|
|
|
Treatment of a Toddler with Eczema |
|
|
|
|
by Melanie Frankland
A female aged 2 years and 8 months presents with pruritic patches of dry scaly skin on torso and flexor surfaces of knees and elbows. The predisposing factor is genetics (Paige, 2002, p1283). The excitatory factors are environmental and food allergens, as well as vaccinations (Singh, Hahn and Sercarz, 1996, p1613-1622). Sustaining factors may also be environmental and food related. Others are not profoundly overt in this patient but stress and GIT need to be considered.
Differential Diagnosis Pruritis must be carefully assessed as there are a number of non-dermatological pathologies that have pruritis and skin rash manifesting insidiously as a sign. Both dermatological and non-dermatological related pruritis have been considered. Dermatological Atopic eczema: – Highly Likely. Itchy erythematous scaly patches, particularly in flexor surfaces of elbows and knees is classic presentation. In infants, the eczema starts on the face before spreading to the body Paige, 2002, p1283). This has also been reported. There is a strong genetic factor with atopic eczema and this is clearly the case for this patient, with both parents and a sibling presenting with forms of atopy.
Contact/ irritant dermatitis:- A possibility as a sustaining factor. This patient is not presenting with a skin rash in an unusual or localised area which is the common presentation. However, it can develop after repeated exposure to a chemical substance in those susceptible to allergic reactions- such as the atopic individual (Paige, 2002, p1286).
Psoriasis:- Less likely. Age of onset is approximately 16-22 years and 55-60 years. Common presentation is on the extensor surfaces of the elbow and knees. Flexural psoriasis does occur but this tends to occur in later life (Paige,2002, p1288).
Scabies:- Unlikely. This is highly contagious, other members of the family are not presenting with the same pattern.
Heat rash:- Highly unlikely. This is relieved in the summer months.
Non dermatological (Rafferty and Lim, 2002, p357)
Liver Disease:- Unlikely. No jaundice, dark urine or steatorrhoea, no spider navei reported. Because of age, patient is highly unlikely to have acquired liver disease, eg. Hepatitis B or C, unless mother has, this has not been reported. No fever or malaise.
Polycythaemia:- Unlikely. Pruritis after a hot bath is a classic presentation. Nothing comparable has been reported. Iron deficiency - anaemia does not have to be present in order for pruritis to occur.:- a possibility as research has shown that many children are deficient in iron (Pitchford, 1993, p253) . This may be a sustaining factor in this patient. Gallbladder disease:-Unlikely. Too young. No dark urine or steatorrhoea reported. No pain from accumaltion of bile salts. No fever or malaise. Diabetes:- Unlikely. 2-6 week history of polyuria, thirst and weight loss not reported. Renal disease:- Unlikely No lethargy, anorexia, nocturia, oliguria, polyuria, Haematuria, frothy urine from proteinuria, oedema or bone pain reported. Hodgkins lymphoma:- No lymphadenopathy, hepatomegaly, splenomegaly, fever or night sweats reported. Thyroid disease:- Unlikely. No heat intolerance, obvious weight loss, general anxiety or diarrhoea reported. No wide starring eyes, lid lag or tremors reported. These would indicate hyperthyroidism. No cold intolerance, mental slowing or unusual weight gain reported, which would indicate hypothyroidism. Tension/sleeplessness:- Likely as a sustaining factor. Working Diagnosis
Aims and actions and herbal indications
Treat skin topically to help relieve irritation:- will also help prevent scratching which further exacerbates this condition. Use an anti inflammatory, antipruritic and emollient cream. Use- Calendula officinalis, Stellaria media, Hypericum perforatum, Trifolium pratense, Althaea officinalis Radix, Avena sativa.
Improve integrity of skin. Decrease inflammation and nourish skin cells. Use- anti inflammatories, depuratives and anti allergics. Viola tricolor, Rumex crispus, Glycyrrhiza glabra, Echinacea purpurea, Matricaria recutitia, Urtica diocia.
Strengthen the GIT. Balance gut flora and promote gastric and pancreatic secretions. – Matricaria recutita, Taraxacum Radix, Gentiana lutea, Artemisia absinthium, Cynara scolymus.
Alleviate nervous tension. Provide trophorestoratives to the nervous system. Use Avena sativa, Matricaria recutita, Scutellaria laterifolia, Withania somniferons.
Prescription and Rationale
RX 1 Matricaria recutita glycerite 20mlGentiana lutea 1:1 5mlRumex crispus 1:1 20ml Viola tricolor 1:1 20ml Avena sativa 1:1 20ml Echinacea purpurea 1:1 15ml Glycyrrhiza glabra 1:1 5ml Sig: 15 gtts tds ac cum aq. Fluid extract for maximum absorbability and rapid action.
Matricaria is a relaxant, carminative, anti-inflammatory, antiallergic and a pre-probiotic. The azulenes, bisabolol and the flavanoids, particularly apigenin are all anti inflammatory and antispasmodic. Its pre probiotic nature will encourage commensal gut flora, soothing the gut and helping to resolve windiness as well as feeding the beneficial branches of the immune system. This will also benefit the lungs via a parasympatholytic action. Quercetin stabilises mast cells, thus reducing mast cell degranulation and histamine release – the perpetrators of atopic reactions. It is traditionally used for many ailments of small children including irritability and disturbed sleep. Gentian stimulates stomach and pancreatic secretions which will enhance immune function and decrease parasympathetic tone. it is also indicated for iron deficiency which may be a factor in this patient. Yellow dock is a gentle laxative that will improve elimination and has been traditionally used for eczema successfully. Improved elimination will decrease accumulation of toxins which may be exacerbating the eczema further. Heartsease is an anti inflammatory, depurative, anti allergenic and dermotrophic. It will help nourish and restore the skin. Another traditional herb for eczema. Echinacea is an immune stimulant, blood cleanser and anti inflammatory. It will help keep infection at bay both locally and generally. Oats are an excellent trophorestorative to the nervous system and particularly suitable for children. They are also rich in silica, a particularly good source of minerals for the skin. Liquorice will sweeten the mixture, as well as being an anti inflammatory and adrenal support. This will harmonise the mixture. This can be administered in drop form in the patients milk or juice. The fluid extracts used will help keep the drop dosage to a minimum. Although children can be adverse to strong tastes, their ability to comply should not be under estimated either. RX 2 Hemp seed Oil Sig: 5ml bds c.c. An excellent source of naturally balanced essential fatty acids, benefiting the skin, immune system, nervous system and every cell in the body. Can be easily added to cold foods such as cereal or yoghurt. RX 3Calendula cream 80ml Stellaria media Tr:10ml Hypericum perforatum Tr:10ml
Sig: Apply PRN
Calendula will act as an anti inflammatory, soothing the skin. Chickweed is an antipruritic, relieving itching of the skin. St Johns wort will help sooth sensory nerve endings, soothing the skin. Topical application to sooth the eczema will provide almost immediate relief.
Other recommendations
Systematic elimination of environmental and food antigens. This will help pinpoint excitatory and sustaining factors more precisely. Ask mother to observe which foods and products are most likely to aggravate. Completely remove common allergenic foods, i.e. dairy, solanaceae and wheat for 6-8 weeks. Then abruptly re-introduce one by one. Observe any reactions.
Remove sugar free squash from diet. Use only diluted fresh pressed juices. Sugar free squash still contains a myriad of questionable ingredients including preservatives such as the benzoates that are known to be skin irritants (Antczac,2001, p31).
Encourage more fish in the diet. This should take the form of oily fish such as salmon, tuna, mackerel and sardines. These are rich in the essential fatty acids EPA and DHA which are particularly relevant to the nervous system and brain function (Fitzsimmons, p37).
Reduce saturated animal fat. These fats stimulate series 2 prostaglandins which are the less desired prostaglandins (Fitzsimmons, p35). They are indicated in the type 1 hypersensitivity reactions that are presenting in this patient and her family. The withdrawal of dairy will help decease these fats.
Suggest to mother that she starts with five drops of the herbal fluid extract and builds up the dose one drop at a time per day to help develop the child’s taste to the mixture. If this advice is followed, it may be helpful not to mention to the child that there is anything different about her juice in order to decrease risk of resistance to the medicine.
Anticipated Outcome
Immediate relief of itching and inflammation from cream. Skin lesions should start to resolve after 2-3 weeks of treatment if advice regarding slowing increase to the recommended dose is taken and compliance is good.
Comments
Ask mother to observe if windiness is related to any particular foods. This will help pinpoint GIT factors. Also to observe if windiness is related to wheezing. This will help establish parasympathetic nervous system interrelationships (See appendix 1).
Discuss alternatives to eliminated foods. This will include wheat free breads and pastas and dairy free products such as rice, oats and sheep. The less the child’s diet appears to have changed the greater the chance of compliance. Discuss risks of calcium deficiency which can accompany a dairy free diet and offer alternatives, particularly the introduction of a mineral rich seaweed such as Arame, which is particularly light in texture and taste and has one of the highest bioavailabilities of calcium (Pitchford, 1993, p183).
Make the minimum amount of fuss about the changes whilst letting the child know that these changes will help with the discomfort she feels.
Treatment Plan Case Summary
|
|
|
|
