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Health Protocols

Skin Disorders

Common Inflammatory Skin Disorders

Skin inflammation may be a sign of allergic, autoimmune, or infectious conditions. Atopic dermatitis, contact dermatitis, and urticaria (hives) are examples of allergic skin conditions (Wollenberg 2013); dermatitis herpetiformis and lichen planus are examples of autoimmune-mediated inflammatory skin diseases (Usatine 2011; Antiga 2015; Jiang 2015). Seborrheic dermatitis and rosacea appear to involve inflammatory reactions to skin microorganisms (Clark 2015; Lucas 2010). Psoriasis and acne are also considered primarily inflammatory in nature; more information about these conditions can be found in the Psoriasis and Acne protocols.

Eczema is a term that encompasses a subset of inflammatory skin disorders that are characterized by itchy rashes. Some conditions included in this group are atopic dermatitis, seborrheic dermatitis, and contact dermatitis. The term is sometimes used interchangeably with atopic dermatitis, which is the most prevalent condition in this group (Weston 2014; Gaby 2011b).

The likely contribution of multiple factors, such as genetics and environmental influences, to inflammatory skin disorders adds complexity to their satisfactory diagnosis and treatment (Nutten 2015; Dessinioti 2013). In addition to allergic, autoimmune, and antimicrobial processes, emotional stress may contribute to skin inflammation (Huynh 2013; Kim, Cho 2013). Anxiety, depression, and other mental health disorders are commonly associated with inflammatory and other skin problems (Yaghmaie 2013; Orion 2014; Dalgard 2015; Jafferany 2016; Marshall 2016). If you or a loved one have a skin disorder and a mental health disorder, consider reviewing additional relevant Life Extension protocols: Depression, Anxiety, Stress Management.

Inflammatory skin disorders frequently respond to dietary and stress-reducing interventions, including food sensitivity testing and avoidance, relaxation, and meditation. For more information about these interventions, see the Diet and Lifestyle section of this protocol.

Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory skin condition affecting up to 20% of children and up to 3% of adults, and research suggests its prevalence worldwide is increasing. A family history of atopic dermatitis or allergies is a risk factor (Wollenberg 2013; Nutten 2015).

Although atopic dermatitis is commonly associated with allergic conditions such as asthma and hay fever, it is still unclear whether allergies are a cause or consequence of atopic dermatitis (Nutten 2015). Alterations in microbial communities and decreased skin microbial diversity have been noted in individuals with atopic dermatitis, and may contribute to an altered inflammatory response (Biedermann 2015; Dybboe 2017). Stress, which may disturb the skin microbiome, damage barrier function, and alter immune function, is another important factor in the initiation and aggravation of atopic dermatitis (Kim, Cho 2013; Bailey 2016; Holmes 2015).

Conventional treatments. Atopic dermatitis is typically treated with topical anti-inflammatory agents such as corticosteroids and calcineurin inhibitors in combination with emollient therapies and antimicrobial therapies (Wollenberg 2013; Clark 2015; Del Rosso 2016). It is important to note that long-term use of topical corticosteroids can have a number of negative effects, including damaging skin structure, interfering with skin repair, and increasing susceptibility to infections (Wollenberg 2013; Ashton 2014; Clark 2015; Dey 2014).

Immunotherapies appear promising in the treatment of atopic dermatitis. This topic is explored in the Novel and Emerging Therapies section.

Integrative treatments. Zinc has an important role in skin immune function (Brocard 2011; Gupta 2014). Inflammatory skin problems are a well-known result of zinc deficiency. One study showed that red blood cell zinc levels were lower in subjects with atopic dermatitis than in controls, and that dermatitis severity increased with lower red blood cell zinc levels (Karabacak 2016). In another study, zinc supplementation raised low hair zinc levels and decreased itching in children with atopic dermatitis (Kim, Yoo 2014).

Topical zinc may also have a role in managing atopic dermatitis. One interesting study found that sleeping in garments made with a zinc oxide-impregnated material for three consecutive nights reduced symptom severity and itching, and led to improved sleep in individuals with atopic dermatitis (Wiegand 2013). In a randomized controlled trial, 47 subjects with chronic hand eczema were treated with either a cream containing the high-potency corticosteroid clobetasol (Clobederm, 0.05%) plus zinc sulfate (2.5%) or clobetasol (0.05%) alone twice daily for two weeks. The clobetasol plus zinc cream was more effective at relieving symptoms and was associated with fewer recurrences at an eight-week follow-up (Faghihi 2008).

Vitamin D receptors in skin cells participate in the regulation of immune and inflammatory responses (Piotrowska 2016). A meta-analysis concluded that individuals with atopic dermatitis have lower vitamin D levels than their healthy counterparts, and pooled findings from four randomized controlled trials using 1000–1600 IU vitamin D daily for one to two months showed that vitamin D supplementation was effective for reducing the severity of atopic dermatitis (Kim, Kim 2016). In one study, the relationship between low vitamin D levels and atopic dermatitis severity was significant only in those participants whose condition involved food sensitivities, suggesting vitamin D supplements may be particularly helpful in such cases (Lee 2013).

In a randomized controlled trial in 20 atopic dermatitis patients, symptom scores were lower after four weeks of treatment with 2000 IU vitamin D daily. In addition, colonization with Staphylococcus aureus decreased with vitamin D supplementation (Udompataikul 2015). Staphylococcus aureus is a common cause of secondary infections and is thought to be a trigger of chronic inflammation in atopic dermatitis (Piotrowska 2016).

Probiotics have demonstrated effectiveness in animal models of atopic dermatitis in clinical trials (Shin 2016; Choi, Iwasa 2016; Choi, Konkit 2016; Yeom 2015; Kim, Park 2013; Inoue 2014; Wang 2015; Kim, Ah 2014). A meta-analysis concluded that supplements containing mixed strains of probiotic bacteria plus prebiotic fibers have a positive impact on atopic dermatitis severity in children (Chang 2016).

In a 12-week controlled clinical trial in 48 atopic dermatitis patients, a probiotic supplement containing Lactobacillus salivarius LS01 plus Bifidobacterium breve BR03 decreased symptom severity and improved quality of life. In addition, participants taking the probiotic supplement had less inflammatory activity and improved gut barrier function as reflected in reduced movement of bacteria across the gut mucosa (Iemoli 2012). In other clinical studies, Lactobacillus salivarius LS01 (Drago 2011), Lactobacillus acidophilus L92 (Inoue 2014), Bifidobacterium animalis subspecies lactis LKM512 (Matsumoto 2014), and a combination of Lactobacillus salivarius LS01, Streptococcus thermophilus ST10, and tara gum (a viscous material made from natural carbohydrate complexes) (Drago 2014) have all been found to reduce atopic dermatitis severity.

Also, probiotics may improve skin barrier function, which is disrupted in atopic dermatitis. In one study, an experimental candy prepared with extracts from Lactobacillus plantarum, derived from traditional Korean kimchi, was compared to a candy with no probiotic extracts in 41 participants with dry skin. After eight weeks, those using the experimental candies had better skin hydration, less water loss via the skin, and diminished thickness of the outermost layer of skin affected by dryness. These same Lactobacillus plantarum enzymes were also found to restore skin integrity in a mouse model of atopic dermatitis (Kim, Kim 2015).

Evening primrose oil, a rich source of the omega-6 fatty acid gamma-linolenic acid (GLA), has been found to be helpful in several clinical trials. Studies in patients with skin disorders have shown that evening primrose oil supplementation can increase blood levels of phospholipids that help modulate the inflammatory response. In eczema patients, evening primrose oil reduced concentrations of the inflammatory interleukin-2 receptor (Horrobin 2000). Borage oil, another high-GLA oil, has also proven helpful in some clinical trials (Foster 2010). One study showed that supplementation with GLA in adults with dry skin and mild atopic dermatitis improved skin barrier function, possibly via production of anti-inflammatory metabolites (Kawamura 2011).

Fish oil and its omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), may help people with atopic dermatitis. In one trial, 31 atopic dermatitis patients received either 10 grams of fish oil daily, providing 1.8 grams EPA, or a placebo containing olive oil daily. After 12 weeks, the fish oil-treated subjects had reductions in scaling, itching, and overall severity (Bjorneboe 1987). In an eight-week controlled trial involving 53 subjects with atopic dermatitis, 5.4 grams per day of DHA reduced symptom severity and the production of allergy-related antibodies more than a placebo fatty acid blend (Koch 2008).

Research suggests other oils may have positive impacts on atopic dermatitis. Hempseed oil, a source of essential fatty acids as well as GLA, reduced dryness and itchiness when taken at 30 mL (two tablespoons) per day for eight weeks (Callaway 2005). A daily dose of 4.76 grams (about a teaspoon) of sunflower oil, a rich source of linoleic acid, was more effective than both fish oil and an olive oil placebo in one 12-week study with 48 participants affected by severe atopic dermatitis (Gimenez-Arnau 1997).

Topical colloidal oatmeal (a water suspension of oats [Avena sativa]) has been used historically to relieve skin itching and irritation. Colloidal oatmeal has anti-inflammatory and soothing properties, and has been found to improve skin barrier function (Pazyar 2012; Cerio 2010; Reynertson 2015) and may be beneficial in the treatment of atopic dermatitis (Fowler 2014). A set of two studies reported together found that topical application of a colloidal-oatmeal-containing cream reduced itchiness and improved skin hydration in subjects with mild-to-moderate atopic dermatitis (Lisante 2017).

French maritime pinebark extract (Pycnogenol) has been shown to counteract inflammatory skin conditions. For instance, in one study in patients with moderate-to-severe plaque psoriasis, Pycnogenol plus standard care outperformed standard care alone. Subjects took 50 mg of Pycnogenol three times daily for 12 weeks. Subjects who took Pycnogenol took fewer other drugs and incurred less treatment-related costs (Belcaro 2014). Several studies have evaluated mechanisms by which Pycnogenol may improve skin health. Some possibilities include improved skin barrier function (Grether-Beck 2016), better hydration (Marini 2012), and enhanced resilience to photodamage (Furumura 2012; Saliou 2001).

Emerging Therapies for Atopic Dermatitis

Allergen-specific immunotherapy involves repeated exposure to gradually increasing doses of allergens, usually administered sublingually or through subcutaneous injection (Tam 2016). An analysis of data from 217 atopic dermatitis patients treated with allergen-specific immunotherapy for three years or more noted improvement in 88% of subjects, with near-complete or complete remission in almost 64% (Lee 2016). A clinical study examined the effects of subcutaneous immunotherapy in 251 subjects affected by atopic dermatitis and dust allergy. The overall response rate was nearly 74%, and the response rate in those with severe disease was almost 91% (Nahm 2016).

Crisaborole is a topical non-steroidal anti-inflammatory medication that interferes with the local production of inflammatory chemicals by inhibiting the action of the enzyme phosphodiesterase. A review of four phase I and II clinical trials found a 2% crisaborole ointment was safe and effective for reducing symptoms of mild-to-moderate atopic dermatitis (Zane 2016). Two identically designed randomized controlled trials were then undertaken, enrolling a total of 1522 participants for 28 days of treatment with 2% crisaborole ointment or placebo. Crisaborole treatment resulted in greater reduction in itching and more overall improvement compared with placebo (Paller 2016). The FDA approved crisaborole in 2016 for use in the treatment of atopic dermatitis (FDA 2016).

Monoclonal antibodies. Randomized controlled trials have shown that dupilumab (Dupixent), an antibody against receptors for the pro-inflammatory cytokine interleukin-4, can reduce itching, relieve symptoms of anxiety and depression, and improve quality of life in individuals with moderate-to-severe atopic dermatitis (Simpson 2016). In 2017, the FDA approved dupilumab (Dupixent) for moderate-to-severe atopic dermatitis not adequately controlled by topical therapies (Blakely 2016; FDA 2017). Omalizumab (Xolair), an antibody that binds to IgE receptors and thereby blocks allergic reactions, is currently under investigation for its potential to treat atopic dermatitis. In a case series, four of eight atopic dermatitis patients treated with 300 mg subcutaneous omalizumab every four weeks had a good or excellent response to treatment. The researchers went on to review other reports and found that 74% of 174 reported patients experienced some degree of positive response to omalizumab (Holm 2017). Omalizumab is FDA approved to treat allergic asthma and chronic urticaria (a recurring skin reaction involving hives and wheals) (Genentech USA 2017).

Seborrheic Dermatitis

Seborrheic dermatitis causes itchy, scaly, flaky, reddened patches of skin primarily on the scalp and face and, to a lesser extent, on other areas of the body such as the chest (Sampaio 2011). It occurs in approximately 1–3% of the general population, but has a higher prevalence in immune-compromised individuals. It is more common in cold, dry climates and is often related to stress (Clark 2015). Seborrheic dermatitis may be caused by an inflammatory immune reaction to Malassezia yeast, despite the widespread presence of Malassezia on healthy skin. Individual factors allowing for the transformation of Malassezia into a pathogen and/or triggering an altered immune response are being explored (Clark 2015; Dessinioti 2013).

Conventional treatments. Like atopic dermatitis, seborrheic dermatitis is generally treated with topical anti-inflammatory agents in combination with emollient and antimicrobial therapies (Wollenberg 2013; Clark 2015; Del Rosso 2016). Because long-term use of topical corticosteroids can damage skin integrity, they should be used judiciously (Wollenberg 2013; Ashton 2014; Clark 2015; Dey 2014). Selenium sulfide, zinc pyrithione, and tar (from pine or coal) are antifungal compounds found in topical preparations and shampoos used to treat seborrheic dermatitis. Patients with seborrheic dermatitis may also benefit from topical treatments like salicylic acid, sulfur, and tar that soften and reduce the buildup of lipids and keratin on the skin surface (Clark 2015; Barnes 2016; Paghdal 2009; Reeder 2011; Van Cutsem 1990).

Integrative treatments. Deficiencies of the B vitamins biotin, riboflavin (vitamin B2), and pyridoxine (vitamin B6) can manifest as seborrheic dermatitis or a similar skin dysfunction, possibly due to the importance of these B vitamins in fatty acid and protein metabolism (Stone 1989; Higdon 2013; Schwartz 2006; Anonymous 1952; Bonjour 1977; Mock 1991). Biotin deficiency in infants can cause a form of infantile seborrheic dermatitis of the scalp that generally resolves without treatment. Biotin injections and intravenous biotin have been reported to be helpful in more extensive cases (Messaritakis 1975). It has been reported that a water-soluble cream with 10 mg of pyridoxine per gram, used topically four times daily, was beneficial in seborrheic dermatitis patients, suggesting a possible defect in skin metabolism of vitamin B6 leading to an increased need locally (Schreiner 1952; Anonymous 1952).

Tea tree oil has been studied for its possible role in treating seborrheic dermatitis (Mayo Clinic 2014a). In one clinical trial, 126 participants with dandruff presumed to be related to seborrheic dermatitis of the scalp used either a 5% tea tree oil shampoo or placebo daily for four weeks. The tea-tree oil-treated group had greater improvements in itchiness, greasiness, and overall dandruff severity (Satchell 2002a). Tea tree oil should be used carefully due to its potential to cause skin irritation when used in high concentrations and allergic reactions in some individuals (Hammer 2006).

Honey has been used traditionally to promote wound healing and prevent infections (Pereira 2016; Al-Waili 2001). In a clinical study, 30 subjects with seborrheic dermatitis of the scalp, face, and chest applied diluted crude honey (90% honey diluted in water) on their lesions every other day for four weeks. The honey was gently rubbed into the skin for two to three minutes and then left in place for three hours before being rinsed off. Patients showed improvement in itching, scaling, and the subjective evaluation of hair loss. Patients who showed improvement were included in a second phase lasting for six months. During this second phase, none of the 15 participants who continued weekly applications of diluted honey had any relapses, while 12 of the remaining 15 who did not continue treatment experienced relapses (Al-Waili 2001).

Contact Dermatitis

Contact dermatitis is a localized skin reaction to an irritant or allergen. Chemicals in soaps, cosmetics, and fragrances; jewelry metals such as nickel; and plants such as poison ivy are among the many triggers of contact dermatitis (Mayo Clinic 2014b; Torres 2009; Baer 1986).

Conventional treatment. Antihistamines are sometimes effective for temporary relief of itching, but identifying and avoiding allergens is critical to long-term management (Jafilan 2015).

Integrative treatments. Oxidative stress may be one of the important factors involved in contact dermatitis and, therefore, therapies that restore the balance between oxidant and antioxidant systems could have a role in treatment (Nakai 2012; Eisen 2004; Schempp 2012). In two clinical studies, participants with known reactivity to p-phenylenediamine, a common irritant found in hair dye, had decreased reactions when their skin was treated with topical vitamin C and then exposed to the chemical (Basketter 2016; Coenraads 2016). A 1% mixture of the biological antioxidant nicotinamide adenine dinucleotide (NADH) in petroleum jelly was reported to be effective for the treatment of contact dermatitis in adults (Wozniacka 2003). Animal research suggests that several additional natural antioxidants and anti-inflammatory agents may protect the skin against topical irritants. These include:

  • topical rutin (a flavonoid found in citrus and other plants) (Choi 2013)
  • silymarin (a mixture of flavonoids from milk thistle) (Han 2007)
  • grape seed proanthocyanidins (Tang 2012)
  • carotenoids (Sakai 2011)
  • coenzyme Q10 (Li 2016)

Quercetin is a flavonoid that has been shown to inhibit mast cells, which are the immune cells that are central to allergic, inflammatory, and autoimmune conditions. In 10 volunteers sensitive to contact with nickel, taking 2 grams per day of quercetin for three days reduced their nickel reactions: eight subjects had 50% reductions and two had 100% reductions in their reactions (Weng 2012).

In an animal model of contact dermatitis, topical colloidal oatmeal reduced skin inflammation (Fowler 2014). In experimentally induced contact dermatitis, tea tree oil reduced dermatitis in response to provocation with nickel in patients with a known nickel allergy (Wallengren 2011). Because tea tree oil may cause an allergenic reaction in some people, it should be used judiciously by those who have not used it before (Christoffers 2014). If you suspect you are prone to react to tea tree oil, your dermatologist may be able to perform a skin patch test for confirmation (Rutherford 2007). One small clinical study found that a cream containing Calendula officinalis L. extract reduced contact dermatitis in response to sodium lauryl sulfate when the cream and the sodium lauryl sulfate were applied at the same time (Fuchs 2005). Wearing medicated gloves containing aloe vera gel resulted in decreased skin redness and wrinkling and improved skin integrity on the hands of workers with dry skin and contact dermatitis related to occupational exposures (West 2003). In a study in 22 subjects, ginkgo biloba extract in combination with a chemically modified beta glucan reduced contact dermatitis. The participants applied the ginkgo-containing formulation twice daily for two weeks before being challenged with an allergen under experimental conditions. Sixty-eight percent of experts who judged the severity of the reactions to the irritants determined that reactivity was diminished in areas treated with the ginkgo-containing formulation compared with those treated with a placebo (Castelli 1998).

Urticaria

Urticaria, commonly referred to as hives, is mediated by allergy-related immune cells (eg, eosinophils) and chemicals (eg, histamine) (Wang 2016; de Graauw 2015). Urticaria can be acute or chronic, and while it may involve a known trigger, urticaria is far more often idiopathic, which is without a known cause (Jafilan 2015; Wang 2016; Deacock 2008). In such cases, patch testing may be useful for identifying allergies to metals and chemicals (Hession 2012). Chronic urticaria may reduce quality of life, and is frequently associated with anxiety, depression, and other psycho-emotional disorders (Wang 2016). Urticaria often presents with angioedema, which refers to the sudden swelling of the skin, mucous membranes, or both; may be life-threatening; and requires emergency medical attention, such as taking the patient to the emergency department for evaluation (Schaefer 2017; Kanani 2011; Kaplan 2008).

Conventional treatments. Antihistamines and other anti-inflammatory medications are sometimes used to relieve urticarial symptoms (Jafilan 2015; Wollenberg 2013). In some cases, short-duration adjunctive therapy with corticosteroids or leukotriene receptor blockers may help control symptoms (Schaefer 2017).

Integrative treatments. Vitamin D insufficiency (blood levels of 25-hydroxyvitamin D <30 ng/mL) and deficiency (<20 ng/mL) have been associated with chronic urticaria (Oguz Topal 2016; Boonpiyathad 2014; Movahedi 2015; Woo 2015). In addition, decreasing vitamin D status has been associated with increasing symptom severity and duration (Woo 2015). In a case-control study, supplementation with 20,000 IU vitamin D2 per day for six weeks resulted in decreased symptoms and improved quality of life in participants with chronic urticaria and vitamin D insufficiency who were also being treated with antihistamines (Boonpiyathad 2014). Similar results were seen in another clinical study in which subjects with chronic urticaria and vitamin D insufficiency added 300,000 IU vitamin D3 per month to their standard therapy for three months (Oguz Topal 2016). In one study, 4000 IU daily of vitamin D3 led to benefits after 12 weeks in chronic urticaria patients being treated with standard medications; however, no effects were seen with 600 IU per day (Rorie 2014). Findings from other research suggest vitamin D3 plus standard therapy may be more effective than either vitamin D or standard therapy alone (Rasool 2015).

Low levels of vitamin B12 have been observed in individuals with chronic idiopathic urticaria (Mete 2004; Wu 2015). The effects of B12 supplements in chronic urticaria have not been studied thoroughly, but some old papers report success using intramuscular injections (Simon 1951; Simon 1964). More research in this area is needed.

Low iron or ferritin levels have also been observed in some patients with chronic urticaria; iron supplementation may be useful in these cases (Guarneri 2014; Wu 2015).

In some individuals with celiac disease and chronic urticaria, the urticaria responded to a gluten-free diet (Haussmann 2006; Caminiti 2005; Peroni 2010; Ludvigsson 2013).

Rosacea

Rosacea is characterized by persistent or episodic acne-like lesions and redness, often affecting the face; the lesions are sometimes accompanied by burning or stinging (Mikkelsen 2016). The cause of rosacea is multifactorial: environmental factors such as sun exposure and heat, food and chemical sensitivities, and microbial factors have all been reported to trigger the immune responses that occur in certain individuals with rosacea (Vemuri 2015).

Conventional treatments. The rosacea rash is typically treated with topical agents that have both anti-inflammatory and antimicrobial properties, such as certain antibiotics and azelaic acid (Azelex) (Mikkelsen 2016; Cardwell 2016; Schulte 2015). Brimonidine (Mirvaso), a topical gel that stimulates vascular constriction, is sometimes used to treat rosacea’s redness. Laser and light-based therapies may be used to treat dilation of superficial blood vessels (Micali 2016).

Integrative treatments. In a controlled trial, 138 participants with rosacea were treated with either a 90% kanuka honey cream (a New Zealand honey closely related to manuka honey) in a 10% glycerin base or a placebo cream. After eight weeks of twice daily application, more of those receiving the honey cream than the placebo cream had significant reductions in rosacea severity (Braithwaite 2015). Phytochemicals such as licochalcone (from Glycyrrhiza inflata, licorice), silymarin (from Silybum marianum, milk thistle), and epigallocatechin gallate (EGCG, from Camellia sinensis, green tea) have shown promise as topical treatments for rosacea (Saric 2017; Fisk 2015). A 1% NADH cream in a petrolatum base was also reportedly helpful in treating rosacea (Wozniacka 2003).

Dermatitis Herpetiformis

Dermatitis herpetiformis is a skin manifestation often associated with celiac disease that causes small, itchy blisters typically on the buttocks, arms, and legs. Celiac disease is an autoimmune-mediate disorder of the digestive tract triggered by exposure to gluten, a protein in wheat and some other grains (Reunala 2015; Antiga 2015). If dermatitis herpetiformis is suspected, tests for the presence of IgA transglutaminase antibodies in blood and IgA deposits in the skin are helpful for making the diagnosis (Antiga 2015). More general information about celiac disease is available in the Celiac Disease protocol.

Conventional treatments. Dermatitis herpetiformis can be successfully treated with a gluten-free diet (Reunala 2015), but oral corticosteroid therapy is sometimes used to manage the itching and burning sensations (Antiga 2015). Oral corticosteroids have many negative side effects, which are more serious with prolonged use. These include adrenal suppression, decreased immune activity, metabolic disturbances, cardiovascular disease, bone loss, and psychiatric problems (Liu 2013).

Integrative treatments. Certain nutrients may aid in recovery either through a therapeutic role or by repairing deficiencies due to malabsorption. These include zinc, magnesium, selenium, iron, and vitamins B3, B12, and folic acid (Gaby 2011a).

Lichen Planus

Lichen planus is an autoimmune disorder that affects as much as 4% of the general population. It can affect the skin, hair, nails, and mucous membranes. On the skin, lichen planus usually develops on areas prone to flexural movement such as the wrists, and causes small, flat-topped lesions that may itch. The lesions appear most commonly on the surfaces of the wrists, forearms, and legs, but may also occur on the oral mucosa, genital mucosa, nails, and scalp (Usatine 2011). Most cases resolve on their own in six to 18 months (Chuang 2017).

Conventional treatments. Lichen planus is often treated aggressively, using the high-potency topical corticosteroid clobetasol and the calcineurin inhibitor tacrolimus (Protopic), as well as oral immunosuppressant medications as needed (Usatine 2011). Self-care measures are recommended in lichen planus, including tub soaking with colloidal oatmeal, cool compresses, over-the-counter hydrocortisone cream, and avoidance of scratching (Mayo Clinic 2017c).

Integrative treatments. Because of its autoimmune nature, it is possible that integrative treatments used to treat some other autoimmune conditions will be helpful in lichen planus. These include anti-inflammatory supplements such as omega-3 fatty acids from fish oil (Lorente-Cebrian 2015) and curcumin (Abdollahi 2017; Kunnumakkara 2016) as well as immune modulators such as reishi (Ganoderma lucidum) (Bhardwaj 2014; Xi Bao 2006) and vitamin D (Lucas 2014). A number of botanical therapies appear to be beneficial in the treatment of lichen planus lesions of the oral mucosa and may be helpful in treating its skin lesions as well. These include topical chamomile (Lopez Jornet 2016), aloe vera (Ali 2016), and grape skin anthocyanins (Rivarola de Gutierrez 2014), as well as oral curcuminoids from turmeric (Chainani-Wu 2007; Chainani-Wu, Collins 2012; Chainani-Wu Madden, 2012) and total glucosides of peony (Zhou 2016).

Acne Inversa (Hidradenitis Suppurativa)

Acne inversa, also known as hidradenitis suppurativa, is a severe type of chronic, recurrent folliculitis marked by intense pain and scarring. It is much overlooked and often misdiagnosed despite its prevalence of at least 1% and up to 4% worldwide (Dufour 2014; Tolaas 2009; Mi 2011). It is more common in women than men (AAD 2017). Acne inversa likely results from both impaired immunity in the hair follicles and an excessive response to certain skin bacteria (Scheinfeld 2013a), and is often associated with and worsened by obesity and smoking (Scheinfeld 2013a; Tolaas 2009; Dufour 2014).

Conventional treatments. Mild cases may be effectively treated with topical antibiotics, but more widespread or severe cases require oral or intravenous antibiotics, or possibly surgery (Gulliver 2016; Scheinfeld 2013a). Because acne inversa is multifactorial, a range of approaches and combinations of therapeutics may be helpful (Napolitano 2017). Vitamin A analogs (Verdolini 2015; Brown 1988; Hogan 1988), hormonal therapies, and immunosuppressive medications are among the treatments that may help patients with acne inversa. Pain management is an important consideration (Scheinfeld 2013a; Gulliver 2016; Blok 2013). Adalimumab (Humira) is an anti-inflammatory biologic medication FDA-approved to treat acne inversa. According to expert opinion, adalimumab is likely to deliver good results with weekly 40 mg subcutaneous injections in patients with inflamed lesions, but is unlikely to be effective for those with non-inflamed, non-scarring lesions (Zouboulis 2016).

Integrative treatments. In a small clinical study, 15 mg of oral elemental zinc (as 90 mg zinc gluconate) per day led to improvements in 100% of patients with acne inversa that were unresponsive to other treatments; out of 22 subjects, eight had complete resolution and 14 had partial remission (Brocard 2007).

Vitamin D is important for skin immune function, and vitamin D deficiency has been found to be widespread in people with acne inversa. In 14 acne inversa patients treated with vitamin D for six months at doses determined by their vitamin D levels, participants had an at least 20% decrease in the number of nodules and an at least 20% reduction in flare-up frequency, and those who experienced greater increases in vitamin D levels had greater positive effects (Guillet 2015).

Pityriasis rosea

Pityriasis rosea is an inflammatory skin rash characterized by patches on the skin; it sometimes follows a flu-like illness with symptoms such as fever, sore throat, fatigue, and headache. Although the cause is unknown, the involvement of infectious agents such as viruses and bacteria, as well as noninfectious causes such as autoimmunity, have been discussed (Mahajan 2016; Ozyurek 2014).

Conventional treatments. Pityriasis rosea typically resolves without treatment in one to three months; however, topical or oral corticosteroids and antihistamines may be helpful in some cases (Mayo Clinic 2015a; Chuh 2007). There is some evidence that the antiviral medication acyclovir (Zovirax) and the antibiotic erythromycin may each effectively decrease severity of symptoms and shorten duration of pityriasis rosea (Chuh 2016; Amatya 2012); however, other research suggests lack of efficacy for these medications (Singh, Tiwary 2016; Pandhi 2014).

Integrative treatments. Zinc oxide cream is sometimes used to relieve the symptoms of pityriasis rosea (AAFP 2004). Because of its inflammatory nature and possible connection to infection, immunomodulatory therapies such as reishi (Xi Bao 2006), vitamin D (Lucas 2014), and astragalus (Jin 2014) may be helpful.

Several studies have looked at the effect of light therapy in patients with pityriasis rosea. In one study, UV-B therapy for five days led to reductions in itching and extent of the condition in about half of 20 symptomatic participants, and seemed most effective when used within the first week of appearance of the rash (Arndt 1983). A similar study in 17 participants noted that UV-B therapy five times per week for two weeks reduced severity of the pityriasis rash, but did not affect itching or the course of the condition (Leenutaphong 1995).

Miliaria (Heat Rash or Prickly Heat)

Miliaria, often called heat rash or prickly heat, is a skin rash that comes on during hot, humid weather and is caused by perspiration trapped under the skin’s surface. Miliaria may be preventable by avoiding heavy sweating and overheating in general (Mayo Clinic 2015b).

Conventional treatments. Miliaria usually resolves without treatment. Symptoms are treated with cold compresses and ice packs, and patients are instructed to avoid further sweating and wear loose clothing. Anhydrous lanolin may be helpful in preventing future lesions by keeping sweat ducts open. In addition, topical steroids may be used to relieve symptoms in more severe cases, and antibiotics may be required in cases of secondary infection (Oakley 1997; Mayo Clinic 2015b).

Integrative treatments. Colloidal oatmeal, with its soothing, anti-inflammatory, and anti-itch effects (Fowler 2014), may be helpful in relieving symptoms of miliaria.