Complementary and Alternative Medicine in Dermatology….just what is it and why has it finally come of age? What specifically are the diet, nutrition, and supplements which help make skin appear healthy and youthful?
This is a subject which has finally become more mainstream. When I first began investigating holistic dermatology 20 years ago, I was relegated to the hinterland of oddball alternative folks by other more conventional dermatologists. But middle-of-the-road America today embraces complementary and alternative medicine therapies, thanks in part to their unhappiness with the current state of the US health care system, media moguls like Dr. Andy Weil, and the realization that the typical American diet is not a healthy one. Just walking down the aisles of Target this week you can see there is an area devoted to natural skin care, featuring the Acure Line from plant stem cells and the supplement area has a generic hair, nails, and skin supplements. Almost all main grocery stores feature an organic and local produce section. Last year’s Natural Foods and Expo West trade show in LA had an audience of 50,000 vendors, salespeople, marketing professionals and entrepreneurs attending and capitalizing on the natural food, supplement and lifestyle trend!
Finally, traditional medicine and dermatology is open to integrating some of the complementary and alternative therapies which American patients and people from across the world have been doing for some time.
First of all…what is alternative medicine in dermatology? Just like in all aspects of medicine, it entails a wide range of preventative and therapeutic techniques to keep one’s skin healthy and to help heal dermatologic disease states. You can teach your patients to care for their skin through an integrative, holistic approach that combines the best of conventional medicine, diet, nutritional supplements, herbs, aromatherapy, homeopathy, acupuncture, acupressure, stress reduction, and mind/body medicine.
For the past 25 or so years, there has been an informal AAD meeting of the dermatologists interested in alternative and complementary dermatology. However, in 2012 this was formalized into the Complementary and Alternative Medicine Task Force to advise the AAD and dermatologists worldwide how to sort through the exponentially increasing number of alternative therapy and natural product claims made in a totally uncontrolled, unsubstantiated, extremely lucrative market sector. In 2015, the AAD website will include a section done by the 10 or so members of this Task Force on the human clinical trials referenced in PubMed which substantiate the use of diet, supplement, and herbal therapies in various healthy and diseased skin care states.
Oxford Press in 2013 came out with the Integrative Dermatology Text, licensed, and written solely by board-certified dermatologists. In this recently published textbook you will see that there are many scientific studies which substantiate anecdotal claims which were made by alternative health practitioners over the past 25 years or more years. Smart Medicine for Your Skin, which I authored and was published in 2001 by Penguin Putnam, is a 400 page discussion of integrative dermatology and of complementary treatments for 33 different skin diseases and states. Much of this information still holds true today. Thus, you can see that you, the modern dermatologist, has not only pharmaceutical, immunologic, and laser advances, but also many complementary medicine tools at your disposal to help your patients look and feel better.
The skin is the largest and most visible organ in the body, and so is a great indicator of general health as well as organ health. “Your skin is the fingerprint of what is going on inside your body, and all skin conditions, from psoriasis to acne to aging, are the manifestations of your body’s internal needs, including its nutritional needs,” says Georgiana Donadio, PhD, DC, MSc, founder and director of the National Institute of Whole Health in Boston (Bouchez)1. Vitamins, minerals, and other nutrients give the skin a more radiant, healthy, and youthful glow. Studies have shown that a deficiency of vitamins B12, B6, C, E, folic acid, iron or zinc appears to mimic radiation in damaging DNA, causing single- and double-strand breaks, oxidative lesions or both. Many common micronutrient deficiencies, such as those of iron or biotin, also cause mitochondrial decay with oxidant leakage leading to accelerated aging (Ames 2004).2
It is best to get essential nutrients for one’s skin through one’s daily diet, but usually this is not entirely possible. Oral supplements and topical creams help. Dietary supplements include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes.
A balanced, whole foods, unprocessed natural diet is crucial to the health of your patient’s skin. Drinking a sufficient amount of pure filtered water, about 8 glasses a day, is necessary to keep one’s skin well hydrated and healthy. Adequate intake through a healthy diet and, if necessary, nutritional supplementation of vitamins B, C, D, E, and K, as well as beta-carotene, are especially important in keeping the skin healthy. The minerals chromium, copper, and zinc are also necessary for the normal functioning of one’s skin. If nutrients cannot be adequately absorbed with a balanced diet, taking supplements such as bioflavonoids and quercetin, coenzyme Q10, dehydroepiandrosterone (DHEA), essential fatty acids, and selenium can often be very helpful for keeping skin healthy or restoring it to its former state.
Studies suggest a diet incorporating the principles of the Mediterranean, anti-inflammatory, and low glycemic diets are beneficial for healthy, youthful skin as well as most disease states. The Mediterranean diet is based upon fruits, vegetables, whole grains, legumes, monounsaturated fats like those found in olive oil, and a healthy ratio of omega-3 to omega-6 polyunsaturated fatty acids. It has been linked with longer lifespans and better cardiovascular, cognitive, and metabolic health by Galland 3 in 2010 and Kastorini 4 in 2011. Caperle 5 in 1996 noted a reduced incidence of cancer in patients following the Mediterranean diet. This is also beneficial for the skin, as its anti-inflammatory effect is due in part to its emphasis on extra virgin olive oil, which is high in compounds that modulate oxidative stress and quiet inflammatory reactions.
For example, oleocanthal, one of the components of olive oil, has recently been shown by Galland 3 in 2010 and Lucas 6 in 2011, to possess anti-inflammatory actions similar to ibuprofen.
Fortes 7 in 2008 found that protection from melanoma was associated with eating shellfish, fish rich in omega 3 fatty acids, regular tea drinking, and greater consumption of fruits and vegetables.
Thus, Shapira 8 in 2010 advocated that a nutritional approach using the Mediterranean diet would be a useful complement to externally applied sun protection strategies to help defend patients against melanoma.
To maintain healthy skin, one’s diet must be rich in antioxidants, which are also anti-inflammatory. Free radical damage has been shown to be a significant factor in the aging process and in the progression of cancer. Inflammation is also thought to be the root cause of wrinkles and aged skin with sagging, discoloration, enlarged pores, and lack of radiance. Dietary choices considerably influence the extent of inflammation, so it needs to be emphasized to your patients that they do have significant control over their skin’s health and appearance. Double blind independent studies similarly confirm that the diet for healthy, youthful skin should also integrate the principles of the anti-inflammatory diet, which has become popular in the past decade.
Antioxidants fight against free radicals which gobble up collagen and elastin, the fibers that support skin structure, causing wrinkles and other signs of aging. Free radicals and reactive oxygen species are synthesized endogenously (in energy metabolism and the antimicrobial defense system of the body) and produced as reactions to exogenous exposure (such as cigarette smoke, poor diet, over-exercise, environmental pollutants, and food contaminants). Human dietary intervention studies based on the use of antioxidant compounds show how they can protect from endogenous and exogenous environmental assaults and neutralize sun-induced effects on the skin.
In addition, studies advocate that the diet for beautiful skin should include the tenets of a low glycemic diet. This is a diet that is low in refined carbohydrates and processed foods, and high in produce and lean protein, helping to preserve stable blood sugar levels. A high glycemic diet can result in insulin resistance, the body needing to produce ever-increasing amounts of insulin in order to clear glucose from the blood. Van Boekel 9 in 1991 showed that, based on the accelerated rate of aging seen in diabetics, chronic glucose exposure is known to affect how the body ages by a process called glycation. Studies by Cosgrove 10 in 2007; Piccardi 11 in 2009, Epstein 12 in 2010; and Nagata13, also in 2010 showed that insulin resistance leads to more skin inflammation and aging.
It has also been demonstrated that insulin resistance and inflammation causes collagen malformation. Once sugars enter the circulation they attach themselves to proteins such as collagen to slowly rearrange their youthful structure into advanced glycation end products (AGEs), the main perpetrators of skin damage. Pageon 14,15 in 2005 and 2008 and Danby 16 in 2010 showed that AGE molecules are particularly destructive since they can undergo extensive cross-linking with other proteins, causing once healthy collagen fibers to lose their elasticity, become rigid, more brittle, and susceptible to breakage. Avery 17 in 2006; Danby 16 in 2010 and Pageon 18, again in 2010, demonstrated that glycation occurs naturally in all tissues of the body, but is augmented by a high sugar diet and, within the skin, excessive sun exposure.
Using data from the first National Health and Nutrition Examination Survey (NHANES), Cosgrove 10 and others in 2007 examined associations between nutrient intake and skin aging in 4025 women. Nutrients were estimated by 24 hour recall, and skin aging was defined as wrinkling, senile dryness and skin atrophy. The investigators found that higher vitamin C intakes were associated with a lowered likelihood of a wrinkled appearance and senile dryness. Higher linoleic acid intakes were also associated with a lower likelihood of senile dryness and skin atrophy. However, an increase in fat and carbohydrates increased the likelihood of a wrinkled appearance and atrophy.
Purba19 and others in 2001 studied the dietary intakes of patients living in Greece, Melbourne, and Sweden, using a food frequency questionnaire. The Swedish elderly had the least skin wrinkling in sun exposed sites. Correlation analyses on pooled data suggested that there may be less actinic skin damage with a higher intake of vegetables, olive oil, fish, and legumes and with lower intakes of butter, margarine, milk products and sugar products.
Carotenoids, Vitamin C, D, E, free fatty acids, and selenium supplementation have been clinically shown to reduce the signs of photoaging and aging of the skin. Adequate amounts of bioflavonoids and quercetin, calcium, magnesium, zinc, alpha-lipoic acid, acety-L-carnitine, CoQ10, DMAE, copper, and chromium are also thought to be necessary for healthy, youthful-looking skin. These nutrients ideally would be supplied by the diet, but oral supplements may sometimes be necessary. For example, as one ages, one cannot absorb all the vitamin D one needs from the sun and food sources, and additional Vitamin D supplementation is necessary.
Studies have shown that groups of oral antioxidants taken together help to create and restore youthful skin. Thirty-nine volunteers with healthy skin were divided into 3 groups and supplemented for a period of 12 weeks (Heinrich 2006) 20. Group 1 received a mixture of lycopene (3 mg/day), lutein (3 mg/day), beta-carotene (4.8 mg/day), alpha-tocopherol (10 mg/day) and selenium (75 mcg/day). Group 2 was supplemented with a mixture of lycopene (6 mg/day), and no lutein but the other supplements remained the same. Skin density and thickness was significantly increased and roughness and scaling were improved in Groups 1 and 2 compared to the Group 3 placebo control.
Other studies confirm and expand on these results. A clinical, randomized, double-blind, parallel group, placebo-controlled study was conducted in healthy young female volunteers investigating the preventive, photoprotective effect of oral supplementation with Seresis, an antioxidative combination containing beta-carotene, lycopene, vitamins C and E, selenium and proanthocyanidins. Seresis was able to slow down the time of the development and grade of UVB-induced erythema by decreasing the UV-induced expression of MMP-1 and 9, which Gruel hypothesized was important in photoprotective processes (Gruel) 21.
Miguel 22 studied menopausal women and emphasized the important role of the B vitamins, the key antioxidant vitamins C and E, as well as beta-carotene, lipoic acid and the soy isoflavones (Miguel 2006). These nutrients may help to prevent antioxidant deficiency and thus protect the mitochondria against premature oxidative damage with loss of ATP synthesis and specialized cellular functions, including that of the skin. Therefore, Miguel concluded that the administration of synergistic combinations of some of the above mentioned antioxidants in the diet as well as topically may have favorable effects on the health and quality of life of women, especially of menopausal age and older.
As another example of the importance of diet and supplements, probiotics have been shown to improve acne in 7 scientific studies. The most recent one was Jung’s 2013 23 study comparing an acne treatment regimen with and without a probiotic supplement and minocycline in patients with mild to moderate acne. He found that the probiotics provided a synergistic anti-inflammatory effect with systemic antibiotics, reducing the total number of acneiform lesions while also reducing potential adverse events secondary to chronic antibiotic use.
Today, more than 50% of all Americans take dietary supplements. Patients should inform their doctors which supplements and herbs they are taking, as some can interact with certain pharmaceutical drugs. Rarely, a nutritional supplement may cause an unwanted side effect. The Office of Dietary Supplements was established in 1994 at the National Institutes of Health. Around 2000, the NIH launched an online database devoted entirely to dietary supplements that cited studies from more than 3,000 scientific journals at that time. With the increasing popularity of alternative medicine and the emphasis on individuals assuming greater responsibility for their own health care, the over-the-counter supplement business has expanded rapidly in the last 15 years. It promises to grow to even greater proportionally in the years to come.
Thus, Integrative or complementary and alternative dermatology is the personalized application of the best of conventional dermatology, healthy diet, nutritional supplements, herbs, aromatherapy, homeopathy, acupuncture, acupressure, stress reduction, and mind/body medicine. We can see that there are many evidence-based studies in the medical literature to support a healthy, Mediterranean, low glycemic, anti-inflammatory diet for healthy and youthful skin. There are also many double blind, controlled studies on the effectiveness of individual or a combination of vitamins and supplements to improve the health and beauty of the skin. This has already been accepted, publicized, and capitalized on by mainstream America. Some of the patients are just waiting for their doctors to verify and condone what they are already are embracing, while others need and want the education only an informed, up-to-date dermatologist can provide for them.