CASE STUDY
The Effect of Dietary Change in a Patient With Ichthyosis Vulgaris: A Case Report Brian Anderson, DC, CCN, MPH, MS
Abstract Ichthyosis vulgaris (IV) is a genetic skin condition of autosomal dominant inheritance. The main symptom associated with IV is scaling of the skin. Traditional treatment involves the application of various topical creams or ointments. The current case study documents significant improvement in the symptoms of a 20-y-old
Brian Anderson, DC, CCN, MPH, MS, is an attending clinician at the National University of Health Sciences in Lombard, Illinois. Corresponding author: Brian Anderson, DC, CCN, MPH, MS E-mail address: [email protected]
I
chthyosis vulgaris (IV) is a genetic skin condition of autosomal dominant inheritance. The term ichthyosis was coined more than 200 years ago from the Greek word for “fish”.1 IV is the most common type of ichthyosis, with an incidence of 1:250 live births.2 The genetic mutation involves decreased production of a protein in the skin called filaggrin (ie, filament-aggregating protein).3 This protein is broken down into its constituent amino acids, which become osmotically active and maintain hydration in the stratum corneum.4 Approximately two-thirds of patients have 2 filaggrin mutations, causing relatively serious disease, whereas the remaining one-third have 1 mutation and a milder disease.5 Filaggrin deficiency increases ultraviolet sensitivity markedly in vitro. This sensitivity could potentially explain the allegedly higher prevalence of nonmelanoma skin cancer in patients with ichthyosis and atopic dermatitis (AD). In addition, Thyssen et al6 have found that increased permeation of chemicals and allergens occurs across filaggrin-deficient skin. Anderson—Ichthyosis Improvement With Dietary Change
female patient with IV through use of dietary change based on food-sensitivity testing and supplement use— fish oil, vitamin D, and probiotics. She had previously used traditional topical therapies with less than optimal results. More research is required to substantiate the changes documented in this report.
The main symptom associated with IV is scaling of the skin. The scales are fine, white, and irregular and curl up at the edges, giving a rough feel. The extensor surface of the extremities is primarily involved. The palms and soles often show mild hyperkeratosis (thickened outer skin layer). Another characteristic feature is keratosis pilaris, which are spiny parafollicular papules that feel like a cheese grater when palpated.1 Fifty percent of patients with IV develop AD, and a further 20% develop rhinitis and/or bronchial asthma. Symptoms often spontaneously resolve in the summer, whereas they worsen in the winter.5 Medical therapy for IV is somewhat limited. Nearly all patients with ichthyosis show improvement through use of systemic retinoids. However, the side effects of long-term retinoid use include the development of ligamentous calcifications, teratogenic effects (birth defects), epiphyseal (growth plate) fusion, and diffuse skeletal hyperostosis (hardening of ligaments).7 Topical creams and ointments, including urea, lactic acid, glycerin, and vitamin A, are all used with varying levels of success. Beyond looking at blood levels of various essential fatty acids in patients with IV,8 the role that diet might play in this condition has largely been ignored. Case Report This case report describes a 20-year-old female who consulted with the author, a chiropractic physician, for treatment alternatives related to a diagnosis of IV. She had been diagnosed with the disease by a dermatologist at age 14 years. From a very young age, the patient had suffered Integrative Medicine • Vol. 14, No. 3 • June 2015
55
Figure 1. Lower leg photos before and after intervention. Figure 1A shows the patient’s right foot preintervention in December 2013; Figure 1B shows the same foot postintervention in March 2014.
56
Figure 1A
Figure 1B
from dry, itchy, and scaling skin. She described her symptoms as “cracking, bleeding skin.” Her initial diagnoses included atopic disease, asthma, and dry skin. During the winter months, her skin would get significantly worse, involving the hands and face. Various topical preparations were attempted, with none having any success. Initially her parents were applying ammonium lactate cream, which was very painful. This cream was then cut with Eucerin cream, which decreased the burning, but the symptoms returned whenever she stopped using it. She eventually stopped using all medications, because she believed that they were not helpful. The patient’s mother believed that all of her symptoms had started on introduction of solid foods as a child. In addition to her dermatological complaints and asthma, the patient had suffered from constipation for her entire life. She also described bumpy, red lesions on the extensor surfaces of both upper extremities. On examining her, the author noted that the classic signs of IV were present: (1) hyperkeratosis around the lateral malleoli and calcaneus; (2) fine, white scaling outlined with erythema that was most prominent in the distal part of her lower extremities bilaterally; and (3) keratosis pilaris on the extensor surfaces of her upper extremities bilaterally. A food-sensitivity test revealed sensitivity to a number of foods, including dairy, eggs, peanuts, spelt, whole wheat, gliadin, gluten, and baker’s yeast (Table 1). It was suggested to the patient that she should eliminate those foods from her diet, which she did. Noticeable improvement in her skin condition was evident within 2 weeks. The cracking in her skin improved dramatically (Figure 1). The asthma symptoms, previously controlled with fluticasone and salmeterol, practically disappeared, and her constipation completely resolved. The patient’s improvement plateaued somewhat after 1 month. At that point, the patient was prescribed several daily supplements, including (1) fish oil—2 capsules, each
containing 360 mg eicosapentaenoic acid and 240 mg docosahexaenoic acid; (2) vitamin D—5000 IU; and (3) probiotics—1 capsule, containing a 50/50 mix of Lactobacillus acidophilus and Bifidobacterium lactis. The patient did not note any significant changes in her condition after introduction of the supplements. She was convinced that the majority of the improvement was a result of dietary change. The patient currently continues to make progress and is extremely pleased with the outcome. She is committed to continuing the dietary and lifestyle changes that were recommended. Due to the seasonal variation in symptoms of IV, the reader should note that the intervention spanned the period from December through March.
Integrative Medicine • Vol. 14, No. 3 • June 2015
Discussion Aside from a single case report describing the correlation between IV and celiac disease,9 no literature exists describing the possible therapeutic value of dietary change for IV. Dermatitis herpetiformis is the only dermatological condition for which research has shown that diet has a definitive therapeutic value. The dermatologic conditions for which a probable role exists for diet include AD, acne vulgaris, psoriasis, pemphigus, urticaria, pruritus, and allergic contact dermatitis.10 Regarding the potential role of food allergens in dermatological conditions, Kalmal et al10 state, “… after ingestion, resorption, and hematogenous transport of food allergens to the various target organs, other symptoms can occur. The skin is the most frequently affected organ.” Multiple clinical studies have indicated that between 30% and 40% of patients with AD have a food allergy and that up to two-thirds get symptomatic relief on eliminating certain foods from their diets. This phenomenon has been known since the early 1900s.11 As stated previously, 50% of patients with IV have AD. Given the overlap between these conditions, it should not be surprising that food allergy may also play a role in IV. The mechanism by which food allergy Anderson—Ichthyosis Improvement With Dietary Change
Table 1. Food-sensitivity Test Resultsa Food Category
Reaction Class
Food Category
Reaction Class
Food Category
Reaction Class
Casein
3
Almond
0
Lemon
0
Cheddar Cheese
3
Amaranth
0
Orange
1
Cottage Cheese
3
Barley
1
Papaya
0
Mozzarella Cheese
3
Kidney Bean
0
Peach
0
Milk
4
Lima Bean
0
Pear
0
Goat Milk
2
Pinto Bean
0
Pineapple
0
Whey
4
Soy Bean
0
Plum
0
Yogurt
4
String Bean
0
Raspberry
0
Beef
0
Buckwheat
0
Strawberry
0
Chicken
0
Coconut
1
Clam
0
Chicken Egg Whites
5
Corn
2
Cod
0
Duck Egg Whites
3
Wheat Gliadin
3
Crab
1
Chicken Egg Yolk
4
Wheat Gluten
3
Halibut
0
Lamb
0
Hazelnut
1
Lobster
1
Pork
0
Lentil
0
Red Snapper
0
Turkey
0
Oat
0
Salmon
0
Cocoa Bean
0
Green Pea
0
Scallop
0
Coffee Bean
2
Peanut
3
Shrimp
0
Bee Honey
0
Pecan
2
Sole
0
Sugar Cane
1
White Rice
0
Tuna
2
Baker’s Yeast
3
Rye
2
Cabbage
0
Brewer’s Yeast
2
Sesame Seed
2
Carrot
0
Apple
0
Spelt
3
Cauliflower
0
Apricot
0
Sunflower Seed
1
Celery
0
Banana
0
English Walnut
0
Cucumber
0
Blueberry
0
Whole Wheat
4
Garlic
0
Cranberry
2
Avocado
0
Lettuce
0
Grape
0
Beet
0
Mushroom
1
Grapefruit
1
Broccoli
0
Olive
0
Onion
0
Green Bell Pepper
0
Sweet Potato
0
White Potato
0
Pumpkin
0
Radish
0
Spinach
0
Zucchini Squash
0
Tomato
0
0, no reaction; 6, extreme reaction.
a
Anderson—Ichthyosis Improvement With Dietary Change
Integrative Medicine • Vol. 14, No. 3 • June 2015
57
can lead to AD has been well established. The pattern of cytokine expression in lymphocytes invading lesions of AD is known to promote eosinophil influx and activate eosinophil products (ie, histamines).11 Limitations Objective outcome measures were not used in this case study, which means that numerical symptomatic change cannot be determined. Also, due to the nature of the condition, evaluating visual changes based on pictures is somewhat challenging. Finally, the improvements that the patient clearly described could have been the result of something other than dietary change and supplement use. IV is known to improve spontaneously during the summer months.5 However, the changes made in diet and the supplement use were implemented in the winter months of a Midwest climate, so spontaneous improvement is unlikely.
Conclusions The current case report has indicated that incorporating dietary change and supplement use improved symptomatology and quality of life of a patient suffering from IV. The patient described in this case report did not get adequate relief from topical or oral pharmaceuticals and was interested in alternative treatments. It is likely that other patients suffering from IV have had experiences similar to the current patient’s with conventional treatments. The dietary approach to the treatment of IV needs further investigation to demonstrate its efficacy. Author Disclosure Statement
The author received no internal or outside funding for this case report and has no conflicts of interest related to the study.
Acknowledgements
This case report is submitted as partial fulfillment of the requirements for the degree of Master of Science in Advanced Clinical Practice in the Lincoln College of Post-professional, Graduate, and Continuing Education at the National University of Health Sciences. The author would like to acknowledge Drs Nick and Mackenzie Burgei for their assistance in completing this manuscript.
References
1. Shwayder T, Ott F. All about ichthyosis. Pediatr Clin North Am. 1991;38(4):835-857. 2. DiGiovanna JJ, Robinson-Bostom L. Ichthyosis: etiology, diagnosis, and management. Am J Clin Dermatol. 2003;4(2):81-95. 3. McGrath JA, Uitto J. The filaggrin story: novel insights into skin-barrier function and disease. Trends Mol Med. 2008;14(1):20-27. 4. Williams ML. Ichthyosis: mechanisms of disease. Pediatr Dermatol. 1992;9(4):365-368. 5. Traupe H, Fischer J, Oji V. Nonsyndromic types of ichthyoses—an update. J Dtsch Dermatol Ges. 2014;12(2):109-121. 6. Thyssen JP, Godoy-Gijon E, Elias PM. Ichthyosis vulgaris: the filaggrin mutation disease. Br J Dermatol. 2013;168(6):1155-1166. 7. Digiovanna JJ, Mauro T, Milstone LM, Schmuth M, Toro JR. Systemic retinoids in the management of ichthyoses and related skin types. Dermatol Ther. 2013;26(1):26-38. 8. Grattan C, Burton JL, Manku M, Stewart C, Horrobin DF. Essential-fattyacid metabolites in plasma phospholipids in patients with ichthyosis vulgaris, acne vulgaris and psoriasis. Clin Exp Dermatol. 1990;15(3):174-176. 9. Menni S, Boccardi D, Brusasco A. Ichthyosis revealing coeliac disease. Eur J Dermatol. 2000;10(5):398-399. 10. Kaimal S, Thappa DM. Diet in dermatology: revisited. Indian J Dermatol Venereol Leprol. 2010;76(2):103-115. 11. Burks W. Skin manifestations of food allergy. Pediatrics. 2003;111(6, pt 3):1617-1624.
58
Integrative Medicine • Vol. 14, No. 3 • June 2015
Anderson—Ichthyosis Improvement With Dietary Change
The Effect of Dietary Change in a Patient With Ichthyosis Vulgaris: A Case Report Brian Anderson, DC, CCN, MPH, MS
Abstract Ichthyosis vulgaris (IV) is a genetic skin condition of autosomal dominant inheritance. The main symptom associated with IV is scaling of the skin. Traditional treatment involves the application of various topical creams or ointments. The current case study documents significant improvement in the symptoms of a 20-y-old
Brian Anderson, DC, CCN, MPH, MS, is an attending clinician at the National University of Health Sciences in Lombard, Illinois. Corresponding author: Brian Anderson, DC, CCN, MPH, MS E-mail address: [email protected]
I
chthyosis vulgaris (IV) is a genetic skin condition of autosomal dominant inheritance. The term ichthyosis was coined more than 200 years ago from the Greek word for “fish”.1 IV is the most common type of ichthyosis, with an incidence of 1:250 live births.2 The genetic mutation involves decreased production of a protein in the skin called filaggrin (ie, filament-aggregating protein).3 This protein is broken down into its constituent amino acids, which become osmotically active and maintain hydration in the stratum corneum.4 Approximately two-thirds of patients have 2 filaggrin mutations, causing relatively serious disease, whereas the remaining one-third have 1 mutation and a milder disease.5 Filaggrin deficiency increases ultraviolet sensitivity markedly in vitro. This sensitivity could potentially explain the allegedly higher prevalence of nonmelanoma skin cancer in patients with ichthyosis and atopic dermatitis (AD). In addition, Thyssen et al6 have found that increased permeation of chemicals and allergens occurs across filaggrin-deficient skin. Anderson—Ichthyosis Improvement With Dietary Change
female patient with IV through use of dietary change based on food-sensitivity testing and supplement use— fish oil, vitamin D, and probiotics. She had previously used traditional topical therapies with less than optimal results. More research is required to substantiate the changes documented in this report.
The main symptom associated with IV is scaling of the skin. The scales are fine, white, and irregular and curl up at the edges, giving a rough feel. The extensor surface of the extremities is primarily involved. The palms and soles often show mild hyperkeratosis (thickened outer skin layer). Another characteristic feature is keratosis pilaris, which are spiny parafollicular papules that feel like a cheese grater when palpated.1 Fifty percent of patients with IV develop AD, and a further 20% develop rhinitis and/or bronchial asthma. Symptoms often spontaneously resolve in the summer, whereas they worsen in the winter.5 Medical therapy for IV is somewhat limited. Nearly all patients with ichthyosis show improvement through use of systemic retinoids. However, the side effects of long-term retinoid use include the development of ligamentous calcifications, teratogenic effects (birth defects), epiphyseal (growth plate) fusion, and diffuse skeletal hyperostosis (hardening of ligaments).7 Topical creams and ointments, including urea, lactic acid, glycerin, and vitamin A, are all used with varying levels of success. Beyond looking at blood levels of various essential fatty acids in patients with IV,8 the role that diet might play in this condition has largely been ignored. Case Report This case report describes a 20-year-old female who consulted with the author, a chiropractic physician, for treatment alternatives related to a diagnosis of IV. She had been diagnosed with the disease by a dermatologist at age 14 years. From a very young age, the patient had suffered Integrative Medicine • Vol. 14, No. 3 • June 2015
55
Figure 1. Lower leg photos before and after intervention. Figure 1A shows the patient’s right foot preintervention in December 2013; Figure 1B shows the same foot postintervention in March 2014.
56
Figure 1A
Figure 1B
from dry, itchy, and scaling skin. She described her symptoms as “cracking, bleeding skin.” Her initial diagnoses included atopic disease, asthma, and dry skin. During the winter months, her skin would get significantly worse, involving the hands and face. Various topical preparations were attempted, with none having any success. Initially her parents were applying ammonium lactate cream, which was very painful. This cream was then cut with Eucerin cream, which decreased the burning, but the symptoms returned whenever she stopped using it. She eventually stopped using all medications, because she believed that they were not helpful. The patient’s mother believed that all of her symptoms had started on introduction of solid foods as a child. In addition to her dermatological complaints and asthma, the patient had suffered from constipation for her entire life. She also described bumpy, red lesions on the extensor surfaces of both upper extremities. On examining her, the author noted that the classic signs of IV were present: (1) hyperkeratosis around the lateral malleoli and calcaneus; (2) fine, white scaling outlined with erythema that was most prominent in the distal part of her lower extremities bilaterally; and (3) keratosis pilaris on the extensor surfaces of her upper extremities bilaterally. A food-sensitivity test revealed sensitivity to a number of foods, including dairy, eggs, peanuts, spelt, whole wheat, gliadin, gluten, and baker’s yeast (Table 1). It was suggested to the patient that she should eliminate those foods from her diet, which she did. Noticeable improvement in her skin condition was evident within 2 weeks. The cracking in her skin improved dramatically (Figure 1). The asthma symptoms, previously controlled with fluticasone and salmeterol, practically disappeared, and her constipation completely resolved. The patient’s improvement plateaued somewhat after 1 month. At that point, the patient was prescribed several daily supplements, including (1) fish oil—2 capsules, each
containing 360 mg eicosapentaenoic acid and 240 mg docosahexaenoic acid; (2) vitamin D—5000 IU; and (3) probiotics—1 capsule, containing a 50/50 mix of Lactobacillus acidophilus and Bifidobacterium lactis. The patient did not note any significant changes in her condition after introduction of the supplements. She was convinced that the majority of the improvement was a result of dietary change. The patient currently continues to make progress and is extremely pleased with the outcome. She is committed to continuing the dietary and lifestyle changes that were recommended. Due to the seasonal variation in symptoms of IV, the reader should note that the intervention spanned the period from December through March.
Integrative Medicine • Vol. 14, No. 3 • June 2015
Discussion Aside from a single case report describing the correlation between IV and celiac disease,9 no literature exists describing the possible therapeutic value of dietary change for IV. Dermatitis herpetiformis is the only dermatological condition for which research has shown that diet has a definitive therapeutic value. The dermatologic conditions for which a probable role exists for diet include AD, acne vulgaris, psoriasis, pemphigus, urticaria, pruritus, and allergic contact dermatitis.10 Regarding the potential role of food allergens in dermatological conditions, Kalmal et al10 state, “… after ingestion, resorption, and hematogenous transport of food allergens to the various target organs, other symptoms can occur. The skin is the most frequently affected organ.” Multiple clinical studies have indicated that between 30% and 40% of patients with AD have a food allergy and that up to two-thirds get symptomatic relief on eliminating certain foods from their diets. This phenomenon has been known since the early 1900s.11 As stated previously, 50% of patients with IV have AD. Given the overlap between these conditions, it should not be surprising that food allergy may also play a role in IV. The mechanism by which food allergy Anderson—Ichthyosis Improvement With Dietary Change
Table 1. Food-sensitivity Test Resultsa Food Category
Reaction Class
Food Category
Reaction Class
Food Category
Reaction Class
Casein
3
Almond
0
Lemon
0
Cheddar Cheese
3
Amaranth
0
Orange
1
Cottage Cheese
3
Barley
1
Papaya
0
Mozzarella Cheese
3
Kidney Bean
0
Peach
0
Milk
4
Lima Bean
0
Pear
0
Goat Milk
2
Pinto Bean
0
Pineapple
0
Whey
4
Soy Bean
0
Plum
0
Yogurt
4
String Bean
0
Raspberry
0
Beef
0
Buckwheat
0
Strawberry
0
Chicken
0
Coconut
1
Clam
0
Chicken Egg Whites
5
Corn
2
Cod
0
Duck Egg Whites
3
Wheat Gliadin
3
Crab
1
Chicken Egg Yolk
4
Wheat Gluten
3
Halibut
0
Lamb
0
Hazelnut
1
Lobster
1
Pork
0
Lentil
0
Red Snapper
0
Turkey
0
Oat
0
Salmon
0
Cocoa Bean
0
Green Pea
0
Scallop
0
Coffee Bean
2
Peanut
3
Shrimp
0
Bee Honey
0
Pecan
2
Sole
0
Sugar Cane
1
White Rice
0
Tuna
2
Baker’s Yeast
3
Rye
2
Cabbage
0
Brewer’s Yeast
2
Sesame Seed
2
Carrot
0
Apple
0
Spelt
3
Cauliflower
0
Apricot
0
Sunflower Seed
1
Celery
0
Banana
0
English Walnut
0
Cucumber
0
Blueberry
0
Whole Wheat
4
Garlic
0
Cranberry
2
Avocado
0
Lettuce
0
Grape
0
Beet
0
Mushroom
1
Grapefruit
1
Broccoli
0
Olive
0
Onion
0
Green Bell Pepper
0
Sweet Potato
0
White Potato
0
Pumpkin
0
Radish
0
Spinach
0
Zucchini Squash
0
Tomato
0
0, no reaction; 6, extreme reaction.
a
Anderson—Ichthyosis Improvement With Dietary Change
Integrative Medicine • Vol. 14, No. 3 • June 2015
57
can lead to AD has been well established. The pattern of cytokine expression in lymphocytes invading lesions of AD is known to promote eosinophil influx and activate eosinophil products (ie, histamines).11 Limitations Objective outcome measures were not used in this case study, which means that numerical symptomatic change cannot be determined. Also, due to the nature of the condition, evaluating visual changes based on pictures is somewhat challenging. Finally, the improvements that the patient clearly described could have been the result of something other than dietary change and supplement use. IV is known to improve spontaneously during the summer months.5 However, the changes made in diet and the supplement use were implemented in the winter months of a Midwest climate, so spontaneous improvement is unlikely.
Conclusions The current case report has indicated that incorporating dietary change and supplement use improved symptomatology and quality of life of a patient suffering from IV. The patient described in this case report did not get adequate relief from topical or oral pharmaceuticals and was interested in alternative treatments. It is likely that other patients suffering from IV have had experiences similar to the current patient’s with conventional treatments. The dietary approach to the treatment of IV needs further investigation to demonstrate its efficacy. Author Disclosure Statement
The author received no internal or outside funding for this case report and has no conflicts of interest related to the study.
Acknowledgements
This case report is submitted as partial fulfillment of the requirements for the degree of Master of Science in Advanced Clinical Practice in the Lincoln College of Post-professional, Graduate, and Continuing Education at the National University of Health Sciences. The author would like to acknowledge Drs Nick and Mackenzie Burgei for their assistance in completing this manuscript.
References
1. Shwayder T, Ott F. All about ichthyosis. Pediatr Clin North Am. 1991;38(4):835-857. 2. DiGiovanna JJ, Robinson-Bostom L. Ichthyosis: etiology, diagnosis, and management. Am J Clin Dermatol. 2003;4(2):81-95. 3. McGrath JA, Uitto J. The filaggrin story: novel insights into skin-barrier function and disease. Trends Mol Med. 2008;14(1):20-27. 4. Williams ML. Ichthyosis: mechanisms of disease. Pediatr Dermatol. 1992;9(4):365-368. 5. Traupe H, Fischer J, Oji V. Nonsyndromic types of ichthyoses—an update. J Dtsch Dermatol Ges. 2014;12(2):109-121. 6. Thyssen JP, Godoy-Gijon E, Elias PM. Ichthyosis vulgaris: the filaggrin mutation disease. Br J Dermatol. 2013;168(6):1155-1166. 7. Digiovanna JJ, Mauro T, Milstone LM, Schmuth M, Toro JR. Systemic retinoids in the management of ichthyoses and related skin types. Dermatol Ther. 2013;26(1):26-38. 8. Grattan C, Burton JL, Manku M, Stewart C, Horrobin DF. Essential-fattyacid metabolites in plasma phospholipids in patients with ichthyosis vulgaris, acne vulgaris and psoriasis. Clin Exp Dermatol. 1990;15(3):174-176. 9. Menni S, Boccardi D, Brusasco A. Ichthyosis revealing coeliac disease. Eur J Dermatol. 2000;10(5):398-399. 10. Kaimal S, Thappa DM. Diet in dermatology: revisited. Indian J Dermatol Venereol Leprol. 2010;76(2):103-115. 11. Burks W. Skin manifestations of food allergy. Pediatrics. 2003;111(6, pt 3):1617-1624.
58
Integrative Medicine • Vol. 14, No. 3 • June 2015
Anderson—Ichthyosis Improvement With Dietary Change
