Doctors at the British Association of Dermatologists’ Annual Conference in Liverpool have issued a warning about the dangers of using unlabelled herbal treatments, after potent steroids were detected in samples of several such products.

Doctors are also urging people not to use herbal preparations for the treatment of skin cancer, following a series of cases in which this has occurred, leaving patients in need of reconstructive surgery.

Herbal remedies are particularly popular for treating skin conditions, with researchers estimating that approximately 33 per cent of all herbal treatments are used to target wounds or skin diseases, this compares with only one to three per cent of Western medicines.

Herbal products with few or no ingredients listed, and often claiming to be ‘miracle creams’, were obtained from 11 patients, and tested by Researchers from the Birmingham Skin Centre, based at City Hospital, using a liquid chromatography–mass spectrometry–(time of flight) analyser, a highly sensitive and specific technology used to detect drugs and other chemicals to a high degree of accuracy. Super-potent topical steroids such as clobetasol propionate were found in seven of the 11 samples, which were largely being used to treat chronic skin conditions, such as eczema or psoriasis particularly in children.

In the UK, all cosmetic products are subject to European Union safety regulations and must comply with detailed compositional and labelling requirements. The failure of the products tested to provide a detailed ingredients list is a breach of these regulations.

Dr Sue Ann Chan, one of the researchers from the Birmingham Skin Centre, which is run by Sandwell and West Birmingham Hospitals NHS Trust, said:

“It is very concerning that unregulated topical herbal remedies continue to be accessible to patients with chronic skin disorders. The people selling these products in the UK are doing so illegally, and are putting peoples’ health in jeopardy. A common reason why people resort to these products is fear of potential long-term side effects of prescribed Western medicines, however, they end up inadvertently using potent drugs that should be used under instruction from a doctor.”

Dr Donna Thompson, Consultant Dermatologist and Head of Department at the Birmingham Skin Centre, who was also one of the researchers, said:

“The results of our tests were quite shocking, a number of these so-called herbal ‘miracle creams’ in fact contained super-potent steroids, which could have significant adverse health implications for users, particularly if they are being used on a regular basis. People have the right to know what ingredients are present in the treatments they are using and public awareness should be raised regarding this matter. If you notice that a cream you are using does not list ingredients, then I would strongly urge you not to use it on yourself or on your children.”

Another study at the BAD Annual Conference involved four cases in which patients had been self-medicating with herbal remedies that they believed were capable of treating skin cancers. All patients delayed seeing a doctor and undergoing surgical intervention due to their faith in the efficacy of their herbal treatments, this delay resulted in larger surgical defects in all cases, according to the doctors from St James’ Hospital, Dublin.

One 51-year-old man with a basal cell carcinoma (BCC, the most common type of skin cancer) on his nose had been diagnosed a year before by a dermatologist but instead of surgical removal decided to apply an alternative treatment* on a daily basis for several months. This delay resulted in a large crater-like tumour, which required two stages of surgery to remove resulting in the complete loss of the tip of his nose and necessitating a reconstructive procedure called a paramedian forehead flap, where skin from the forehead above the eyebrow is used to replace missing tissue from the nose.

In other cases a 70-year-old man presented with a nonhealing lesion over the right cheek, which turned out to be a squamous cell carcinoma (SCC, the second most common type of skin cancer). He had been applying an alternative topical therapy (pawpaw ointment), which was sent to him by his daughter living in Australia. A 46-year-old woman was referred with a BCC on her nose, which she was treating with an alternative treatment and a supplement, convinced that these would result in a nonsurgical cure of the BCC. Finally, a 58-year-old woman who 10 years previously had had a BCC excised from the left temple presented with a recurrence of the cancer, the patient had been using topical zinc chloride paste over the site as a means of treatment.

Dr Rupert Barry, Consultant Dermatologist and Dermatological surgeon, one of the researchers from St. James’s Hospital, Dublin, said:

“We feel that it’s really important to highlight the increasing trend of patients who seek alternative topical therapies for skin cancers, even for high-risk facial tumours. Interestingly, all of these patients were utterly convinced by the online claims made by either the manufacturers or in forums of the efficacy of such therapies, despite a lack of clinical evidence to suggest this.”

Dr Michael Lavery, another researcher from St. James’s Hospital, Dublin, said:

“Surgical removal of skin cancer is a highly effective treatment; the earlier it is done the better. Scarring for small non-melanoma skin cancers can be relatively minor, but if left the cancer has time to grow and scarring can be significant in some cases. It is understandable that people are hesitant about surgery, and want a non-surgical option, but it’s important that people understand that it really is the best option.”

Matthew Gass of the British Association of Dermatologists said:

“We’ve been concerned about the popularity of herbal creams for the treatment of skin disease for a long time. The increasing availability of some bogus treatments online has made them easier than ever to buy. The dangers of these products are two-fold, firstly that it is claimed that they treat a disease which they don’t, leaving it unchecked, and secondly that they are poorly labelled, and often contain ingredients that should only be used on advice from a doctor.

“Big online marketplaces need to make a concerted effort to root out these unprincipled sellers and remove them from their websites. More efforts need to be made to educate people, who are often scared and desperate, on the dangers of these products. It’s also important for people to remember that when you recommend untested herbal treatments to friends, family members, or co-workers with a cancer you are potentially risking their life – please encourage them to see a doctor instead.”

-Ends-
Notes to editors:

* The names of all products can be found in the study abstract provided below please note that in most cases it is members of the public, or third-party sellers making claims about these products’ abilities to treat different conditions, not the manufacturers.

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.

The conference will be held at the ACC Liverpool from July 4th to 6th and is attended by approximately 1,300 UK and international dermatologists.

For more information please contact the media team: comms@bad.org.uk, 0207 391 6084. Website: www.bad.org.uk.

About us:
The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. For further information about the charity, visit www.bad.org.uk

P100 Unravelling the mystery of the miracle cream: a retrospective regional review

S.A. Chan and D.A. Thompson Birmingham Skin Centre, Birmingham, U.K.

Approximately one-third of all herbal medicines are used to treat wounds or skin diseases, compared with only 1–3% of Western medicines, with their uses based mainly on historical and anecdotal evidence. Two reports have demonstrated evidence of topical corticosteroids in some herbal preparations. However, dermatologists continue to find patients using these preparations with little or no ingredients labelling. In the U.K., all cosmetic products are subject to wide European Union safety regulations and must comply with detailed compositional and labelling requirements. We conducted a 5-year retrospective review (2011–2015) to examine recent trends in the usage of topical herbal preparations for skin conditions. Samples sent to a regional toxicology unit for analysis were identified from 11 patients, all of Asian ethnicity (Indian, Pakistani and other), with an age range of 2–39 years. All patients had atopic dermatitis and reported obtaining preparations from the following sources: ‘herbalists’ (unclear source) (n = 6), Birmingham herbalists (n = 2), India (n = 2) and Pakistan (n = 1).

All samples were inappropriately labelled with little or no ingredients listed. Samples were analysed using a liquid chromatography–mass spectrometry–time of flight analyser, a highly sensitive and specific technology used to detect drugs and other analytes to a high degree of accuracy. Gross appearances of the samples included light orange-pink cream (n = 4; three of the four creams with this appearance were labelled as ‘miracle cream’), clear paraffin consistency (n = 2), light green fragrant paraffin consistency (n = 2), clear fragrant brown oil (n = 1) and perfumed white cream (n = 1, labelled as ‘hydrogel cream’ and found to contain clotrimazole). Superpotent topical steroids/clobetasol propionate were found in seven of the eleven samples, including orange-pink cream (n = 4), light brown oil (n = 1), clear paraffin consistency (n = 1) and another with no clear description.

Three other samples were free of drugs/corticosteroids, one of which was labelled ‘95% graphite’ cream. Unregulated topical herbal remedies continue to be accessible to patients with chronic skin disorders, particularly to those of Asian ethnicity, who often resort to these alternative preparations fearing potential long-term side effects of prescribed Western medicines. The majority of the products marketed as herbal preparations may contain potent topical steroids not mentioned on the labels, and dermatologists need to highlight the potential harms of these herbal remedies to their patients.

DS51 ‘Natural’ topical therapies don’t lead to healthy surgical defects

M.J. Lavery, J. Boggs, D. Wall, P. Ormond and R.B.M. Barry St James’ Hospital, Dublin, Ireland

Basal cell carcinomas (BCCs) are the most common cutaneous neoplasm. Treatment is predominantly surgical; however, the use of herbal medicines is becoming more common. We present a case series of four patients who self-medicated with alternative medicine topical therapies. The delayed presentation to a dermatologist resulted in larger, more extensive surgical defects. A 51-year-old man was seen as a tertiary referral for a biopsy-proven infiltrative BCC on the nasal tip. He had been diagnosed 1 year previously by the referring dermatologist but elected to pursue alternative topical treatment (‘Curaderm Bec 5’ on a daily basis for several months). One year later, the tumour was now a large crateriform scar-like BCC that now extended into multiple nasal cosmetic subunits. He underwent Mohs micrographic surgery (MMS) of the tumour, which was cleared after two stages, resulting in a deep large nasal defect (27 9 26 mm) requiring a paramedian forehead flap.

A 70-year-old man presented with a nonhealing eroded plaque over the right zygomatic cheek. He had been applying an alternative topical therapy (Lucas’ Pawpaw ointment) acquired from Australia. A diagnostic biopsy showed a moderately differentiated invasive squamous cell carcinoma. This was excised after one stage of MMS and repaired with superficial muscular aponeurotic system plication sutures, which enabled primary closure. A 46-year-old woman was referred with a biopsy-proven BCC on the right nasal sidewall. She had been using topical ‘Curaderm Bec 5’ and a Juiceplus supplement, convinced that these would result in a nonsurgical cure of the BCC. She ultimately underwent MMS and required a full-thickness skin graft to repair a 16 9 14-mm defect. A 58- year-old woman with a past history of a BCC excised from the left temple 10 years previously presented with a recurrence at the inferior margin of the scar. The patient had been using topical zinc chloride paste over the site as a means of treatment. The patient underwent MMS excision and was repaired with a primary layered closure with a W-plasty at the lateral canthus. We highlight the increasing trend of some patients who seek alternative topical therapies for nonmelanoma skin cancers, even for high-risk facial tumours. Interestingly, all of these patients were utterly convinced by the online claims of efficacy of such therapies. In fact, all patients delayed appropriate surgical excision of their facial tumours, leading to larger surgical defects.