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18.2. BACKGROUND AND CONTEXT

In India, records of Ayurvedic medicine date back to about 3000 BC. The system of Ayurvedic medicine combines physiological and holistic principles. It is based on the concept that the human body consists of five energy elements that also make up the universe: (1) earth, (2) water, (3) fire, (4) air, and (5) space. The interactions of these five elements give rise to the three doshas (forces), seven dhatus (tissues), and three malas (waste products). All diseases are attributed to an imbalance among the three doshas (Bedi and Shenefelt 2002). Diagnosis is made by an elaborate system of examining the physical findings, pulse, and urine, as well as by an eightfold detailed examination to evaluate both the physical and mental aspects of the condition. The treatment is then tailored to suit an individual based on the findings (Routh and Bhowmik 1999).

Records of TCM date back to about 4000 years. Similar to Ayurvedic medicine, TCM also is aimed at treating the whole person. It is based on the complementary forces yin and yang. In healthy individuals, yin and yang are in balance, and illness occurs when there is inequality between the forces. The Chinese also recognize five elements: (1) earth, (2) water, (3) fire, (4) air, and (5) metal, each related to specific organs. In addition, they recognize a flow of energy, called chi or qi, through the body in 14 major meridians. The Chinese evaluate the exchange between the environment and the body, such as food, drink, and air into the body and waste leaving the body. Special attention is given to the physical examination of the tongue, iris, and pulses of the individual to determine the cause of the imbalance and then to determine the appropriate individual treatment. Treatment is usually a mixture of herbs, massage, and acupuncture (Latchman et al. 1994). An entire textbook on dermatology in TCM is available (Xu 2004).

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In Western medicine, herbal therapy began as folk medicine. In the United States, it began in the colonial days, when homemade botanicals were used by women at home (Winslow and Kroll 1998). Native American use of botanical treatments also greatly influenced the use of herbal therapy in the United States. Iroquois medical botanicals in the northeastern United States became well known to the colonists (Herrick 1995). In the nineteenth century, these Old World European and Native American traditions were expanded and used by a group of physicians known as the “eclectics.” As herbal medicine continued to develop in the United States, it was further influenced by European and Chinese practices (Winston and Dattner 1999).

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Herbal therapy has increased in popularity in the past two decades among patients seeking alternative treatments to conventional Western allopathic medicine. The number of visits to alternative medicine practitioners in the United States has grown rapidly and in 1997 it was estimated to be 629 million, surpassing the number of visits to all primary care physicians (Neldner 2000). Approximately US$27 billion was spent on these alternative therapies in 1997, of which US$3.24 billion was spent on herbal therapy (Klepser and Klepser 1999). It has been estimated that about 50% of the population uses some form of alternative medicine. Many patients choose not to tell this information to their physicians. The group most likely to use unconventional treatment modalities according to a previous survey consisted of nonblack, college-educated individuals between the ages of 25 and 49 years, having an annual income greater than US$35,000 (Eisenburg et al. 1993). Most patients seek alternatives because conventional therapy has failed to help them sufficiently or because they feel there are fewer side effects with the natural products. The recent increase in the use of alternative medicine has led to more research regarding alternatives and requires education of physicians on the subject to enable them to better inform and care for their patients. In the United States, herbal remedies continue to be sold as dietary supplements, with no standards of potency and efficacy required currently. The Dietary Supplement Health and Education Act of 1994 did set purity standards for some commonly used herbs. In Germany, a regulatory authority known as Commission E extensively reviewed common European botanicals. In all, Commission E evaluated the quality of evidence for the clinical efficacy, safety, and uses of 300 herbal preparations (Blumenthal et al. 1998; Bisset and Wichtl 2001). In Germany, this information has led to standardization of herbal treatments. A number of herbal therapies have stood the test of time for their efficacy in treating dermatologic conditions, with a few having significant scientific evidence of usefulness.

With alternative herbal therapies, an individual patient often treats himself or herself, many times without high-quality professional advice. Patients are advised to ensure the safe use of herbal therapies by deciding on health goals; informing themselves on efficacy, safety, interactions, and usage of the medicine; selecting therapies that are likely to achieve their goals; having a correct diagnosis before using the therapy; consulting reputable practitioners; informing the practitioners about all the remedies they are using; monitoring the effects of the remedies, both positive and negative; waiting patiently for effects to become noticeable; and adjusting doses as needed to accommodate surgery, illness, or changes in conventional therapy (Dunning 2003). Product-labeling information that the patient should look for includes the name and composition of the product, including the parts of the plant and quantity of raw material used, daily dosage and timing of dosages, allergy and other warning statements, quality and safety testing, expiration date, manufacturer, country of manufacture, claims and indications for use, and details on how to store the product (Kron 2002). The Botanical Safety Handbook (McGuffin et al. 1997) places herbs in different classes of safety, with Class 1 herbs being safe to consume appropriately, Class 2 safe to consume with restrictions (2a for external use only, 2b not for use in pregnancy, 2c not for use while nursing, and 2d indicating other specific restrictions), Class 3 herbs restricted to use only when supervised by an expert, and Class 4 herbs have insufficient data for classification of safety.

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