An investigation into the use of complementary and alternative medicine for atopic eczema.
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Atopic eczema (AE) is one of the most common skin diseases that patients frequently present with to dermatological practices in South Africa (SA). It has shown to impact negatively on the quality of life of many patients suffering from it. Epidemiological studies have shown high rates of AE prevalence, ranging from 2-7% in adults and 7-20% in children. Over the last decade, the lifetime prevalence of physician-diagnosed AE has almost doubled in SA. This rise continues despite accessible effective treatments. Due to AE’s chronic and relapsing nature and the unattainability of complete clinical cure, patients are progressively exploring complementary and alternative medicines (CAM) in search of a solution. Although the global popularity of CAM for AE is on the rise, a review of the literature demonstrated contradictory evidence with regards to their efficacy with shortcomings in many of the published data thus making it difficult for clinicians to assess their role, if any, in the management of AE. Objective One To objectively evaluate the information on the efficacy and safety of CAM in light of the most recent findings, the study entitled “Complementary Therapy in Atopic Eczema: The Latest Systematic Reviews” in Chapter Two of this thesis collectively evaluated all published systematic reviews (SRs) to date on the most popular CAM modalities for AE. These SRs included those of Chinese herbal medicines(CHM), homeopathy, oral herbal remedies (including evening primrose oil and borage oil), probiotics and certain dietary supplements. The study concluded that none of the alternative therapies evaluated demonstrated obvious and indisputable evidence of efficacy due to many limitations in study design, poor methodologies, patient numbers etc. Further studies may be warranted with some therapies (CHM, different probiotic strains and fish oil), whereas homoeopathy failed to show any treatment effect and further studies with evening primrose oil and borage oil may be difficult to justify. This overview was able to provide objective information to enable dermatologists and general practitioners to advise and manage their patients holistically in the light of the most recent findings. Objective Two Topical corticosteroids remain the mainstay of treatment for AE. However, many patients are concerned about their long-term safety and thus seek evidence-based safer alternatives. Many published papers have made reference to the wide use of topical herbal creams for AE and many of these been tested, but few in controlled clinical trials. No SRs of these trials could be found, although SRs of topical herbal extracts have been published for other chronic skin conditions. The study entitled “Topical Herbal Medicines for Atopic Eczema: A Systematic Review of Randomised Controlled Trials” in Chapter Three of this thesis was the first SR to be conducted for topical herbal preparations for AE. Using Cochrane SR methodology, numerous databases were searched from inception until June 2014. All controlled clinical trials of topical herbal medicines for AE in humans of any age and published in English were included regardless of the control intervention or randomisation. Of eight studies that met the inclusion criteria, seven investigated extracts of single plants and one an extract from multiple plants. The study concluded that there is currently insufficient evidence of efficacy for any topical herbal extract in AE with many studies having methodological flaws. Even studiesthat did show efficacy over placebo were single trials with small patient cohorts. Together with providing clarity to both prescribers and patients, the study was able to identify opportunities for future research in better designed trials with topical extracts that showed a promising effect and had a low risk of bias across all domains. These were randomised controlled trials (RCTs) of licorice gel and Hypericum perforatum. Objective Three The literature has thus far reported on numerous international studies on the widespread use of CAM for AE. These studies not only investigated the prevalence of CAM use but also the modalities used, motivations for use and demographic variables that influence their use. All these factors potentially impact on the treatment of AE. No such studies conducted anywhere in Africa could be found. Given the lack of literature in SA, the study entitled “Complementary and Alternative Medicine Use amongst patients with Atopic Eczema - a South African Perspective” in Chapter Four of this thesis was a cross-sectional study that was conducted amongst AE patients in Durban, KwaZulu-Natal to bridge this gap in knowledge. This study found a 66% current or previous CAM use, which was moderately higher than those reported in other countries. Frequently used CAM were vitamins, aromatherapy oils, herbal creams, traditional African medicines and homeopathy. Non-disclosure to the dermatologist was high and almost half of the patients interviewed said they were not questioned about CAM use. More Indian patients used CAM and Muslims were the most frequent CAM users. Duration of AE was also a predictor of use. Although not statistically significant, the more educated and higher income bracket used CAM more. The study was able to provide detailed trends of CAM use by South Africans for AE which is an important addition to the literature. This information is able to highlight to dermatologists and healthcare professionals treating AE patients, the need to be more conversant with CAM that patients explore, as this could impact overall clinical outcome. Objective Four Although evident from the literature that patients have embraced CAM, it is uncertain whether mainstream healthcare professionals are as embracing. Their attitude and knowledge of CAM will influence their pro-activeness in enquiring about CAM and confidently discussing proven/unproven remedies with their patients, thereby influencing an overall positive clinical experience and disease course. Several international studies have explored the knowledge, attitudes and practices amongst general practitioners (GPs), physicians, pharmacists, paediatricians, academic doctors and other healthcare workers towards CAM, but none within the context of a specific disease. No published studies conducted in SA or elsewhere investigating HCPs’ knowledge, attitudes and norms of practice with regards to CAM for AE could be found. As a result, and given the extensive use among SA patients with AE as per the study’s previous findings, a cross-sectional study entitled “Knowledge, Attitude and Practices of South African Healthcare Professionals towards Complementary and Alternative Medicine Use for Atopic Eczema - A Descriptive Survey” was conducted. Results amongst GPs, dermatologists, paediatricians and pharmacists are reported in Chapter Five of this thesis. GPs and pharmacists were significantly more embracing of CAM compared to dermatologists and paediatricians. The study revealed poor CAM knowledge and communication between HCPs and patients, however there was a strong interest to learn more. It was also found that there is an urgent need for continuing education programmes on CAM and inclusion into undergraduate curriculums as most HCPs were interested in learning more about CAM. Conclusion Overall, this thesis was able to fill a gap in the knowledge of CAM use for AE both globally and within the context of SA. The study provided clarity and objective conclusions from the many SRs previously published for popular oral CAM therapies. Furthermore, the study conducted and published the first SR on topical herbal therapies for AE. This SR identified therapies that have demonstrated positive results for AE with low risk of bias and is thus able to provide direction for future research in this regard. Within the SA context, the study described the perspectives and practices of both patients and mainstream healthcare professionals on CAM use for AE, which was lacking in Africa. With this information we were able to ascertain the popular CAM that SA patients are using, the extent of their use as well as establish CAM education needs for local healthcare professionals.