Integrative, Integrated Medicine But No Integration: Tarnishing Steroid and Chinese Medicine is Vanity
On June 21, 2017, the Department of Health (DH) of the Hong Kong Government urged clients who consulted a registered Chinese medicine practitioner (CMP) not to use creams prescribed by that CMP as the creams were suspected to contain undeclared Western medicine (WM) ingredients.1 The investigation followed complaints of skin hypopigmentation of two 6-month-old male infants whose parents had applied on their infants unlabeled bottles of brownish grey cream prescribed by the CMP for the treatment of eczema. Part 1 poisons clobetasol propionate and miconazole were detected in the cream. The DH's officers conducted investigations in the premises concerned for the possible source of the ingredients. Compared with adults, children are at higher risk of both local and systemic effects.2,3 According to the Pharmacy and Poisons Ordinance (Cap 138), illegal sale or possession of Part I poisons are criminal offences. The maximum penalty for each offence is a fine of HK$100,000 and two years' imprisonment. The DH has set up a hotline and has referred the case to the Chinese Medicine Council of Hong Kong for possible disciplinary actions. The CMP responded to reporters that the cream would not have been prescribed if he knew that it contained corticosteroid (CS), indirect implying that CS is an evil product and he was also a victim. Within the same period, another CMP in the same district was reported to prescribe CS to young children with eczema. A mini-outbreak of CS phobia occurred involving over two hundred anxious parents phoning DH for consultation. The DH issued letters to all CMPs and Chinese medicine associations to alert them to these recent cases. They were again reminded that CMPs must not prescribe Chinese medicines (CM) which contain WM to their patients as such act violates the laws and endangers public safety and health.4
The incidents reflect the ongoing dilemma of non-integration of medical disciplines.
From time to time, the local media report cases of illegal prescription of CS to children with eczema by CMPs, some of them were depicted figuratively as "divine doctor for childbirth", "holy hand for eczema" and "father of naturopathy" etc.2 Physicians should be aware that unregistered CM can contain potent drugs such as CS.
Like asthma and allergic rhinitis, childhood eczema is a common atopic disease which is associated with chronicity and impaired quality of life of the patients and their families.2,5 Management includes patient education, avoidance of triggers, optimal skin care through the regular use of emollient, appropriate use of topical CS, antihistamines, and even immunotherapy.5 Nevertheless, fears and non-adherence on various therapeutic aspects of WM prevail and management of this disease remains suboptimal.6 CS is the cornerstone of treatment during disease flare.5 Steroid phobia, however, has overwhelmingly counter-benefited the therapeutic efficacy of CS.7,8 In Hong Kong, many parents would seek alternative and folklore treatment of unproven efficacy, possibly because of their dissatisfaction with current WM treatment.2,6 Paradoxically, some of these alternative treatments may knowingly or unknowingly contain potent CS, and definitely unknowingly used by steroid-phobic parents.6,9 Many steroid-phobic parents are very skeptical about WM.2-4 In parallel to this skeptism and non-trust, many citizens idolize complementary and alternative medicine (CAM) and believe that traditional Chinese medicine (TCM) and herbs are without much side effects.2,5 Many parents would purchase proprietary topical and oral preparations without knowing what they are, and use them liberally and indiscriminately on their children.2,5,7,8 Pressed by public's quest for efficacious and safe treatment and lucrative profits, CAM practitioners may risk prescribing CS and "WM" in the name of TCM. Hence, despite the prevalence of "steroid phobia" which may lead to the suboptimal use of prescribed topical CS, parents might unknowingly use over-the-counter potent CS and TCM which contains CS.2,9
Eminent CMPs are especially tempted to prescribe CS to preserve their reputation that CM is efficacious as panacea treatment of any disease. It is difficult to convince anxious steroid-phobic parents to be vigilant in the use of often adulterated proprietary CM. Nevertheless, government and the media play important roles not to disgrace CM and tarnish CS usage. Scientifically, CM is an important branch of medicine, and topical or systemic CS is a very important class of immunomodulating and anti-inflammatory medication.10 The authors believe that in Hong Kong, both CM and CS have complementary roles in disease management and that the important and fashionable concept of integrative medicine (IM) is worth promoting. Tarnishing CS or CM usage certainly does not help with the already evil image of CS among steroid phobic parents. As a matter of fact, combining treatment with WM and CM has benefits in the treatment of atopic dermatitis because such treatment may prevent the adverse reactions induced by WM, while improving the efficacy of WM.11 WM and CM practitioners and the media should therefore work together to promote correct public health education on this important class of medicine. Western medicine practitioners should be more knowledgeable about CM and vice versa for CMPs. Both Western medicine practitioners and CMPs should pay attention to the interactions between WMs and CMs because CMs can affect the pharmacokinetic properties of WMs. Our common enemy is the naive belief by the naive parents that exclusive CM is the ultimate and safe solution for eczema. Money is not evil but the love of money is the root of all evil. In this regard, CS is definitely not an evil.2
Notorious Examples of Non-integration
Attention of Hong Kong physicians was aroused when news broke out on December 17, 2015 that a 23-year-old man with eczema jumped off his apartment window and found dead whilst his mother was preparing herbal medicine decoction for him in the sitting room.12 There is no lack of dermatologists, allergists, internists, family medicine practitioners, CAM practitioners, and CMPs in Hong Kong for this common childhood condition. It is unacceptable that the patient should suffer and die of this miserable condition where treatment is readily available.
In Australia, an infant with eczema was denied WM and the parents exclusively used CAM.13 The homeopathy couple was jailed over their daughter's death. The daughter died of malnutrition and sepsis after the parents chose to use homeopathic remedies rather than conventional medicine to treat their daughter's severe skin disorder. Similarly, a tragic case was reported of an infant with eczema who died of group B streptococcus septicemia and malnutrition despite expensive dietary supplements.14 These tragic cases of "status eczematicus", defined arbitrarily as eczema exacerbation that does not respond adequately to ordinary therapeutic measures and usually requires hospitalisation, serve to remind us the grave consequences of inappropriately managed cases of eczema.
If either CM or WM is not "efficacious" in certain diseases, notably chronic and terminal illnesses, the ideal treatment will be integrative or combined CM and WM. In principle, integrative medicine will minimise side effects and maximise efficacy.15-17 CM and WM disciplines share a lot of similarities. Indeed, perhaps disagreed by some practitioners, the two branches of medicine are very similar in that both have long history of tradition, and both therapeutic processes involve detailed history taking and physical examination to arrive at a diagnosis and treatment discussed with patients based on the diagnosis. However, there is often no detail on clinical pharmacology on CM. IM may offer some benefits but well-designed scientific studies are lacking.18-21 Despite its advocacy, genuine IM is seldom practiced in the city of Hong Kong. CM and WM often go in parallel or exclusive rather than integrative. Local Hospital Authority and the two medical schools in Hong Kong have established certificate and diploma courses of CM for medical practitioners and allied health. This is a way in bridging the knowledge for WMPs. CMPs claim to treat pre-disease (i.e. preventive medicine) primarily. Contrary to common fallacies, CM can be potent and efficacious, but may not cure many diseases. In modern CM training, practitioners are more receptive to WM. Non-herbal medicines are commonly used too, such as insect exo-skeleton, animal body parts, minerals, and a rsenic.
The authors consider eczema a mental or psycho-social disease, rendering WM, CM, TCM, traditional Chinese herbal medicine, food avoidance, food supplementation, acupuncture and any CAM alone sub-optimal in efficacy. We need to be unified and join hands to create a holistic psycho-educational approach for this disease. The only chance for a successful management of complex psychosocial disease is to complement the strength and weakness of the two medical disciplines to make this truly integrative. The real problem often lies within the patient. Parents/patients generally do not want combined or IM. Many of them believe that CM has to be used alone. Even with an integrative approach, many parents/patients would demand to remove the WM component and request pure herbal ingredients (pure Han formula, purely herbal). Hence, our common "enemies" are the myths ("mind devils"), fallacies, fake or pseudo-CM, and the parent(s).
1. http://www.info.gov.hk/gia/general/201706/21/P2017062101004.htm (accessed May 9, 2017).
2. Hon KL, Lee VW, Leung TF. Stop tarnishing steroid and Chinese medicine. World J Pediatr 2016;12:133-4.
3. Franke V, Scholtens WF, von Rosenstiel IA, Walenkamp MJ. Exogenous Cushing's syndrome due to a Chinese herbalist's prescription of ointment containing dexamethasone. BMJ Case Rep 2017;2017. pii: bcr-2016-218721.
4. https://www.consumer.org.hk/ws_en/consumer_alerts/recalls_and_alerts/20170627.htm (accessed May 9, 2017).
5. Leung AK, Hon KL, Robson WL. Atopic dermatitis. Adv Pediatr 2007;54:241-73.
6. Hon KL, Leung TF, Yau HC, Chan T. Paradoxical use of oral and topical steroids in steroid-phobic patients resorting to traditional Chinese medicines. World J Pediatr 2012;8:263-7.
7. Aubert-Wastiaux H, Moret L, Le Rhun A, et al. Topical corticosteroid phobia in atopic dermatitis: a study of its nature, origins and frequency. Brit J Dermatol 2011;165:808-14.
8. Hon KL, Tsang YC, Pong NH, et al. Correlations among steroid fear, acceptability, usage frequency, quality of life and disease severity in childhood eczema. J Dermatolog Treat 2015;26:418-25.
9. Hon KL, Burd A. 999 abuse: do mothers know what they are using? J Dermatolog Treat 2008;19:241-5.
10. Hon KL, Chan BC, Leung PC. Chinese herbal medicine research in eczema treatment. Chin Med 2011;6:17.
11. Kim JH, Kim H. Combination treatment with herbal medicines and Western medicines in atopic dermatitis: Benefits and considerations. Chin J Integr Med 2016;22:323-7.
12. http://hongkong.coconuts.co/2015/12/22/long-term-eczema-sufferer-plunges-death-hong-kong-after-condition-worsens; http://orientaldaily.on.cc/cnt/news/20151218/00176_051.html; http://www.ejinsight.com/20151218-long-term-eczema-sufferer-ends-it-all/ (accessed May 9, 2017).
13. https://www.theguardian.com/world/2009/sep/28/homeopathy-baby-death-couple-jailed; http://www.smh.com.au/national/parents-guilty-of-manslaughter-over-daughters-eczema-death-20090605-bxvx.html (accessed May 9, 2017).
14. Hon KL, Ying NS, Cheung KL. A tragic case of atopic eczema: malnutrition and infections despite multivitamins and supplements. Iran J Allergy Asthma Immunol 2012;11:267-70.
15. Chung VC, Ma PH, Hong LC, Griffiths SM. Organizational determinants of interprofessional collaboration in integrative health care: systematic review of qualitative studies. PLoS One 2012;7:e50022.
16. Robinson N. Integrated traditional Chinese medicine. Complement Ther Clin Pract 2006;12:132-40.
17. Zhao L, Chan K. Patient-reported outcomes (PROs): an approach to evaluate treatment efficacy of Chinese medicine or integrative medicine. Chin J Integr Med 2005;11:151-3.
18. Bukutu C, Deol J, Shamseer L, Vohra S; American Academy of Pediatrics Provisional Section on Complementary, Holistic, and Integrative Medicine. Complementary, holistic, and integrative medicine: atopic dermatitis. Pediatr Rev 2007;28:e87-e94.
19. DiNicola C, Kekevian A, Chang C. Integrative medicine as adjunct therapy in the treatment of atopic dermatitis-the role of traditional Chinese medicine, dietary supplements, and other modalities. Clin Rev Allergy Immunol 2013;44:242-53.
20. Boneberger S, Rupec RA, Ruzicka T. Complementary therapy for atopic dermatitis and other allergic skin diseases: facts and controversies. Clin Dermatol 2010;28:57-61.
21. Hon KL, Leung AKC, Leung TNH, Lee VWY. Complementary, Alternative and Integrative Medicine for Childhood Atopic Dermatitis. Recent Pat Inflamm Allergy Drug Discov 2017;11:114-24.
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