British Journal of Medicine & Medical Research 4(9): , SCIENCEDOMAIN international

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1 British Journal of Medicine & Medical Research 4(9): , 2014 SCIENCEDOMAIN international Use of Complementary and Alternative Medicine and Assessment of Dermatology Quality of Life Index among Dermatology Outpatients: A Cross-sectional Comparative Study Gulsen Tukenmez Demirci 1* and Ilknur Kivanc Altunay 2 1 Baskent University İstanbul Hospital, Dermatology Clinic, Turkey. 2 Sisli Etfal Training and Research Hospital, Dermatology Department.Turkey. Authors contributions Authors IKA and GTD designed the study, performed the statistical analyses, wrote the protocol, and wrote the first draft of the manuscript. Author GTD managed the analyses and the literature searches. Both authors read and approved the final manuscript. Original Research Article Received 16 th September 2013 Accepted 11 th December 2013 Published 9 th January 2014 ABSTRACT Aims: The aims of this study were to examine the frequency of complementary and alternative medicine (CAM) use among dermatology outpatients, and compare the socio demographic factors and dermatology life quality index (DLQI) values between CAM users and non-users. The CAM approaches and knowledge of the patients were also evaluated. Study Design: A descriptive cross-sectional study design was used. Place and Duration of Study: This study was conducted at the Sisli Etfal Training and Research Hospital Dermatology outpatient clinic, between January of 2011 and May of Method: A total of 522 consecutive patients were included in this study. The patients were older than 18 years old, and answered an interviewer-administered questionnaire about CAM use. The demographics, dermatological condition, CAM treatment, time of usage, benefits and side effects, and the patients answers from the questions about CAM were recorded. The quality of life was evaluated using the Turkish version of the *Corresponding author: gulsentukenmez@yahoo.com;

2 DLQI questionnaire. Results: The prevalence of CAM use was 16.8%, and the mean age of CAM users (28.2±14.3) was statistically lower than that of non-cam users (36.0±16.9): 50% of the CAM users did not know the definition of CAM; 56.8% learned the CAM treatment model from a friend, neighbour or relative; 61.3% used CAM because of dissatisfaction with conventional medicine; 10% of the CAM users explained that they had benefits; and 18.2% claimed that they had side effects. There was a statistically significant difference between the mean DLQI scores of the CAM users (13.2±5.2) and non-users ( 11.5±4.2) (p=.05). Conclusion: This study determined that the usage of CAM was common; however, the knowledge of CAM was poor in our patients. The most commonly used CAM treatment was herbal therapy, and the major factors for choosing CAM were the disease duration and dissatisfaction with western conventional medicine. The measurement of the DLQI of the patients showed that CAM users were the patients most greatly affected by their skin conditions. Keywords: Herbal therapies; skin diseases; unconventional medicine; alternative therapies. 1. INTRODUCTION The term complementary and alternative medicine (CAM) is defined by the World Health Organization as a broad set of health care practices that are not part of the country s own tradition and are not integrated into the dominant healthcare system [1]. There are five major types of CAM: alternative medical systems (e.g., homeopathy or traditional Ch inese medicine), mind-body medicine (e.g., meditation, prayer, and creative activities such as dance, art and music), biologically-based therapies (e.g., herbal medicines and dietary supplements), manipulative and body based methods (e.g., chiropractic med icine and massage), and energy therapies (e.g., qi gong, Reiki and healing touch) [2]. CAM is more popular than ever before all over the world, and according to surveys from several different countries, the lifetime prevalence of CAM use by dermatological patients ranges from 35% to 69% [3]. Although most people intend to use CAM because they are afraid of the side effects of conventional medicine, many serious side effects of CAM have also been reported in the literature [4]. Thus, investigations into CAM are needed to elucidate the unknown aspects as well as the benefits of these treatments. There have have been studies conducted on CAM use among dermatology patients in different geographical areas, such as in the US, Europe and Asia. In fact, social and cultural factors, even in geographically similar regions, are suggested to affect the type of CAM being used. Turkey, as a bridge between Western and Eastern countries, presents a mixture of these these types of CAM treatments and Western medicine. In this study, we aimed to determine the prevalence of CAM use in a given population, compare socio-demographic features, dermatology quality of life index (DLQI) measures of CAM users and non-users, patient knowledge of CAM, CAM benefits and side effects, and the proportion of dermatological conditions in CAM users. 1813

3 2. MATERIALS AND METHODS A cross-sectional survey was conducted including 522 consecutive patients attending the dermatology outpatient clinic at Sisli Etfal Training and Research Hospital in Istanbul city between February of 2011 and May of Patients of any age and any dermatological condition were included. Informed verbal consent was documented in the medical record, and the questionnaire given via a face to face structured interview with the patient. In agreement with the definition of the American National Centre for CAM (NCCAM) and the National Institutes of Health, CAM was defined as health care systems, practices and products not currently considered to be part of conventional medicine. After a detailed dermatological examination, the diagnosis was made clinically in most of the patients, and laboratory investigations and histopathological examinations were done if necessary. The first part of the questionnaire was designed to obtain demographic information on gender, age, educational level, household income and marital status. The second part of the questionnaire was about the patient s dermatological condition, duration of the condition and whether any family member had the same dermatological condition. The third part included questions about life style and health, including regular exercise, smoking, alcohol consumption, participation in social or religious groups, and other health problems. The fourth part of the questionnaire included questions about the specific type of CAM treatment, as well as the patient s definition of CAM, source of CAM information, duration of CAM use, benefits or side effects of CAM, whether they had discussed CAM use with their physicians, and whether they had side effects or benefits from CAM treatment. The Turkish version of the DLQI questionnaire, which was validated by Ozturkcan et al. was used in this study for CAM users over 18 years old [5]. It is a questionnaire containing 10 questions and 6 domains regarding the previous 7 days. The six domains include the symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment. The interpretation of the DLQI scores was as follows: 0-1 = no effect at all, 2-5 = small effect, 6-10 = moderate effect, = very large effect, and = extremely large effect. Our patients were asked to reply to this questionnaire without the assistance of others. The results were expressed as simple percentages plus a qualitative description of the comments where appropriate. The groups were compared using a simple chi square test and Fisher s exact test for inconvenient conditions. Significance was set at p =.05, and Mann-Whitney U tests were used for the non-parametric data. The distribution of the data was calculated by the Kolmogorov-Smirnov tests, and the results were analysed using SPSS v19.0 (Statistical Package for the Social Sciences; SPSS Inc., Chicago, IL, USA). 3. RESULTS AND DISCUSSION 3.1 Demographics A total of 522 patients participated in the study, and the response rate to the questionnaire was 100%. The mean age of the subjects was 34.8±16.7 (range 4-85), and 64 of the subjects (12.6%) were under the age of 18. There were 302 female and 220 male patients, 51.5% had finished primary school, and 42.2% had a monthly income of Turkish liras (approximately US dollars). 1814

4 Overall, 16.8% of all the subjects had used at least one CAM to treat their dermatological conditions. Table 1 presents the demographic distribution of the CAM users and non-users over 18 years old. The mean age of the CAM users (32.6±13.9) was statistically lower than that of the non-cam users (38.4±16.2). The duration of disease was statistically longer in the CAM users (5.0±5.9) tha n non-cam users (2.9±5.4), and 69.6% of the CAM users were female. There were no statistically significant differences regarding educational level, household income, marital status, regular exercise, smoking, alcohol use, family members with the same disease, being a social or religious club member, or accompanying systemic disease between the two groups. Table 1. Comparison of characteristic features of complementary and alternative medicine users and non-users over 18 years old. Characteristics Non-users Users P n % n % Education Primary school % % High school % % University and beyond % % Income* No regular income % 3 4.3% <1000 TL % % TL % % >2500 TL % 6 8.7% Marital status Married % % single % % divorced % 3 4.3% Regular No % % exercise Yes % % Smoking No % % yes % % Drinking alcohol no % % yes % % Social or relıgious club member Family member with the same disease no % % yes % % no % % yes % % Co-morbidity no % % yes % % p values were calculated by chi-square tests. Significance set at p=.05 *Turkish Liras 3.2 Complementary Therapy There were 88 CAM users in the study, and 19 (21.6%) were betw een 0-17 years old, 38 (43.2%) were between years old, 21(23.1%) were between years old, and 10 (11.4%) were 50 years old or over. The types of CAM used by the subjects are presented in Table 2, which shows that herbal medicine was the most commonly used CAM (52.3%), followed by religious methods (12.5%), and aromatherapy (10.2%). 1815

5 Table 2. Percentages of complementary and alternative medicinal treatments used by the subjects. Some of the subjects used more than one type of treatment Treatment types Users % Herbal therapies (oral/topical) % Others % Religion % Aromatherapy % Megavitamin 2 2.3% Balneotherapy 2 2.3% Hirudotherapy 1 1.1% Colon therapy 1 1.1% Reflexology 1 1.1% Chiropractic 1 1.1% Chinese medicine 1 1.1% Immunotherapy 1 1.1% Of the CAM users, 31.8%, 15.9%, 13.6% and 11.4% were diagnosed with acne vulgaris, verruca vulgaris, psoriasis vulgaris and alopecia areata, respectively. The mean duration of CAM use was 27.9±69.4 days; however, 50% of the subjects answered that they did not know the definition of CAM, and 56.8% learned the CAM treatment model from a friend, neighbour or relative. Of these patients, 61.3% used CAM because they were dissatisfied with Western conventional medicine, 36.33% used CAM because they thought it was harmless, 62.5% used CAM because they wanted to try it, and 77.2% used CAM because they could not find time to go to a dermatologist. Of the subjects in this study, 10% of the CAM users explained that they had benefits from the treatments, 18.2% claimed that they had side effects, 55.7% of the subjects told their Western medicine physicians that they had used CAM, 4.5% found that CAM was safer than Western conventional medicine, 21.6% would recommend CAM to others, 40.9% thought CAM could be used with conventional Western medicine at the same time, and 53.4% of the subjects wished that their dermatologists would provide CAM alternatives. The DLQI questionnaire was given to 69 CAM users and 389 non-cam users, who were older than 18 years of age. The mean score for the DLQI in CAM users was 13.2±5.2, and 11.5±4.2 in non-cam users. There was a statistically significant difference between the mean DLQI scores of the CAM users and non-users (Table 3), and the patients with scores of 20 and higher were found to have used CAM more frequently than the others (p=0.009, 95% confidence interval) (Table 4). Table 3. The statistically significant differences among gender, age, disease duration and mean scores of the dermatology life quality index between complementary medicine users and non-users Complementary and alternative medicine Non-users Users Gender Female (n %) % % Male (n %) % % Age 38.4 ± ± Disease duration (years) 2.9 ± ± Dermatology Life Quality Index Score means 11.5 ± ± Chi square / Mann-Whitney U test 95% confidence interval 1816

6 Table 4. The complementary and alternative medicine users with statistically significant scores higher than 20 Quality of life index scores Complementary and alternative medicine P Non-users Users n % n % % 0 0.0% scores % 2 2.9% % % % % scores % % 4. DISCUSSION The lifetime prevalence of CAM use by dermatological patients is variable, changing from 35% to 69% according to different national surveys [4]. Consistent with the previous study of Kutlu et al. on Turkish dermatology patients, the proportion of CAM use was 12.8%, which was lower than that described in other countries [6]. We found that 16.8% of our study population used CAM, and in Turkey, there are variable reports which show a high rate of CAM use, especially in the eastern regions [7]: (70%) in children with variable immunodeficiency in some patients [8], (71.5%) in groups such as cancer patients [9], (83.7%) in patients with gastroenterological disorders [10], and (36.6%) in asthma patient s [11]. Although patients with skin disorders have been suggested to prefer CAM, we found that the frequency of CAM use in dermatological patients was lower than in the other patient groups of Turkey, and in Western and Eastern countries. We believe that this is because the patients in our city can reach out to a dermatologist more easily since the number of government and private hospitals and dermatological offices is larger than in other cities. The fact that the patients did not disclose their use of CAM to their doctors may be another reason. The mean age of CAM users was lower than that of non-users, and almost half of the CAM users were between 18 and 29 years old in our study. This result was similar to Chen s study on Taiwanese dermatology outpatients [12]. Eisenberg et al. reported that people aged years had a higher rate of CAM use than either younger or older people [13]. The disease duration was found to be significantly longer in CAM users. Studies on chronic skin disorders such as psoriasis and atopic dermatitis show that the prevalence of CAM use is high [14]. Patients are demanding different treatment options because they have become tired as well as bored of the same prescriptions from conventional medicine physicians. Some of the patients with longer disease durations explained that they used CAM because they had some side effects from the conventional treatments. Ernst has reported that the most commonly used CAM treatment modalities of dermatology patients comprise homeopathy, herbalism and dietary supplements, in his systematic review [3]. In the study by Nicolaou from the U.K., the most frequently used CAM treatments of contact dermatitis patients were herbal therapy, Chinese herbal therapy, and Indian medicine and aromatherapy [15]. Hon et al. from Hong Kong reported that herbal tea and soap were most often used by children with atopic dermatitis [16], and Hughes et al., from Ireland, reported that herbal therapy and homeopathy were the most common treatment modalities of CAM in children with atopic dermatitis [14]. Kutlu et al. found that herbal 1817

7 therapy, religious therapy and balneotherapy were the most frequent modalities in Turkish dermatology patients [6], and we found that herbal therapy was the most frequent CAM treatment in our patients, followed by religious methods and aromatherapy. We also determined that some kinds of CAM treatments were not used in Turkish patients, such as neural therapy, homeopathy, reflexology, acupuncture, massage and yoga. Praying for the treatment of verrucas was found to be a common and well-known CAM treatment in our patients, which seems to be a well-known treatment model for Turkish people, because we did not find a similar treatment model for verrucas in other countries in our internet search. Religious and spiritual practices were found to be used mostly on cancer patients, in some studies [17]. In our study, 18.2% of the CAM users revealed that they had side effects. The most common side effects were irritants and allergic contact dermatitis due to herbal therapies and aromatherapy; although most people think that herbal therapies are more natural or more safe, they may cause serious and sometimes life-threatening side effects. Lord et al. reported two cases which developed nephropathy and subsequent end-stage renal failure after taking herbal therapies to treat eczema [18]. Side effects have also been reported with aromatherapy oils, including contact dermatitis, similar to those found in our patients [19,20]. Organ toxicity has been observed to be associated with various herbal preparations involving the liver, kidneys and the heart, and some herbs may have carcinogenic properties. The potential sensitizing capacity of numerous herbal remedies may lead to allergic contact dermatitis and, more rarely, to IgE-mediated clinical symptoms [21]. The side effects of CAM are not limited to herbal remedies, and side effects have been reported with mechanical injuries following acupuncture, severe malnutrition after strict diets, and interactions with drugs [21]. Quality of life is a broad concept and is concerned with whether the disease or impairment limits the person's ability to fulfil a normal role, and it can be used to assess the burden of illness and the outcomes of medical treatments [22]. After the establishment of socio demographic characteristics and some features related to CAM use, we aimed to determine if any relationship existed between DLQI and CAM use. See et al. found that DLQI scores were higher in their CAM using dermatology outpatients [23]. The mean score of the DLQI of CAM users in our study was found to be 13.2 and in non-cam users it was found to be 11.5, which means that these patients were largely affected by their skin conditions. Patients who were extremely affected, with scores higher than 20, were statistically shown to use CAM more frequently. 5. CONCLUSION The prevalence of CAM use among dermatology outpatients was not found to be high, and the knowledge of CAM was poor. We found that female patients, younger patients and patients with longer disease duration preferred CAM. The measurement of the DLQI of the patients showed that CAM users are the patients who are most largely affected by their skin conditions. CONSENT All authors declare that written informed consent was obtained from the patient (or other approved parties) for publication of this case report, and accompanying images. 1818

8 ETHICAL APPROVAL The authors have obtained ethical approval from the National Committee. COMPETING INTERESTS The authors declare that they have no competing interests. REFERENCES 1. World Health Organization. Guidelines on developing consumer information on proper use of traditional, complementary and alternative medicine. (WHO) Geneva. 2004; Straus SE, Chesney MA. Science and government. Enhanced: in defence of NCCAM. Science. 2006;313: Ernst E. The usage of complementary therapies by dermatological patients: a systematic review. Br J Dermatol. 2000;142: Ernst E, Pittler MH, Stevinson C. Complementary/alternative medicine in Dermatology: Evidence-assessed efficacy of two diseases and two treatments. Am J Clin Dermatol. 2002;3(5): Oztürkcan S, Ermertcan AT, Eser E, Sahin MT. Cross validation of the Turkish version of dermatology life quality index. Int J Dermatol. 2006;45(11): Kutlu S, Ekmekçi TR, Köşlü A, Purisa S. Complementary and alternative medicine among patients attending to dermatology outpatient clinic. Turkiye Klinikleri J Med Sci. 2009;29(6). 7. Gönül M, Gül U, Cakmak SK, Kiliç S. Unconventional medicine in dermatology outpatients in Turkey. Int J Dermatol. 2009;48: Tan M, Uzun O, Akçay F. Trends in complementary and alternative medicine in eastern Turkey. J Altern Complement Med. 2004;10: Can G, Erol O, Aydiner A, Topuz E. Quality of life and complementary and alternative medicine use among cancer patients in Turkey. Eur J Oncol Nurs. 2009;13: Kav T. Use of complementary and alternative medicine: a survey in Turkish gastroenterology patients. BMC Complement Altern Med. 2009;9: Tokem Y, Aytemur ZA, Yıldırım Y, Fadiloglu C. Investigation into the use of complementary and alternative medicine and affecting factors in Turkish asthmatic patients. J Clin Nurs Mar;21(5-6): Chen YF, Chang JS. Complementary and alternative medicine use among patients attending a hospital dermatology clinic in Taiwan. Int J Dermatol. 2003;42: Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, : results a follow up national survey. J Am Med Assoc. 1998;280: Hughes R, Ward A, Tobin M, Keegan K, Kirby B, et al. The use of alternative medicine in paediatric patients with atopic dermatitis. Pediatr Dermatol. 2007;24: Nicolaou N, Johnston GA. The use of complementary medicine by patients referred to a contact dermatitis clinic. Contact dermatitis 2004;51: Hon KL, Ma KC, Wong Y, Leung TF, Fok TF. A survey of traditional Chinese medicine use in children with atopic dermatitis attending a paediatric dermatology clinic. J Dermatol Treat 2005;16(3): Ambs AH, Miller MF, Smith AW, et al. Religious and spiritual practices and identification among individuals living with cancer and other chronic disease. J SocIntegrOncol Spring;5(2):

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