STUDY
Complementary and Alternative Medicines and Childhood Eczema: A US Population-Based Study Jonathan I. Silverberg, MD, PhD, MPH,*†‡ Mary Lee-Wong, MD,§ and Nanette B. Silverberg, MD|| The prevalence of complementary and alternative medicine (CAM) use in US children with eczema is unknown. Furthermore, it is unknown whether CAM use in the United States is associated with higher eczema prevalence. We sought to determine the eczema prevalence in association with CAM usage. We analyzed data from the 2007 National Health Interview Survey that included a nationally representative sample of 9417 children ages 0 to 17 years. Overall, 46.9% (95% confidence interval, 45.6%Y48.2%) of children in the United States used 1 or more CAM, of which 0.99% (0.28%Y1.71%) used CAM specifically to treat their eczema, including herbal therapy (0.46%), vitamins (0.33%), Ayurveda (0.28%), naturopathy (0.24%), homeopathy (0.20%), and traditional healing (0.12%). Several CAMs used for other purposes were associated with increased eczema prevalence, including herbal therapy (survey logistic regression; adjusted odds ratio [95% confidence interval], 2.07 [1.40Y3.06]), vitamins (1.45 [1.21Y1.74]), homeopathic therapy (2.94 [1.43Y6.00]), movement techniques (3.66 [1.62Y8.30]), and diet (2.24 [1.10Y4.58]), particularly vegan diet (2.53 [1.17Y5.51]). In conclusion, multiple CAMs are commonly used for the treatment of eczema in US children. However, some CAMs may actually be harmful to the skin and be associated with higher eczema prevalence in the United States.
A
topic dermatitis (AD) or eczema is a chronic inflammatory skin disorder that is related to a complex interaction between genetics and environmental exposures. Eczema can be provoked by multiple modifiable risk factors, including irritants, contact allergens, food and inhaled allergens, stress, and infections.1 Recent population-based studies of US children and adults found associations between eczema prevalence and sociodemographic factors, including race/ethnicity, higher education levels, and household income.2 A recent study found that foreign-born US children had significantly lower rates of eczema and other allergic disease than American-born children.3 Furthermore, the odds of eczema increased after 10 years of residence in the United States. These associations may be related to cultural and behavioral differences of skin care practices, nutrition, and environmental exposures in specific demographic groups. One example of such differences is the use of complementary and alternative medicine From the Departments of *Dermatology, ÞPreventive Medicine, and þMedical Social Sciences, Northwestern University, Chicago, IL; §Department of Allergy & Immunology, Beth Israel Medical Center; and || Department of Dermatology, St Luke’s-Roosevelt Hospital and Beth Israel Medical Centers, New York, NY. Address reprint requests to requests to Jonathan I. Silverberg, MD, PhD, MPH, Department of Dermatology, Northwestern University, Suite 1400, 680 Lakeshore Dr, Chicago, IL 60611. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. Manuscript authorship: J.I. Silverberg, M. Lee-Wong, and N.B. Silverberg. Data analysis and interpretation: J.I. Silverberg, M. Lee-Wong, and N.B. Silverberg. Statistical analysis: J.I. Silverberg. DOI: 10.1097/DER.0000000000000072 * 2014 American Contact Dermatitis Society. All Rights Reserved. 246
(CAM) for the treatment of eczema and other medical disorders. Numerous case reports/series found that CAM caused various types of localized and diffuse eczematous reactions.4Y15 However, little is known about the relationship between CAM use and the prevalence of eczema. We hypothesized that common use of CAM in the US population may actually be associated with eczema prevalence. Complementary and alternative medicines are commonly used for a variety of medical disorders.16 There are no recent studies of the prevalence of CAM use in US children. Some types of CAM may be more commonly used in specific populations, such as herbal treatments in Asians and Ayurveda in Indians.17 However, little is known about the determinants of CAM use in the US population. Moreover, there are no US population-based estimates of the use of CAM in children with eczema. The goal of this study was to determine the prevalence of CAM use in US children with eczema and to determine whether CAM use is associated with increased eczema prevalence in the United States.
METHODS National Health Interview Survey We used the 2007 National Health Interview Survey (NHIS), which is the principal source of information on the health of the civilian population of the United States. The survey included a separate questionnaire about children’s health with parental questionnaires to estimate the prevalence of various child health issues. The survey was administered in person to selected households by the Bureau of the Census using approximately 400 trained interviewers with computer-assisted personal interviewing. One DERMATITIS, Vol 25 ¡ No 5 ¡ September/October, 2014
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was approved by the institutional review board at the Northwestern University.
History of Eczema Questions related to this study are presented in Supplementary Table 1 (http://links.lww.com/DER/A1). History of eczema was determined by an affirmative response to the question, ‘‘During the past 12 months, have you been told by a doctor or other health professional that the (child) had eczema or any kind of skin allergy?’’ We shall use the term eczema interchangeably with that question to provide brevity and consistency throughout this study.
History of CAM Histories of using acupuncture, Ayurveda, biofeedback, chelation, chiropractic or osteopathic therapy, energy healing, hypnosis, massage therapy, naturopathy, traditional healing, movement techniques, herbal therapy, vitamin therapy, homeopathy, and/or diet were recorded. Composite binary variables were generated for use of 1 or more item from each category of and for any CAM.
Demographics Demographic and socioeconomic factors were examined as potential confounders for an association between CAM use and eczema, including age, sex, race, Hispanic origin, birthplace in the United States, household income, highest level of education in the household, health care interaction in the past year, current health insurance coverage, and prescription medication coverage. These variables were selected based on the results of previous studies2,3,18 and the a priori hypotheses.
Data Processing and Statistical Methods
FIGURE 1. Complementary and alternative medicines that were associated with higher odds of eczema in US children. Complementary and alternative medicines that were significantly associated with eczema prevalence are presented in the diagram in order of the magnitude of their OR.
child was randomly selected for the sample child questionnaire. Interviews were conducted in English and Spanish. Using data from the US Census Bureau, sample weights were created that factored age, sex, race, ethnicity, household size, and educational attainment of the most educated household member using a multistage area probability sampling design by the NHIS. These sample weights are needed to provide nationally representative prevalence estimates for each state’s population of noninstitutionalized children aged 0 to 17 years. Frequency data are presented as raw and weighted values as indicated; weighted prevalence estimates are presented. This study
All data processing and statistical analyses were performed in SAS version 9.3 (SAS Institute, Cary, NC). All prevalence estimates and analyses of survey responses were performed using survey procedures that account for the complex weighting established by the NHIS. Bivariate analyses were performed using Rao-Scott W2 tests. Associations between histories of eczema and CAM were tested by survey logistic regression. Because some subjects might have used specific modalities of CAM for the treatment of previously diagnosed eczema, we excluded such subjects from the models. Multivariate logistic regression models were constructed that included significant variables identified in bivariate analyses as covariates. Subset analyses were performed for individual items of a particular category if a significant association was found for the overall category of CAM and raw frequencies were 5 or more per cell in 2-by-2 tables. If a significant association was found for the overall category of CAM and there were fewer than 5 per cell, comparisons were presented in the text without formal statistical tests performed. Complete data analysis was performed, that is, subjects with missing data were excluded. Two-way and 3-way interactions were tested and only included in the final models if the P value was less
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than 0.01 and the modification of estimates were greater than 20%. Multicollinearity was tested using variable inflation factors and tolerance. Post hoc correction for multiple dependent tests (k = 81) was performed by minimizing the false discovery rate with the approach of Benjamini and Hochberg19 resulting in critical P value of 0.027. Therefore, P values less than or equal to 0.027 were considered significant.
versus Hispanics (9.3% vs 7.4%, P = 0.02), those born in the United States compared with foreign-born Americans (9.1% vs 3.7%, P = 0.0001), after high school versus lower than high school education (10.0% vs 5.1%, P G 0.0001), and those unable to afford prescription medications compared with those who could (20.0% vs 8.6%, P G 0.0001; Table 1).
Associations With CAM Use RESULTS Associations With Childhood Eczema Data were collected on a total of 9417 children. Overall, eczema occurred in 8.9% (95% confidence interval [95% CI], 8.2%Y9.6%) or 6,561,146 US children. Prevalence of eczema was significantly higher with younger age (P G 0.0001), in African Americans compared with whites (10.7% vs 8.7%, P = 0.05), non-Hispanics
Overall, 46.9% (95% CI, 45.6%Y48.2%) or 34,606,254 of children in the United States used 1 or more CAM. Complementary and alternative medicine use was significantly higher with older age (P = 0.004), whites and Asians compared with African Americans and multiracial/other (51.1% and 48.0% vs 36.7% and 35.4%, respectively), non-Hispanics compared with Hispanics (49.9% vs 35.6), those with household income more than or equal to $50,000 versus $0 to $49,000 (55.7% vs 37.9%, P G 0.0001), after high school
TABLE 1. Subject Characteristics Eczema Variable Age, mean (95% CI), y Race, n (%) African American White Asian Multiracial/other Hispanic origin, n (%) No Yes Born in the United States, n (%) No Yes Sex, n (%) Female Male Household income ($1000), n (%) 0Y49 Q50 Highest level of education in the household GHigh school (HS) HS or Graduate Equivalency Diploma (GED) 9HS No. children in household, n (%) 1 2+ Health care interaction in past year, n (%) No Yes Could not afford prescription medicines, n (%) No Yes
CAM
No (n = 8556)
Yes (n = 856)
P
8.6 (8.5Y8.8)
7.8 (7.4Y8.2)
G0.0001 0.05
1500 5384 299 1373
(89.3) (91.3) (91.9) (92.4)
191 (10.7) 523 (8.7) 28 (8.1) 114 (7.6)
No (n = 5276)
Yes (n = 4136)
8.5 (8.3Y8.6)
8.7 (8.5Y8.9)
1082 (63.3) 3052 (48.9) 168 (52.0) 977 (64.6)
611 (36.7) 2857 (51.1) 159 (48.0) 511 (35.4)
3373 (50.1) 1906 (64.4)
3174 (49.9) 964 (35.6)
648 (9.3) 208 (7.4)
512 (96.3) 8038 (90.9)
22 (3.7) 834 (9.1)
326 (59.1) 4947 (52.8)
208 (40.9) 3930 (47.2)
4116 (90.8) 4440 (91.4)
435 (9.2) 421 (8.6)
2502 (52.1) 2777 (54.0)
2050 (47.9) 2088 (46.0)
4092 (91.3) 3948 (90.6)
388 (8.7) 434 (9.4)
2868 (62.1) 2070 (44.3)
1616 (37.9) 2312 (55.7)
1180 (94.9) 2022 (92.1) 5289 (90.0)
68 (5.1) 173 (7.9) 615 (10.0)
937 (75.9) 1442 (65.0) 2847 (55.1)
311 (24.1) 754 (35.0) 3061 (44.9)
3451 (90.3) 5105 (91.3)
364 (9.7) 492 (8.7)
2104 (51.6) 3175 (53.5)
1713 (48.4) 2425 (46.5)
1053 (96.0) 7363 (90.5)
44 (4.0) 800 (9.5)
802 (68.6) 4354 (50.7)
296 (31.4) 3813 (49.3)
7240 (91.4) 204 (80.0)
701 (8.6) 50 (20.0)
4217 (50.1) 137 (51.5)
3729 (49.9) 117 (48.5)
0.004 G0.0001
G0.0001
0.02 5894 (90.7) 2662 (92.6)
P
0.0001
0.03
0.36
0.16
G0.0001
0.31
G0.0001
G0.0001
0.16
0.14
G0.0001
G0.0001
G0.0001
0.74
*Rao-Scott W2 test. †Survey-weighted t test. Raw frequency and weighted percent prevalence values are presented.
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versus lower than high school education (44.9% vs 24.1%, P G 0.0001), and those with more than or equal to 1 health care interaction in the past year compared with those without (49.3% vs 31.4%, P G 0.0001; Table 1).
0.33%), Ayurveda (0.03% and 0.28%), naturopathy (0.02% and 0.24%), homeopathy (0.02% and 0.20%), and traditional healing (0.01% and 0.12%) (Supplemental Table 2, http://links.lww.com/DER/A2).
Association of CAM and Eczema Prevalence Distribution of CAM The raw frequency, weighted frequency, and prevalence (95% CI) of individual types of CAM among US children are presented in Supplemental Table 2 (http://links.lww.com/DER/A2). Most vitamin and herbal therapies were not being taken to treat a specific medical problem. The weighted prevalence (95% CI) of individual types of CAM used among children with and without eczema is presented in Table 2. The 5 most common CAMs used in children both with and without eczema include vitamins, herbal therapy, relaxation therapy/stress management, and Yoga/Tai Chi/Qi (Table 2). Children with eczema used CAM for any indication more commonly than children without eczema (weighted frequency: 3,827,617 vs 30,769,874; prevalence [95% CI], 58.4% [54.3%Y62.3%] vs 45.8% [44.5%Y47.2%]). The reasons for using CAM in children with and without eczema are presented in Table 3. The 3 most common reasons for using CAM in both groups of children were head or chest cold, back or neck pain, and other musculoskeletal complaints. However, most children used CAM for overall health and not to treat a specific disorder (weighted frequency: 5,819,132 vs 63,666,383; prevalence [95% CI], 11.3% [8.6%Y14.0%] vs 5.2% [4.5%Y5.8%). Several CAMs were specifically used to treat eczema (weighted frequency: 65,143; prevalence, 0.99% of children using CAM; 95% CI, 0.28%Y1.71%), including herbal therapy (0.04% of all US children and 0.46% of US children with eczema), vitamins (0.03% and
Bivariate and multivariate logistic regression models were constructed to determine whether any types of CAM are associated with higher prevalence of eczema. We excluded from the models any children that used that CAM for the treatment of previously diagnosed eczema. Herbal therapy use was associated with higher odds of eczema (adjusted odds ratio or aOR [95% CI], 2.07 [1.40-3.06]; Table 4). Subset analyses of combination herb pills, Echinacea, and fish oil/ omega-3/DHA did not reveal significant associations with any of these 3 types of herbal therapy. Associations between other types of herbal therapy and eczema prevalence were not assessed due to low frequencies for these subsets. Vitamin therapy was also associated with higher odds of eczema (aOR [95% CI], 1.45 [1.21Y1.74]; Table 4). Children with eczema were more likely to use supplementation with multivitamins (1.40 [1.15Y1.69]), calcium (2.44 [1.21Y4.91]), vitamin B complex (3.67 [1.44Y9.33]), vitamin D (4.56 [1.58Y13.14]), but not iron, or vitamins C or E. Associations between other types of vitamins and eczema prevalence were not assessed due to low frequencies for these subsets. Eczema prevalence was also associated with use of homeopathic therapy (2.94 [1.43Y6.00]), movement techniques (3.66 [1.62Y8.30]), and diet (2.24 [1.10Y4.58]), particularly vegan diet (2.53 [1.17Y5.51]). There were marginal associations of eczema prevalence with hypnosis (5.93 [1.00Y35.17]) and massage therapy (2.00 [0.99Y4.06]) but not acupuncture, Ayurveda, biofeedback, chelation, chiropractic or
TABLE 2. Type of CAM Used in Children With and Without Eczema Ordered by Rank Type of CAM Used Eczema Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Type Vitamins Herbal therapy Relaxation or stress management Yoga/Tai Chi/Qi Gong Homeopathy Chiropractor or osteopathic adjustment Massage Diet Movement techniques Traditional healer Naturopathy Ayurveda Energy healing Hypnosis Biofeedback Acupuncture Chelation
No Eczema Prevalence (95% CI) 53.64 7.41 5.77 3.71 3.16 3.09 1.93 1.40 1.14 1.00 0.42 0.39 0.37 0.32 0.22 0.16 0.11
(49.53Y57.74) (5.14Y9.67) (3.87Y7.67) (2.14Y5.29) (1.31Y5.00) (1.68Y4.51) (0.74Y3.12) (0.50Y2.30) (0.37Y1.90) (0.12Y1.87) (0.00Y0.90) (0.00Y0.85) (0.00Y0.75) (0.00Y0.73) (0.00Y0.49) (0.00Y0.39) (0.00Y0.32)
Type Vitamins Herbal therapy Chiropractor or osteopathic adjustment Relaxation or stress management Yoga/Tai Chi/Qi Gong Homeopathy Traditional healer Massage Diet Movement techniques Naturopathy Acupuncture Energy healing Biofeedback Chelation Ayurveda Hypnosis
Prevalence (95% CI) 42.25 3.58 2.74 2.65 2.06 1.06 1.03 0.93 0.72 0.34 0.32 0.21 0.21 0.16 0.10 0.08 0.07
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(40.89Y43.61) (3.02Y4.14) (2.25Y3.24) (2.18Y3.12) (1.68Y2.45) (0.72Y1.40) (0.75Y1.30) (0.68Y1.19) (0.49Y0.94) (0.20Y0.48) (0.15Y0.48) (0.10Y0.32) (0.09Y0.32) (0.06Y0.26) (0.01Y0.19) (0.00Y0.16) (0.00Y0.15)
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TABLE 3. Reason for CAM Use in Children With and Without Eczema Ordered by Rank Type of CAM Used Eczema Rank
Reason
No Eczema Prevalence (95% CI)
Reason
Prevalence (95% CI) 0.89 (0.66Y1.13) 0.82 (0.56Y1.08) 0.54 (0.35Y0.72) 0.39 (0.21Y0.57) 0.22 (0.09Y0.35) 0.16 (0.05Y0.27)
0.14 (0.00Y0.37) 0.13 (0.02Y0.23) 0.12 (0.03Y0.21) 0.12 (0.04Y0.20)
1 2 3 4 5 6
Head or chest cold Back or neck pain Other musculoskeletal Eczema or skin allergy Anxiety or stress Asthma
2.34 (0.64Y4.05) 1.54 (0.56Y2.52) 1.12 (0.02Y2.22) 0.99 (0.28Y1.71) 0.75 (0.09Y1.42) 0.65 (0.00Y1.47)
7
Attention-deficit/hyperactivity disorder or attention-deficit disorder
0.65 (0.12Y1.17)
8 9 10 11
Insomnia or trouble sleeping Sinusitis Influenza or pneumonia Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies Food or digestive allergy Anemia Sore throat other than strep or tonsillitis Frequent or repeated diarrhea or colitis Fever Abdominal pain Nausea and/or vomiting Depression Respiratory allergy Migraine headaches Nonmigraine headaches Skin problems other than eczema, acne, or warts Sickle cell anemia Other chronic pain
0.50 (0.00Y1.03) 0.50 (0.00Y1.25) 0.48 (0.00Y1.24) 0.46 (0.00Y0.93)
Back or neck pain Head or chest cold Other musculoskeletal Anemia Sore throat other than strep or tonsillitis Attention-deficit/hyperactivity disorder or attention-deficit disorder Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies Influenza or pneumonia Sinusitis Anxiety or stress Insomnia or trouble sleeping
0.45 (0.01Y0.88) 0.44 (0.00Y0.90) 0.40 (0.00Y0.98) 0.40 (0.00Y0.96) 0.37 (0.00Y1.10) 0.32 (0.00Y0.70) 0.32 (0.00Y0.95) 0.31 (0.00Y0.64) 0.19 (0.00Y0.47) 0.17 (0.00Y0.40) 0.16 (0.00Y0.39) 0.16 (0.00Y0.48)
Respiratory allergy Asthma Food or digestive allergy Abdominal pain Fever Recurring constipation Three or more ear infections Depression Problems with being overweight Nonmigraine headaches Frequent or repeated diarrhea or colitis Menstrual problems
0.11 (0.00Y0.22) 0.10 (0.01Y0.20) 0.08 (0.01Y0.14) 0.07 (0.00Y0.14) 0.07 (0.00Y0.15) 0.07 (0.01Y0.14) 0.06 (0.02Y0.11) 0.06 (0.01Y0.12) 0.06 (0.00Y0.15) 0.05 (0.00Y0.10) 0.05 (0.00Y0.10) 0.05 (0.01Y0.09)
0.12 (0.00Y0.34) 0.09 (0.00Y0.28)
Autism Urinary problems, including urinary tract infection Hay fever Fatigue or lack of energy Other chronic pain
0.05 (0.00Y0.10) 0.04 (0.00Y0.09)
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Problems with being overweight Other heart condition Lung or breathing problem, other than asthma Neurological problems Recurring constipation Acid reflux or heartburn Arthritis
0.09 (0.00Y0.26) 0.08 (0.00Y0.25) 0.05 (0.00Y0.16) 0.04 (0.00Y0.12) 0.03 (0.00Y0.08) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
33 34 35 36 37 38 39 40 41
Autism Cancer Cerebral palsy Chicken pox Congenital heart disease Cystic fibrosis Diabetes Down syndrome Fatigue or lack of energy
0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
Neurological problems Severe acne Cerebral palsy Skin problems other than eczema, acne, or warts Nausea and/or vomiting Down syndrome Vision problem Mental retardation Seizures Phobia or fears Sickle cell anemia Stuttering or stammering Strep throat or tonsillitis
0.16 (0.04Y0.28)
0.04 (0.00Y0.08) 0.04 (0.01Y0.07) 0.04 (0.00Y0.07) 0.04 (0.00Y0.09) 0.03 (0.00Y0.08) 0.03 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.07) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.05) 0.02 (0.00Y0.04) 0.01 (0.00Y0.04) 0.01 (0.00Y0.03) (Continued on next page)
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TABLE 3. (Continued) Type of CAM Used Eczema Reason
Rank
No Eczema Prevalence (95% CI)
Reason
Prevalence (95% CI) 0.01 (0.00Y0.03) 0.01 (0.00Y0.02) 0.01 (0.00Y0.02) 0.00 (0.00Y0.01) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
42 43
Gum disease Hay fever
0.00 (0.00-0.00) 0.00 (0.00-0.00)
44 45 46 47 48 49 50 51 52 53 54 55 56
Hearing problem Incontinence, including bed wetting Menstrual problems Mental retardation Muscular dystrophy Other developmental delay Phobia or fears Seizures Severe acne Strep throat or tonsillitis Stuttering or stammering Three or more ear infections Urinary problems, including urinary tract infection Vision problem Warts
0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00Y0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
Migraine headaches Lung or breathing problem, other than asthma Arthritis Diabetes Acid reflux or heartburn Cancer Chicken pox Congenital heart disease Cystic fibrosis Eczema or skin allergy Gum disease Hearing problem Incontinence, including bed wetting Muscular dystrophy Other developmental delay
0.00 (0.00-0.00) 0.00 (0.00-0.00)
Other heart condition Warts
57 58
osteopathic, energy healing, naturopathy, or traditional healing. Of note, some of these analyses had low cell frequencies. There were no significant 2-way or 3-way interactions and no issues of multicollinearity identified.
DISCUSSION Using a population-based approach, the present study describes the use of CAM in US children overall and for the treatment of eczema. The most frequently used CAM for the treatment of eczema were herbal therapy, vitamins, Ayurveda, naturopathy, homeopathy, and traditional healing. Multiple CAMs used for purposes other than treatment of eczema were associated with higher prevalence of eczema in US children, including herbal therapy, multivitamins, calcium, vitamin B complex, vitamin D, homeopathic therapy, movement techniques, and vegan diet (Fig. 1). These results suggest an association between increased CAM use and eczema prevalence. The cross-sectional nature of the study does not allow us to determine the direction of such associations. It may be that some commonly used CAM might contribute toward eczema. Alternatively, children with eczema may be more inclined to use CAM for comorbid disorders and overall health. Regardless, the results of this study suggest that children with eczema are at higher risk for the adverse effects of some CAM. Future prospective studies are needed to confirm these novel associations and to determine the time course of the relationship between eczema and CAM use. The 46.9% prevalence of CAM use in US children is consistent with previous studies that found prevalences ranging from 28.9%
to 54.0% between 1995 and 2007.20 Some of the differences that account for the wide prevalence range of CAM use include different sampling methods, definitions of CAM, and use of sample weighting.20 The 58.4% prevalence of CAM use in US children with eczema is consistent with a previous cross-sectional questionnaire of 70 US patients with AD that found the prevalence of CAM use to be 50.4%.21 The decision to use CAM is often multifactorial, including barriers to obtaining or concerns about using conventional medications,22 dissatisfaction with conventional treatment, and frustration with the chronic nature of the eczema.21 Unfortunately, parents may not voluntarily disclose CAM use during a health care encounter.23 It is therefore appropriate for providers to inquire routinely about CAM use in eczema patients using focused questions. A potentially harmful role for some CAM has previously been demonstrated. Herbal therapies include irritants, contact allergens, and contaminants that might trigger or flare eczematous reactions.4Y7 Ayurveda is commonly practiced in India and includes herbal remedies that can cause diffuse dermatitis.8,9 Naturopathic remedies have been shown to cause contact dermatitis,10 and homeopathic remedies can cause blistering reactions24 and localized and systemic contact dermatitis.11Y15 On the other hand, previous studies found no associations between maternal use of folic acid and other B vitamin supplementation during pregnancy and subsequent risk of eczema and other allergic disease in the offspring.25Y27 Clinicians should be alert for the increased use of CAM in children with eczema, their motivations, and potential adverse effects. Previous randomized controlled studies demonstrated efficacy of a variety of herbal preparations for the treatment of AD (reviewed in
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TABLE 4. Association Between Eczema and CAM in Children* Eczema No Type of CAM Herbal therapy No Yes Combination herb pill No Yes Echinacea No Yes Fish oil/omega-3/DHA No Yes Vitamin therapy No Yes Multivitamin No Yes Calcium No Yes Iron No Yes Vitamin B complex No Yes Vitamin C No Yes Vitamin D No Yes Vitamin E No Yes Homeopathic therapy No Yes Any diet No Yes Vegan diet No Yes Movement techniques No Yes Acupuncture No
Yes*
Frequency (%)
Frequency (%)
OR (95% CI)
P
aOR (95% CI)
P
8169 (91.4) 260 (84.0)
785 (8.6) 55 (15.9)
1.00 (ref ) 2.01 (1.38Y2.95)
0.0003
1.00 (ref ) 2.07 (1.40Y3.06)
0.0002
8273 (91.3) 23 (89.2)
808 (8.7) 6 (10.8)
1.00 (ref ) 1.28 (0.43Y3.83)
0.66
1.00 (ref ) 1.74 (0.63Y4.80)
0.29
8251 (91.4) 45 (83.5)
803 (8.6) 11 (16.5)
1.00 (ref ) 2.09 (0.97Y4.52)
0.06
1.00 (ref ) 2.05 (0.93Y4.52)
0.08
8262 (91.3) 34 (89.9)
807 (8.7) 7 (10.1)
1.00 (ref ) 1.18 (0.45Y3.08)
0.74
1.00 (ref ) 1.29 (0.52Y3.19)
0.59
5125 (92.7) 3288 (89.0)
424 (7.3) 419 (11.0)
1.00 (ref ) 1.57 (1.32Y1.87)
G0.0001
1.00 (ref ) 1.45 (1.21Y1.74)
G0.0001
5285 (92.5) 2591 (88.9)
449 (7.5) 336 (11.1)
1.00 (ref ) 1.56 (1.30Y1.87)
G0.0001
1.00 (ref ) 1.40 (1.15Y1.69)
0.0006
2668 (89.1) 83 (79.6)
348 (10.9) 13 (20.4)
1.00 [ref] 2.10 (1.04Y4.22)
V 0.04
1.00 [ref] 2.44 (1.21Y4.91)
V 0.01
2691 (88.8) 60 (90.0)
355 (11.2) 6 (10.0)
1.00 [ref] 0.70 (0.21Y2.34)
V 0.57
1.00 [ref] 0.68 (0.21Y2.18)
V 0.51
2723 (88.9) 28 (74.8)
353 (11.1) 8 (25.6)
1.00 [ref] 2.73 (1.04Y7.16)
V 0.04
1.00 [ref] 3.67 (1.44Y9.33)
V 0.006
2576 (88.9) 175 (87.3)
333 (11.1) 28 (12.7)
1.00 [ref] 1.17 (0.66Y2.08)
V 0.59
1.00 [ref] 1.37 (0.75Y2.50)
V 0.30
2736 (89.0) 15 (61.6)
354 (11.0) 7 (38.4)
1.00 [ref] 4.25 (1.33Y13.52)
V 0.01
1.00 [ref] 4.56 (1.58Y13.14)
V 0.005
2736 (88.9) 15 (71.9)
356 (11.1) 5 (28.1)
1.00 [ref] 2.49 (0.55Y11.29)
V 0.24
1.00 [ref] 3.14 (0.81Y12.22)
V 0.10
8358 (91.2) 75 (78.6)
826 (8.8) 20 (21.4)
1.00 [ref] 2.85 (1.40Y5.78)
V 0.004
1.00 [ref] 2.94 (1.43Y6.00)
V 0.003
8371 (91.1) 63 (83.9)
834 (8.9) 13 (16.1)
1.00 [ref] 1.97 (0.95Y4.06)
V 0.07
1.00 [ref] 2.24 (1.10Y4.58)
V 0.026
8390 (91.1) 46 (80.9)
837 (8.9) 11 (19.1)
1.00 [ref] 2.42 (1.11Y5.32)
V 0.027
1.00 [ref] 2.53 (1.17Y5.51)
V 0.02
8406 (91.1) 31 (75.4)
837 (8.9) 10 (24.6)
1.00 [ref] 3.37 (1.52Y7.44)
V 0.003
1.00 [ref] 3.66 (1.62Y8.30)
V 0.002
8426 (91.0)
848 (9.0)
1.00 [ref]
V
1.00 [ref]
V
(Continued on next page)
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Silverberg et al ¡ Complementary Medicine and Eczema
253
TABLE 4. (Continued) Eczema No Frequency (%)
OR (95% CI)
P
aOR (95% CI)
P
2 (6.7)
0.73 (0.15Y3.56)
0.70
0.87 (0.17Y4.42)
0.86
8438 (91.1) 6 (88.4)
847 (8.9) 1 (11.6)
1.00 [ref] 1.34 (0.15Y12.00)
V 0.79
1.00 [ref] 1.69 (0.17Y16.69)
V 0.65
8432 (90.9) 13 (81.3)
846 (9.1) 3 (18.8)
1.00 [ref] 1.39 (0.35Y5.46)
V 0.64
1.00 [ref] 1.63 (0.40Y6.67)
V 0.49
8439 (91.1) 6 (90.1)
848 (8.9) 1 (9.9)
1.00 [ref] 1.12 (0.13Y9.69)
V 0.92
1.00 [ref] 1.23 (0.13Y11.81)
V 0.86
196 (90.0) 8250 (91.1)
24 (10.0) 824 (8.9)
1.00 [ref] 1.31 (0.68Y1.88)
V 0.63
1.00 [ref] 1.11 (0.66Y1.88)
V 0.70
8428 (91.1) 17 (15.0)
844 (8.9) 4 (85.0)
1.00 [ref] 1.80 (0.57Y5.75)
V 0.31
1.00 [ref] 1.94 (0.58Y6.54)
V 0.29
8441 (91.1) 4 (68.9)
846 (8.9) 3 (31.1)
1.00 [ref] 4.60 (0.82Y25.71)
V 0.08
1.00 [ref] 5.93 (1.00Y35.17)
V 0.05
8371 (91.1) 74 (83.1)
834 (8.9) 14 (16.9)
1.00 [ref] 2.10 (1.06Y4.16)
V 0.03
1.00 [ref] 2.00 (0.99Y4.06)
V 0.05
8423 (91.1) 21 (94.8)
845 (8.9) 2 (5.2)
1.00 [ref] 0.56 (0.12Y2.56)
V 0.46
1.00 [ref] 0.52 (0.11Y2.44)
V 0.41
8356 (91.0) 86 (92.1)
843 (9.0) 5 (7.9)
1.00 (ref ) 0.87 (0.32Y2.38)
0.78
1.00 (ref ) 0.85 (0.31Y2.33)
0.76
Frequency (%)
Type of CAM Yes Ayurveda No Yes Biofeedback No Yes Chelation No Yes Chiropractic or osteopathic No Yes Energy healing No Yes Hypnosis No Yes Massage therapy No Yes Naturopathy No Yes Traditional healer No Yes
Yes*
20 (93.3)
Note: Any CAM used for the treatment of eczema was excluded from these models. *Multivariate logistic regression models were constructed with eczema (yes/no) modeled as the dependent variables and specific types of CAM as independent variables. Odds ratio and 95% CI for eczema were determined. Adjusted ORs were determined from multivariate models by including sex, current age (continuous), race (African American/black, white, Asian, multiracial/other), Hispanic origin (yes/no), birthplace in the United States (yes/no), household income ($0-$49,000; Q$50,000), highest level of education in the household (lower than high school, high school graduate or equivalent, higher than high school graduate), and health care interaction in the past year (yes/no).
Tan et al28). However, there are minimal data to support the safety and efficacy of naturopathy in AD. Furthermore, recent systematic reviews found insufficient evidence in support of and demonstrated higher costs for homeopathy for eczema.29,30 Vitamin D supplementation in lactating mothers was found to have no benefit,31 and there was actually an increased risk for AD in children during the first year of life.32 In contrast, Sidbury et al33 demonstrated improvements in AD with oral vitamin D supplementation in a Boston pediatric population. Finally, a recent Cochrane review of randomized controlled trials of vitamins and other dietary supplements found no convincing evidence to support clinical or populationbased recommendations for any vitamin supplementation.34 The strengths of this study include being a large-scale, US population-based survey of children with minimal selection bias and controlling for confounding demographic variables in multivariate models. However, the study has some limitations. Eczema was assessed by parental report. However, the NHIS
question asked about eczema diagnosed by a ‘‘doctor or other health care provider,’’ which is more specific and accurate than selfdiagnosis. Furthermore, previous studies used and validated single questions utilizing parental recall of physician-diagnosed eczema, and this approach is routine for epidemiologic studies of children.35,36 The NHIS question for eczema is rather broad and might overestimate the prevalence of eczema per se by inclusion of other entities such as allergic contact dermatitis, although such entities are relatively uncommon compared with eczema in pediatric age groups. Thus, the results of the survey with this question are likely meaningful and accurate. Finally, despite the large sample size, the frequencies of some CAM usage were small or zero, which limits the ability to generate accurate prevalence estimates for those modalities. However, even these low frequencies provide valuable information about the low usage of particular modalities of CAM. Even larger studies would be needed to further explore the nuances related to those less frequently used modalities.
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DERMATITIS, Vol 25 ¡ No 5 ¡ September/October, 2014
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In conclusion, the present study determined rates of CAM use in US children with eczema. Furthermore, herbal therapy, multivitamins, calcium, vitamin B complex and/or vitamin D supplementation, homeopathic therapy, movement techniques, and vegan diet were all associated with higher prevalence of eczema in US children. The results of this study suggest that use of CAM should be screened for during the evaluation of children with eczema. Future research is needed to confirm these findings and to determine the time course and mechanism for such associations.
REFERENCES 1. Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2006;118:152Y169. 2. Shaw TE, Currie GP, Koudelka CW, et al. Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol 2011;131:67Y73. 3. Silverberg JI, Simpson EL, Durkin HG, et al. Prevalence of allergic disease in foreign-born American children. JAMA Pediatr 2013;167:554Y560. 4. Sen P, Ho MS, Ng SK, et al. Contact dermatitis: a common adverse reaction to topical traditional Chinese medicine. Int J Dermatol 2010;49:1255Y1260. 5. Oiso N, Yamadori Y, Higashimori N, et al. Allergic contact dermatitis caused by sesame oil in a topical Chinese medicine, shi-un-ko. Contact Dermatitis 2008;58:109. 6. Lee TY, Lam TH. Irritant contact dermatitis due to a Chinese herbal medicine lu-shen-wan. Contact Dermatitis 1988;18:213Y218. 7. Ernst E. Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000;143:923Y929. 8. Llanchezhian R, Joseph CR, Rabinarayan A. Urushiol-induced contact dermatitis caused during Shodhana (purificatory measures) of Bhallataka (Semecarpus anacardium Linn.) fruit. Ayu 2012;33:270Y273. 9. Lakshmi C, Srinivas CR. Allergic contact dermatitis following aromatherapy with valiya narayana thailamVan ayurvedic oil presenting as exfoliative dermatitis. Contact Dermatitis 2009;61:297Y298. 10. Roberge RJ, Leckey R, Spence R, et al. Garlic burns of the breast. Am J Emerg Med 1997;15:548. 11. Reutemann P, Ehrlich A. Neem oil: an herbal therapy for alopecia causes dermatitis. Dermatitis 2008;19:E12YE15. 12. De Medeiros LM, Fransway AF, Taylor JS, et al. Complementary and alternative remedies: an additional source of potential systemic nickel exposure. Contact Dermatitis 2008;58:97Y100. 13. Cardinali C, Francalanci S, Giomi B, et al. Contact dermatitis from Rhus toxicodendron in a homeopathic remedy. J Am Acad Dermatol 2004;50: 150Y151. 14. Giordano-Labadie F, Schwarze HP, Bazex J. Allergic contact dermatitis from camomile used in phytotherapy. Contact Dermatitis 2000;42:247. 15. Van Ulsen J, Stolz E, Van Joost T. Chromate dermatitis from a homeopathic drug. Contact Dermatitis 1988;18:56Y57. 16. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;(12):1Y23. 17. Lilly E, Kundu RV. Dermatoses secondary to Asian cultural practices. Int J Dermatol 2012;51:372Y379; quiz 379Y382.
18. Silverberg JI, Hanifin J. Adult eczema prevalence and associations with asthma and other health and demographic factors: a US population-based study. Journal Allergy Clin Immunol 2013;132:1132Y1138. 19. Benjamini Y, Hochberg Y. Controlling the false discovery rateVa practical and powerful approach to multiple testing. J R Stat Soc Series B Stat Methodol 1995;57:289Y300. 20. Harris PE, Cooper KL, Relton C, Thomas KJ. Prevalence of complementary and alternative medicine (CAM) use by the general population: a systematic review and update. International journal of clinical practice 2012;66:924Y939. 21. Simpson EL, Basco M, Hanifin J. A cross-sectional survey of complementary and alternative medicine use in patients with atopic dermatitis. American journal of contact dermatitis: official journal of the American Contact Dermatitis Society 2003;14:144Y147. 22. Mcquaid EL, Fedele DA, Adams SK, et al. Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families. Academic pediatrics 2014;14:192Y199. 23. Sidora-Arcoleo K, Yoos HL, Kitzman H, Mcmullen A, Anson E. Don’t ask, don’t tell: parental nondisclosure of complementary and alternative medicine and over-the-counter medication use in children’s asthma management. Journal of pediatric health care: official publication of National Association of Pediatric Nurse Associates & Practitioners 2008;22:221Y229. 24. Jurj G, Waisse S. Blisters and homeopathy: case reports and differential diagnosis. Homeopathy 2011;100:168Y174. 25. Bekkers MB, Elstgeest LE, Scholtens S, et al. Maternal use of folic acid supplements during pregnancy, and childhood respiratory health and atopy. Eur Respir J 2012;39:1468Y1474. 26. Magdelijns FJ, Mommers M, Penders J, et al. Folic acid use in pregnancy and the development of atopy, asthma, and lung function in childhood. Pediatrics 2011;128:e135Ye144. 27. Miyake Y, Sasaki S, Tanaka K, et al. Maternal B vitamin intake during pregnancy and wheeze and eczema in Japanese infants aged 16Y24 months: the Osaka Maternal and Child Health Study. Pediatr Allergy Immunol 2011;22:69Y74. 28. Tan HY, Zhang AL, Chen D, et al. Chinese herbal medicine for atopic dermatitis: a systematic review. J Am Acad Dermatol 2013;69:295Y304. 29. Ernst E. Homeopathy for eczema: a systematic review of controlled clinical trials. Br J Dermatol 2012;166:1170Y1172. 30. Roll S, Reinhold T, Pach D, et al. Comparative effectiveness of homoeopathic vs. conventional therapy in usual care of atopic eczema in children: long-term medical and economic outcomes. PLoS One 2013; 8:e54973. 31. Norizoe C, Akiyama N, Segawa T, et al. Increased food allergy with vitamin D: a randomized, double-blind, placebo-controlled trial. Pediatr Int 2014;56:6Y12. 32. Back O, Blomquist HK, Hernell O, et al. Does vitamin D intake during infancy promote the development of atopic allergy? Acta Derm Venereol 2009;89:28Y32. 33. Sidbury R, Sullivan AF, Thadhani RI, et al. Randomized controlled trial of vitamin D supplementation for winter-related atopic dermatitis in Boston: a pilot study. Br J Dermatol 2008;159:245Y247. 34. Bath-Hextall FJ, Jenkinson C, Humphreys R, et al. Dietary supplements for established atopic eczema. Cochrane Database Syst Rev 2012;2:CD005205. 35. Laughter D, Istvan JA, Tofte SJ, et al. The prevalence of atopic dermatitis in Oregon schoolchildren. J Am Acad Dermatol 2000;43:649Y655. 36. Kramer U, Schafer T, Behrendt H, et al. The influence of cultural and educational factors on the validity of symptom and diagnosis questions for atopic eczema. Br J Dermatol 1998;139:1040Y1046.
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Complementary and Alternative Medicines and Childhood Eczema: A US Population-Based Study Jonathan I. Silverberg, MD, PhD, MPH,*†‡ Mary Lee-Wong, MD,§ and Nanette B. Silverberg, MD|| The prevalence of complementary and alternative medicine (CAM) use in US children with eczema is unknown. Furthermore, it is unknown whether CAM use in the United States is associated with higher eczema prevalence. We sought to determine the eczema prevalence in association with CAM usage. We analyzed data from the 2007 National Health Interview Survey that included a nationally representative sample of 9417 children ages 0 to 17 years. Overall, 46.9% (95% confidence interval, 45.6%Y48.2%) of children in the United States used 1 or more CAM, of which 0.99% (0.28%Y1.71%) used CAM specifically to treat their eczema, including herbal therapy (0.46%), vitamins (0.33%), Ayurveda (0.28%), naturopathy (0.24%), homeopathy (0.20%), and traditional healing (0.12%). Several CAMs used for other purposes were associated with increased eczema prevalence, including herbal therapy (survey logistic regression; adjusted odds ratio [95% confidence interval], 2.07 [1.40Y3.06]), vitamins (1.45 [1.21Y1.74]), homeopathic therapy (2.94 [1.43Y6.00]), movement techniques (3.66 [1.62Y8.30]), and diet (2.24 [1.10Y4.58]), particularly vegan diet (2.53 [1.17Y5.51]). In conclusion, multiple CAMs are commonly used for the treatment of eczema in US children. However, some CAMs may actually be harmful to the skin and be associated with higher eczema prevalence in the United States.
A
topic dermatitis (AD) or eczema is a chronic inflammatory skin disorder that is related to a complex interaction between genetics and environmental exposures. Eczema can be provoked by multiple modifiable risk factors, including irritants, contact allergens, food and inhaled allergens, stress, and infections.1 Recent population-based studies of US children and adults found associations between eczema prevalence and sociodemographic factors, including race/ethnicity, higher education levels, and household income.2 A recent study found that foreign-born US children had significantly lower rates of eczema and other allergic disease than American-born children.3 Furthermore, the odds of eczema increased after 10 years of residence in the United States. These associations may be related to cultural and behavioral differences of skin care practices, nutrition, and environmental exposures in specific demographic groups. One example of such differences is the use of complementary and alternative medicine From the Departments of *Dermatology, ÞPreventive Medicine, and þMedical Social Sciences, Northwestern University, Chicago, IL; §Department of Allergy & Immunology, Beth Israel Medical Center; and || Department of Dermatology, St Luke’s-Roosevelt Hospital and Beth Israel Medical Centers, New York, NY. Address reprint requests to requests to Jonathan I. Silverberg, MD, PhD, MPH, Department of Dermatology, Northwestern University, Suite 1400, 680 Lakeshore Dr, Chicago, IL 60611. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. Manuscript authorship: J.I. Silverberg, M. Lee-Wong, and N.B. Silverberg. Data analysis and interpretation: J.I. Silverberg, M. Lee-Wong, and N.B. Silverberg. Statistical analysis: J.I. Silverberg. DOI: 10.1097/DER.0000000000000072 * 2014 American Contact Dermatitis Society. All Rights Reserved. 246
(CAM) for the treatment of eczema and other medical disorders. Numerous case reports/series found that CAM caused various types of localized and diffuse eczematous reactions.4Y15 However, little is known about the relationship between CAM use and the prevalence of eczema. We hypothesized that common use of CAM in the US population may actually be associated with eczema prevalence. Complementary and alternative medicines are commonly used for a variety of medical disorders.16 There are no recent studies of the prevalence of CAM use in US children. Some types of CAM may be more commonly used in specific populations, such as herbal treatments in Asians and Ayurveda in Indians.17 However, little is known about the determinants of CAM use in the US population. Moreover, there are no US population-based estimates of the use of CAM in children with eczema. The goal of this study was to determine the prevalence of CAM use in US children with eczema and to determine whether CAM use is associated with increased eczema prevalence in the United States.
METHODS National Health Interview Survey We used the 2007 National Health Interview Survey (NHIS), which is the principal source of information on the health of the civilian population of the United States. The survey included a separate questionnaire about children’s health with parental questionnaires to estimate the prevalence of various child health issues. The survey was administered in person to selected households by the Bureau of the Census using approximately 400 trained interviewers with computer-assisted personal interviewing. One DERMATITIS, Vol 25 ¡ No 5 ¡ September/October, 2014
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Silverberg et al ¡ Complementary Medicine and Eczema
247
was approved by the institutional review board at the Northwestern University.
History of Eczema Questions related to this study are presented in Supplementary Table 1 (http://links.lww.com/DER/A1). History of eczema was determined by an affirmative response to the question, ‘‘During the past 12 months, have you been told by a doctor or other health professional that the (child) had eczema or any kind of skin allergy?’’ We shall use the term eczema interchangeably with that question to provide brevity and consistency throughout this study.
History of CAM Histories of using acupuncture, Ayurveda, biofeedback, chelation, chiropractic or osteopathic therapy, energy healing, hypnosis, massage therapy, naturopathy, traditional healing, movement techniques, herbal therapy, vitamin therapy, homeopathy, and/or diet were recorded. Composite binary variables were generated for use of 1 or more item from each category of and for any CAM.
Demographics Demographic and socioeconomic factors were examined as potential confounders for an association between CAM use and eczema, including age, sex, race, Hispanic origin, birthplace in the United States, household income, highest level of education in the household, health care interaction in the past year, current health insurance coverage, and prescription medication coverage. These variables were selected based on the results of previous studies2,3,18 and the a priori hypotheses.
Data Processing and Statistical Methods
FIGURE 1. Complementary and alternative medicines that were associated with higher odds of eczema in US children. Complementary and alternative medicines that were significantly associated with eczema prevalence are presented in the diagram in order of the magnitude of their OR.
child was randomly selected for the sample child questionnaire. Interviews were conducted in English and Spanish. Using data from the US Census Bureau, sample weights were created that factored age, sex, race, ethnicity, household size, and educational attainment of the most educated household member using a multistage area probability sampling design by the NHIS. These sample weights are needed to provide nationally representative prevalence estimates for each state’s population of noninstitutionalized children aged 0 to 17 years. Frequency data are presented as raw and weighted values as indicated; weighted prevalence estimates are presented. This study
All data processing and statistical analyses were performed in SAS version 9.3 (SAS Institute, Cary, NC). All prevalence estimates and analyses of survey responses were performed using survey procedures that account for the complex weighting established by the NHIS. Bivariate analyses were performed using Rao-Scott W2 tests. Associations between histories of eczema and CAM were tested by survey logistic regression. Because some subjects might have used specific modalities of CAM for the treatment of previously diagnosed eczema, we excluded such subjects from the models. Multivariate logistic regression models were constructed that included significant variables identified in bivariate analyses as covariates. Subset analyses were performed for individual items of a particular category if a significant association was found for the overall category of CAM and raw frequencies were 5 or more per cell in 2-by-2 tables. If a significant association was found for the overall category of CAM and there were fewer than 5 per cell, comparisons were presented in the text without formal statistical tests performed. Complete data analysis was performed, that is, subjects with missing data were excluded. Two-way and 3-way interactions were tested and only included in the final models if the P value was less
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than 0.01 and the modification of estimates were greater than 20%. Multicollinearity was tested using variable inflation factors and tolerance. Post hoc correction for multiple dependent tests (k = 81) was performed by minimizing the false discovery rate with the approach of Benjamini and Hochberg19 resulting in critical P value of 0.027. Therefore, P values less than or equal to 0.027 were considered significant.
versus Hispanics (9.3% vs 7.4%, P = 0.02), those born in the United States compared with foreign-born Americans (9.1% vs 3.7%, P = 0.0001), after high school versus lower than high school education (10.0% vs 5.1%, P G 0.0001), and those unable to afford prescription medications compared with those who could (20.0% vs 8.6%, P G 0.0001; Table 1).
Associations With CAM Use RESULTS Associations With Childhood Eczema Data were collected on a total of 9417 children. Overall, eczema occurred in 8.9% (95% confidence interval [95% CI], 8.2%Y9.6%) or 6,561,146 US children. Prevalence of eczema was significantly higher with younger age (P G 0.0001), in African Americans compared with whites (10.7% vs 8.7%, P = 0.05), non-Hispanics
Overall, 46.9% (95% CI, 45.6%Y48.2%) or 34,606,254 of children in the United States used 1 or more CAM. Complementary and alternative medicine use was significantly higher with older age (P = 0.004), whites and Asians compared with African Americans and multiracial/other (51.1% and 48.0% vs 36.7% and 35.4%, respectively), non-Hispanics compared with Hispanics (49.9% vs 35.6), those with household income more than or equal to $50,000 versus $0 to $49,000 (55.7% vs 37.9%, P G 0.0001), after high school
TABLE 1. Subject Characteristics Eczema Variable Age, mean (95% CI), y Race, n (%) African American White Asian Multiracial/other Hispanic origin, n (%) No Yes Born in the United States, n (%) No Yes Sex, n (%) Female Male Household income ($1000), n (%) 0Y49 Q50 Highest level of education in the household GHigh school (HS) HS or Graduate Equivalency Diploma (GED) 9HS No. children in household, n (%) 1 2+ Health care interaction in past year, n (%) No Yes Could not afford prescription medicines, n (%) No Yes
CAM
No (n = 8556)
Yes (n = 856)
P
8.6 (8.5Y8.8)
7.8 (7.4Y8.2)
G0.0001 0.05
1500 5384 299 1373
(89.3) (91.3) (91.9) (92.4)
191 (10.7) 523 (8.7) 28 (8.1) 114 (7.6)
No (n = 5276)
Yes (n = 4136)
8.5 (8.3Y8.6)
8.7 (8.5Y8.9)
1082 (63.3) 3052 (48.9) 168 (52.0) 977 (64.6)
611 (36.7) 2857 (51.1) 159 (48.0) 511 (35.4)
3373 (50.1) 1906 (64.4)
3174 (49.9) 964 (35.6)
648 (9.3) 208 (7.4)
512 (96.3) 8038 (90.9)
22 (3.7) 834 (9.1)
326 (59.1) 4947 (52.8)
208 (40.9) 3930 (47.2)
4116 (90.8) 4440 (91.4)
435 (9.2) 421 (8.6)
2502 (52.1) 2777 (54.0)
2050 (47.9) 2088 (46.0)
4092 (91.3) 3948 (90.6)
388 (8.7) 434 (9.4)
2868 (62.1) 2070 (44.3)
1616 (37.9) 2312 (55.7)
1180 (94.9) 2022 (92.1) 5289 (90.0)
68 (5.1) 173 (7.9) 615 (10.0)
937 (75.9) 1442 (65.0) 2847 (55.1)
311 (24.1) 754 (35.0) 3061 (44.9)
3451 (90.3) 5105 (91.3)
364 (9.7) 492 (8.7)
2104 (51.6) 3175 (53.5)
1713 (48.4) 2425 (46.5)
1053 (96.0) 7363 (90.5)
44 (4.0) 800 (9.5)
802 (68.6) 4354 (50.7)
296 (31.4) 3813 (49.3)
7240 (91.4) 204 (80.0)
701 (8.6) 50 (20.0)
4217 (50.1) 137 (51.5)
3729 (49.9) 117 (48.5)
0.004 G0.0001
G0.0001
0.02 5894 (90.7) 2662 (92.6)
P
0.0001
0.03
0.36
0.16
G0.0001
0.31
G0.0001
G0.0001
0.16
0.14
G0.0001
G0.0001
G0.0001
0.74
*Rao-Scott W2 test. †Survey-weighted t test. Raw frequency and weighted percent prevalence values are presented.
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Silverberg et al ¡ Complementary Medicine and Eczema
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versus lower than high school education (44.9% vs 24.1%, P G 0.0001), and those with more than or equal to 1 health care interaction in the past year compared with those without (49.3% vs 31.4%, P G 0.0001; Table 1).
0.33%), Ayurveda (0.03% and 0.28%), naturopathy (0.02% and 0.24%), homeopathy (0.02% and 0.20%), and traditional healing (0.01% and 0.12%) (Supplemental Table 2, http://links.lww.com/DER/A2).
Association of CAM and Eczema Prevalence Distribution of CAM The raw frequency, weighted frequency, and prevalence (95% CI) of individual types of CAM among US children are presented in Supplemental Table 2 (http://links.lww.com/DER/A2). Most vitamin and herbal therapies were not being taken to treat a specific medical problem. The weighted prevalence (95% CI) of individual types of CAM used among children with and without eczema is presented in Table 2. The 5 most common CAMs used in children both with and without eczema include vitamins, herbal therapy, relaxation therapy/stress management, and Yoga/Tai Chi/Qi (Table 2). Children with eczema used CAM for any indication more commonly than children without eczema (weighted frequency: 3,827,617 vs 30,769,874; prevalence [95% CI], 58.4% [54.3%Y62.3%] vs 45.8% [44.5%Y47.2%]). The reasons for using CAM in children with and without eczema are presented in Table 3. The 3 most common reasons for using CAM in both groups of children were head or chest cold, back or neck pain, and other musculoskeletal complaints. However, most children used CAM for overall health and not to treat a specific disorder (weighted frequency: 5,819,132 vs 63,666,383; prevalence [95% CI], 11.3% [8.6%Y14.0%] vs 5.2% [4.5%Y5.8%). Several CAMs were specifically used to treat eczema (weighted frequency: 65,143; prevalence, 0.99% of children using CAM; 95% CI, 0.28%Y1.71%), including herbal therapy (0.04% of all US children and 0.46% of US children with eczema), vitamins (0.03% and
Bivariate and multivariate logistic regression models were constructed to determine whether any types of CAM are associated with higher prevalence of eczema. We excluded from the models any children that used that CAM for the treatment of previously diagnosed eczema. Herbal therapy use was associated with higher odds of eczema (adjusted odds ratio or aOR [95% CI], 2.07 [1.40-3.06]; Table 4). Subset analyses of combination herb pills, Echinacea, and fish oil/ omega-3/DHA did not reveal significant associations with any of these 3 types of herbal therapy. Associations between other types of herbal therapy and eczema prevalence were not assessed due to low frequencies for these subsets. Vitamin therapy was also associated with higher odds of eczema (aOR [95% CI], 1.45 [1.21Y1.74]; Table 4). Children with eczema were more likely to use supplementation with multivitamins (1.40 [1.15Y1.69]), calcium (2.44 [1.21Y4.91]), vitamin B complex (3.67 [1.44Y9.33]), vitamin D (4.56 [1.58Y13.14]), but not iron, or vitamins C or E. Associations between other types of vitamins and eczema prevalence were not assessed due to low frequencies for these subsets. Eczema prevalence was also associated with use of homeopathic therapy (2.94 [1.43Y6.00]), movement techniques (3.66 [1.62Y8.30]), and diet (2.24 [1.10Y4.58]), particularly vegan diet (2.53 [1.17Y5.51]). There were marginal associations of eczema prevalence with hypnosis (5.93 [1.00Y35.17]) and massage therapy (2.00 [0.99Y4.06]) but not acupuncture, Ayurveda, biofeedback, chelation, chiropractic or
TABLE 2. Type of CAM Used in Children With and Without Eczema Ordered by Rank Type of CAM Used Eczema Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Type Vitamins Herbal therapy Relaxation or stress management Yoga/Tai Chi/Qi Gong Homeopathy Chiropractor or osteopathic adjustment Massage Diet Movement techniques Traditional healer Naturopathy Ayurveda Energy healing Hypnosis Biofeedback Acupuncture Chelation
No Eczema Prevalence (95% CI) 53.64 7.41 5.77 3.71 3.16 3.09 1.93 1.40 1.14 1.00 0.42 0.39 0.37 0.32 0.22 0.16 0.11
(49.53Y57.74) (5.14Y9.67) (3.87Y7.67) (2.14Y5.29) (1.31Y5.00) (1.68Y4.51) (0.74Y3.12) (0.50Y2.30) (0.37Y1.90) (0.12Y1.87) (0.00Y0.90) (0.00Y0.85) (0.00Y0.75) (0.00Y0.73) (0.00Y0.49) (0.00Y0.39) (0.00Y0.32)
Type Vitamins Herbal therapy Chiropractor or osteopathic adjustment Relaxation or stress management Yoga/Tai Chi/Qi Gong Homeopathy Traditional healer Massage Diet Movement techniques Naturopathy Acupuncture Energy healing Biofeedback Chelation Ayurveda Hypnosis
Prevalence (95% CI) 42.25 3.58 2.74 2.65 2.06 1.06 1.03 0.93 0.72 0.34 0.32 0.21 0.21 0.16 0.10 0.08 0.07
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(40.89Y43.61) (3.02Y4.14) (2.25Y3.24) (2.18Y3.12) (1.68Y2.45) (0.72Y1.40) (0.75Y1.30) (0.68Y1.19) (0.49Y0.94) (0.20Y0.48) (0.15Y0.48) (0.10Y0.32) (0.09Y0.32) (0.06Y0.26) (0.01Y0.19) (0.00Y0.16) (0.00Y0.15)
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TABLE 3. Reason for CAM Use in Children With and Without Eczema Ordered by Rank Type of CAM Used Eczema Rank
Reason
No Eczema Prevalence (95% CI)
Reason
Prevalence (95% CI) 0.89 (0.66Y1.13) 0.82 (0.56Y1.08) 0.54 (0.35Y0.72) 0.39 (0.21Y0.57) 0.22 (0.09Y0.35) 0.16 (0.05Y0.27)
0.14 (0.00Y0.37) 0.13 (0.02Y0.23) 0.12 (0.03Y0.21) 0.12 (0.04Y0.20)
1 2 3 4 5 6
Head or chest cold Back or neck pain Other musculoskeletal Eczema or skin allergy Anxiety or stress Asthma
2.34 (0.64Y4.05) 1.54 (0.56Y2.52) 1.12 (0.02Y2.22) 0.99 (0.28Y1.71) 0.75 (0.09Y1.42) 0.65 (0.00Y1.47)
7
Attention-deficit/hyperactivity disorder or attention-deficit disorder
0.65 (0.12Y1.17)
8 9 10 11
Insomnia or trouble sleeping Sinusitis Influenza or pneumonia Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies Food or digestive allergy Anemia Sore throat other than strep or tonsillitis Frequent or repeated diarrhea or colitis Fever Abdominal pain Nausea and/or vomiting Depression Respiratory allergy Migraine headaches Nonmigraine headaches Skin problems other than eczema, acne, or warts Sickle cell anemia Other chronic pain
0.50 (0.00Y1.03) 0.50 (0.00Y1.25) 0.48 (0.00Y1.24) 0.46 (0.00Y0.93)
Back or neck pain Head or chest cold Other musculoskeletal Anemia Sore throat other than strep or tonsillitis Attention-deficit/hyperactivity disorder or attention-deficit disorder Allergies other than hay fever, respiratory allergies, food or digestive allergies, or skin allergies Influenza or pneumonia Sinusitis Anxiety or stress Insomnia or trouble sleeping
0.45 (0.01Y0.88) 0.44 (0.00Y0.90) 0.40 (0.00Y0.98) 0.40 (0.00Y0.96) 0.37 (0.00Y1.10) 0.32 (0.00Y0.70) 0.32 (0.00Y0.95) 0.31 (0.00Y0.64) 0.19 (0.00Y0.47) 0.17 (0.00Y0.40) 0.16 (0.00Y0.39) 0.16 (0.00Y0.48)
Respiratory allergy Asthma Food or digestive allergy Abdominal pain Fever Recurring constipation Three or more ear infections Depression Problems with being overweight Nonmigraine headaches Frequent or repeated diarrhea or colitis Menstrual problems
0.11 (0.00Y0.22) 0.10 (0.01Y0.20) 0.08 (0.01Y0.14) 0.07 (0.00Y0.14) 0.07 (0.00Y0.15) 0.07 (0.01Y0.14) 0.06 (0.02Y0.11) 0.06 (0.01Y0.12) 0.06 (0.00Y0.15) 0.05 (0.00Y0.10) 0.05 (0.00Y0.10) 0.05 (0.01Y0.09)
0.12 (0.00Y0.34) 0.09 (0.00Y0.28)
Autism Urinary problems, including urinary tract infection Hay fever Fatigue or lack of energy Other chronic pain
0.05 (0.00Y0.10) 0.04 (0.00Y0.09)
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Problems with being overweight Other heart condition Lung or breathing problem, other than asthma Neurological problems Recurring constipation Acid reflux or heartburn Arthritis
0.09 (0.00Y0.26) 0.08 (0.00Y0.25) 0.05 (0.00Y0.16) 0.04 (0.00Y0.12) 0.03 (0.00Y0.08) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
33 34 35 36 37 38 39 40 41
Autism Cancer Cerebral palsy Chicken pox Congenital heart disease Cystic fibrosis Diabetes Down syndrome Fatigue or lack of energy
0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
Neurological problems Severe acne Cerebral palsy Skin problems other than eczema, acne, or warts Nausea and/or vomiting Down syndrome Vision problem Mental retardation Seizures Phobia or fears Sickle cell anemia Stuttering or stammering Strep throat or tonsillitis
0.16 (0.04Y0.28)
0.04 (0.00Y0.08) 0.04 (0.01Y0.07) 0.04 (0.00Y0.07) 0.04 (0.00Y0.09) 0.03 (0.00Y0.08) 0.03 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.07) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.06) 0.02 (0.00Y0.05) 0.02 (0.00Y0.04) 0.01 (0.00Y0.04) 0.01 (0.00Y0.03) (Continued on next page)
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Silverberg et al ¡ Complementary Medicine and Eczema
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TABLE 3. (Continued) Type of CAM Used Eczema Reason
Rank
No Eczema Prevalence (95% CI)
Reason
Prevalence (95% CI) 0.01 (0.00Y0.03) 0.01 (0.00Y0.02) 0.01 (0.00Y0.02) 0.00 (0.00Y0.01) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
42 43
Gum disease Hay fever
0.00 (0.00-0.00) 0.00 (0.00-0.00)
44 45 46 47 48 49 50 51 52 53 54 55 56
Hearing problem Incontinence, including bed wetting Menstrual problems Mental retardation Muscular dystrophy Other developmental delay Phobia or fears Seizures Severe acne Strep throat or tonsillitis Stuttering or stammering Three or more ear infections Urinary problems, including urinary tract infection Vision problem Warts
0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00Y0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00) 0.00 (0.00-0.00)
Migraine headaches Lung or breathing problem, other than asthma Arthritis Diabetes Acid reflux or heartburn Cancer Chicken pox Congenital heart disease Cystic fibrosis Eczema or skin allergy Gum disease Hearing problem Incontinence, including bed wetting Muscular dystrophy Other developmental delay
0.00 (0.00-0.00) 0.00 (0.00-0.00)
Other heart condition Warts
57 58
osteopathic, energy healing, naturopathy, or traditional healing. Of note, some of these analyses had low cell frequencies. There were no significant 2-way or 3-way interactions and no issues of multicollinearity identified.
DISCUSSION Using a population-based approach, the present study describes the use of CAM in US children overall and for the treatment of eczema. The most frequently used CAM for the treatment of eczema were herbal therapy, vitamins, Ayurveda, naturopathy, homeopathy, and traditional healing. Multiple CAMs used for purposes other than treatment of eczema were associated with higher prevalence of eczema in US children, including herbal therapy, multivitamins, calcium, vitamin B complex, vitamin D, homeopathic therapy, movement techniques, and vegan diet (Fig. 1). These results suggest an association between increased CAM use and eczema prevalence. The cross-sectional nature of the study does not allow us to determine the direction of such associations. It may be that some commonly used CAM might contribute toward eczema. Alternatively, children with eczema may be more inclined to use CAM for comorbid disorders and overall health. Regardless, the results of this study suggest that children with eczema are at higher risk for the adverse effects of some CAM. Future prospective studies are needed to confirm these novel associations and to determine the time course of the relationship between eczema and CAM use. The 46.9% prevalence of CAM use in US children is consistent with previous studies that found prevalences ranging from 28.9%
to 54.0% between 1995 and 2007.20 Some of the differences that account for the wide prevalence range of CAM use include different sampling methods, definitions of CAM, and use of sample weighting.20 The 58.4% prevalence of CAM use in US children with eczema is consistent with a previous cross-sectional questionnaire of 70 US patients with AD that found the prevalence of CAM use to be 50.4%.21 The decision to use CAM is often multifactorial, including barriers to obtaining or concerns about using conventional medications,22 dissatisfaction with conventional treatment, and frustration with the chronic nature of the eczema.21 Unfortunately, parents may not voluntarily disclose CAM use during a health care encounter.23 It is therefore appropriate for providers to inquire routinely about CAM use in eczema patients using focused questions. A potentially harmful role for some CAM has previously been demonstrated. Herbal therapies include irritants, contact allergens, and contaminants that might trigger or flare eczematous reactions.4Y7 Ayurveda is commonly practiced in India and includes herbal remedies that can cause diffuse dermatitis.8,9 Naturopathic remedies have been shown to cause contact dermatitis,10 and homeopathic remedies can cause blistering reactions24 and localized and systemic contact dermatitis.11Y15 On the other hand, previous studies found no associations between maternal use of folic acid and other B vitamin supplementation during pregnancy and subsequent risk of eczema and other allergic disease in the offspring.25Y27 Clinicians should be alert for the increased use of CAM in children with eczema, their motivations, and potential adverse effects. Previous randomized controlled studies demonstrated efficacy of a variety of herbal preparations for the treatment of AD (reviewed in
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DERMATITIS, Vol 25 ¡ No 5 ¡ September/October, 2014
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TABLE 4. Association Between Eczema and CAM in Children* Eczema No Type of CAM Herbal therapy No Yes Combination herb pill No Yes Echinacea No Yes Fish oil/omega-3/DHA No Yes Vitamin therapy No Yes Multivitamin No Yes Calcium No Yes Iron No Yes Vitamin B complex No Yes Vitamin C No Yes Vitamin D No Yes Vitamin E No Yes Homeopathic therapy No Yes Any diet No Yes Vegan diet No Yes Movement techniques No Yes Acupuncture No
Yes*
Frequency (%)
Frequency (%)
OR (95% CI)
P
aOR (95% CI)
P
8169 (91.4) 260 (84.0)
785 (8.6) 55 (15.9)
1.00 (ref ) 2.01 (1.38Y2.95)
0.0003
1.00 (ref ) 2.07 (1.40Y3.06)
0.0002
8273 (91.3) 23 (89.2)
808 (8.7) 6 (10.8)
1.00 (ref ) 1.28 (0.43Y3.83)
0.66
1.00 (ref ) 1.74 (0.63Y4.80)
0.29
8251 (91.4) 45 (83.5)
803 (8.6) 11 (16.5)
1.00 (ref ) 2.09 (0.97Y4.52)
0.06
1.00 (ref ) 2.05 (0.93Y4.52)
0.08
8262 (91.3) 34 (89.9)
807 (8.7) 7 (10.1)
1.00 (ref ) 1.18 (0.45Y3.08)
0.74
1.00 (ref ) 1.29 (0.52Y3.19)
0.59
5125 (92.7) 3288 (89.0)
424 (7.3) 419 (11.0)
1.00 (ref ) 1.57 (1.32Y1.87)
G0.0001
1.00 (ref ) 1.45 (1.21Y1.74)
G0.0001
5285 (92.5) 2591 (88.9)
449 (7.5) 336 (11.1)
1.00 (ref ) 1.56 (1.30Y1.87)
G0.0001
1.00 (ref ) 1.40 (1.15Y1.69)
0.0006
2668 (89.1) 83 (79.6)
348 (10.9) 13 (20.4)
1.00 [ref] 2.10 (1.04Y4.22)
V 0.04
1.00 [ref] 2.44 (1.21Y4.91)
V 0.01
2691 (88.8) 60 (90.0)
355 (11.2) 6 (10.0)
1.00 [ref] 0.70 (0.21Y2.34)
V 0.57
1.00 [ref] 0.68 (0.21Y2.18)
V 0.51
2723 (88.9) 28 (74.8)
353 (11.1) 8 (25.6)
1.00 [ref] 2.73 (1.04Y7.16)
V 0.04
1.00 [ref] 3.67 (1.44Y9.33)
V 0.006
2576 (88.9) 175 (87.3)
333 (11.1) 28 (12.7)
1.00 [ref] 1.17 (0.66Y2.08)
V 0.59
1.00 [ref] 1.37 (0.75Y2.50)
V 0.30
2736 (89.0) 15 (61.6)
354 (11.0) 7 (38.4)
1.00 [ref] 4.25 (1.33Y13.52)
V 0.01
1.00 [ref] 4.56 (1.58Y13.14)
V 0.005
2736 (88.9) 15 (71.9)
356 (11.1) 5 (28.1)
1.00 [ref] 2.49 (0.55Y11.29)
V 0.24
1.00 [ref] 3.14 (0.81Y12.22)
V 0.10
8358 (91.2) 75 (78.6)
826 (8.8) 20 (21.4)
1.00 [ref] 2.85 (1.40Y5.78)
V 0.004
1.00 [ref] 2.94 (1.43Y6.00)
V 0.003
8371 (91.1) 63 (83.9)
834 (8.9) 13 (16.1)
1.00 [ref] 1.97 (0.95Y4.06)
V 0.07
1.00 [ref] 2.24 (1.10Y4.58)
V 0.026
8390 (91.1) 46 (80.9)
837 (8.9) 11 (19.1)
1.00 [ref] 2.42 (1.11Y5.32)
V 0.027
1.00 [ref] 2.53 (1.17Y5.51)
V 0.02
8406 (91.1) 31 (75.4)
837 (8.9) 10 (24.6)
1.00 [ref] 3.37 (1.52Y7.44)
V 0.003
1.00 [ref] 3.66 (1.62Y8.30)
V 0.002
8426 (91.0)
848 (9.0)
1.00 [ref]
V
1.00 [ref]
V
(Continued on next page)
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Silverberg et al ¡ Complementary Medicine and Eczema
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TABLE 4. (Continued) Eczema No Frequency (%)
OR (95% CI)
P
aOR (95% CI)
P
2 (6.7)
0.73 (0.15Y3.56)
0.70
0.87 (0.17Y4.42)
0.86
8438 (91.1) 6 (88.4)
847 (8.9) 1 (11.6)
1.00 [ref] 1.34 (0.15Y12.00)
V 0.79
1.00 [ref] 1.69 (0.17Y16.69)
V 0.65
8432 (90.9) 13 (81.3)
846 (9.1) 3 (18.8)
1.00 [ref] 1.39 (0.35Y5.46)
V 0.64
1.00 [ref] 1.63 (0.40Y6.67)
V 0.49
8439 (91.1) 6 (90.1)
848 (8.9) 1 (9.9)
1.00 [ref] 1.12 (0.13Y9.69)
V 0.92
1.00 [ref] 1.23 (0.13Y11.81)
V 0.86
196 (90.0) 8250 (91.1)
24 (10.0) 824 (8.9)
1.00 [ref] 1.31 (0.68Y1.88)
V 0.63
1.00 [ref] 1.11 (0.66Y1.88)
V 0.70
8428 (91.1) 17 (15.0)
844 (8.9) 4 (85.0)
1.00 [ref] 1.80 (0.57Y5.75)
V 0.31
1.00 [ref] 1.94 (0.58Y6.54)
V 0.29
8441 (91.1) 4 (68.9)
846 (8.9) 3 (31.1)
1.00 [ref] 4.60 (0.82Y25.71)
V 0.08
1.00 [ref] 5.93 (1.00Y35.17)
V 0.05
8371 (91.1) 74 (83.1)
834 (8.9) 14 (16.9)
1.00 [ref] 2.10 (1.06Y4.16)
V 0.03
1.00 [ref] 2.00 (0.99Y4.06)
V 0.05
8423 (91.1) 21 (94.8)
845 (8.9) 2 (5.2)
1.00 [ref] 0.56 (0.12Y2.56)
V 0.46
1.00 [ref] 0.52 (0.11Y2.44)
V 0.41
8356 (91.0) 86 (92.1)
843 (9.0) 5 (7.9)
1.00 (ref ) 0.87 (0.32Y2.38)
0.78
1.00 (ref ) 0.85 (0.31Y2.33)
0.76
Frequency (%)
Type of CAM Yes Ayurveda No Yes Biofeedback No Yes Chelation No Yes Chiropractic or osteopathic No Yes Energy healing No Yes Hypnosis No Yes Massage therapy No Yes Naturopathy No Yes Traditional healer No Yes
Yes*
20 (93.3)
Note: Any CAM used for the treatment of eczema was excluded from these models. *Multivariate logistic regression models were constructed with eczema (yes/no) modeled as the dependent variables and specific types of CAM as independent variables. Odds ratio and 95% CI for eczema were determined. Adjusted ORs were determined from multivariate models by including sex, current age (continuous), race (African American/black, white, Asian, multiracial/other), Hispanic origin (yes/no), birthplace in the United States (yes/no), household income ($0-$49,000; Q$50,000), highest level of education in the household (lower than high school, high school graduate or equivalent, higher than high school graduate), and health care interaction in the past year (yes/no).
Tan et al28). However, there are minimal data to support the safety and efficacy of naturopathy in AD. Furthermore, recent systematic reviews found insufficient evidence in support of and demonstrated higher costs for homeopathy for eczema.29,30 Vitamin D supplementation in lactating mothers was found to have no benefit,31 and there was actually an increased risk for AD in children during the first year of life.32 In contrast, Sidbury et al33 demonstrated improvements in AD with oral vitamin D supplementation in a Boston pediatric population. Finally, a recent Cochrane review of randomized controlled trials of vitamins and other dietary supplements found no convincing evidence to support clinical or populationbased recommendations for any vitamin supplementation.34 The strengths of this study include being a large-scale, US population-based survey of children with minimal selection bias and controlling for confounding demographic variables in multivariate models. However, the study has some limitations. Eczema was assessed by parental report. However, the NHIS
question asked about eczema diagnosed by a ‘‘doctor or other health care provider,’’ which is more specific and accurate than selfdiagnosis. Furthermore, previous studies used and validated single questions utilizing parental recall of physician-diagnosed eczema, and this approach is routine for epidemiologic studies of children.35,36 The NHIS question for eczema is rather broad and might overestimate the prevalence of eczema per se by inclusion of other entities such as allergic contact dermatitis, although such entities are relatively uncommon compared with eczema in pediatric age groups. Thus, the results of the survey with this question are likely meaningful and accurate. Finally, despite the large sample size, the frequencies of some CAM usage were small or zero, which limits the ability to generate accurate prevalence estimates for those modalities. However, even these low frequencies provide valuable information about the low usage of particular modalities of CAM. Even larger studies would be needed to further explore the nuances related to those less frequently used modalities.
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In conclusion, the present study determined rates of CAM use in US children with eczema. Furthermore, herbal therapy, multivitamins, calcium, vitamin B complex and/or vitamin D supplementation, homeopathic therapy, movement techniques, and vegan diet were all associated with higher prevalence of eczema in US children. The results of this study suggest that use of CAM should be screened for during the evaluation of children with eczema. Future research is needed to confirm these findings and to determine the time course and mechanism for such associations.
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