consistent with the previous survey, in which 51% of patients seen in a fibromyalgia treatment program had used herbs.7 The most frequently used herb or other dietary supplement in our study was green tea (n ¼ 104, 35%), which was also similar to the fibromyalgia study.7 The overall findings from our study reveal that dermatology patients do use CAM and that herbal or other dietary supplements are most commonly used. It is important for dermatologists to be aware of these results because dietary supplements can interact with prescription drugs. Our study also shows that CAM use is greatest in older patients and in women, which is consistent with national data.3 In addition, our study highlighted the growing interest among patients in the United States regarding CAM therapies, as seen in other surveys. It should be noted that CAM is in flux as therapies, when deemed safe and effective, become conventional medicine. Therefore, a therapy that is considered CAM currently may be considered conventional in the future. Seventy-eight percent (n ¼ 235) of our patients have requested that we consider incorporating CAM approaches into our treatment recommendations. Furthermore, 89% (n ¼ 267) of patients feel we
should study CAM approaches in our research activities. These 2 findings emphasize that our patients desire more integrative medicine in their care. 4. Conclusion CAM is being used by patients seen in the department of dermatology of a tertiary care center, and this interest in integrative medicine is in keeping with increasing public acceptance of CAM in the United States. Moreover, a significant majority of our dermatology patients have requested that we conduct research on CAM approaches and consider incorporating CAM in our treatment recommendations. Conflict of interest statement Amer N. Kalaaji, MD and Brent A. Bauer, MD are involved in a clinical trial testing a commercially available Aveeno moisturizer (Johnson & Johnson, New Brunswick, New Jersey) for dry skin in patients. The other authors have no conflict of interest to disclose. Acknowledgment There were no sources of funding and no sponsorship involvement with this manuscript. References 1. National Institutes of Health: National center for complementary and alternative medicine [Internet]. Bethesda (MD): NCCAM [cited 18 Nov 2010]. Available from: http://nccam.nih.gov/health/whatiscam/. 2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990e1997: results of a follow-up national survey. JAMA 1998 Nov 11;280(18):1569e75. 3. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Rep 2008 Dec;10(12):1e23.
A.N. Kalaaji et al. / Complementary Therapies in Clinical Practice 18 (2012) 49e53 4. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993 Jan 28;328(4):246e52. 5. Ernst E. The usage of complementary therapies by dermatological patients: a systematic review. Br J Dermatol 2000 May;142(5):857e61. 6. Wahner-Roedler DL, Elkin PL, Lee MC, Vincent A, Gay RE, Loehrer LL, et al. Complementary and alternative medicine: use by patients seen in different specialty areas in a tertiary-care centre. Evid Based Integr Med 2004;1(4):253e60. 7. Wahner-Roedler DL, Elkin PL, Vincent A, Thompson JM, Oh TH, Loehrer LL, et al. Use of complementary and alternative medical therapies by patients referred to a fibromyalgia treatment program at a tertiary care center. Mayo Clin Proc 2005 Jan;80(1):55e60. 8. Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001 Aug 21;135(4):262e8. 9. Reuter J, Merfort I, Schempp CM. Botanicals in dermatology: an evidence-based review. Am J Clin Dermatol 2010;11(4):247e67. 10. Treloar V. Integrative dermatology for psoriasis: facts and controversies. Clin Dermatol 2010 JaneFeb;28(1):93e9. 11. Choonhakarn C, Busaracome P, Sripanidkulchai B, Sarakarn P. A prospective, randomized clinical trial comparing topical aloe vera with 0.1% triamcinolone acetonide in mild to moderate plaque psoriasis. J Eur Acad Dermatol Venereol 2010 Feb;24(2):168e72. 12. Smith N, Weymann A, Tausk FA, Gelfand JM. Complementary and alternative medicine for psoriasis: a qualitative review of the clinical trial literature. J Am Acad Dermatol 2009 Nov;61(5):841e56. 13. Boneberger S, Rupec RA, Ruzicka T. Complementary therapy for atopic dermatitis and other allergic skin diseases: facts and controversies. Clin Dermatol 2010 JaneFeb;28(1):57e61. 14. Zedan H, Hofny ER, Ismail SA. Propolis as an alternative treatment for cutaneous warts. Int J Dermatol 2009 Nov;48(11):1246e9. 15. Davis SC, Perez R. Cosmeceuticals and natural products: wound healing. Clin Dermatol 2009 SepeOct;27(5):502e6.
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16. Binic I, Jankovic A, Jankovic D, Jankovic I, Vrucinic Z. Evaluation of healing and antimicrobiological effects of herbal therapy on venous leg ulcer: pilot study. Phytother Res 2010 Feb;24(2):277e82. 17. Li YH, Wu Y, Wei HC, Xu YY, Jia LL, Chen J, et al. Protective effects of green tea extracts on photoaging and photommunosuppression. Skin Res Technol 2009 Aug;15(3):338e45. 18. Camouse MM, Domingo DS, Swain FR, Conrad EP, Matsui MS, Maes D, et al. Topical application of green and white tea extracts provides protection from solar-simulated ultraviolet light in human skin. Exp Dermatol 2009 Jun;18(6):522e6. 19. Ditre C, Wu J, Baumann LS, Rigel D. Innovations in natural antioxidants and their role in dermatology. Cutis 2008 Dec;82(6 Suppl):2e16. 20. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994 Jul 9;309(6947):107e11. 21. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996 Mar 2;347(9001):569e73. 22. Fleischer Jr AB, Feldman SR, Rapp SR, Reboussin DM, Exum ML, Clark AR. Alternative therapies commonly used within a population of patients with psoriasis. Cutis 1996 Sep;58(3):216e20. 23. Baron SE, Goodwin RG, Nicolau N, Blackford S, Goulden V. Use of complementary medicine among outpatients with dermatologic conditions within Yorkshire and South Wales, United Kingdom. J Am Acad Dermatol 2005 Apr;52(4):589e94. 24. Ben-Arye E, Ziv M, Frenkel M, Lavi I, Rosenman D. Complementary medicine and psoriasis: linking the patient’s outlook with evidence-based medicine. Dermatology 2003;207(3):302e7. 25. Chen YF, Chang JS. Complementary and alternative medicine use among patients attending a hospital dermatology clinic in Taiwan. Int J Dermatol 2003 Aug;42(8):616e21. 26. Clark CM, McKay RA, Fortune DG, Griffiths CE. Use of alternative treatments by patients with psoriasis. Br J Gen Pract 1998 Dec;48(437):1873e4. 27. Jensen P. Use of alternative medicine by patients with atopic dermatitis and psoriasis. Acta Derm Venereol 1990;70(5):421e4.
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Use of complementary and alternative medicine by patients seen at the dermatology department of a tertiary care center Amer N. Kalaaji a, *, Dietlind L. Wahner-Roedler b, Amit Sood b, Tony Y. Chon b, Laura L. Loehrer b, Stephen S. Cha c, Brent A. Bauer b a b c
Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
a b s t r a c t Keywords: CAM Complementary and alternative medicine Dietary supplements Herbs Vitamins
The use of complementary and alternative medicine (CAM) among patients with dermatologic conditions has not been well studied. The aim of this study was to evaluate the frequency and pattern of CAM use in patients referred to the dermatology department of a tertiary care center. Patients referred to the dermatology department of an academic tertiary referral center between February 2, 2010, and February 10, 2010, were invited to participate in an 86-question survey regarding CAM use during the previous year. A total of 300 patients completed the survey, of whom 154 (51%) were women. Eighty-two percent (n ¼ 247) of the respondents had used some type of CAM during the previous year. The most frequently used treatment and technique was massage therapy (33%), and the most commonly used vitamin was vitamin C (31%). Herbs or other dietary supplements were used by 58% (n ¼ 173) of patients. Seventyeight percent (n ¼ 235) of patients stated that physicians should consider incorporating CAM approaches into their treatment recommendations, and 89% of patients (n ¼ 267) stated that our dermatology department should study CAM approaches in research studies. CAM utilization is high among patients at a large academic dermatology department. Patients indicated a strong preference for having CAM approaches incorporated into their treatment recommendations and believed in the value of clinical studies to further refine the role of CAM. Ó 2011 Elsevier Ltd. All rights reserved.
Complementary and alternative medicine (CAM) refers to a group of medical and health care practices that are not generally considered part of conventional therapy.1 Traditionally, alternative medicine refers to the use of CAM in place of conventional medicine. Complementary medicine refers to the use of CAM along with conventional medicine. Examples of CAM therapies include herbs and dietary supplements, vitamins, mind/body practices, and hands-on treatments or techniques (eg, acupuncture, massage, or chiropractic). Today, however, there is a growing shift toward integrative medicine that combines conventional and CAM therapies that have been proved safe and effective. This movement toward an increasing presence of CAM in conventional medicine settings has been driven in part by strong interest in CAM by patients, with the use of CAM continuing to increase in the United States.2 According to a survey conducted in 2007 by the Centers for Abbreviation: CAM, complementary and alternative medicine. * Corresponding author. E-mail address: [email protected] (A.N. Kalaaji). 1744-3881/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ctcp.2011.05.003
Disease Control and Prevention, approximately 38% of adults and 12% of children had used some type of CAM in the past 12 months.3 As interest in and use of CAM continues to grow, it is imperative that clinicians be able to help patients make informed decisions regarding the safety and efficacy of the various therapies they encounter.4 Use of CAM by dermatology patients might be expected to be higher than in the general public because of the chronic nature of many dermatologic conditions (eg, psoriasis and eczema). This supposition appears to be borne out by a 2000 systematic review of surveys of CAM use by dermatologic patients, which found that 35%e69% of dermatology patients used CAM at some point in their lifetime.5 Since the use of CAM has continued to grow in the past decade, we wished to determine how CAM was being used currently by dermatology patients in a tertiary care setting. Therefore, we conducted a new survey regarding use of CAM by patients at our dermatology department. We aimed to help focus ongoing and new research and education efforts to ensure that patients and clinicians are optimally informed about the risks and benefits of CAM.
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1. Patients and methods This study was approved by our institutional review board. Adult patients with appointments in the department of dermatology at an academic tertiary referral center between February 2 and February 10, 2010, were approached in person and asked to complete a survey regarding their use of CAM therapies during the previous year. The survey was conducted by 2 study coordinators of the complementary and integrative medicine group at our institution who remained available for questions. The surveys were collected within 30 minutes of distribution. 1.1. Survey instrument The survey instrument has been described in detail previously.6,7 It was modified for this study to fit patients seen in the department of dermatology. The survey addressed the use of different CAM domains, including treatments or techniques, vitamins, and herbs or other dietary supplements during the previous year. The survey also addressed the types of skin conditions for which CAM was being used and patients’ feelings about our department conducting research on CAM and incorporating CAM approaches into our treatment recommendations. 1.2. Statistical analysis Frequency and percentage were used to evaluate the frequency and pattern of CAM use in our dermatology patients. 2. Results A total of 300 patients completed the survey: 154 (51%) women, 143 (48%) men, and 3 did not report their sex. The respondents were divided into categories by age: 138 (46%) older than 60 years, 115 (38%) aged 40e59-years, 41 (14%) aged 20e39 years, 5 (2%) younger than 20 years, and 1 did not report age. Of the 300 respondents, 247 (82%) had used some type of CAM therapy during the previous year.
frequently were massage therapy (n ¼ 100, 33%), chiropractic therapy (n ¼ 65, 22%), relaxation therapy (n ¼ 45, 15%), yoga (n ¼ 41, 14%), and meditation (n ¼ 40, 13%). Use of the most common treatment or technique, massage therapy, was highest in the 40e59-year age group (n ¼ 49, 43%), and it was used by 46% of women vs 20% of men. 2.1.2. Vitamins Eighty-one percent (n ¼ 243) of patients used 1 or more vitamins (Table 2). The most frequently used vitamins were multiple vitamins and vitamin D, used by 70% (n ¼ 209) and 40% (n ¼ 119) of patients, respectively. However, it should be noted that these vitamins have been incorporated into conventional medicine and are no longer considered CAM by the National Center for Complementary and Alternative Medicine. Therefore, excluding these, vitamin C was used most commonly by all patients (n ¼ 93, 31%) (Table 2). Its use was most common in the 40e59-year age group (n ¼ 43, 37%), followed by those 60 years and older (n ¼ 38, 28%). Slightly more women than men used vitamin C (34% vs 28%). 2.1.3. Herbs and other dietary supplements One or more herbs or other dietary supplements were used by 58% (n ¼ 173) of our patients (Table 3). The 5 most commonly used oral herbs or other dietary supplements were green tea (n ¼ 104, 35%), fish oil (n ¼ 91, 30%), flaxseed (n ¼ 62, 21%), glucosamine (n ¼ 50, 17%), and garlic (n ¼ 49, 16%). Aloe was the most commonly used topical herb (n ¼ 52, 17%), which was used by 25% (n ¼ 39) of women. Overall, herbs or other dietary supplements were most commonly used by patients 60 years and older (n ¼ 85, 62%) followed by the 40e59-year age group (n ¼ 68, 59%). Only 7% of patients using this CAM modality were younger than 40 years. 2.1.4. Use of herbs and other dietary supplements for specific dermatologic problems As shown in Table 4, 112 patients (37%) reported having at least 1 skin condition. The 3 most common dermatologic problems for which herbs and other dietary supplements were used included dry skin (n ¼ 86, 29%), pruritus (n ¼ 43, 14%), and wrinkles (n ¼ 22, 7%).
2.1. CAM use by modality 2.1.1. Treatments and techniques One or more treatments or techniques were used by 160 patients (53%) (Table 1). The 5 treatments or techniques used most
2.1.5. Patients’ attitudes toward CAM When asked whether our Department of Dermatology should consider incorporating CAM approaches into treatment recommendations, a significant majority of patients (n ¼ 235, 78%) felt we
Table 1 Treatments and techniques used by patients separated by sex and age groupa. Treatment or technique
Sex Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
Massage Chiropractic Relaxation Yoga Meditation Music therapy Homeopathy Aromatherapy Acupuncture Energy healing Tai chi Hypnosis Biofeedback Magnetic therapies Qigong Chelation therapy At least 1 treatment/technique
100 (33) 65 (22) 45 (15) 41 (14) 40 (13) 35 (12) 33 (11) 31 (10) 27 (9) 19 (6) 12 (4) 10 (3) 8 (3) 7 (2) 5 (2) 4 (1) 160 (53)
28 (20) 29 (20) 11 (8) 7 (5) 12 (8) 8 (6) 11 (8) 3 (2) 8 (6) 6 (4) 1 (1) 1 (1) 1 (1) 2 (1) 0 (0) 2 (1) 57 (40)
71 (46) 35 (23) 34 (22) 34 (22) 28 (18) 27 (18) 22 (14) 28 (18) 18 (12) 13 (8) 10 (6) 9 (6) 7 (5) 5 (3) 5 (3) 2 (1) 102 (66)
1 2 1 0 1 0 0 0 0 1 0 0 0 0 0 0 2
16 (39) 10 (24) 5 (12) 13 (32) 10 (24) 6 (15) 8 (20) 12 (29) 3 (7) 4 (10) 3 (7) 0 (0) 0 (0) 0 (0) 3 (7) 0 (0) 27 (66)
49 (43) 25 (22) 24 (21) 16 (14) 15 (13) 18 (16) 12 (10) 13 (11) 13 (11) 7 (6) 3 (3) 4 (3) 3 (3) 3 (3) 0 (0) 1 (1) 74 (64)
34 (25) 28 (20) 15 (11) 12 (9) 14 (10) 11 (8) 13 (9) 6 (4) 11 (8) 7 (5) 6 (4) 6 (4) 5 (4) 4 (3) 2 (1) 3 (2) 57 (41)
a
Values are No. of patients (%).
Age, y
(20) (40) (20) (0) (20) (0) (0) (0) (0) (20) (0) (0) (0) (0) (0) (0) (40)
A.N. Kalaaji et al. / Complementary Therapies in Clinical Practice 18 (2012) 49e53
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Table 2 Vitamins used by patients separated by sex and age groupa. Vitamin
Vitamin C Vitamin B Vitamin E Vitamin A Beta-Carotene At least 1 vitamin a
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
93 48 47 14 6 243
40 15 18 4 2 102
52 32 29 10 4 140
1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 4 (80)
11 (27) 5 (12) 5 (12) 4 (10) 0 (0) 32 (78)
43 22 24 7 5 96
38 21 18 3 1 111
(31) (16) (16) (5) (2) (81)
(28) (10) (13) (3) (1) (71)
(34) (21) (19) (6) (3) (91)
(37) (19) (21) (6) (4) (83)
(28) (15) (13) (2) (1) (80)
Values are No. of patients (%).
conditions including psoriasis,10e12 atopic dermatitis,13 warts,14 wound healing,15 and cutaneous ulcers.16 The protective effects of green tea extracts on photoaging is also a growing area of investigation,17,18 as is the role of natural antioxidants in dermatology.19 Furthermore, specific CAM therapies aimed at reducing stress levelsdsuch as massage, relaxation therapy, meditation, and yogadmay benefit patients for whom stress aggravates their skin condition (reported by 31% [n ¼ 92] of patients in our study). Several studies have demonstrated enormous popularity of CAM use among patients with inflammatory skin diseases in France (49%), Germany (46%), Australia (48.5%), and the United States (34%).20,21 CAM use among patients with psoriasis is common, with a prevalence of 43%e69%.22e27 Herbs, special diets, and dietary supplements are the most commonly used modalities. In a systematic review of the clinical trial literature regarding CAM use for psoriasis, Smith et al12 concluded that the most promising CAM modalities for psoriasis were fish oil, climatotherapy, and mind/ body approaches. Overall, they concluded that both the results and the quality of the clinical trials varied, and there is significant need for high-quality, controlled clinical trials regarding CAM use in dermatology.
should offer CAM therapy (Table 5). Furthermore, an overwhelming 89% (n ¼ 267) of patients felt that our dermatology department should include CAM approaches in our research activities. 3. Discussion The use of CAM is increasing in the United States. Patients seen in tertiary care centers are usually physician referred and accept conventional medical treatment. Therefore, the use of CAM by this patient population could be considered more complementary than alternative. One of the landmark studies examining complementary medicine in the United States was conducted by Eisenberg and colleagues in 1993.4 Other surveys have concentrated on trends in CAM2,8 or compared the use of CAM among different specialty clinics in a tertiary care center and in a fibromyalgia clinic.6,7 One recent review examining the use of botanicals in various dermatologic conditions, including acne, atopic dermatitis, psoriasis, and skin infections, highlighted that certain plant-derived compounds such as dithranol (anthralin), methoxsalen (8-methoxypsoralen), podophyllin, salicylates, and tannins are already well used in dermatology.9 CAM has also been used for other dermatologic
Table 3 Herbs and other dietary supplements used by patients separated by sex and age groupa. Herb or other dietary supplementb
Green tea Fish oil Flaxseed Aloe Glucosamine Garlic Soy Ginger Probiotics Chondroitin Echinacea Acai berry Coenzyme Q10 Ginseng Lutein Melatonin Cayenne pepper MSM Ginkgo biloba Turmeric Milk thistle Mangosteen Saw palmetto Evening primrose oil At least 1 herb or other dietary supplement listed above or in footnoteb
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
104 (35) 91 (30) 62 (21) 52 (17) 50 (17) 49 (16) 46 (15) 44 (15) 44 (15) 37 (12) 28 (9) 22 (7) 20 (7) 18 (6) 16 (5) 16 (5) 15 (5) 14 (5) 13 (4) 13 (4) 10 (3) 9 (3) 9 (3) 8 (3) 173 (58)
40 (28) 39 (27) 23 (16) 13 (9) 23 (16) 21 (15) 17 (12) 14 (10) 15 (10) 17 (12) 8 (6) 4 (3) 6 (4) 3 (2) 8 (6) 3 (2) 6 (4) 7 (5) 5 (3) 5 (3) 4 (3) 4 (3) 8 (6) 0 (0) 69 (48)
63 (41) 51 (33) 39 (25) 39 (25) 27 (18) 27 (18) 28 (18) 29 (19) 28 (18) 20 (13) 20 (13) 18 (12) 13 (8) 14 (9) 8 (5) 13 (8) 9 (6) 7 (5) 8 (5) 7 (5) 6 (4) 5 (3) 1 (1) 8 (5) 102 (66)
1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 1 (20) 1 (20) 1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (20)
13 (32) 10 (24) 9 (22) 11 (27) 4 (10) 5 (12) 7 (17) 9 (22) 7 (17) 2 (5) 5 (12) 6 (15) 0 (0) 4 (10) 0 (0) 1 (2) 3 (7) 2 (5) 2 (5) 2 (5) 0 (0) 1 (2) 1 (2) 1 (2) 19 (46)
46 (40) 29 (25) 26 (23) 26 (23) 18 (16) 24 (21) 18 (16) 21 (18) 21 (18) 14 (12) 14 (12) 10 (9) 5 (4) 9 (8) 9 (8) 11 (10) 6 (5) 4 (3) 3 (3) 4 (3) 5 (4) 4 (3) 3 (3) 4 (3) 68 (59)
44 (32) 52 (38) 27 (20) 15 (11) 28 (20) 19 (14) 20 (14) 13 (9) 16 (12) 21 (15) 9 (7) 6 (4) 15 (11) 5 (4) 7 (5) 4 (3) 6 (4) 8 (6) 8 (6) 7 (5) 5 (4) 4 (3) 5 (4) 3 (2) 85 (62)
Abbreviation: MSM, methylsulfonylmethane. a Values are No. of patients (%). b Herbs and other dietary supplements used by 2% of patients (listed in decreasing order): goji berry, black cohosh, red yeast rice, St. John’s wort, cat’s claw, feverfew, bilberry, S-adenosyl methionine, stinging nettle, valerian, bitter orange, devil’s claw, hawthorn, and kava.
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A.N. Kalaaji et al. / Complementary Therapies in Clinical Practice 18 (2012) 49e53
Table 4 Skin conditions treated with herbal supplements by patient sex and age groupa. Skin condition
Dry skin Itch Wrinkles Skin cancers Toenail fungus Psoriasis Eczema/dermatitis Acne Warts Hair loss Hyperpigmentation Rosacea Lupus At least 1 skin condition a
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
86 43 22 16 14 12 9 8 8 6 5 5 4 112
30 16 3 9 7 4 5 3 4 3 3 3 2 38
55 27 19 7 7 8 4 5 4 3 2 2 2 73
3 (60) 0 (0) 0 (0) 0 (0) 1 (20) 0 (0) 1 (20) 1 (20) 1 (20) 0 (0) 0 (0) 0 (0) 0 (0) 3 (60)
10 (24) 5 (12) 2 (5) 2 (5) 0 (0) 2 (5) 2 (5) 2 (5) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 14 (34)
33 14 12 4 2 5 3 4 2 1 2 1 2 44
39 23 8 9 11 5 3 1 4 5 3 4 2 50
(29) (14) (7) (5) (5) (4) (3) (3) (3) (2) (2) (2) (1) (37)
(21) (11) (2) (6) (5) (3) (3) (2) (3) (2) (2) (2) (1) (27)
(36) (18) (12) (5) (5) (5) (3) (3) (3) (2) (1) (1) (1) (47)
(29) (12) (10) (3) (2) (4) (3) (3) (2) (1) (2) (1) (2) (38)
(28) (17) (6) (7) (8) (4) (2) (1) (3) (4) (2) (3) (1) (36)
Values are No. of patients (%).
Table 5 Patients’ attitudes toward CAM by sex and age groupa. Patients’ attitudes toward CAM
Incorporate CAM treatments Research CAM treatments
Sex
Age, y
Total (N ¼ 300)
Male (n ¼ 143)
Female (n ¼ 154)
<20 (n ¼ 5)
20e39 (n ¼ 41)
40e59 (n ¼ 115)
60 (n ¼ 138)
235 (78) 267 (89)
106 (74) 127 (89)
127 (82) 138 (90)
5 (100) 5 (100)
36 (88) 35 (85)
96 (83) 107 (93)
98 (71) 120 (87)
Abbreviation: CAM, complementary and alternative medicine. a Values are No. of patients (%).
Our current study was designed to evaluate the frequency and pattern of CAM use in patients referred to our Department of Dermatology. It is clear from our study that dermatology patients seen in our clinic do indeed use CAM. A total of 82% of patients had used at least 1 form of CAM therapy during the previous year. The use of CAM to treat skin conditions was highest among patients 40 years and older. Fifty-three percent of our patients used treatments or techniques, with massage therapy being the most common. Excluding multivitamins and vitamin D, which are now considered part of conventional medicine, vitamin C was the most commonly used vitamin (31% of patients), with higher usage among women and those age 40 years and older. Vitamin C was also the most commonly used vitamin in a previous survey study by WahnerRoedler and colleagues.7 Fifty-eight percent of our patients used one or more herbs or other dietary supplements. This finding is consistent with the previous survey, in which 51% of patients seen in a fibromyalgia treatment program had used herbs.7 The most frequently used herb or other dietary supplement in our study was green tea (n ¼ 104, 35%), which was also similar to the fibromyalgia study.7 The overall findings from our study reveal that dermatology patients do use CAM and that herbal or other dietary supplements are most commonly used. It is important for dermatologists to be aware of these results because dietary supplements can interact with prescription drugs. Our study also shows that CAM use is greatest in older patients and in women, which is consistent with national data.3 In addition, our study highlighted the growing interest among patients in the United States regarding CAM therapies, as seen in other surveys. It should be noted that CAM is in flux as therapies, when deemed safe and effective, become conventional medicine. Therefore, a therapy that is considered CAM currently may be considered conventional in the future. Seventy-eight percent (n ¼ 235) of our patients have requested that we consider incorporating CAM approaches into our treatment recommendations. Furthermore, 89% (n ¼ 267) of patients feel we
should study CAM approaches in our research activities. These 2 findings emphasize that our patients desire more integrative medicine in their care. 4. Conclusion CAM is being used by patients seen in the department of dermatology of a tertiary care center, and this interest in integrative medicine is in keeping with increasing public acceptance of CAM in the United States. Moreover, a significant majority of our dermatology patients have requested that we conduct research on CAM approaches and consider incorporating CAM in our treatment recommendations. Conflict of interest statement Amer N. Kalaaji, MD and Brent A. Bauer, MD are involved in a clinical trial testing a commercially available Aveeno moisturizer (Johnson & Johnson, New Brunswick, New Jersey) for dry skin in patients. The other authors have no conflict of interest to disclose. Acknowledgment There were no sources of funding and no sponsorship involvement with this manuscript. References 1. National Institutes of Health: National center for complementary and alternative medicine [Internet]. Bethesda (MD): NCCAM [cited 18 Nov 2010]. Available from: http://nccam.nih.gov/health/whatiscam/. 2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990e1997: results of a follow-up national survey. JAMA 1998 Nov 11;280(18):1569e75. 3. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Rep 2008 Dec;10(12):1e23.
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16. Binic I, Jankovic A, Jankovic D, Jankovic I, Vrucinic Z. Evaluation of healing and antimicrobiological effects of herbal therapy on venous leg ulcer: pilot study. Phytother Res 2010 Feb;24(2):277e82. 17. Li YH, Wu Y, Wei HC, Xu YY, Jia LL, Chen J, et al. Protective effects of green tea extracts on photoaging and photommunosuppression. Skin Res Technol 2009 Aug;15(3):338e45. 18. Camouse MM, Domingo DS, Swain FR, Conrad EP, Matsui MS, Maes D, et al. Topical application of green and white tea extracts provides protection from solar-simulated ultraviolet light in human skin. Exp Dermatol 2009 Jun;18(6):522e6. 19. Ditre C, Wu J, Baumann LS, Rigel D. Innovations in natural antioxidants and their role in dermatology. Cutis 2008 Dec;82(6 Suppl):2e16. 20. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994 Jul 9;309(6947):107e11. 21. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996 Mar 2;347(9001):569e73. 22. Fleischer Jr AB, Feldman SR, Rapp SR, Reboussin DM, Exum ML, Clark AR. Alternative therapies commonly used within a population of patients with psoriasis. Cutis 1996 Sep;58(3):216e20. 23. Baron SE, Goodwin RG, Nicolau N, Blackford S, Goulden V. Use of complementary medicine among outpatients with dermatologic conditions within Yorkshire and South Wales, United Kingdom. J Am Acad Dermatol 2005 Apr;52(4):589e94. 24. Ben-Arye E, Ziv M, Frenkel M, Lavi I, Rosenman D. Complementary medicine and psoriasis: linking the patient’s outlook with evidence-based medicine. Dermatology 2003;207(3):302e7. 25. Chen YF, Chang JS. Complementary and alternative medicine use among patients attending a hospital dermatology clinic in Taiwan. Int J Dermatol 2003 Aug;42(8):616e21. 26. Clark CM, McKay RA, Fortune DG, Griffiths CE. Use of alternative treatments by patients with psoriasis. Br J Gen Pract 1998 Dec;48(437):1873e4. 27. Jensen P. Use of alternative medicine by patients with atopic dermatitis and psoriasis. Acta Derm Venereol 1990;70(5):421e4.