Complementary and Alternative
Medicines for the Treatment of
Atopic Dermatitis
Patients often describe seeking alternatives and adjuncts to care for the treatment of their atopic
dermatitis. The literature has explored some of the potential in these options.
Jonmichael W. Samsel, BS; Courtney E. Heron, BS; Steven R. Feldman, MD, PhD; and Sarah L. Taylor, MD, MPH
T he pathogenesis of atopic dermatitis (AD) is multifactorial,
involving a complex interplay between genetic susceptibility,
skin barrier abnormalities, immune deregulation, and environ-
mental triggers.1,2 As such, current therapies for AD embrace
a multifactorial approach, with topical corticosteroids (TCS)
and topical calcineurin inhibitors (TCI) to target inflammation,
emollients to restore the skin barrier, antipruritic agents to help
reduce self-inflicted skin damage, and avoidance of exacerbat-
ing factors. Due to the complex pathogenesis of AD and adverse
effects associated with TCS and TCI, a growing movement has
formed among patients, parents, and practitioners seeking alter-
natives to standard of care (SOC) therapies.3
Complementary and alternative medicine (CAM) is a grow-
ing field of therapy utilized by more than 30% of AD patients
searching for innovative approaches to treatment.4 The high
prevalence of CAM use in patients with AD may suggest that the
treatment expectations of some patients may not be fully met by
conventional therapies. According to definitions by the National
Institutes of Health, complementary therapies utilize nonmain-
stream practices in conjunction with SOC or conventional thera-
pies; when these practices are used in place of SOC or conven-
tional therapies, they are considered alternative therapies.5 The
prevalent and ambiguous advertising often associated with these
products may confuse patients and cast doubts on the validity
of these treatments to physicians. Additionally, CAM therapies
frequently fall outside of SOC because too little evidence exists
to determine whether they accomplish their intended purposes.
Therapies within CAM for AD can be divided into three catego-
ries: natural treatments, diet and supplementation, and mind-
body approaches. This article aims to inform readers about the
various CAM therapies for AD and their respective efficacies.
Natural Treatments
Natural herbal therapies have been utilized for a wide range of
diseases, including AD. Sunflower seed oil (SSO) can be considered
an emollient; 60% of SSO composition is linoleic acid, a neces-
sary fatty acid in the maintenance of epidermal barrier function.3,6
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SSO has a high vitamin E content and can convert linoleic acid
to arachidonic acid, a precursor to both prostaglandin E2 and
15-hydroxyeicosatetraenoic acid (15-HETE).3,6,7 15-HETE inhibits
the leukotriene B4-induced chemotaxis of neutrophils, which may
decrease cutaneous inflammation in patients with AD.7 When
applied twice daily to AD lesions, SSO shows a beneficial effect
on skin barrier function via improved dermatoscopic features and
improved scores in three indexes of severity: Children’s Dermatol-
ogy Life Quality Index (CDLQI), Eczema Area and Severity Index
(EASI), and Investigator Global Assessment (IGA).3,6
Another natural oil, virgin coconut oil (VCO), is a popular in-
gredient in hair, skin, and nail products. VCO contains high levels
of lauric acid, a fatty acid with antimicrobial and anti-inflamma-
tory properties that may improve the degree of Staphylococcus
aureus skin colonization.1,3,6 In patients with AD, VCO was shown
to be superior to virgin olive oil in the clearance of S aureus colo-
nies and more efficacious, lowering the objective component of
SCORing of Atopic Dermatitis (SCORAD) indexes after therapy
(P=.004).1,3,6 VCO was also superior to mineral oil as an emollient,
improving transepidermal water loss (TEWL) and both objective
and subjective components of SCORAD post therapy (P=.0069
and P=.0021, respectively), while simultaneously alleviating
symptoms of xerosis including dryness and rash.1,3
Traditional Chinese herbal therapy (TCHT) treats the per-
ceived underlying imbalances of the body believed by some to
cause AD, rather than treating AD itself. TCHT decreases the
release of proinflammatory cytokines and chemokines by sup-
pressing the recruitment and activation of eosinophils, increasing
treatment efficacy, and decreasing the minimum effective dose
of TCS when used complementary to SOC.1,3,8 Although initially
promising, conclusive evidence supporting reduction in AD
severity with oral or topical TCHT is lacking.9 Additionally, cases
of hepatotoxicity and death have been reported with the use of
TCHT for the treatment of AD.3 While TCHT may have some
therapeutic benefit in AD, long-term safety profiles and the exact
combinations of herbal therapies necessary for efficacious treat-
ment are not well defined.3
Continued on page 36
Continued from page 34
Borage oil (BO) and evening primrose oil (EPO) were used his-
torically as treatments for AD due to their high content of gam-
ma-linolenic acid, which has been hypothesized to be deficient
in patients with AD.10 Neither oil improves global AD symptoms,
thus further studies of BO or EPO are difficult to justify.10,11
From biblical references to Greek mythology, therapeutic bathing
in mineral water baths or pools has been regarded as a healing solu-
tion to patients with chronic skin diseases. Consistent use of these
baths is associated with decreased disease severity and improved
quality of life measures in AD patients.12 These minerals are postulat-
ed to be immunomodulatory and anti-inflammatory via inhibition of
tumor necrosis factor alpha-induced adhesion molecules and modu-
lation of IL-8.12 However, the concomitant presence of warm weather
and sun exposure during time spent in the bathing areas creates
difficulty identifying which aspect of therapeutic bathing produces
benefits.12 Warm climates are associated with a lower prevalence
of AD, and sun exposure beneficially impacts AD through a similar
mechanism to phototherapy.12 Replication of these mineral baths
at home is possible by bathing in a 10% Dead Sea salt solution with
narrowband UV-B light. This combination improves the SCORAD
index of patients with AD when compared with narrowband UV-B
phototherapy alone (P<.001).12 A follow-up approach to therapeutic
bathing in patients with AD involves wet wrap therapy to induce a
rapid benefit for patients through occlusive skin moisturization with
emollients. The process begins by applying topical medications and
moisturizers to damp skin and then immediately covering it with a
layer of damp cloth, typically pajamas soaked in warm water with
gauze applied to exposed areas.12 A subsequent layer of dry cloth is
then added, and the wrapping is left in place for several hours or
overnight.12 This technique may improve medication efficacy by
reducing the total amount of corticosteroid used during treatment
periods, potentially decreasing the risk of side effects associated with
TCS use.12 Compared to pretreatment, wet wrap therapy improves
the epidermal barrier by increasing the water content of the skin,
decreasing TEWL, and acting as a physical barrier to reduce skin
trauma associated with scratching.12,13
Diet and Supplementation
Diet has long been postulated to be behind the development of
as well as a potential cure for AD due to the increased prevalence
of food allergies in children with AD.2 However, current data is
inconclusive and does not support the use of any specific diet in
the treatment of AD aside from avoiding proven food allergens.
Although strict dietary practice is not recommended as a treat-
ment for AD due to possible consequences of dietary restriction,
the American Academy of Dermatology (AAD) does recommend
testing for food allergies in children younger than 5 years with
intractable AD or known food-induced reactions.14
Treatment of AD with supplementation of vitamins and biot-
ics is a thriving area of research and debate. Microflora alteration
through the use of probiotics, prebiotics, and synbiotics may convey
allergy protective effects, reducing possible predisposition for AD.10
Supplementation with probiotics may provide health benefits in AD
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both by replenishing commensal bacteria essential for stimulating
immune system development and by preventing the overgrowth of
pathologic bacteria, as microflora diversity prevents the shift toward
type 2 helper T cell-mediated immunity and the subsequent develop-
ment of allergic disease.10,15 Probiotics decrease the SCORAD index
in children with AD as compared with a control group (P<.001), with
the strongest evidence supporting Lactobacillus species administered
for 12 weeks in children 1 year or older.10,15,16 Supplementation with
Bifidobacterium, another probiotic, may be beneficial in preventing
development of AD; infants whose mothers supplemented their
diets with Bifidobacterium for the last 4 weeks of pregnancy and
who themselves were given powder containing Bifidobacterium with
breast milk or formula for the first 6 months of life had a decreased
risk of developing AD in the first 18 months of life compared with
controls.17 Bifidobacterium can be found naturally in foods such as
kimchi, kefir, yogurt, and sauerkraut.
Prebiotics are foods or supplements containing nondigestible
ingredients to stimulate the growth and activity of nonpathologic
microorganisms.10 Naturally occurring sources of prebiotics in-
clude artichokes, asparagus, bananas, onions, and garlic.18 Though
not extensively studied, initial results suggest prebiotics alone
have similar efficacy to synbiotics for lowering the SCORAD in-
dex in children with AD (P<.05).10,15 Compared with placebo, syn-
biotics improved SCORAD scores (P=.03) when given to children
1 year or older (P=.048), but supplementation was not beneficial
when given to infants younger than 1 year (P=.13).10,15,19 Improve-
ments in SCORAD were observed when the synbiotics utilized
contained mixed strains of bacteria (P=.03) vs single strains of
bacteria (P=.22).10,15,19 While not currently recommended by the
AAD, probiotics and prebiotics used in combination hold poten-
tial in the treatment of AD. Further understanding of the strains,
dosing, and targeted populations would be beneficial.10,14,15
Though a possible link between vitamin D deficiency and AD
has been a research focus, it is uncertain whether low levels of
vitamin D are a possible cause or result of chronic inflammation
in AD.10 Vitamin D deficiency is present in some children with AD,
but many studies show no correlation between degree of deficiency
and disease severity.10,20 However, other studies demonstrate levels
of vitamin D are lower in patients with moderate to severe AD
than with mild disease (P<.001).10,20,21 Because of these conflict-
ing results, there is no current recommendation from the AAD
for vitamin D supplementation. In a 2019 meta-analysis, vitamin
D3 supplementation decreased SCORAD and EASI scores when
compared with control groups (z = 6.76; P<.00001).20 This supports
the efficacy of daily supplementation, especially in patients with
moderate to severe AD who may be vitamin D deficient.20
Another vitamin utilized in the treatment of AD is topical vitamin
B12 (TB12). TB12 is a scavenger of nitric oxide and successfully lowers
the Six Area Six Sign Atopic Dermatitis (SASSAD) scores when com-
pared with placebo in patients with AD (P<.001).22 Two randomized
controlled trials support the use of TB12 in treating AD, with both
demonstrating decreases in SCORAD scores when compared with
placebo (z = 5.77; P<.00001).15,20 Because evidence for TB12 is limited,
further understanding of its potential mechanism and efficacy is
indicated to solidify it as a viable treatment option.15,23
Mind-Body Approaches
Psychological stress is often a component of AD and may exac-
erbate disease processes.15 The majority of mind-body approaches
within CAM are utilized as complementary treatments in Western
medicine to mitigate stress in patients with AD. Hypnosis, biofeed-
back, and meditation are often used as relaxation techniques to help
reduce stress by encouraging mindfulness. One study assessing com-
bined hypnosis and biofeedback in the treatment of AD demonstrat-
ed an improvement in subjective assessment of symptomatology
when compared with placebo at 8 and 20 weeks of therapy.12 These
techniques have also been suggested as research-based, psychologi-
cal approaches to control itching and scratching, thus breaking the
cycle of AD and allowing skin to heal.24
Progressive muscle relaxation (PMR) is another mental relax-
ation technique that may be utilized as adjunctive therapy for AD.
Compared with a control group given only conventional therapy,
the addition of PMR reduces state anxiety scores measured with
the State-Trait Anxiety Inventory (STAI) in patients with AD
after 1 month of twice-daily incorporation (P=.04).25 The degree
of pruritus and loss of sleep also decreased after 1 month in the
PMR treatment group (P=.001 and P=.007, respectively).12,25
Massage therapy (MT) is a physical technique involving the
manual manipulation of soft tissue with intentions of promoting
health and well-being.26 Massage is well known to relieve stress
and anxiety, but MT may also help reduce critical features of AD
including pruritus, skin erythema, and xeroderma.26 MT can be
used complementary to emollient application, but it is important
to test all oils and lotions prior to utilization to pre-identify and
avoid possible triggers of AD. MT should be avoided if the skin is
compromised thus vulnerable to infection.26
Acupuncture is another technique practiced for centuries as a
therapeutic approach to a broad array of pathologies, with recent
studies exploring its role in the treatment of AD.27 Qu Chi (LI11),
the acupoint located on the lateral end of the transverse cubital
crease in the elbow, is commonly targeted for pruritus manage-
ment.12,27 Acupuncture use to reduce itch perception, measured
by Visual Analogue Scale (VAS), is as effective as cetirizine
when comparing preventative interventions for pruritus (P<.05)
and superior to cetirizine as an abortive intervention (P<.05).27
Acupuncture also decreases basophil activation, measured by
cluster of differentiation (CD) 63 surface expression, improving
the IgE-mediated immunity of AD.27,28 Similarly, acupressure is
now being studied as a possible treatment for AD and is useful
in patients who may shy away from the idea of needles. Acupres-
sure accesses the same acupoints utilized in acupuncture but
applies pressure through a tiny metal pellet instead of puncturing
the skin with needles.29 Self-administered acupressure applied
at the Qu Chi point used in conjunction with SOC resulted in a
decrease in pruritus and lichenification after 4 weeks of therapy
(P=.03) compared with SOC alone.29 It is uncertain whether
these benefits are produced by local tissue modulation or the
global effects of stress reduction and improved well-being seen in
acupoint therapies. Despite the potential of these techniques as
AD treatments, current evidence of acupuncture as treatment for
AD is likely insufficient, revealing a need for further research to
assess efficacy.30
Conclusion
As more evidence-based research becomes available for many
of the CAM therapies discussed above (eTable1,3,6-10,12,14-17,19,20,22-29),
it is important for physicians to stay informed about alternate
therapeutic approaches in treating patients with AD. Providers
who remain aware of the literature surrounding these therapies
are equipped to have informative discussions with their patients
about the appropriate use of CAM. Practitioners can best provide
their expertise to patients by supporting further study of the
safety and efficacy of CAM therapies while continuing to treat
their patients’ AD with current SOC.6 n
Mr Samsel is a medical student and research fellow at the Center for
Dermatology Research in the department of dermatology at Wake Forest
School of Medicine in Winston-Salem, NC. Ms Heron is a medical student
and research associate at the Center for Dermatology Research in the de-
partment of dermatology at Wake Forest School of Medicine. Dr Feldman
is with the Center for Dermatology Research and the departments of der-
matology, pathology, and social sciences & health policy at Wake Forest
University School of Medicine and the department of dermatology at the
University of Southern Denmark, Odense, Denmark. Dr Taylor is assis-
tant professor of dermatology at the Center for Dermatology Research in
the department of dermatology at Wake Forest School of Medicine.
Disclosure: Dr Feldman has received research, speaking, and/or consulting
support from a variety of companies including Galderma, GSK/Stiefel, Almi-
rall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant,
AbbVie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi,
Novan, Qurient, National Biological Corporation, Caremark, Advance
Medical, Sun Pharma, Suncare Research, Informa, UpToDate, and National
Psoriasis Foundation. He is founder and majority owner of www.DrScore.com
and founder and part owner of Causa Research, a company dedicated to
enhancing patients’ adherence to treatment. The remaining authors have no
relevant financial relationships.
References
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potential of natural herbal medicines for the treatment of mild-to-severe atopic
dermatitis: a review of human clinical studies. Biomed Pharmacother. 2017;93:596-
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2. Habif TP. Clinical Dermatology. 6th ed. Elsevier; 2015.
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part 1. Clin Dermatol. 2017;35(4):383-386. doi:10.1016/j.clindermatol.2017.03.011
4. Holm JG, Clausen ML, Agner T, Thomsen SF. Use of complementary and alterna-
tive therapies in outpatients with atopic dermatitis from a dermatological university
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com/article/nea0820.
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 eTable. CAM for the Treatment of Atopic Dermatitis1,3,6-10,12,14-17,19,20,22-29
Supporting Study Proposed Mechanism Utility
Natural treatments
SSO Karagounis et al6 Improves skin barrier function and decreases Improved scores in CDLQI, EASI, and IGA
Lin et al7 cutaneous inflammation
Silverberg3
VCO Hussain et al1 Improves skin barrier function and has inherent Improved SCORAD and TEWL
Karagounis et al6 antimicrobial and anti-inflammatory properties
Silverberg3
TCHT Gu et al9 Suppresses the release of proinflammatory No conclusive evidence for reducing the
Hussain et al1 cytokines and chemokines and lowers serum levels severity of AD
Silverberg3 of IL-12
Tsang et al8
Therapeutic bathing Goddard et al12 Mineral-induced immune modulatory and Improved SCORAD and quality of life
anti-inflammatory actions measures
Wet-wrap therapy Goddard et al12 Reduces trauma from scratching and improves Decreased total amount of TCS used and
medication efficacy and epidermal barrier function improved TEWL, skin capacitance, and
when complementing emollient application SCORAD
Natural treatments
Probiotics Adler-Neal et al15 Stimulates immune system development and Improved SCORAD and decreased risk of
Enomoto et al17 prevents the growth of pathological bacteria AD development in infants
Kim et al16
Schlichte et al10
Silverberg et al14
Prebiotics Adler-Neal et al15 May create a nutrient-rich intestinal environment Improved SCORAD
Schlichte et al10 and stimulates the growth of nonpathologic colonic
bacteria
Synbiotics Adler-Neal et al15 Stimulates the growth and activity of Improved SCORAD
Chang et al19 nonpathologic, probiotic microorganisms
Schlichte et al10
Silverberg et al14
Vitamin D3 Schlichte et al10 May produce tolerogenic dendritic cells to the Improved EASI and SCORAD
Zhu et al20 allergic phenotype in children
TB12 Adler-Neal et al15 Scavenges nitric oxide Improved SASSAD and SCORAD
Nistico et al23
Stücker et al22
Zhu et al20
Mind-body approach
Hypnosis, biofeed- Goddard et al12 Relieves stress and helps control itching and Improved scores in subjective assessments
back & meditation Grossbart et al24 scratching of symptomatology
PMR Bae et al25 Encourages coping with stress through relaxation Improved scores in subjective assessments
Goddard et al12 and reduces anxiety of pruritus, LOS, and as STAI
MT Beider et al26 Relieves stress and anxiety Improved scores in the STAI and the STAI
for children
Acupuncture Goddard et al12 Reduces itch perception and decreases basophil Improved VAS itch severity scores and
Pfab et al28 activation decreases activation of CD63(+) basophils
van den Berg-Wolf et al27
Acupressure Lee et al29 Reduces itch perception Improved VAS itch severity scores and IGA
and EASI lichenification index scores, but
not overall EASI scores
LOS: loss of sleep.

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doi:10.1111/ced.12732

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