Skin

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chapter 42 Skin

INTRODUCTION AND OVERVIEW

The skin is the most obvious organ in the body and every practitioner sees lots of it—about two square metres of it walks through the door with each adult patient. Skin is our interface with the environment and it always tells us things about the patient.

Every primary practitioner sees a wide variety of skin diseases in patients of all age groups, including eczema, psoriasis, infections, acne, urticaria, various pigmented lesions and solar damage including skin cancer. Up to 15% of general practice presentations are for skin conditions.

The skin can itch, burn, swell and appear unsightly, and this can frequently lead to anxiety or psychological reactions. The skin presents to the world and even an apparently trivial skin blemish may be considered a major problem by the patient. Many skin conditions can also cause such persistent discomfort and inconvenience in day-to-day living that patients feel restricted, even in the most basic of activities, resulting in loss of confidence, low self-esteem and diminished quality of life.

The more skin conditions can be understood and managed in relation to the patient’s general health, the more likely there is to be a cure, sustained relief or benefit to the patient as a whole.

This chapter is too brief to give a comprehensive coverage of skin disease. Instead, it provides a framework to enable a clinician to approach skin conditions from an integrative perspective, using some common conditions as examples. Some skin conditions are covered at greater length, with integrative approaches, while others have been included only briefly, to represent what is common in primary care practice.

As in other areas of medicine it is important to ensure that both diagnosis and treatment of skin conditions address causes, rather than suppressing symptoms alone. Skin conditions often have multiple contributing causes, including topical influences, autoimmune or genetic susceptibility, food factors and numerous ancillary triggers.

DIAGNOSIS

While diagnosis of many skin conditions relies on pattern recognition, sometimes it is elusive. A well-honed systematic approach is essential for diagnosis.

Systematic steps:

TREATMENT PLAN

Each skin condition requires specific treatment measures. In general, however, integrated management could include the following:

SPECIFIC SKIN CONDITIONS

In order to see how a well-honed systematic approach can be applied in practice, we will look at the management of some specific skin conditions. Some of these conditions are well managed using an integrative approach and are discussed more fully. Others require standard medical treatment alone, and many of these are covered only briefly, in order to provide a more representative picture of skin presentations.

ECZEMA

Eczema is the most common skin reaction. It is an inflammatory disorder and the term is interchangeable with dermatitis, although sometimes ‘dermatitis’ is used when the cause is external or exogenous (Box 42.1).

Constitutional or endogenous eczema

Atopic eczema

Atopic eczema is dealt with in detail here, as it is a good example of how a practitioner can make a great contribution to the wellbeing of the patient and their family, by employing integrative principles. This discussion emphasises management in children, where atopic eczema is most common, but the principles can be adapted to all age groups.

Atopic eczema is common, often very itchy and usually begins in young children from allergic families. Atopic patients have an allergic predisposition to asthma, eczema, hay fever, urticaria and other allergies. It is important to spend time with the patient, collecting information and piecing together the puzzle. Patients or parents will tell you the answers if you ask and listen. Avoid reflex prescriptions for medications, including nutritional supplements.

Atopic eczema can be likened to a slow-burning scrub fire. It is much more than a steroid-responsive dermatosis. Each patient needs to be managed with an appreciation of the causes, triggers and individual patterns of their disease.

The prevalence of atopic eczema and allergic disease has increased dramatically over the past three decades. One theory put forward to explain this is the ‘hygiene hypothesis’, which argues that early childhood exposure to infections inhibits the tendency to develop allergic disease. The idea behind this hypothesis is that bacterial and viral infections during childhood somehow ‘tone up’ the immune system and thereby reduce the tendency to develop allergic disease. Children in Western societies have a more hygienic and ‘sanitised’ lifestyle and a greater risk of developing allergic illness. The increasing prevalence of autoimmune disease may be related.

The cause of atopic eczema is probably multifactorial: genetic, immunological and environmental.

Other predisposing factors to be considered may include a family history of allergies, early introduction of cow’s milk or wheat, and of antibiotics (beta-lactam), vaccinations (pertussis, influenza), dust mite or cockroach exposure, a smoking parent and stress.

Atopic eczema will resolve in at least half of children by the age of five, but a significant number will go on to develop asthma. Atopic eczema is a T helper 2 (Th2) dominant disease.

Assessment

A detailed history should be taken, including suspected allergies, details of the diet and preparations used to treat the skin. The family will usually have suspicions about factors thaat may be contributing, and clues will emerge about foods or general triggers. These families have a child with a chronic disease that requires ongoing monitoring, considerable thought and a lot of care each day. The impact on the family as a whole needs to be appreciated.

Food sensitivity is more likely to be a factor in childhood eczema than in adults, and parents will often ask about this. Features in the history that suggest food intolerance as more probable than inhalant allergy include: early age of onset; past history of atopic disease; infective pattern to asthma; sinusitis, otitis media, glue ear or grommets; associated symptoms relating to other systems, such as irritable bowel syndrome, migraine, fatigue, behaviour problems in children; recurrent croup; positive family history of food problems; negative skin tests for inhalants; and a poor response to drug therapy.

Children tend to react to foods that they eat frequently or crave. Wheat, potato, tomato, cows’ milk and citrus are common food sensitivities that may contribute to eczema.

Sometimes skin testing for inhalant allergens, and particularly for those that can be avoided, such as house dust mite, cat or dog, can be useful. Radioallergosorbent test (RAST) is an alternative technique with blood testing to test for IgE-mediated allergies.

Most food sensitivity is not IgE mediated, and skin or blood testing (IgE or IgG) is not reliable in excluding food problems. The most accurate way of diagnosing food sensitivities is through food elimination and challenge dietary testing.

Treatment

These approaches are directed towards young children, but are adaptable to all age groups.

How much ointment will be needed? To work out the dose needed, use the ‘rule of hand’ (Fig 42.1).4 Four hand areas (using the area under the flat of the hand) requires one gram of ointment per treatment. For example, if ointment is being used daily over eight hand areas, this is 2 grams daily, and a 15-gram tube will last 1 week. It is important to prescribe an adequate quantity to last until the next review.