The use of complementary treatment has increased dramatically in the past ten years. There are several reasons for this increase. One reason is probably patients increasing knowledge about diseases and their wish to take active part in their disease management. To day we must accept that a certain number of patients don’t want to take prescribed medication. Quotation like; I prefer to try complementary treatment first because there are no side effects combined with this sort of treatment, are quite common, despite there actually can be even serious side effects associated with complementary treatment. An other reason for the increase of complementary medicine is probably absolutely uncritical article from "Ladies magazine" where one often will see heading like; My psoriasis disappeared after five treatment with Mr NN. Finally we must accept that a certain group of patients have lost confidence in orthodox medicine and want to explore other avenues. Patients suffering from psoriasis are not an exception from this. Often patients have tried all possible treatment offered by orthodox medicine without any success. It is not surprising that patients in desperation seek complementary treatment. Some has been cured and more has been disappointed.

Unfortunately, it is very rare that patients seek complementary treatment because of its demonstrated efficacy.

The reason is obvious - we don’t have any quality research in this field. If would be wonderful as a doctor if you could advise your patient on this subject and e.g. say; If you take this herbal medication three times a day for three months, you would be cured. Likewise, it would be wonderful if we could tell our patients that the use of this herbal medication has been proper investigated and it has been shown that it is ineffective.

Unfortunately, we are unable to give such advise.

One might ask; why are there no research in this field? First we need to admit that there has been a strong reservation and scepticism among doctors, who often has regarded complementary medicine as a pure placebo treatment. This negative attitude and scepticism has been changed during the last few years and many doctors to day must accept that complementary medicine might have something to offer their patients.

The market is big and opaque and the problem is - where do we begin? Which area are worth investigating?

Even to a simple question like this we do not have the answer. There are many ways in which we can approach the problem, because it is obvious we need to investigate the potential of complementary treatment to enable us to give our patients a correct answer when they ask; Do you believe it would be worth trying this treatment?

Before we can initiate a research project which is both expensive and time consuming we need to have some knowledge and a belief in this treatment might be useful. It is among other things this knowledge we try to achieve with questionnaire.

In co-operation with the Psoriasis Association a questionnaire was mailed together with the Psoriasis Journal to 1000 random selected members in the beginning of 1998. The purpose of the questionnaire was to investigate the following questions:

• The use of complementary treatment among patients suffering from Psoriasis.
• Patients assessment of the achieved results
• Investigate which complementary treatment which was the most used
• On the basis of the recorded data recommend research in the field

It is not within the limit of a paper in this journal to discuss all questions and I will concentrate on the essential question; Does complimentary treatment work for patients suffering from psoriasis, and if yes, which treatment is the best?

Among the 1000 distributed questionnaire 186 (18.6%) was returned. Among the returned questionnaire 78

(42%) were men and 101 (54%) were women. In 7 (4%) no information was given regarding the sex.

The questionnaire were divided in four paragraphs. One which should give us information about heredity and additional symptoms like joint pains, psoriasis in the nails etc. The second part concerns previous treatment. The third part concerns the present treatment. The final part was regarding the use of complementary treatment and the results achieved after the treatment. The results were subsequent transferred to a database for further analysis.

The results are presented in table 1 to 8.

Table 3 do not need a lot of comments. It is known that psoriasis often appears among family members as well as the disease often is associated with additional symptoms like joint pain and psoriasis in the nails.

Joint problems are reported in 81 cases (44%). But because 35% of the patients belong to the age group over fifty years it is likely that a part of these joint pain are due to osteoarthritis and bear no relation to the psoriasis. 55% rapport they are suffering from psoriasis in the nails, which are rather surprising to me. 15%rapport’s intestinal symptoms. If these symptoms are related to the psoriasis is unclear and will need further investigation.

Table 4 confirm our knowledge about the standard treatment of psoriasis where steroid cream or Daivonex are first drugs to prescribe. If it is impossible to control the disease this way the next steps are usually either UVB or PUVA treatment. Only in severe cases Methotrexate or Cyclosporin are used.

Table 5 inform us about the present treatment and it appears that 37% need to use a steroid cream to keep the condition under control, which is not particular surprising.

Table 6 inform us about the number of patients who have tried complementary treatment. It is obvious that four treatments; acupuncture, aromatherapy, homeopathy and Chinese herbal medicine are the most frequent used treatments. Moreover it appears that a number of patients have sought several types of complementary treatment. On average the group of patients who have tried complementary treatment have had 1.1 different treatment. Never the less it is a rather small proportion of patients who have sought complementary treatment, in the region of 10%.

Table 7 inform us about the results among the patients who have tried complementary treatment, and the results of further analysis are shown in table 8. If we read table 7 and 8 without reservation it appear that there have been a success rate on 47%, which are unrealistic. A number of treatments like hypnotherapy, biomagnetic treatment, chiropractic and Kinesiology only include a small number of patients and a cure in this group will have a dramatic influence on the total outcome. In fact there are only four groups which include that many patients (25 or more) that some suggestions can be made.

Acupuncture and homeopathy shows a success rate between 36% and 40% which are very close to the expected placebo effect which are known to be in the region of 30%-35%. Aromatherapy shows a success rate on 64% which is unrealistic. There are no doubt that patients feel aromatherapy as a pleasant treatment and that the treatment could improve the patients general well being but I find it difficult to accept a success rate on 64%. Therapist who use this treatment will probably argue, that the herbal ointment used for the treatment are penetrating the skin and thus should have a curative effect. To the best of my knowledge a controlled study involving an active oil and an inactive oil has never been published and until I am presented for more hard evidence I can not accept this figures.

Chinese herbal medicine showed a success rate on 47%, which is slightly higher than the expected placebo effect and it might be possible that this treatment have something to offer. A number of years ago it was demonstrated under controlled procedures that Chinese herbs were able to cure a number of skin diseases.

Unfortunately, it was later shown that the treatment could produce serious side effects such as liver damage.

On basis of the data available it appears that complementary medicine in general is of little value in the treatment of psoriasis. These findings are in accordance with the limited literature on the subject. I will not deny that some patients have had benefit from complementary treatment. Neither will I deny, that a patient will not know if they belong to the responders or the non responders until the treatment has been tried. In general one must conclude that complementary treatment can be justified in treatment for a number of diseases where the technique has been proved effective. In psoriasis this is unfortunately not the case.

Palle Rosted, Consultant Acupuncturist Weston Park Hospital, Clinical Lecturer Sheffield University In this paragraph I would like first to thank all the psoriasis suffers who took the time to fill in the questionnaire. A substantial number of the questionnaire have attached letters or comments which I am very grateful to have received. In the following I will summarise all these questions and give some guideline for the use of complementary treatment.

The influence of stress is a general comment on the questionnaire, which is in accordance with my experience. It is obvious that itching and scaling must be of great irritation for the patient and when we add the amount of stress we all are suffering from it is a logic consequent that it will aggravate the condition.

The influence of the food is often mentioned and I have received a number of suggestions. Unfortunately, there are no constancy in the suggestions. It would be nice if we could inform our patients that it would be a god idea to avoid, e.g. tomato, but I am afraid, I am unable to make a conclusion from the received suggestions. My best advise is to use your common sense. If you have observed that, e.g. tomato aggravate you condition then avoid tomato. Otherwise, I doubt that diet in general is important in psoriasis.

The influence of infections is another frequent comment. This is in accordance with my experience. It is quite often that an aggravation of the disease will start just after an infection such as flue or a tonsillitis,

The influence of vitamins and minerals are mentioned of many patients. Our knowledge on this subject is very limited. Personally, I am convinced that vitamins and minerals might have some influence on psoriasis, in particular zinc and folic acid.

Some patients are against complementary treatment, which of course is their personal opinion.

Other patients are afraid of complementary treatment, and this is certainly not without reason. Serious side effects has been reported after complementary treatment. For example a patient could report of liver damage after homeopathy. The same side effects has been reported after Chinese herbal medicine. The basis for a lot of the medication we are using to day is due the old monks who described the herbal medicine 700-800 years ago. Many of the herbs they used are potential poisonous, but used in the correct dosage they might have a curative effect. The problem is in the right concentration of the active drug which is impossible to control without modern laboratory technology. In the case of Chinese herbs the amount are often measured on a simple scale and in fact one portion may have a content of the active drug ten times higher than recommended.

Some patients will only accept treatment which has been investigated under controlled procedures.

There are no doubt that this is the ideal situation.

Hocus-pocus is a description a number of patients used for complementary treatment and I agree. There are far to many unqualified therapist who promise that they will be able to cure what ever you are suffering from. It is easy to understand that patients suffering from a chronic disease in desperation are prepared to try everything. At the same time we must accept the this group of patients are an easy victim for swindler.

Never the less it is not all complementary treatment which are hocus-pocus. For example, acupuncture has in a number of randomised controlled studies proved effective for some diseases, in particular painful conditions. To day a lot of serious research on the effect of acupuncture are carried out on several universities. Actually, acupuncture is no longer considered a complementary treatment but is to day regarded as an extra tool in the doctors bag.

How can you avoid these swindlers? My best advise is to discuss your idea with your family doctor. Most doctors to day are rather open-minded and he or she might be able to suggest a therapist. Actually, quite a number of doctors do different forms of complementary treatment themselves. If you doctor is unable to advise you, you need to make some investigation yourself. The first thing to ask about is the therapist qualifications and if the therapist belongs to a professional body. Remember in England everybody can call themselves a doctor or even a professor. If the person call themselves a doctor then ask if the are registered with General Medical Council, you need to be a proper medical doctor to be included in this register. Some of the therapist will call themselves professor. Ask them at which university they have an appointment. Remember it is easy to get a professor title. The only thing you need is to go to the Far East and you can bye the title without sitting any examine.

In general you should know after five or six treatments if the technique are doing you any good. I did a study on the effect of acupuncture on various skin diseases a number of years ago. I was able to show that if you have not seen any reaction after six treatments it was very unlikely that the treatment was going to work. So if no improvement has occurred after six treatments, I will suggest that you should terminate the treatment. I have among the received questionnaire patients who have tried 50-100 treatments without effect. In my opinion it is unethical.

Of course it depends on which treatment you have chosen, but among other thins I was able to show that patients on average began to improve after two to three treatments.

Finally, if you despite of my pessimistic report want to try complementary treatment, and I don’t blame you for trying, please take your precautions. It might save you a lot of annoyance and money in the long run.