NIH Responds to The Integrator/Traub on Challenge Regarding Integrative Strategies for Skin Conditions
September 20, 2016
Does the NIH article on complementary health approaches for skin conditions reflect science? In the article, integrative dermatology expert Michael Traub, ND, DHANP, FABNO, challenged the science behind the NIH National Center for Complementary and Integrative Health (NCCIH) “Clinical Digest” entitled “Skin Conditions and Complementary Health Approaches: What Does the Science Say?” I told readers that I would contact the NCCIH with the question. This article includes the thorough response from Josephine Briggs, MD, director of the NCCIH – together with additional comments from Traub. Traub, the author, of “Essentials of Dermatological Diagnosis and Integrative Therapeutics,” was direct in his challenge. “[The Clinical Direct offering] has more disinformation and misinformation than accurate information … My question: Who wrote this? Was it a graduate student? Somebody tasked to it who doesn’t know much? Any literature review must have been cursory. This does not reflect what is out there.” Traub then provided a sample series of citations of scientific articles that he felt should have informed the Digest, but were not represented. I sent the article to Briggs and the NCCIH communications staff, with the request for a response. Briggs was on a short, 2-month mini-sabbatical until September 12. On Friday, September 16, Dr. Briggs (pictured below) sent the following statement by e-mail. Response from Dr. Briggs, MD, NCCIH Director, to Dr. Traub "Thank you for bringing this critique to our attention. I thought you might appreciate knowing the process we follow in developing the Clinical Digest," she said. "The Clinical Digest is designed to provide a brief summary of the science regarding complementary approaches that patients may commonly use or ask about, as well as offer links to resources, including clinical practice guidelines and relevant literature searches so that healthcare professionals can delve more deeply into the literature. When we prepare content for a Clinical Digest, our process involves searching the literature in PubMed as well as the Cochrane Library, focusing first on systematic reviews and meta-analyses as well as large RCTs, if available. In addition, we determine whether there are relevant, recent clinical practices guidelines that have also assessed the evidence regarding complementary approaches. We then look carefully at the scope of what to include as it is not possible to cover all potential topics. Finally, once draft text is developed, it is then reviewed by members of our scientific staff as well as externally by a physician." “In the critique, a few of the articles suggested for inclusion were focused on diet-based approaches for skin conditions. In determining the scope for this Clinical Digest, we opted to keep a more narrow focus and did not look at the dietary literature. When we next update the content of this Clinical Digest, we can re-examine the scope and decide whether to expand it to include diet-based approaches. In regard to the review on probiotics for atopic dermatitis published in Beneficial Microbes, in that section of the Clinical Digest we referenced the latest clinical practice guidelines on atopic dermatitis from the American Academy of Dermatology." “We also appreciate the feedback regarding listing reviewers; this is a complex issue. We have included reviewer acknowledgments for some content, but we concede we have not arrived at a consistent policy on this matter and are certainly willing to reassess. We do work to enlist excellent reviewers with appropriate expertise, drawing from experts both within the government and outside as well as from conventional and integrative practice communities.” I forwarded the NCCIH from Briggs response to Traub – whose remarkable CV is here - with a brief note that I thought it a “good response.” I added that it seemed to me that “the main thing is agreement (or not) on the atopic dermatitis decision, yes? What else?” I shared that I planned to publish the response, with comments from him, if he had any. Below is the response from Traub (pictured). Dr. Traub’s Response “I agree it’s a good response. I think the problem is applying the conventional standard of [here he quotes the Briggs response] ‘focusing first on systematic reviews and meta-analyses as well as large RCTs, if available. In addition, we determine whether there are relevant, recent clinical practices guidelines that have also assessed the evidence regarding complementary approaches.’" “Most CAM and integrative clinical treatments have not been studied extensively enough to have been subjected to systematic reviews, meta-analyses and large RCTs, nor have clinical practice guidelines been developed in CAM/IHC professions like they have been in conventional medicine. The lack of these studies and guidelines thus considerably handicap CAM/IHC when a conventional standard or clinical guideline is applied to assess safety and effectiveness of a CAM/IHC treatment. “I think that well-designed, sufficiently-powered DBPCTs [double blinded placebo-controlled trials] and observational studies are more appropriate standards to evaluate most CAM and integrative therapies at this time in their evolution. Exceptions might be certain chiropractic and acupuncture treatments that have been extensively studied.” Comment: First, major kudos to Briggs and the NCCIH for taking the time to respond conscientiously and transparently. Perhaps more notable was the expressed willingness to look back at their methods and consider adding the additional references regarding dietary approaches. These, after all, are “alternative” to the typical approach of a conventionally practicing dermatologist. It will be a public service to have these strategies noted. Second, the consideration of greater transparency is also welcome. Without naming the individual human beings behind the statement, these pronunciations can seem to come down from either from the all-knowing and purely objective God or from behind the curtain of the similarly all-known and objective Wizard of Oz, depending on one’s bias. Traub’s structural point is the most challenging. I side with Traub that, in an evidence context that lacks significant governmental and other investment in trials, and therefore no conclusive evidence pro or con at that level, the public is served by citing the quality DBPCTs that exist. The NCCIH can caveat this all it wants: These studies do not build a case with certainty pro or con due to the lack of sufficient investment to date in scientific trials. The evidence provided here is at the very best suggestive. Such a statement makes the case for more investment in the NCCIH to get these done – a good thing. And what adolescent kid looking in the mirror at those atrociously expanding archipelago’s of a seemingly hostile foreign takeover does not deserve to be awakened to any possibility of attack?