A unlicensed product sold as 'pure herbal' for eczema
A 29-year-old woman with chronic eczema attends a herbal practice. She brings a tub of dark ointment purchased online from an overseas seller, labelled only in Chinese and English as '100% pure herbal, no steroids'. She has used it on her face and hands for four months and says it works better than anything her dermatologist prescribed. On examination the facial skin is thinned and shiny with visible telangiectasia, and there is a sharp demarcation between clear skin where the ointment was applied and inflamed skin elsewhere. She has not used it on the rest of her body. She wants to know whether she can keep using it alongside a prescribed herbal decoction. She takes no other medication, has no known allergies, and is otherwise well. She asks whether the product could be 'tested' to prove it is safe.
1. What is the most likely explanation for the clinical findings, and what is the basis for your concern?
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The most likely explanation is that the ointment contains an undeclared topical corticosteroid, despite the label. The evidence is clinical and characteristic:
- Skin thinning and shininess, which are typical of prolonged topical steroid use.
- Telangiectasia on the face, a recognised effect of potent topical steroids on thin facial skin.
- A sharp demarcation between affected and unaffected areas, which follows the area of application rather than the distribution of eczema.
- Rapid and marked improvement that exceeds what the patient has experienced with prescribed treatment.
- Four months of continuous use on the face, a high-risk site.
Products marketed as 'pure herbal' with no steroids have repeatedly been found on analysis to contain corticosteroids, and labels from online overseas sellers are not a reliable assurance. The concern is not only the steroid itself but the absence of medical supervision, the unknown potency, and the risk of withdrawal flare when stopped abruptly.
The practitioner should not assume the label is accurate simply because it says 'no steroids'. The clinical signs are the stronger evidence.
2. How should the practitioner respond to the request to continue the ointment alongside a herbal decoction, and what advice about stopping is needed?
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The practitioner should advise stopping the ointment, but not abruptly and unsupervised, because four months of likely topical steroid use on the face carries a risk of significant rebound flare. The safe course is to refer the patient to her GP or dermatologist for assessment and a supervised withdrawal plan, explaining the clinical findings and the suspicion of an undeclared steroid.
The herbal decoction should not be presented as a substitute that will prevent the flare. The practitioner can offer supportive care within their competence, but must be honest that a rebound is possible and that medical review is needed.
The practitioner should also explain why continuing is unsafe: unknown potency, facial application, skin thinning and telangiectasia, and the risk of worsening with longer use. The patient should be told not to buy further supplies and to keep the product in case the seller or a regulator needs it.
If the patient refuses referral, the practitioner should document the advice, explain the risks clearly, and offer review. The practitioner should not simply take over management of a likely steroid withdrawal without medical involvement.
3. What professional and regulatory issues arise, and what action should the practitioner take regarding the product and the record?
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Professional issues:
Selling or supplying an unlicensed product with undeclared active ingredients is a regulatory matter. The practitioner should not endorse, supply, or help source the product.
The practitioner has a duty to protect the patient and, where appropriate, to report a suspect product to the relevant medicines regulator or trading standards body. Reporting is not an accusation of the patient; it is a public-protection step.
The practitioner should work within their scope: advising on the herbal decoction is within competence, but diagnosing and managing topical steroid withdrawal is a medical matter requiring referral.
Consent and honesty: the patient should be told what the practitioner suspects and why, in plain language, and should be involved in decisions.
Record: the product details as far as known (label, seller, duration and sites of use), the clinical findings, the suspicion and its basis, the advice given including the recommendation for supervised withdrawal, the referral made, the patient's response, and any report to a regulator. Keep the product details factual and avoid defamatory assertions in the notes; describe the findings and the suspicion rather than asserting fraud as fact. Retain records according to local requirements.
On testing: the practitioner can explain that testing is possible in principle but is not something they can arrange as a substitute for medical care, and that the clinical signs already warrant stopping.