Self-care treatment for lymphoedema of lymphatic filariasis using integrative medicine.

BACKGROUND: Lymphatic filariasis (LF) is a neglected tropical disease presenting mainly as lymphoedema (elephantiasis). At present, LF is not effectively treated. Integrative medicine (IM) treatment for lymphoedema uses a combination of Indian traditional medicine, Ayurveda, alongside yoga exercises, compression therapy, antibiotics and antifungal treatments, providing a useful combination where resources are limited and different practices are in use. OBJECTIVES: To assess the effectiveness of the IM in the existing clinical practice of lower-limb lymphoedema management and to determine whether the treatment outcomes align with the World Health Organization (WHO) global goal of LF management. METHODS: Institutional data from electronic medical records of all 1698 patients with LF between 2010 and 2019 were retrospectively analysed using pre- and post-treatment comparisons and the National Institute for Health and Care Excellence guidelines for clinical audit. The primary treatment outcomes evaluated were limb volume, bacterial entry points (BEEPs), episodes of cellulitis, and health-related quality of life (HRQoL). Secondary outcomes included the influence of the patient's sex, duration of illness, education and employment status on volume reduction. Multiple regression analysis, t-test, χ2-test, analysis of variance, Mann-Whitney U-test and the Kruskal-Wallis test were used to assess the association between IM and patients' treatment outcomes. RESULTS: Limb volume reduced by 24.5% [95% confidence interval (CI) 22.47-26.61; n = 1660] following an intensive supervised care period (mean 14.84 days, n = 1660). Limb volume further reduced by 1.42% (95% CI 0.76-2.07; n = 1259) at the first follow-up visit (mean 81.45 days), and by 2.3% between the first and second follow-up visits (mean 231.32 days) (95% CI 1.26-3.34; n = 796). BEEPs were reduced upon follow-up; excoriations (78.4%) and intertrigo (26.7%) were reduced at discharge and further improvements was achieved at the follow-up visits. In total, 4% of patients exhibited new BEEPs at the first follow-up [eczema (3.9%), folliculitis (6.5%), excoriations (11.9%) and intertrigo (15.4%); 4 of 7 BEEPs were recorded]. HRQoL, measured using the disease-specific Lymphatic Filariasis Specific Quality of Life Questionnaire, showed an average score of 73.9 on admission, which increased by 17.8 at the first follow-up and 18.6 at the second follow-up. No patients developed new cellulitis episodes at the first follow-up, and only five patients (5.3%) developed new episodes of cellulitis at the second follow-up. CONCLUSIONS: IM for lower-limb lymphoedema successfully reduces limb volume and episodes of cellulitis, and also reduces BEEPs, leading to improved HRQoL. IM aligns with the LF treatment goals of the WHO and is a low-cost, predominantly self-care management protocol. IM has the potential to change care models and improve the lives of patients with lymphoedema.

Human skin fibrosis: up-regulation of collagen type III gene transcription in the fibrotic skin nodules of lower limb lymphoedema.

OBJECTIVES: To investigate the cellular and molecular pathophysiology involved in the development of fibrotic skin of grade-3 lymphoedema patients with a focus on collagen types. METHODS: Fibrotic and normal skin biopsy samples obtained from grade-3 lymphoedema patients and normal individuals, respectively, were analysed by histopathology, quantitative real-time PCR and immunohistochemistry to examine collagen gene expression. RESULTS: Histopathologic analysis revealed epidermal changes such as orthokeratosis, hypergranulosis and irregular acanthosis in the skin biopsies. The thickened dermis contained nodules of haphazardly arranged thick collagen bundles. Real-time PCR data showed significant (P-value 0.0003) up-regulation of Collagen type I and type III gene transcripts in the fibrotic skin of patients resulting in 38.94-fold higher transcription of Collagen type III alpha-1 gene than of Collagen type I alpha-1 gene. Semi-quantification of the per cent of haematoxylin-DAB-stained area of immunohistochemistry images also showed significant (P < 0.0001) enhancement of both collagen proteins in the fibrotic skin of patients vs. normal human skin. CONCLUSIONS: Gene transcript analysis revealed significant up-regulation of Collagen type III vs. Collagen type I in fibrotic skin of limb nodules from patient biopsies. Histopathological and immunohistochemical analysis also revealed enhancement of Collagen types I and III in fibrotic vs. normal skin. The findings of this preliminary study indicate the potentially significant involvement of Collagen type III in the development of the fibrotic skin of grade-3 lymphoedema patients.

OBJECTIFS: Etudier la physiopathologie cellulaire et moléculaire impliquée dans le développement de la fibrose cutanée chez les patients atteints de lymphœdème de grade 3 en mettant l'accent sur les types de collagène. MÉTHODES: Des échantillons de biopsie cutanée fibrotique et normale obtenus respectivement de patients atteints de lymphœdème de grade 3 et d'individus normaux ont été analysés par histopathologie, par PCR quantitative en temps réel et par immunohistochimie pour examiner l'expression des gènes de collagène. RÉSULTATS: L'analyse histopathologique a révélé des changements épidermiques tels que l'orthokératose, l'hypergranulose et l'acanthose irrégulière dans les biopsies cutanées. Le derme épaissi contenait des nodules de faisceaux de collagène épais disposés au hasard. Les données de PCR en temps réel ont montré une régulation à la hausse significative (P = 0.0003) des transcrits des gènes de collagène de type I et III dans la peau fibrotique des patients, résultant en une transcription 38,94 fois plus élevée du gène alpha-1 du collagène de type III par rapport à celui du gène alpha-1 du collagène de type I. La semi-quantification du pourcentage de zone colorée à l'hématoxyline-DAB des images d'immunohistochimie a également montré une amélioration significative (P < 0.0001) des deux protéines de collagène dans la peau fibrotique des patients par rapport à la peau humaine normale. CONCLUSIONS: L'analyse de transcription génétique a révélé une régulation à la hausse importante du collagène de type III par rapport à celle du collagène de type I dans la peau fibrotique des nodules des membres provenant de biopsies de patients. L'analyse histopathologique et immunohistochimique a également révélé une amélioration du collagène de types I et III dans la peau fibrotique pa rapport à la peau normale. Les résultats de cette étude préliminaire indiquent l'implication potentiellement significative du collagène de type III dans le développement de la peau fibrotique des patients atteints de lymphœdème de grade 3.

Integrative Skin Care: Dermatology and Traditional and Complementary Medicine.

Skin problems and diseases are extremely common globally and, due to their visibility, often result in severe distress and stigma for sufferers. Traditional (i.e., indigenous or local) and complementary health systems are widely used and incorporate many treatment modalities suitable for skin care, and a body of evidence for their efficacy and safety has built up over many decades. These approaches are often used as part of a broader "integrative medicine" (IM) approach that may also include, for example, nutrition and mind-body approaches. This article presents an overview of current knowledge about traditional and complementary medicine (T&CM) and IM principles and practices for skin health; reviews published epidemiologic studies, clinical trials, and wider literature; and discusses the challenges of conducting research into T&CM and IM. It also highlights the need for an innovative research agenda-one which is congruent with the principles of IM, as well as taking policy and public health dimensions into consideration.

Yoga protocol for treatment of breast cancer-related lymphedema.

INTRODUCTION: Vaqas and Ryan (2003) advocated yoga and breathing exercises for lymphedema. Narahari et al. (2007) developed an integrative medicine protocol for lower-limb lymphedema using yoga. Studies have hypothesized that yoga plays a similar role as that of central manual lymph drainage of Foldi's technique. This study explains how we have used yoga and breathing as a self-care intervention for breast cancer-related lymphedema (BCRL). METHODS: The study outcome was to create a yoga protocol for BCRL. Selection of yoga was based on the actions of muscles on joints, anatomical areas associated with different groups of lymph nodes, stretching of skin, and method of breathing in each yoga. The protocol was piloted in eight BCRL patients, observed its difficulties by interacting with patients. A literature search was conducted in PubMed and Cochrane library to identify the yoga protocols for BCRL. RESULTS: Twenty yoga and 5 breathing exercises were adopted. They have slow, methodical joint movements which helped patients to tolerate pain. Breathing was long and diaphragmatic. Flexion of joints was coordinated with exhalation and extension with inhalation. Alternate yoga was introduced to facilitate patients to perform complex movements. Yoga's joint movements, initial positions, and mode of breathing were compared to two other protocols. The volume reduced from 2.4 to 1.2 L in eight patients after continuous practice of yoga and compression at home for 3 months. There was improvement in the range of movement and intensity of pain. DISCUSSION: Yoga exercises were selected on the basis of their role in chest expansion, maximizing range of movements: flexion of large muscles, maximum stretch of skin, and thus part-by-part lymph drainage from center and periphery. This protocol addressed functional, volume, and movement issues of BCRL and was found to be superior to other BCRL yoga protocols. However, this protocol needs to be tested in centers routinely managing BCRL.

The wow factor as a determinant of funding for disorders of the skin.

As people live beyond 100 years, there is an extended period of impaired quality of life for the increasing numbers of individuals with skin disorders. There is also a growing work force of fit elderly individuals who are able to provide low technology skin care and who can teach self-help if well instructed. The International Society of Dermatology's sub-committee Skin Care for All: Community Dermatology seeks to bring together those who care for skin diseases and those who manage wounds, burns, lymphoedema and neglected tropical diseases affecting the skin for the purpose of skin care. Their focus is the repair of four functions: barrier, thermoregulation, sensory perception and communication. The curriculum includes low cost self-help and the restoration of absent skin. The care expectation is one of technical proficiency integrated with kindness and altruism. The concept is attracting wide attention but needs to develop compelling and persuasive arguments ("wow factors") regarding why it should be funded. There is probably no greater wow factor than tracing the path of a severely injured patient from the battlefield through the course of immediate first aid by paramedics to the surgeon in the frontline tent who can almost guarantee survival. Seeing these disfigured persons winning trophies at the Olympic Games has garnered the admiration of millions of viewers.

Yoga for correction of lymphedema's impairment of gait as an adjunct to lymphatic drainage: A pilot observational study.

INTRODUCTION: Yoga used as a major component of integrative treatment protocol in 14 Indian village camps improved quality-of-life in 425 lymphatic filariasis patients. They experienced better mobility and reduced disability. This paper documents the gait abnormalities observed in lower limb lymphedema patients and the locomotor changes following integrative treatment. MATERIALS AND METHODS: Yoga postures were performed as explained by traditional yoga practice in two sessions: Before ayurvedic oil massage without compression bandages and after the massage with compression bandages. Each yoga posture lasted for 5 min and the whole session ended in 45 min. Throughout each session, we advised patients to do long, diaphragmatic breathing, concentrating on each breath. The flexion of joints was coordinated with exhalation and extension with inhalation. We educated the patients to do longer expiration than inspiration. RESULTS AND DISCUSSION: A total of 98 patients (133 limbs) attending the 6(th) month follow-up were evaluated. The most common gait abnormality was antalgic gait. Structural and functional abnormalities were observed in hip, knee and ankle joints. We found that yoga as an adjunct to other components in integrative treatment improved the gait problems. Long standing lymphedema caused altered gait and joint deformities. This was mostly due to inactivity causing muscle weakness and edema within and around the muscles. Both large and small limbs have shown significant volume reduction (P < 0.01) during follow-up after 6 months. CONCLUSION: There can be a mixed etiology for gait related problems in lymphedema patients. Further studies are recommended to understand the causes of deformities in lymphedema patients and an exact role of yoga.

Human pigmentation: A side effect adapted from a primitive organism's survival. Part 2: The melanocyte as mentor of the keratinocye.

Pigmentation featured millions of years ago and perhaps began with an amoeba frightening off a predator with some agent such as dopamine to prevent its attachment for phagocytosis by an enemy. This paper suggests that the environmental forces of grip and stick, rather than pure chemical influences, deserve greater emphasis, and that the influence of the mechanical forces involved in grip and stick or release from attachment, all point to control of proteases as a function underlying pigmentation. How and why pigmentation varies with temperature and sunlight is discussed. The toxicity of melanin, pH, transepidermal water loss, and the influence of endocrine factors are also addressed.

Human pigmentation: A side effect adapted from a primitive organism's survival, acting through cell attachment with an affinity for the keratinocyte and for elastin: Part I.

Pigmentation featured millions of years ago and perhaps began with an amoeba frightening off a predator with some agent such as dopamine to prevent its attachment for phagocytosis by an enemy. This paper suggests that the environmental forces of grip and stick deserve greater emphasis and that mechanical forces involved in grip and stick or release from attachment, all point to control of proteases underlying pigmentation. There is an affinity for elastin as a pathway for melanin to exit its peripheral location in the epidermis into lymphatics and play a humeral role in defense mechanisms. The hair follicle follows the epidermal-dermal pattern of behavior with an affinity for elastin, a controlling function of melanin and through the bulge, an influence of mechanical forces and control by protease inhibitors.

A seminar on gardens for the health of the skin.

This is a report on a seminar held on January 12, 2013, at the Regional Dermatology Training Centre in Tanzania, sponsored by the International Society of Dermatology as part of its Taskforce Program for Skin Care for All: Community Dermatology. There were four themes: (i) Gardens attached to health centers increase their attractiveness and result in increased attendance and, thus, increase the utilization of effective skin care interventions. Literature on the positive effect of greenery surrounding health centers on health and the environment is reviewed. (ii) Adding an expert on agriculture to the staff of health centers in Rwanda has provided nutrition and safe medicines. (iii) In southern India, these interventions are channeled through the empowerment of tribal women in an area noted for anxiety due to unemployment in the tea and forestry industry. The gardens are used for teaching about nutrition and herbal medicines, and the women are further attracted by childcare facilities. (iv) Measuring barrier function defects gives early warning of malnutrition of the skin after damage by trauma or by ultraviolet radiation. Higher cost research techniques may help to provide the science required to produce its evidence base. In conclusion, Gardens for health should be adopted as policy by skin care providers.

Community level morbidity control of lymphoedema using self care and integrative treatment in two lymphatic filariasis endemic districts of South India: a non randomized interventional study.

BACKGROUND: Currently there is no global program to manage lymphoedema as a result of lymphatic filariasis (LF). The primary aim of this study was to determine the efficacy of a previously proposed integrative treatment protocol, using locally available resources to address the morbidity, in a community village setting. METHODS: Two LF endemic districts of south India, Gulbarga in Karnataka (GK) and Alleppey in Kerala (AK), were selected for the study. All known patients were invited to an LF camp. Patients with grade two late or three lymphoedema were enrolled. All patients were given training in the integrative procedure which involved patient education and the domiciliary protocol. RESULTS: A total of 730 patients (851 limbs) completed the three and half month follow up. There was a statistically significant (1%) reduction up to mid thigh level volume measurement for both small (0.7-1.1 liters) and large (1.8-5.0 liters) limbs, p < 0.000. In AK inflammatory episodes at the three months interval reduced from 37.5% (127 patients) to 28.3% (96 patients) and in GK from 37.6% (147 patients) to 10.2% (40 patients), p < 0.000. All patients had reduced bacterial entry points. There was an overall improvement in quality of life in all domains of LF specific quality of life questionnaire p < 0.000. CONCLUSIONS: Self care and integrative treatment is possible in resource poor Indian village settings. Further work is needed to explore factors leading to better compliance by randomizing the interventions such as washing and emollient compression vs Ayurvedic and yoga interventions before integrative treatment is considered for national health programmes in developing countries.

Integrative medicine selects best practice from public health and biomedicine.

The meaning of terms Integrated and Integrative are described variously by an amalgam of latest scientific advances with ancient healing systems, of complementary medicine and biomedicine, and sexually transmitted infections and HIV/AIDS. It means seamless good quality care between hospital and primary care. They provoke approval mostly from patients and disapproval mostly from advocates of science and evidence-based medicine. The Institute of Applied Dermatology in Kasaragod, Kerala, India has championed a mix of Biomedicine, Yoga and herbals from Ayurvedic medicine, partly based on publications from the Department of Dermatology of the University of Oxford. In Oxford dermatology, acceptance of value of integrative medicine (IM) is demonstrated, especially in wound healing and the skin's blood supply. This has long featured in the university's research program. A variety of approaches to the practice of medicine are illustrated with reference to Osler, Garrod, and Doll. IM is believed to underlie contemporarily best practice. Particular emphasis is given to the control of heat, pain, redness, and swelling, all manifestations of inflammation, and the importance of emotion as a stimulus or inhibitor carried by neural pathways. These may explain some unbelievable Asian practices and one of the many roles of Yoga. The concept of Integrative is expanded to include care of the earth and nutrition, the hazards of climate change, Gardens for Health, do (k) no (w) harm as a key to good practice.

Guidelines on the role of skin care in the management of mobile populations.

The Task Force for Skin Care for All: Community Dermatology, when seeking to collate evidence for capacity to benefit, wanted to know how best to manage mobile populations. The task force met where there is most experience at a time of maximum migration to the Mediterranean islands and to Italy from Somalia, Sudan, Cote d'Ivoire, Tunisia, and Libya. Members attended the workshop hosted by Aldo Morrone at the San Gallicano Hospital, Rome, Italy. Issues discussed were the size of the problem, ethics and legality, potential value of the migrant, dermatologist as carer, challenges met by interpretation, good listening, and transcultural mediation. The experiences of the National Institute for Health Migration and Poverty at the San Gallicano Hospital in Rome, Ethiopia, Malta, and Lampedusa were key to the development of guidelines on cultural competence.

Reporting an alliance using an integrative approach to the management of lymphedema in India.

In India 553 million persons are estimated to live in areas endemic for LF; approximately 21 million have symptomatic filariasis. Of the approximately 16.02 million cases of lymphedema caused by LF globally, 7.44 million (46.4%) are in India. India had seen diethyl carbamizine, and/or albendazole, delivered to whole populations, beginning the project to eliminate the disease. But new populations have developed the infection. In 2003 the need in resource-poor countries for morbidity control of lymphatic filariasis (LF) became clear, prompting the study by the Institute of Applied Dermatology in Kerala, India. Under this study,self help and family members assisted in home-based care, combining compression bandaging, yoga exercises, heat therapy using steaming, and skin care according to Ayurvedic medicine. Lymphedema presents with different patterns in the skin with gross changes in the epidermis, dermis, or subcutaneous tissue. Skilled and time-consuming counselling is important to give patients support. An almost immediate reduction in inflammatory episodes from 80.4% to 8.6% shows up within 2 or 3 weeks, and therefore, intake of antibiotics can be stopped. The second major response is reduction in the size of the limb. Volume reduction for large-sized limbs at 3 months is 39%, with a confidence interval of 4.9 to 5.9 L.

Collaboration with traditional health practitioners in the provision of skin care for all in Africa.

The Task force for Skin Care for All: Community Dermatology seeks to meet WHO objectives, to draw attention to the role of Traditional Health Practitioners and to develop integrated skin care. In many African countries patients will first use traditional medicine to treat skin diseases. Many traditional practices are beneficial but some are harmful. The Task Force recommends education of traditional and modern health practitioners to improve collaboration, safety and efficacy. Thereby, it aims to improve skin care and to reinforce the best practices.

Advancement of women in dermatology.

This article reviews the special role that women dermatologists have played in the improvement of skin care for women and children, as well as the role of the Women's Dermatological Society (WDS) in providing networking, mentoring and leadership opportunities for female dermatologists. Women leaders within the International League of Dermatology Societies (ILDS) have influenced WHO directives to assign higher priorities to areas of women's health. Maria Duran and her legacy at the International Society for Dermatology (ISD) has recognized leaders in the area of dermatology education and mentorship. Volunteerism and the promotion of equal access to health care by women and children are other key activities by women dermatologists.