Asked by L. Rodriguez, Orange County, California
I have suffered from eczema for many years. I changed doctors last year and she thinks that my skin condition may be a result of being allergic to gluten.
Since I have an HMO, she cannot test me for the allergy because they will not pay for it. I have tried going gluten free and the skin condition got better but did not go away. Is there anything that I can do to be sure I was given the proper diagnosis before completely changing my diet and life?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
You ask a fascinating question about a very common disease, much of which was first described only in the past 60 years.
Celiac disease is also called gluten-sensitive enteropathy and nontropical sprue. It is an allergy to gluten in the diet. People with this disease often have mild abdominal discomforts such as bloating and gas after consumption of breads and cereals that contain gluten. Gluten is found in wheat, barley, rye, and oats. Some have more serious symptoms such as bowel mal-absorption, abdominal pain, diarrhea and nutrient or vitamin deficiency. Children with it can have severe malnutrition and growth impairment.
The treatment of a serious gluten allergy is a gluten-free diet, which has a lot of meat, fruit, milk and potatoes. Many grocery stores are starting to carry gluten-free foods. Restaurants in Europe and Australia commonly advertise gluten-free meals. Abdominal symptoms generally improve within a few weeks of changing to a gluten free diet.
This disease is primarily found in whites of Northern European ancestry. It is estimated that 1 in every 300 to 1 in every 500 Northern Europeans have some form of it, usually with relatively mild non-specific abdominal symptoms. This disease was once thought to be one that began in childhood and infancy, and some children eventually grew out of it. It is now realized that some children do go into remission and may relapse later. Also, the prevalence of the disease increases with age, meaning some people develop it as they age. Some will develop first symptoms in their 50s or 60s.
Patients are at higher risk for Type 1 diabetes, mellitus, collagen vascular diseases, autoimmune thyroid disease. Bone mineral deficiencies such as osteopenia and osteoporosis have also been noted. Uncontrolled celiac disease is also associated with a small increased risk of a number of malignancies. There is no special cancer screening recommended for patients with celiac disease.
The disease can be diagnosed using blood tests that measure the amount of immunoglobulin that binds to the proteins gliadin and endomysium. The classic definition of celiac disease includes atrophy of parts of the small bowel as seen on biopsy. A series of small bowel biopsies is often done to confirm it. The biopsies can be done through an endoscopy, in which a fiber-optic tube is placed in the mouth and down into the small bowel or through some even less invasive procedures.
There are some skin illnesses associated with celiac disease. It is very frequently associated with dermatitis herpetiformis, an itchy red raised rash with fluid-filled vesicles. This rash is not related or caused by any of the herpes viruses, but has the name because the rash resembles that of the herpes viruses or shingles. It improves as the disease improves with diet modification.
Patients and their seemingly unaffected family members are more likely to have atopic dermatitis, which is also known as eczema. The hallmark of eczema is itching with the skin scaling, crusting and an oozing of a serous or transparent fluid. Eczema can be worsened by stress, heat, dry air and sweating.
You actually may not have celiac disease or at least you may not have the clinical manifestations of a gluten allergy and you can still have eczema related to celiac disease. It would be preferable that you get the testing to confirm or disprove the diagnosis of gluten allergy. Even if the tests were negative, many physicians would suggest a two month trial of a gluten-free diet to see if the eczema improves. Most would advocate continuing the diet if there seemed to be some improvement in the rash and even if it did not clear up fully.
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