Case Studies
Case 4.11 Atopic eczema
Ryan, aged 2 ½ years, was referred to hospital with extensive eczema. It started behind his knees at the age of 7 months when solids were first introduced into his diet and steadily worsened. The areas affected were the popliteal and antecubital fossae, arms and abdomen. He scratched the eczematous lesions, especially at night, with the result that his and the family's sleep was badly disturbed. Ryan had a strong family history of atopic disease; his mother and maternal grandmother both suffered from asthma. On examination, his height and weight were around the 50th centile. He was covered in extensive eczema, involving 60% of the total skin area.
Laboratory investigations showed a normal haemoglobin (123g/l) with a raised white cell count (16.0 x 109/l): the differential count showed relative (9%) and absolute (650/mm3) eosinophilia. His total serum IgE level was markedly raised at 4600iu/ml (NR for age <50iu/ml) with strongly positive RASTs (see Section 19.8) to grass pollen, cat epithelium, dog dander, house dust mite, cow's milk, wheat and peas. Skin-prick testing was not considered in the presence of such widespread eczema. Samples of dust from his home showed very high levels of house dust mite in the carpet and on several toys.
He was treated with antihistamines at night and liberal applications of an emollient cream to his skin lesions. Environmental control of antigen exposure was also attempted: the mite count was lowered by changing carpets, and covering the mattress, pillows and duvet with covers impermeable to mite allergens, and the cat was found a new home. Ryan was put on a diet free of cow's milk, wheat, oats, peas, beans, nuts, food preservatives and food colourings. Over the following 3 months, there was only partial improvement in the severity of his eczema.
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