February 7, 2018

Integrative Dermatology to Clinical Practice: A Conversation with Raja Sivamani, MD

Sponsored by Dermveda

Skin conditions are common in many clinical practices. In this interview, dermatologist and researcher Raja Sivamani, MD, describes how an integrative approach can help improve outcomes, especially with difficult to treat dermatological conditions.

About the Expert

Raja Sivamani, MD, MS, AP, is a board-certified dermatologist, Ayurvedic practitioner, and serves as the lead Scientific Advisor and Editor for Dermveda and LearnSkin. He is currently an Associate Professor of Clinical Dermatology at the University of California, Davis and serves as the Director of Clinical Research and the Clinical Trials Unit with a focus on engineering, nutrition, and microbiome focused clinical studies. He is also an Adjunct Assistant Professor in the Department of Biological Sciences at the California State University, Sacramento. He engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, cosmetics, and skin biology. With training in both Allopathic and Ayurvedic medicine, he takes an integrative approach to his patients and in his research, with a focus on the gut and skin microbiome and lipidome. He has published over 100 peer-reviewed research manuscripts, 10 textbook chapters, and a textbook titled Cosmeceuticals and Active Cosmetics, 3rd Edition. He has a passion for expanding the evidence and boundaries of integrative medicine for skin care.

About the Sponsor

Dermveda is an integrative skin care, beauty, and wellness site dedicated to inspiring and empowering people to develop a healthier, more holistic relationship with their skin. We provide skin education tools and personalized, science-reviewed health content for both consumers and practitioners. Membership is free at Dermveda.com.

Dermveda's continuing medical education site, LearnSkin, was developed by leading dermatologists and integrative medicine practitioners to support integrative dermatological education throughout the healthcare community. The goal is to share the latest in scientific research and treatment options in dermatology for both Western and Eastern medicine. We aim to meet the growing demand for high-quality, evidence-based education that bridges conventional and alternative medical approaches. The first eczema series will begin in March at LearnSkin.com.

Later this year, Dermveda will be hosting the first annual Integrative Dermatology Symposium in Sacramento, CA, from October 19-21, 2018. Experts from around the world in the practices of Western, Naturopathic, Ayurvedic, and Traditional Chinese Medicine will come together for this special event. The Symposium will feature educational sessions, clinical content, targeted industry trends, practical takeaways, and best practices related to all aspects of skin care. Registration opens in March at IntegrativeDermatologySymposium.com.


Karolyn Gazella: Hello. My name is Karolyn Gazella and I am the publisher of the Natural Medicine Journal. Today our topic is integrative dermatology and my guest is Dr Raja Sivamani, an integrative skin care expert.

Before we begin, I'd like to thank the sponsor of this topic who is Dermveda.

Dr Sivamani, thank you for joining me today.

Raja Sivamani: Thank you so much for having me. It's a pleasure to be here.

Gazella: Well this is an interesting topic and I have to say that we have not covered this a lot in our journal so I'm super excited to talk to you today.

So, let's start with a very basic question. How do you define or describe integrative medicine specifically as it relates to dermatology?

Sivamani: Karolyn, I agree with you, this is actually a really exciting area when we think about integrative dermatology.

So, to answer the question that you're asking, you know, how does integrative medicine specifically relate. Dermatology really has many facets to it and by in large, many times when you go to see a dermatologist the appointment can be a little rushed and typically you're in there for about 15 minutes or so and many times the conversations will be focused on things like the diagnosis, which is super important and then some basic treatment plans and maybe a surgical treatment plan.

When we start thinking about integrative approaches, really then you start to take into all the other aspects of dermatology that are so vital to providing good care when it comes to anything skin related. So things like psychology, preventative approaches, diet, what you're putting on your skin, daily habits. All these things comes together and so, when I think about integrative approaches to dermatology it really is about a team approach and some of that team can be deployed by the practitioner but many times I also think about this expanded team that's working together in a way that, you know, maybe one practitioner's able to provide certain aspects and then another practitioner is able to provide other aspects of care and then them working together. So, that's how I view integrative.

And integrative, just as an add-on but I do want to talk about is, is not to say its separated from conventional medicine. I think bringing in conventional medicine, making that just as an equal part of the conversation, I think is really important.

Gazella: I would agree and that fits perfectly with the focus of our journal so this is great now.

So, what are some of the more common skin conditions that practitioners are faced with in clinical practice?

Sivamani: It turns out dermatology is so common. A lot of people see people with skin conditions. They did a study at the Mayo clinic where they looked at how often and what kind of skin conditions, sorry, what kind of general conditions come in and skin conditions were really high.

The ones that are common and they tend to be pretty prevalent in the general population are things like acne, of course, these all depend on different age groups as well but, acne is very, very common. When we talk about eczema specifically, atopic dermatitis, that's another one that's common but there's also other conditions that may not be as common as those two but are still pretty common. Things like psoriasis and there's also seborrheic dermatitis, rosacea so, there's quite a few things that come up over and over again.

And, another sub-set of eczema, not atopic dermatitis, which is more dealing with pediatric population, and that does extend into an adult population but then there's also just common irritations that come up on the skin on a day-to-day basis that anyone can get. Things that mean to us as contact dermatitis either from irritation or an allergy.

Gazella: Now out of all of the skin conditions that are out there and, there are a lot of them, what are some of the more difficult to treat skin conditions that practitioners are faced with and, why are they so difficult to treat?

Sivamani: Karolyn, this is such a great question. I really like this question for a couple of reasons. When we talk about difficulty I really break that up into two modes, two facets to what makes a skin condition difficult to treat.

Firstly, a skin condition can be difficult to treat just because it's a rare condition and it will require some treatments that sometimes aren't always well studied because it's rare. And so, you can have conditions that just don't happen that often and when they do often and sometimes you know this condition can be auto-immune or other facets to them that really make it more difficult.

I think there's a second facet, though, that really is a challenge as well. And that's conditions that are chronic and that require constant management. We really have to integrate in lifestyle and other approaches and symptom management isn't enough. So, you have conditions like acne that, you know, they just won't cure on their own, you need to have some sort of active management to that in a very, what I believe, holistic conversation and things like eczema require so much activity from, you know, if you're a patient and you're taking care of eczema that's one thing but, if you're a baby, then you're really dependent on caregivers and so then it becomes a conversation with the caregivers and managing how they are approaching the treatment.

And so, I think that that second group where you have chronic conditions that don't necessarily have a cure but, if you can get really good management then it can make a huge difference. I think that is also a pretty big difficulty because it requires constant conversation and a lot of education. I think education is key in those kinds of situations.

Gazella: Yeah, that would make a lot of sense.

Now, I find it interesting that you have training in both allopathic and Ayurvedic medicine. I'd like to focus a bit on Ayurvedic medicine. So, for our listeners, what is Ayurvedic medicine?

Sivamani: Yeah, so, Ayurvedic medicine is, it was born from a tradition that's very rich in India. It's over 5,000 years old and their approach is really looking at homeostasis, meaning when you're in balance. Just to simplify it, is when are we in balance and when are we in a state of imbalance? And so Ayurvedic medicine has some tendance in how it measures what it means to be imbalanced, what is your imbalance state and I'll just use a couple of cavular terms. One is, prakriti which is your state of balance or what they say your original constitution but then you also have this notion of what's known as Vikrity which is your imbalance state and they use the three doshas which are known as vata, pitta, and kapha in a very broad manner to identify what those imbalances are and, a lot of approaches including lifestyle approaches, dietary approaches, what you put on your skin, believe it or not, you can even describe western medicine from an Ayurvedic perspective and the idea is, can you take this imbalance and move it back towards balance?

What I really like about Ayurvedic medicine is that it can really go well in an integrative approach. So, you clearly have conventional approaches that tend to be focused much more on symptom management and then Ayurvedic medicine gives you tools, and I think that's really important, just having this ability to have this conversation to what it means to be in balance so you have these tools to talk about what are different lifestyle changes you can make or what would be an appropriate dietary change that you could make.

If I may add, one of the fun things I think about Ayurvedic medicine is that it gives you the opportunity to personalize and in conventional medicine they're really good about research studies that will study a large group of people and then in many ways you get kind of an average outcome and then you can apply that to each patient.

So, if you bring the two together you have this really powerful system where Ayurvedic medicine allows you to personalize a little bit more on top of what you're going to do and then conventional medicine gives you the ability to have broad-stroke approaches that might give you a good starting point, especially for symptom management.

But, Ayurvedic medicine is really rich on the personalization aspect.

Gazella: I think that's important. That really has become a big emphasis, it's no longer one size fits all. I would assume, especially in the area of dermatology and these difficult to treat skin conditions.

Can you give us a few examples of how you apply Ayurvedic medicine to dermatology in clinical practice?

Sivamani: Sure, you know, that is one of the funnest parts and really interesting parts of my practice. I feel like I get to know my patients better. If I may say, from one of the really key aspects of Ayurvedic medicine is, I have to get to know the patients habits much more and understand what kind of things are they doing in their daily life. That in and of itself gives me a greater connection.

So, for example, if I have a patient coming in with eczema and Atopic dermatitis, we're talking about different management approaches. One of the things that can sometimes come up is if we're just taking a pharmacological approach and we're talking about steroids, a lot of people want to know, am I going to be doing these steroids for the rest of my life, is there any sort of way that I could do management that doesn't require the steroids to be used?

So then you have this rich knowledge in Ayurvedic medicine about all these different oils and how oils are used on the skin and, there's a rich, rich literature, rich history on different oil therapies and what they call oliation and what's known as abhyanga, so self massage or massage with oils. And it really opens up a conversation because you can start talking about moisturization but bringing in the science of natural oils and, this is an area that's started to really grow in dermatology, what's the role of coconut oil, what's the role of olive oil, what's the role of sunflower, safflower oil, this has now started to hit the medical literature.

What Ayurvedic medicine does is it goes one step further and you can do herbal infused oils and I have these conversations with my patients. I tell them, you know, why don't we talk about maybe some simple ways to make a herbally infused oil where you can have a moisturizer that is really based on an oil therapy.

And what starts happening is, people start to become very engaged with themselves. Their skin becomes a part of them that they're not afraid of anymore and they're used to touching themselves in a way that's actually very therapeutic and then, you know, funny thing is, when I have these conversations then they realize that there's a holistic approach and then they're okay with using the steroids and they understand why we're using steroids and then it's part of a bigger picture approach to managing their symptoms.

So that's one example that comes up very frequently in my practice.

Gazella: And now give us an example of a herbal infused oil. Like which herb would you put with the oil for which condition? Is it that simple?

Sivamani: It's a little bit more nuanced.

Gazella: Okay.

Sivamani: What you have is you have different dosha imbalances and different oils, there can be, some oils that are warming in tendency or they can be cooling, I mean, you have to balance that with the doshas but, I'll give you one example, which I think is a pretty good one.

Coconut oil is widely used now as a moisturizer and sometimes what we can do is we can infuse, there's a herb called neem. Neem has both anti-bacterial and anti-fungal properties and we've been studying it. Actually, I have a basic science laboratory as well and we've been looking at neem specifically. But, one thing you can do is you can create an infused oil that has coconut oil as the base with a neem infusion and what that does is it gives you this oil that's not only going to be helpful for bolstering the skin barrier and nourishing the skin and, from that aspect but you also get that extra little antibacterial effect.

Now, I don't want to claim that it's an antibacterial like something that's been studied through the FDA but that being said, in eczema, sometimes, its smaller shifts in the microbiome and one of the things that we try to do is think about, from a practical perspective, can be infusing oil that might be able to touch upon those kind of aspects and then eventually it would be nice if we could start studying them in controlled studies and really looking at how, what is it doing to, for example, the microbiome?

But that's one of the examples of an infused oil that we might use.

Gazella: Yeah, that's a great example.

Now what advice do you have to healthcare professionals who may be struggling to treat some of these difficult to treat skin conditions in their clinical practice?

Sivamani: This is such a fantastic topic to talk about.

When it comes to treating conditions that are a little bit more difficult, I think it's important to realize that there's a team available and there's also the patient perspective. But I think the team approach is really important.

You're not alone and, what I mean is that, if you have someone that has a really bad itch, for example, we can do our best as a, myself, as a dermatologist, I can talk to them about what are some of the things they can do to help their skin not be as dry or are there some treatment options to help reduce the itch even from a pharmacological perspective. But then, I think it's really helpful to start thinking about the psychology of itch. What are the other approaches that we can take so then, if we can get them to one of my colleagues in, for example, traditional Chinese medicine and they can take an approach where maybe they look at acupuncture, and that can channel in on a different aspect to itch and, you know, focusing a little bit more on some of the other approaches, I think that's where it really becomes important.

When you're struggling to treat a more difficult condition that may even be chronic, it's to start thinking about a team approach and I feel like that's the essence of integrative approaches anyway and so if we can start developing teams and developing good partnerships with other healthcare professionals then as a healthcare professional we won't feel alone and as a patient, the patient won't feel alone either and they see that there's a team working for them.

Gazella: Yeah, absolutely, and that definitely is in line with the integrative approach that you described in the very beginning.

Now, you are an advisor to the company Dermveda. Why did you want to work with Dermveda and how is it different from other skincare companies?

Sivamani: What I really like about Dermveda is it's focused on education and, if you look at the founding team, the founding team consisted of people that are really dedicated to dermatology, they're very good teachers and lecturers and, also they have a good education background and, I like education first approaches because I think if you can teach people to start thinking more deeply about their condition, and when I say deeply, not just about maybe the molecular mechanisms or some sort of cellular pathway but really understanding that that's important but, it's also important to think about things that may be affecting you emotionally or psychologically and allowing people the space to see that these are also important and by opening them up to have better conversations with themselves and their practitioners.

That's why I'm so passionate about this company. I'd personally really dedicated to education, I like education in all of its aspects and I think its really important to empower patients and practitioners and so, because of that approach, I really am drawn to the Dermveda's approach and also, the holistic and the integrative approach allowing us to learn about, not just conventional medicine but also thinking about Ayurvedic medicine, traditional Chinese medicine. Our naturopathic colleagues have such great insight into the botanicals and into plant based approaches but I think that, giving a platform for this open discourse that's honest and credible is super important so that's why I'm so interested in this whole approach.

Gazella: Yes, I was thrilled to see that Michael, Dr Michael Traub is on your team. He is a friend of the Natural Medicine Journal and on our editorial board. A very top-notch doctor so, that was exciting for us to see that as well. And now, Dermveda is also hosting an integrative dermatology symposium this October in Sacramento, California. Can you tell us a little bit more about that symposium and why you feel it may be important for practitioners to attend.

Sivamani: We are so excited about the symposium, the integrative dermatology symposium is going to be the first time where we're going to get all the different perspectives into the same room and have a good open discourse and really start talking to each other ina way that we can start building relationships.

This symposium is going to really feature a wide variety of things. You mentioned Dr Traub, he's going to be one of the speakers there.

I still remember one of the first lectures that I saw with him and I was really impressed by, not only was he able to talk about the pharmacological approaches but it was so nice that he put in things about, and this was with eczema, we were talking about treating eczema, he had a lecture on that and, he put in things about a humor and what does that do for a child at the end of the night when they're about to go to bed, if you can have some way of getting them to laugh, does that make a difference?

I think its important to talk about these aspects and what we'd like to do in the symposium is really put that into a situation with all come together in a focused way where we have this combined goal of just making it better for each other to treat our patients and leaning what's new and what's coming out that's in the new literature and realize that any one perspective isn't the full approach.

And, if you can start taking a different perspectives it really makes a difference and, I'll give you an example. So one of the things that we're going to be talking about is like one of the lectures is going to talk about emerging approaches to eczema and there'll be conversations about all these new medications that are now coming out but then there's also going to be conversations about what is the latest science on the oils that are being used for eczema. Which oils seem to be the best, which one's may not be the best.

And then from there, they'll also swing into a conversation about diet and so, I think one of the things that sometimes we miss out on in just the medical education that we might go through is that you might get pieces and bits but when we start thinking about continuing education, you want to start really have good, honest discourse about all the aspects because that's really what the patient really wants. They want to have a good, holistic conversation about everything. They want to know what can I do with diet or, what can I do with my lifestyle approaches.

So, this is going to give practitioners, that attend, the chance to be empowered to understand what is the latest in that but not only that, I think the most exciting part about it is, we're going to get everybody in the same room and you just never know what's going to develop in those kind of situations. What kind of partnership and friendships are going to come out of that and I think that's the way to really push the boundaries of medicine so that when we talk about integrative medicine it really just becomes medicine and it's just the approach that we all would want to take with any patient that comes in.

Gazella: Yeah, that's a very good point and it sounds very comprehensive and we have a link to the conference. So, for our listeners who want to learn about more information about the integrative dermatology symposium, you can just click on that link and then you'll be able to find out more information.

Well, once again, Dr Sivamani, thank you so much for joining me and I would also like to once again thank our sponsor, Dermveda.

Sivamani: Thank you so much and it's been a pleasure to be here with you.

Gazella: Great. Have a great day.

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