Description of the condition
Definition, clinical features, and epidemiology
Atopic eczema (AE) is difficult to define because of its variable morphology and distribution and its intermittent nature (Williams 2005). In infants, the disease typically appears on the face and scalp, while in children, it tends to occur on the hands, feet, wrists, ankles, the popliteal surface (behind the knees), and the antecubital region (in front of the elbows). Adults usually develop AE on the face, neck, back of the hands, and top of the feet (Akdis 2006). Itching is a predominant symptom of AE. It can often lead to a vicious cycle of scratching, which causes skin damage that in turn results in more itching: This is commonly referred to as the itch-scratch cycle of AE. The diagnosis of AE relies on the assessment of clinical features because there is no definitive test to diagnose the condition. Hanifin and Rajka (Hanifin 1980) originally developed diagnostic criteria for AE, which have subsequently been refined and validated (Williams 1994; Williams 1994a; Williams 1994b; Williams 1996; Williams 2005). A systematic review demonstrated that only the UK Working Party (Williams 1994) diagnostic criteria have been validated more than once and independently (Brenninkmeijer 2008). However, the Hanifin and Rajka diagnostic criteria have long been in use in dermatology, and they have been validated not only by consensus among leading clinical experts on AE but also via some scientific testing, albeit not as extensively as the UK Working Party's diagnostic criteria. Generally, the diagnosis is made in the presence of itchy skin, with three or more of the following: history and visible signs of eczema at areas of skin creases (such as the inner sides of the elbows and knees), history of dry skin, onset under the age of two years, or personal history of asthma. There are slight adaptations for diagnostic criteria in children aged under four years. Childhood AE is very common, at some point affecting up to 20% of children aged five or under (Williams 2008). A systematic review of the epidemiology of AE however found that there is no specific overall global trend in the epidemiology of AE for either children or adults (Deckers 2012). Epidemiologic evidence of the disease for adults is less definitive. One study done in Japan suggests that only up to 3.3% of adults are affected by AE in their lifetime (Muto 2003). Nevertheless, the disease is often more chronic and severe in adults than in children (Herd 1996).
Atopic eczema causes significant distress in terms of discomfort and effect on appearance. In the case of children, the impact on the child and family is mainly due to sleep disturbance and itch (Chamlin 2004; Lewis-Jones 1995). Research suggests that the impact of eczema on quality of life is second only to that of cerebral palsy, with greater impact reported for AE than for asthma or diabetes (Beattie 2006; Kemp 2003). Some of the many causes of treatment failure include the following: the fact that carers often do not use treatments correctly because of a lack of understanding of how they should be used, the refusal of children to allow carers to apply the treatment as prescribed, and the fact that the therapy can often be very time-consuming (Beattie 2003). However, it should be noted that another major cause of treatment failure is the inherently persistent nature of AE itself. The disease also has a substantial impact on the lives of adolescents and adults. Atopic eczema has been described as a disease that causes cumulative life-course impairment, which signifies that it impacts on a person's qualify of life in virtually all aspects and over the entire course of their lives, including in employment; personal relationships, such as familial ties; and mental health (Ibler 2013). Many of these disturbances are due to the social and psychological stigma associated with having a very visible skin disease (Ibler 2013). Sleep disturbance and itch also affects adults with AE (Bender 2003). The financial impact of AE on both the person and society also cannot be understated (Herd 2002).
Atopic eczema has many causes. The manner of development of the disease is still unclear. It is thought to include genetic predisposition, disturbed skin barrier function, and immunologic defects. Several studies suggest that there is an increased risk of developing AE in individuals with loss-of-function mutations in the filaggrin gene, which is present in up to 10% of western European populations (O'Regan 2009). Filaggrin is one of a number of structural proteins of the epidermis, which contribute to maintaining an effective skin barrier. Disturbances in skin barrier function facilitate greater penetration of allergens through the skin (Fallon 2009). It is thought that AE may be aggravated by contact with soaps or detergents, which can compromise the barrier function of the skin (Cork 2006). Protection of the skin barrier by excellent eczema care in early disease may decrease the risk of developing other atopic conditions (van den Oord 2009). It is important to note however that genetics and practices related to skin barrier protection alone do not explain the epidemiology of the disease: There is evidence that the environment, which can be influenced by socioeconomic and lifestyle factors, plays a role in AE (Williams 1995).
Description of the intervention
Many treatments are available for the management of AE in order to achieve satisfactory disease control. They have been classified into 10 groups (Hoare 2000). The initial approach to treating people requires basic therapy, which is focused on the use of hydrating topical treatments and the identification and avoidance of specific and non-specific precipitating factors (Ring 2012). Topical application of corticosteroids is a cornerstone medical therapy for AE, followed by calcineurin inhibitors, such as pimecrolimus and tacrolimus (Boguniewicz 2008). Those with severe AE not responding to topical therapy require systemic therapy. Systemic pharmaceutical treatments include corticosteroids, antihistamines, antibiotics, cyclosporine, azathioprine, mycophenolate mofetil, methotrexate, leflunomide, alitretinoin, intravenous immunoglobulins, interferon-γ, monoclonal antibodies, and fusion proteins (Simon 2011). Phototherapy and photochemotherapy have also been used as conventional treatment options.
There has been a documented increase in the proportion of the general population who use Complementary and Alternative Medicine (CAM) for a variety of ailments in many countries, such as Korea (68.9%), France (49%), Germany (46%), United States (34%), Belgium (31%), UK (26%), and Sweden (25%) (Fisher 1994). More recently, one study suggested that there is a growing interest in CAM as a primary, maintenance, or simultaneous treatment for AE and demonstrated that there was a statistically significantly higher interest in treating AE with CAM interventions than psoriasis (Kim 2013), although epidemiological evidence of this kind for other parts of the world is lacking at this time.
Defining CAM is challenging, namely due to the fact that the field is not only very broad, encompassing dozens of disparate methods and practices from a variety of sociocultural contexts, but it is also constantly changing and evolving. The National Center for Complementary and Alternative Medicine (NCCAM), a centre of the National Institutes of Health in the United States, defines CAM as a "group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine" (NCCAM 2013). Complementary and alternative medicine therapies represent "a group of therapeutic interventions that exist largely outside the institutions where conventional healthcare is taught and provided" (Zollman 1999). It has also been defined as "diagnosis, treatment or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine" (Ernst 1995).
How the intervention might work
A total of 128 systematic reviews of variable quality have been conducted on all aspects of AE since the year 2000, demonstrating the interest of the scientific community in this topic (Futamura 2013). Of those, eight are Cochrane systematic reviews on CAM treatments for AE alone. These include published systematic reviews on Chinese herbal medicine (Gu 2013), dietary exclusions (Bath-Hextall 2008), dietary supplements (Bath-Hextall 2012), probiotics (Boyle 2008; Osborn 2007a), prebiotics (Osborn 2007), psychological and educational interventions (Ersser 2014), and oral evening primrose oil and borage oil (Bamford 2013), as well as a published protocol on specific allergen immunotherapy (Calderon 2010). Non-Cochrane systematic reviews have also been published on some of these interventions (Ernst 2012; Foolad 2013; Simonart 2011).
However, not all CAM treatments have been reviewed. Acupuncture, aromatherapy, bath therapy, bioresonance, chromotherapy, homeopathy, hypnotherapy, massage therapy, phytotherapy, and relaxation techniques constitute some of the other CAM therapies that are known to be used for treating AE (Artik 2003). Yet, no Cochrane systematic review has been conducted on these interventions to date, despite their active use by people with AE. In this context, it appears to be of high importance to evaluate and critically appraise all CAM interventions used for AE that have not yet been reviewed, in order to assess their effect on AE. While this list is certainly not exhaustive, what follows is a brief description of some of the CAM interventions that have been used to treat AE but have not yet been the subject of a Cochrane systematic review.
Acupuncture is a well-known holistic treatment method that originated from eastern Asia but is now used in many other parts of the world. It consists of both needle and non-needle treatments, although the former is more popularly associated with acupuncture than the latter. Non-needle acupuncture is made up of many different methods, such as cupping, acupressure, and moxibustion (Chen 2003). In traditional eastern medicine, acupuncture needles are inserted at specific points "to stimulate, disperse, and regulate the flow of 'chi', or vital energy, and restore a healthy energy balance" (Cochrane CAM Field 2003). It is thought be potentially beneficial for those with a range of skin diseases, such as psoriasis, urticaria, and AE.
This therapy uses essential oils, distilled from plants, to treat emotional disorders, such as stress and anxiety, and a wide range of other ailments (Cochrane CAM Field 2003). In this CAM treatment, which is often used complementary with other non-traditional therapies, such as acupuncture and herbology, various oils are administered to the body either via direct massage into the skin, inhalation, or distillation in baths.
Baths or soaks (balneotherapy) involve immersing the skin in a variety of substances for the purpose of removing crusts or scales, washing away old medications, or alleviating itching and inflammation (Kubota 1997). They are useful for a variety of disorders involving large areas of the skin. By relieving dryness, inflammation, and itchiness of the skin, they can help reduce disease severity when used in combination with conventional topical antimicrobial treatment (Huang 2009).
The theory behind this treatment assumes that "electromagnetic waves of the body can be conducted via external cables to an instrument that recognizes electromagnetic wave patterns, normalizes them, and then returns them to the patient via another electrode" (Artik 2003).
This involves the therapeutic use of colour, light, and relaxation techniques, which reduce the feelings of tension and the effects of stress.
Homeopathy is a system of medicine in which the administration of specific chemical preparations to healthy participants produces similar manifestations of the disorder as seen in diseased individuals: This is known as the "similia principle" (Swayne 2000).
Massage therapy includes a range of approaches rooted in both eastern and western healing practices. It involves the practice of "kneading or otherwise manipulating a person's muscles and other soft tissue with the intent of improving a person's well-being or health" (Cochrane CAM Field 2003).
Phytotherapy consists of the use of plants, herbs, or plant extracts for medicinal purposes. Usually, the botanical extracts - besides Chinese herbal medicine - used for the treatment of AE are as follows: St John's wort (Hypericum perforatum); oolong tea; Arnica montana; calendula flowers; tea tree oil; German chamomile; Oregon grape root (Mahonia aquifolium); and a combination of Oregon grape, pansy (Viola tricolor), gotu kola (Centella asiatica), and liquorice (Glycyrrhiza glabra) (Torley 2013).
This general term describes a variety of techniques that use Sequential Muscle Relaxation (SMR), meditation, yoga, breathing techniques, Qigong, Reiki, Shiatsu, and Tai chi to promote physical, mental, and spiritual well-being. Some techniques induce relaxation or reduce pain, whereas others improve strength, and balance and treat emotional and mental distress (Cochrane CAM Field 2003).
Why it is important to do this review
According to the Global Burden of Disease study, AE is the most debilitating skin disease in the world, ahead of psoriasis, alopecia, and cellulitis (IMHE 2011), making it the most important dermatological disease to combat with respect to the quality of life of the world's population. It is a common, chronic inflammatory skin disease of both adults and children (Turner 2006; Williams 2005). Some CAM treatments, such as certain diets, evening primrose oil, homeopathy, hypnotherapy, and massage, are well known to be important sources of therapy sought by people with this condition (Bhuchar 2012). In essence, CAM can be broadly defined as a group of treatment methods that may be used either complementary or alternatively to conventional (i.e. western) medicine (NCCAM 2013). In fact, many people rely on these treatments as their primary tools to cure their illness or at least to improve the duration and quality of symptomatic relief. Yet, the clinical effectiveness of these interventions is often unclear. At the same time, it is evident that clinicians need to become more aware of the great variety of CAM treatments their patients are using to treat their illness (Bhuchar 2012). These issues are further compounded by the fact that the literature inconsistently represents the potential of these treatments to interact, both positively and negatively, with pharmacological agents, as well as to cause adverse effects even when used alone.
The parents of children with AE often feel that the disease is not taken sufficiently seriously by practitioners (Gore 2005) and wish for greater support from health services in dealing with their condition (Long 1993; Noerreslet 2009). Affected individuals are interested in pursuing non-pharmacological approaches to AE management, such as exploring the role of diet, and they become frustrated when they perceive that their healthcare providers show little interest in these (Santer 2012). Clinicians are very much aware that people with AE often seek CAM therapies for clinical relief. Indeed, their patients may seek their advice on these treatments; yet, both clinicians and patients would benefit from greater clarity about the effectiveness of these interventions. Leading clinical journals, such as the Journal of the European Academy of Dermatology & Venereology, acknowledge the need for guidance on CAM treatments for AE, as shown by the recent publication of guidelines on this topic (NICE 2007; Ring 2012; Ring 2012a). Furthermore, there has been a tremendous proliferation of psychometrically tested outcomes tools for measuring the clinical improvements achieved with treatments for AE, with some tools shown to be more reliable and valid than others (Schmitt 2007).
Having thus reviewed the literature, we found no comprehensive, up-to-date, cohesive, and evidence-based sources of information regarding the clinical effectiveness of CAM interventions for AE. In our review, we will seek to fill this knowledge gap by investigating the CAM treatments known to be used for AE that are not addressed by existing Cochrane systematic reviews that limited their research questions to the effectiveness of a single CAM intervention or class of interventions on AE.