Integumentary system

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
Endogenous eczema 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

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
• Worsening skin rash that can ooze pus, making it prone to secondary infection	• Allergies that have not been properly diagnosed or managed	• James may be finding increased stress and anxiety due to an overwhelming study load • Determine if self-harm of skin is occurring – skin showing signs of bleeding
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
• Long-term use of corticosteroid cream, which suppresses the condition but does not treat the cause	• James is not providing sufficient nutrients for his needs • Poor quality of James’ skin • Stress and anxiety triggering or aggravating his condition • Asthma may be not be optimally managed	• Poor condition of James’ skin affecting his self-esteem, which may lead to social isolation
REFERRAL	REFERRAL	REFERRAL
• Medical check to diagnose the skin rash and review treatment options	• Allergy testing • Dietary assessment • Medical review of his asthma-management program and medication	• Counsellor to assess mental status

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)	Positive: ringworm, tinea, fungal infections, Candida Negative: dyshidrotic eczema on feet
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

Treatment aims

Lifestyle alterations/considerations

Dietary suggestions

Physical treatment suggestions

TABLE 11.11 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Albizia Albizia lebbeck

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]

TABLE 11.12 HERBAL TEA

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
Nettle leaf Urtica dioica	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]
Licorice root powder Glycyrrhiza glabra	2 parts	Anti-inflammatory [20, 19, 13]; antioxidant [20, 19]; adrenal tonic [20, 19]; immunomodulator [20, 19]; antiallergic action [13]
Cleavers Galium aparine	2 parts	Depurative [22, 39]; traditionally used for chronic skin disorders such as eczema [22, 39]
Skullcap Scutellaria lateriflora	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 fish oil 6000 mg daily [20]	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]
Quercetin 2000 mg daily in divided doses [20]	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]
High-potency practitioner-strength probiotic supplement containing therapeutic doses of human strain organisms including Lactobacillus rhamnosus GG [20, 48, 52, 56] Dosage as directed by the manufacturer	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]