Medical mystery: A young lifeguard, an unusual skin condition
My young patient thought he was dealing with a flare of his eczema. Testing revealed he had bigger problems.
A 14-year-old patient of mine came in for a routine physical. He had a history of mild eczema and asthma but he was excited to start his summer job as a lifeguard, and then high school in the fall.
His only complaints were intermittent stomach pain for several months and an eczema flare that had been going on for the last few weeks. He was concerned — and self-conscious — especially about his eczema because he had it on his elbows, shoulders, and buttocks, and was facing hours in a swimsuit seated in a lifeguard chair.
He complained that the eczema was more itchy than in the past, and that there were small blisters scattered within the lesions. He wasn’t too concerned about his belly pain, and figured it might be connected with the pressure of starting school, employment, and now his eczema flare.
Other than his skin problems, his physical exam was completely normal including his abdominal exam. On both his elbows, his lower thighs, knees, and buttocks, he had multiple small red bumps with scattered small blisters mixed in.
He had a theory about that, too. “I spend a lot of time gaming” he explained, “and I have my computer on my lap a lot and elbows at the ready position leaning on the chair arms.” He thought that the pressure and friction of this activity could be exacerbating his eczema.
The exam suggested that his growth was slowing down, which was a little unusual because he was starting puberty and this usually causes an acceleration in height.
“Please do something about my eczema” he pleaded. “I start work in two weeks.”
I wrote him a prescription for a high-dose steroid to help with the itching and inflammation, but also sent him to our lab for a few tests.
Solution
Louis Duhring was an American physician and professor of dermatology at the University of Pennsylvania until his death in 1913. He was considered a leading authority in American dermatology, and is remembered especially for describing a condition that he called dermatitis herpetiformis.
As the name implies, and as the rash presents, it looks like typical herpes lesions (small blisters) on the skin. What Duhring did not know, and what wasn’t recognized until 1967, is the association with one of the most common gastrointestinal disorders worldwide, gluten sensitive enteropathy, or more commonly, celiac disease.
An estimated one in 100 teens and adults worldwide have celiac disease, in which the body responds to food containing gluten (wheat, rye, and barley) with an immune reaction that damages the small intestine. This leads to problems such as: trouble absorbing foods, affecting growth in children; chronic abdominal pain; risk of other autoimmune diseases such as Type 1 diabetes; and anemia. Long-term complications can include heart disease, osteoporosis, infertility, and intestinal cancer. The only treatment for persons with celiac disease is a lifelong avoidance of gluten.
Another manifestation of celiac that can precede any other symptom, is dermatitis herpetiformis — the chronic, intensely itchy rash that my patient has. The immune cells that affect the intestines in celiac disease can also deposit in the skin, especially in areas of friction and pressure (his game chair). There are various treatment options, but once a gluten-free diet is initiated, the lesions will slowly resolve.
His tests for celiac came back positive and our gastroenterologist confirmed by intestinal biopsy that he could never eat gluten again.
In typical teenage fashion, on followup, his main concern was not about the long-term complications of this disorder, but if his rash would be gone before the start of high school. In his case, his skin provides him extra incentive to follow his gluten-free diet.
Daniel R. Taylor, D.O., is an associate professor at Drexel University College of Medicine and director of community pediatrics and child advocacy at St. Christopher’s Hospital for Children.