host posted on April 08, 2009 13:05
Dear Readers,
Skin problems are the bane of everyone but the dermatologist. In traditional medicine, the rules for treating dermatitis are this: “If it is dry, wet it. If it is wet, dry it. If it doesn’t respond to treatment, refer it to a dermatologist.” Not surprisingly, this doesn’t treat the cause. With that said, let’s begin this month’s case study.
Here is the disclaimer. This case study is for educational purposes only. I am using it to show you how a typical patient presents and the things I consider when I make a diagnosis. The patient’s name has been changed to protect her identity. I practice integrative/alternative medicine and my recommendations for treatment are often considered outside traditional practice. It is not my intent to criticize or denounce traditional medicine. I am merely providing an alternative opinion. Most importantly, the information provided here should not be used as a substitute for an examination and/or treatment by a licensed health care provider.
Presenting illness (Mom): Mrs. April is a 26 year old female who presented to the clinic with her husband and daughter for evaluation and treatment of chronic fungal/yeast infections. Mrs. April hoped that I would be able to make some recommendations for treatment of her daughter (Baby April) as well. Mrs. April reports that during her pregnancy with Baby April (BA)) she was diagnosed with vaginal bacterial and fungal infections. She was treated with multiple courses of antibiotics as well as with a few doses of an oral antifungal and a topical antifungal. Mrs. April began to dilate prematurely and received two courses of steroids in an effort to mature the baby’s lungs before birth.
Past medical history: Mrs. April reports that she has a history of childhood asthma with a recent reoccurrence during her pregnancy with Baby A. She has a history of irritable bowel syndrome, gastro-esophageal reflux disease and migraines.
Past surgical history: Mrs. April has had her wisdom teeth extracted. She underwent cesarean section for delivery of Baby A in 2008.
Medications: Mrs. April has an inhaler that she uses as needed for asthma.
Vitamins/Supplements: Mrs. April is taking olive leaf extract, probiotics and magnesium.
Social history: Mrs. April has a part-time job that allows her to work from her home. She does not smoke or drink alcohol. She reports that she exercises and is following an antifungal diet. Mrs. April’s first child is well and does not have any health or skin problems.
Review of systems: Mrs. April states that, as a child, she had recurrent episodes of strep throat which were treated with multiple courses of antibiotics. Mrs. April has had two pregnancies. Her first pregnancy was unremarkable and she underwent a normal vaginal delivery. However, after the birth of her first child in 2005, Mrs. April developed mastitis which was treated with antibiotics. (Mastitis is a clinical term for inflammation of the breast which can be caused by plugging of the milk ducts or cracks in the nipple through which an infectious organism can gain entrance to the breast tissue). During treatment for her mastitis, Mrs. April was also diagnosed with mononucleosis. Since her pregnancy with Baby A, she has not had a menstrual cycle. Mrs. April also reports a history of irregular menstrual cycles prior to her pregnancy. She does not have any root canals.
Physical examination: Weight: 91.5 lbs Height: 5’4”. Mrs. April’s physical examination was unremarkable with the exception of dry skin.
Presenting illness (Baby): Baby April is an 8 ½ month old, white female infant who was born via cesarean section, without complications. Baby April (BA) is a breast fed infant. BA developed baby acne which resolved spontaneously. Baby acne is a relatively common occurrence that develops during the weeks after birth. It is thought to be due to hormones that passed from mother to infant during the last stage of pregnancy. At two months of age, BA developed gastro-esophageal reflux. Baby April then developed a skin rash which was diagnosed as impetigo/eczema. She has been treated for this with the oral antibiotics bactrim and clindamycin and the topical antibacterials retapamulin and mupirocin. BA is currently being treated with the steroid skin cream and with oral hydroxyzine for itching.
Supplements/Vitamins: Baby April is on probiotics as well as magnesium.
Review of Systems: Mrs. April reports that Baby April began having problems with constipation at about two months of age. With regards to diet, BA was eating some baby foods for a short period of time but has not shown much interest in eating them lately. The rash covers most of her body and is very pruritic. Hydroxyzine is an antihistamine that has been found to be useful for management of itching due allergic skin conditions. Baby A is given hydroxyzine at night to prevent scratching and allow the baby sleep. Baby April is on breast milk and has recently been supplemented with a hypoallergenic baby formula.
Physical exam: Baby April has multiple areas of contiguous, red and honey colored, raised, dry and crusting skin, most prominently on her face, but also present on her scalp, arms, legs and trunk. The lesions are too numerous to count and cover the majority of her body. The worst areas appear on the baby’s face. The remainder of her physical examination is unremarkable.
I thought this case would be interesting because I believe that both Mrs. April and Baby April have chronic fungal infections. This is fairly obvious in the case of Mrs. April, based on her history, but is certainly more controversial with regards to Baby April. How can I call it a chronic problem in an infant? I realize that Baby April is only 8 ½ months old but she has had this problem her entire life.
Eczema is described as an inflammation of the skin, more commonly found in children although adults can have it, too. There are several types of eczema and sometimes a person can have more than one type. In Baby April’s case, I believe we are dealing with atopic dermatitis. According to EczemaNet (an online web resource hosted by the American Academy of Dermatology) 10-20% of the world’s population will develop atopic dermatitis, of which 65% will develop in their first year of life. Many of the cases of atopic dermatitis will resolve by the age of two; however, 50% may continue to have problems into adulthood. Traditional medicine holds that the cause of atopic dermatitis is most likely multifactoral and is thought to be due to the genes we inherit and to a malfunctioning, overactive immune system. Interestingly, the prevalence of atopic dermatitis in the United States is increasing.
Before birth, the fetal gastrointestinal tract is completely free of any bacteria or fungus. The infant begins the acquisition of gastrointestinal (GI) microflora during birth. The mother’s intestinal and genital microflora, maternal diet, medications, manner of delivery and birthing environment all influence its initial development. Infants who are born via cesarean section have this development altered. Since these infants do not pass through the birth canal, they do not acquire the initial exposure to the maternal microorganisms but rather the microbes from the hospital environment. Antibiotics given to the mother prior to the surgery (cesarean section) further effect the acquisition of normal intestinal microflora. Studies of infants delivered by cesarean section have consistently found that establishment of an intestinal microflora is delayed and imbalanced.1
Why all the concern about intestinal microflora? The gastrointestinal tract is one of our main routes of contact with the external environment. What most people do not realize is that the gastrointestinal system is actually the largest immune organ in the body and represents almost 70% of our entire immune system. This immune organ is referred to as the gut-associated lymphoid tissue (GALT).2 If you have gastrointestinal dysbiosis (leaky gut), your immune system is compromised. Gastrointestinal dysbiosis is associated with a multitude of problems, including but not limited to irritable bowel syndrome, food allergies, malabsorption of vitamins and nutrients and most chronic medical diseases.
Assessment/Plan: Mrs. April clearly has problems with chronic fungal disease. I am certain she has gastrointestinal dysbiosis. Irritable bowel syndrome and gastro-esophageal reflux disease are symptoms of this problem. I have recommended that she begin on a course of ketoconazole and nystatin. She is already following the antifungal diet. I have also recommended that she start on an iodine supplement to support her thyroid. I have not seen a patient with chronic fungal disease who did not have a problem with thyroid metabolism.
Children and infants are not little adults, which is why pediatrics is a separate specialty. Mrs. April may have been my scheduled evaluation but it was immediately clear that the appointment was as much for Baby April as it was for her mom. My plan for treatment of Baby April is “from the hip” as there are no real guidelines for this. Well, that is not exactly true but current treatment of Baby April has not been successful to this point. Traditional treatment is symptomatic at best and takes a “wait and see” approach. She might “grow out of it” but ,as I stated before, 50% may continue to have problems into adulthood. “If you always do what you’ve always done, you’ll always get what you’ve always got” (Doug Kaufmann)
I felt that Baby April needed to be on a systemic antifungal, so I recommended that she be started on ketoconazole. Ketoconazole has been less studied than nystatin with regards to infants but it has been used for treatment of infants with oral thrush with success. A compounding pharmacy can make it in a liquid form for use in infants and children. I also recommend that Baby A should have her liver enzymes checked before beginning treatment and after 30 days of treatment.
My next recommendation is a little more controversial. I recommended that Mrs. April discontinue breast feeding. There is no question that breast milk is highly superior to any infant formula; this has been extensively studied and documented. In this case, given her history, I strongly believe that Baby A’s eczema may be an “id reaction.” The id reaction is thought to be an allergic response to a fungal infection or antigen (mycotoxin). I would like to decrease Baby April’s exposure to mycotoxins. There is a strong chance that ,when Mrs. April begins her own treatment with the antifungals, she will have significant die-off with release of large amounts of mycotoxins into her system. Mycotoxins can be passed through the breast milk. Mrs. April and I discussed this issue at length. Mrs. April is not entirely comfortable with the idea of discontinuing breast feeding. I think that Baby April could be slowly introduced to pureed vegetables and fruits, as well as water and juices, which would most likely resolve any constipation problems. I also recommended that she be kept on probiotics. My ultimate goal is to restore the normal gastrointestinal flora of Baby A and try to prevent the development of other chronic medical problems. She has a whole lifetime ahead of her.
For those of you who are interested in learning more about the fungal link to chronic medical disease, I recommend: The Fungus Link Volumes 1-3 by Doug Kaufmann.3 I have also included the other sources of information I have used in this article.
Blessings,
Lynn Jennings, M.D.
Champions Clinic
1: Olmstead S, Snodgrass R, Meiss D, Ralston J. Mictrometabolic Imprinting in Infancy: Microflora, Probiotics and Chronic Disease ProThera, Inc Technical Summary
2: Vighi G, Marcucci F, Sensi L, Di Cara G, Frati F. Allergy and the gastrointestinal system. Clin Exp Immunol. 2008;153(1Suppl):3-6.Review.
3: Kaufmann, D. The Fungal Link. 2000
http://www.aatf-africa.org/UserFiles/File/Mycotoxin.pdf
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1519940