Chapter 11 Integumentary system
Eczema
Case history
James’ mother tells you that she has allergic rhinitis and had childhood asthma and eczema. She is quite concerned about James at the moment because she has personal experience of how unpleasant and stressful eczema can be.
TABLE 11.1 COMMON AREAS OF INVOLVEMENT AND CAUSES OF ALLERGIC CONTACT DERMATITIS [1–8]
| Analogy: Skin of the apple | |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Onset | James says he has always had problems with skin rashes. Recently it has become worse and is spreading to his feet. |
| Exacerbating factors | |
| What do you think makes it worse? | I’m not really sure, but it’s much worse since I started to get really stressed about school. It feels worse after I wash and also when I’m in bed at night. |
| Relieving factors | |
| What makes it better? | The cream the doctor gives me, but that doesn’t stop it coming back. |
| Location and radiation | James tells you the rash started in the folds of his elbows and knees and then went to his face, hands, behind his ears and scalp. Now it is spreading to his feet. |
| Examination and inspection Have you noticed your toe/finger nails have developed ridges? (eczema) | |
| Rating scale | |
| On a scale of 1 to 10, with 1 being perfect skin and 10 being the worst you have had, how would you rate your skin at the moment? | Probably about 7 or 8 I think. I don’t like anyone seeing it because it’s so disgusting. |
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Family health | James’ mother has a history of childhood eczema, hayfever and asthma |
| Allergies and irritants | |
| Recreational drug use | |
| No. | |
| Occupational toxins and hazards | |
| Are you exposed to any chemicals at school, maybe in science or other subjects that might be a problem for your skin? | I don’t know. I try not to get anything on my skin in science or woodwork. |
| Infection and inflammation | |
| Has your skin ever been infected? Do you think there is any infection now? | Sometimes in the past I had to have antibiotics. There are couple of spots at the moment that are oozing so maybe they’re infected, but I’m not sure. |
| Stress and neurological disease | |
| You said your stress levels have gone up recently. Can you tell me about this and whether you think if affects your skin? | Yeah, I’m in Year 12 and now they’re really piling the work on so I feel pretty stressed. I think stress must make my skin worse since it’s worse since my stress increased. |
| Eating habits and energy | |
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Emotional health | |
| Do you have any significant fears or anxieties at the moment? | Not really, just stress about school and hoping my marks will be good enough to get me into uni. |
| Stress release | |
| What are you doing to deal with your stress? | Just having down time when I can. When I’m not studying I probably spend most of my time on the computer. |
| Family and friends | |
| How do you get on with your family and friends? | Pretty good most of the time though my little sister is really annoying. I see my friends at school and we usually go out on the weekends. |
| Home life | |
| How do you feel at home? | Good. Sometimes Mum and Dad get on my nerves but they’re pretty good really. |
| Action needed to heal | |
| What do you feel you need to do to get your skin under control again? | I think something to put on it and maybe some medicine. Maybe be less stressed. |
TABLE 11.4 JAMES’ SIGNS AND SYMPTOMS [1, 2, 9]
| Pulse | 75 bpm |
| Blood pressure | 120/75 sitting |
| Temperature | 37.8°C |
| Respiratory rate | 12 resp/min |
| Body mass index | 24 |
| Waist circumference | 85.8 cm |
| Face | Mild erythema on cheeks and around skin line |
| Inspection of skin on the hands and body | Skin red with signs of secondary thickening and lichenification of the skin; skin trauma (excoriation) from scratching and areas of severe erythema; broken skin in skin folds of knees and elbows and joints of fingers has caused weeping of pus and showing signs of bleeding |
| Urinalysis | No abnormality detected (NAD) |
Results of medical investigations
No medical investigations have been carried out.
TABLE 11.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2–4, 64, 67]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| INFECTION AND INFLAMMATION | |
| Plaque psoriasis vulgaris: onset from 15 years of age is common, can cause plaques of skin on scalp, knees and elbows, can come and go and be worse at times of stress. | Scalp can be involved but usually does not spread past the hair margin; usually dry and does not have vesicles that ooze pus; presents as silvery loose scales with sharp margins; skin rash usually only on extensor surfaces of extremities; not common to have facial skin rash; more common to have arthritic involvement |
| ENDOCRINE/REPRODUCTIVE | |
| Diabetes: sometimes children with diabetes will manifest eczema-like skin rashes | Uncommon; urinalysis NAD |
Case analysis
TABLE 11.6 POSSIBLE DIFFERENTIAL DIAGNOSIS
| Not ruled out by tests/investigations already done [2–5, 9, 10, 59–68] | ||
| CONDITIONS AND CAUSES | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
Atopic eczema: the word ‘atopy’ means to react to common environmental factors; can be caused and aggravated by diet, genetic factors, heat, humidity, drying of the skin, contact with woollen clothing, animal saliva touching the skin; house dust mite allergy is thought to be an important factor in facial eczema | Skin rash that causes itching; begins with small vesicles and then spreads to produce thickening of the skin and weeping of pus and blood if scratched excessively; associated with a history of asthma; presenting in flexor folds of the knees, behind the ears, hands, scalp, elbows and face; lesions cause irritation and scratching; lesions worse for anxiety; symmetrical lesions; eating potentially allergic/intolerant foods such as wheat and dairy; maternal link with atopy | |
| The rash is on areas of the body that have close contact with irritants and where chemicals may be applied on the skin such as hands, wrists, neck, eyes, hair, knees; can present in adults and children | Usually asymmetrical lesions in exposed areas and displayed in streaks; determine whether James’ rash is occurring on the palm of his hands; usually presents with no family history of eczema/atopy | |
| Contact eczema – allergic from repeated exposure to chemicals resulting in the development of an allergic reaction; common allergens include nickel, chromate, latex, perfumes and plants | The rash is on areas of the body that have close contact with irritants and where common contact allergens may be applied on the skin; often occurs with repeated exposure; family history of atopy | |
| Photosensitive eczema | Typical features of eczema and thickening of the skin; often occurs in individuals with pre-existing eczema (diagnosis can be missed); can be distributed over areas that are exposed to the sun such as the hands, face and neck; may also spread to areas of the body where the skin is not directly exposed to sunlight | Rare type of eczema, usually develops in middle-aged or elderly men; can develop photosensitivity to artificial lighting |
| Shoe dermatitis: due to chrome in leather tanning | Red scaling of the feet and toes; can occur in adults or children | |
| Atopic asthma | Comes and goes, associated with eczema, could be associated with foods as well as stress | Unclear if additional triggers include cold air, emotion, irritants in a particular environment, pollution, medication or recent viral infection |
| Dermatitis herpetiformis | Extremely itchy rash that is symmetrically distributed over extensor surfaces of the body; this condition is usually associated with gluten-sensitive enteropathy, which can be asymptomatic; James is eating a lot of gluten-containing foods; common to present in early adulthood | James has no significant abdominal symptoms of pain, bloating, diarrhoea or constipation associated with his skin rash; usually associated with bullae (fluid filled palpable mass); more common to present on trunk of the body |
| FUNCTIONAL DISEASE | ||
| Dermatitis artefacta: personality disorder; a person will injure their own skin | High levels of stress and anxiety; skin showing signs of bleeding | Unclear if James is consciously causing his skin lesions and scratching lesions due to stress and has self-destructive tendencies |
| INFECTION AND INFLAMMATION | ||
| Seborrhoeic dermatitis: affects those areas of the skin where there are sebaceous glands such as the face and scalp and occurs more with times of stress [62] | Occurs on the scalp beyond hair margin; usually undefined margin; can present in small percentage of young male adults in areas of scalp (with dandruff) | Need to determine whether James has yellow greasy scales on his skin; usually occurs in different locations to atopic dermatitis or eczema such as in the centre of the chest, between the nose and lips, eyebrows, navel, groin; develops as ‘cradle cap’ in young children; more common as an associated symptom of serious illness in adults and the elderly such as Parkinson’s disease and HIV |
| Exfoliative dermatitis: drug therapy, systemic disease, or an idiopathic entity | Scaling of skin; skin rash usually in flexor surfaces | More commonly develops after the age of 40; generalised skin eruption that can cover the whole body |
| Inverse psoriasis | Will involve flexor skin folds such as the ears; presents as red inflamed areas | Also common areas are axillae, groin, navel, intergluteal crease, penis, lips and webspaces between fingers and toes; does not usually have the white silver scales of typical psoriasis |
| Dyshidrotic eczema: on the feet | Itching vesicles and rash on feet | Usually presents in older adults; need to determine whether the lesions on James’ feet began with feet/toes breaking out in blisters; common to present with coarse pitting of nail beds; check for ridging across the nails |
| Nummular eczema (discoid eczema) | Scaling plaques on elbows and knees; can present in adults or children; can be anywhere including hands; oozing and itching of lesions is a common symptom | Typically found on extensor surface of extremities, back, buttocks, and hands; coin-shaped lesions |
| Tinea capitis: fungal infection of the scalp | Lesions often occur on the scalp and it is common in adolescents and adults; can be mild diffuse scaling with no hair loss | More commonly causes patchy hair loss (alopecia); circular scaly patches seen over the entire scalp; in severe conditions pus may form and a crusted ‘boggy’ scalp will develop; depending on type of fungus it may or may not appear under Wood’s light test |
| Tinea pedis: fungal infection of the feet, between toes | Plaques can appear like nummular eczema; lesions have defined borders; scaling, vesicles and itching | Determine whether the itch is worse in heat; usually red scaly patches with clear centre and redness at the edge; fungal infection of one or more toenails can develop |
| Scalp bacterial infection | Lesions on the scalp | More common in younger children; need to determine whether there are pustular lesions |
| Pediculosis on scalp | Widespread itching on scalp | No report of visually seeing white nits on the hair shaft; more common in young children |
| STRESS AND NEUROLOGICAL DISEASE | ||
| General anxiety disorder (GAD) | Has been at least 6 months of tension and stress about everyday events; anxiety disorder is often associated with threat of a loss (study stresses, fears about losing marks, what to do when he finishes school); craving junk food/sugar | |
| Hyperventilation syndrome – functional breathing concern (causes include increased CO2, fatigue, muscle pain and digestive complaints) | Shortness of breath, breathing quickly, hyperventilation syndrome can be a consequence of chronic anxiety, irritability; habitual patterns of breathing are developed to keep CO2 levels low that leads to anxiety-provoking consequences | James has not mentioned significant muscle pain or fatigue |
Working diagnosis
James and eczema
Atopic eczema can be caused and aggravated by diet, genetic factors, heat, humidity, drying of the skin, contact with woollen clothing, animal saliva touching the skin and house dust. There is a strong genetic maternal link with atopic eczema and a family history of asthma may be associated. Characteristic features of eczema are red and hot skin usually in the flexures of joints such as the ankles, knees, elbows and around the neck. Swelling is common in acute stages of the rash, with weeping and oozing of fluid to the surface of skin developing after the acute stage. Crusting over of this fluid causes scaling, fissuring and excoriation that can cause intense itching. Chronic scratching can lead to secondary infections and if they are extremely bad over a large area of the body, impaired thermoregulation and increased blood flow can lead to cardiac impairment.
General references used in this diagnosis: 2–4, 59–61, 65, 68
TABLE 11.7 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL
TABLE 11.8 DECISION TABLE FOR REFERRAL [2–5, 10, 11]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
| ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE |
| REFERRAL | REFERRAL | REFERRAL |
TABLE 11.9 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 3, 5, 9, 10]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Skin examination by GP/dermatologist | Clinical diagnosis of a skin disorder by sighting the skin lesions; often diagnosis made by seeing the lesion |
| Chest examination: auscultation, percussion | Signs of asthma, obstruction, infection |
| Nijmegen questionnaire | Hyperventilation syndrome |
| Food diary | To help determine any foods that may be triggering or aggravating symptoms |
| Full blood count | Any fever, bacteria or viral association with the skin rash |
| ESR/CRP blood test | Indicates level of inflammation; whether bacterial/viral cause |
| Serum IgE blood test | Atopic eczema and allergic triggers for asthma |
| Skin prick testing | Response to immediate contact allergies test for extrinsic-specific allergies |
| Skin patch tests to particular allergens | Review 2–4 days later for specific delayed contact allergies |
| Rast test (blood) | Test for ingested or inhaled antigens |
| IF NECESSARY: | |
| KOH test of skin discharge/lesion (potassium hydroxide) | |
| Wood’s lamp examination (hand-held ultraviolet light shines certain colours for specific conditions) | Fungus: fluorescent |
| Skin biopsy | Psoriasis, eczema, fungus |
| Monochromator light-testing | Photosensitive eczema |
| Antigliadin antibody blood test | Definitive test for gluten allergy |
| Lung function tests (forced expiratory volume (FEV), peak expiratory flow rate (PEF)) | Will be reduced in asthma |
| Exercise test | Asthma |
| Capnometer/pulmonary gas exchange during orthostatic tests | Hyperventilation syndrome |
Confirmed diagnosis
Atopic eczema with associated atopic asthma
Prescribed medication
TABLE 11.10 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
Treatment aims
• Prevent and relieve the itch [13, 16, 31].
• Reduce the inflammatory response in James’ skin [12].
• Promote skin healing and improve the skin quality, hydration and barrier function [14, 17, 31].
• Normalise essential fatty acid and prostaglandin metabolism [12, 13, 46].
• Balance James’ immune system, normalise his TH1 and TH2 balance [12–15] and reduce excess histamine release [13].
• Identify and reduce or eliminate exposure to food and environmental allergens [13, 15, 26, 31, 49].
• Identify and reduce or eliminate exposure to other trigger factors [12, 15, 31].
• Identify and correct nutritional deficiencies [13, 14] and improve James’ diet.
• Improve James’ digestive function, intestinal microflora [14, 47, 48] and support his eliminative process [18].
• Improve James’ stress response and reduce stress levels [14, 15, 50].
• Educate James about ways to better manage his condition to improve his quality of life [16, 31, 50].
Lifestyle alterations/considerations
• Encourage James to avoid using soap or soap-based products [13, 20, 30, 31] and use pH-balanced, soap-free alternatives instead [30, 20]. He should apply moisturiser immediately after bathing [12, 20, 31].
• Encourage James to bathe in warm rather than hot water [12, 20, 31].
• James may find soaking in a tepid oatmeal bath soothes his skin and reduces itching [12].
• Encourage James to avoid wearing fabrics that irritate his skin [13, 31]. Clothing should be washed in mild soaps and rinsed thoroughly [13].
• Encourage James to determine the environmental triggers to his eczema and avoid them wherever possible [13, 31, 32]. These may include house dust mites, chemicals, perfumes in personal care products or detergents, climate and airborne allergens [13, 32].
• Testing for food or chemical sensitivities may be helpful [14, 32].
• Encourage James to try to find techniques to help him avoid scratching his skin [13, 14, 30]. Scratching damages the skin, increases the chance of infection and increases lichenification [13].
• James may benefit from stress-management techniques and/or psychotherapy to help him manage the stress-related triggers of his condition [13, 32, 50].
• Encourage James to engage in a form of physical exercise that does not aggravate his eczema. Exercise is strongly associated with decreased levels of stress, anxiety and depression [35, 36].
Dietary suggestions
• Food allergies or intolerances should be identified and managed by removing them from the diet [12–14, 26, 32]. Common allergenic foods include dairy food, wheat, eggs, citrus fruit, peanuts and soya [14, 15, 26, 38].
• Encourage James to increase his intake of omega-3 fatty acids from cold-water fish, almonds, walnuts, pumpkin and flax seed [12, 14, 20, 33]. James should eat oily fish at least three times per week [13, 14]. Omega-3 fatty acids can reduce the severity of eczema and improve skin quality [53, 54].
• Encourage James to ensure he drinks sufficient water to ensure adequate skin hydration [14, 31].
• James needs to improve his diet and increase consumption of antioxidant-rich whole foods providing adequate levels of essential nutrients and antioxidants [49, 51].
Physical treatment suggestions
• James may find massage therapy beneficial for both his symptoms of stress and his anxiety [25, 40] as well as for his eczema [26].
• James may find acupuncture therapy helpful for his anxiety symptoms [27, 28]. Acupuncture also has immune modulating effects, which may also be beneficial [29].
• Hydrotherapy: constitutional hydrotherapy to assist immune function and tone lungs [41, 42, 45]. Oatmeal half-neutral bath 20 minutes twice daily [43, 44]. Alternate hot/cold douche shower direct to thighs and upper chest to tone the body [44]. Cold sponge bath on the body before bed to ease the rash [44].
TABLE 11.11 HERBAL FORMULA (1:2 LIQUID EXTRACTS)
| HERB | FORMULA | RATIONALE |
|---|---|---|
| 45 mL | Antiallergic [19, 20]; traditionally used for eczema [19, 20]; stabilises mast cells [19, 20] | |
| 40 mL | Antioxidant [20, 21]; hepatoprotective [20, 21]; traditionally used as a depurative for eczema [20, 21] | |
| 50 mL | Beneficial in inflammatory disorders involving the immune system [19, 21], particularly allergic skin rashes [19]; may help protect against suppressive effects of corticosteroid therapy [19, 21]; traditional therapeutic use for skin rashes [13, 19, 21] | |
| 20 mL | Depurative [22]; traditionally used for skin disorders, especially eczema [22, 23] | |
| 45 mL | Adaptogen [19, 20]; immunomodulator [19, 20]; anti-inflammatory [19, 20]; antioxidant [20]; tonic [19]; cognitive enhancer [20]; beneficial in stress [19, 20] and anxiety [20] | |
| Supply: | 200 mL | Dose: 5 mL 3 times daily |
Licorice (Glycyrrhiza glabra) applied topically in the form of a gel is effective in reducing redness, swelling and itch in atopic dermatitis [13, 24, 19]
Calendula (Calendula officinalis) cream is soothing and healing to the skin [12, 20]
| Can be used as an alternative to the herbal tonic or taken in conjunction with the herbal tonic as an alternative to tea and coffee | ||
| HERB | FORMULA | RATIONALE |
| 3 parts | Anti-inflammatory [20]; antioxidant [20]; depurative [22]; antiallergic [22]; traditionally used in skin conditions such as eczema [20, 22, 23]; specifically indicated for nervous eczema [23] | |
| 2 parts | Anti-inflammatory [20, 19, 13]; antioxidant [20, 19]; adrenal tonic [20, 19]; immunomodulator [20, 19]; antiallergic action [13] | |
| 2 parts | Depurative [22, 39]; traditionally used for chronic skin disorders such as eczema [22, 39] | |
| 1 part | Nervine tonic [22]; sedative [23]; indicated for use in nervous tension and anxiety [22, 23] | |
Infusion: 1 tsp per cup – 1 cup 3 times daily
TABLE 11.13 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| High-potency practitioner-strength multivitamin, mineral and antioxidant supplement containing therapeutic doses of vitamins A, C, D and E, zinc, selenium and B-group vitamins [12–14] | Optimal levels of essential nutrients are associated with reduced symptom severity in eczema [49]; oxidative stress and altered antioxidant function is involved in acute atopic dermatitis [51]; zinc deficiency is common in atopic dermatitis [13] |
| Omega-3 fatty acids regulate inflammatory prostaglandin formation [33]; deficiency is associated with dry, itchy, peeling and flaky skin [33]; omega-3 fatty acids have anti-inflammatory and immune-modulating properties that may be beneficial in atopic dermatitis [14, 20]; people with atopic dermatitis have altered essential fatty acid and prostaglandin metabolism [13]; the ratio of omega-3 to omega-6 fatty acids is lower in people with atopic dermatitis [13]; supplementation with 6000 mg of omega-3 oils daily improves clinical symptoms of atopic dermatitis [53, 54]; reduces plasma catecholamine levels thereby reducing anxiety levels via the HPA axis [34] | |
| Antiallergic [20, 33, 57]; antioxidant [20, 33, 57, 58]; immunomodulator [20, 57]; anti-inflammatory [20, 33, 58]; inhibits inflammatory enzymes, prostaglandins and leukotrienes [20, 57], stabilises mast cells [20, 57] and inhibits histamine release [33, 57] | |
| Moderates inflammatory and immune responses [20, 56]; strengthens intestinal barrier function [20, 56]; supplementation with probiotics may reduce the severity of symptoms in established atopic dermatitis [20, 55, 56]; effective in the primary prevention of eczema [48, 52, 55, 56] |
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