This case study describes the management of an 11-year-old boy living in the desert of Saudi Arabia who was diagnosed with severe eczema. The traditional therapy used by a local physician to treat this common disease had negatively affected his management. Recommendations are made to improve the future treatment of skin conditions in rural areas of the country.

INTRODUCTION
Eczema is the most common form of dermatitis and is characterised by pruritus, eczematous lesions, dry skin and lichenification (thick, leathery skin) [Fig 1]. It can also be associated with other atopic diseases, such as asthma, allergic rhinitis, urticaria and acute allergic reactions to foods [1].

Fig 1 -  An example of eczema where the skin has become itchy and may scale and blister.

 
Eczema is also common around leg ulcers and along with other skin conditions, such as lipodermatosclerosis, oedema, atrophie blanche and cellulitis, can be a predictor of leg ulcer development.
 
In one study, the highest rates of eczema (greater than 15%) were observed in urban centres in Africa, Australia, and northern and western Europe, whereas the lowest prevalence (less than 5%) was found in China, eastern Europe and central Asia [2]. In Saudi Arabia, dermatitis and eczema were the most frequent dermatoses (19.6%), with atopic dermatitis constituting 36% of eczemas [3].

Eczema can affect all age groups, although in children the estimated prevalence is 16-20%. It usually starts under the age of six months and by one year 60% of those likely to develop eczema will have done so. In 75% of cases, remission occurs by 15 years of age, although some children develop worsening symptoms in their teenage years and others relapse later in adulthood[ 4].  


CASE REPORT
History
Patient A is an 11-year-old boy who has had chronic eczema since the age of five, although he had experienced dry, excoriated skin since he was two years old. His family has a history of allergic disorders, for example his father has asthma and a younger sibling also has eczema.
 
Living in the desert means coping with humidity-free air and high temperatures and atopic dermatitis thrives in these extremes, resulting in dry skin that in turn increases the effects of eczema [5].
 
School-aged children with moderate-to-severe atopic eczema are also at high risk of developing psychological difficulties, which may have implications for their academic and social development [6].
 
Patient A had a lot of psychosocial problems because of his eczema. He was bullied at school and was shunned by classmates and even some relatives. People avoided close contact with him as they were afraid that they would 'catch' eczema. In addition, there was parental anxiety, especially from his mother, as he was falling behind in his studies, sometimes refusing to go to school.
 
Patient A's parents believe in traditional therapies and initially consulted a local physician. Local physicians use a variety of methods, including herbal preparations, Unani (an ancient form of Greek medicine used throughout the Muslim world) and various traditional Iranian and Islamic techniques. However, the physicians themselves are often not qualified and the techniques are transmitted orally throughout communities and families - this means that on occasion the inappropriate use of these traditional medicines can have negative or even dangerous side effects [7].