DermHelpCentral

Allergies, IgE, and Prick Testing

This very important article appeared in the NY Times on March 20, 2007.  Anyone who is to be skin tested for allergies or has a child in that category should read it carefully.  We are going to ask some of our colleagues to comment on this.  Please check the comment section.

"Allergists have typically turned to blood testing as a last resort when skin testing cannot be used. Few in the United States use blood testing routinely, experts say, though it is being used more often to help diagnose food allergies. Yet studies have found that newer blood tests are as sensitive as skin tests [for diagnosing allergies] and less subjective.

The blood test is also part of a larger debate about who should be treating allergy sufferers. Blood testing would allow pediatricians and other primary care doctors to diagnose allergies and treat many patients. But allergists contend that these generalists are not qualified to assess the laboratory results."

To read full article go to Permalink

A Healthy Tan?

by Ingrid Wickelgren
Science, volume 315, 2 March 2007

William DwWitt, C. Carlisle and Margaret Tippit Professor of Biology; Chair, Biology Department at Williams College, brought this important essay to our attention.  We are indebted to him for enlightening us.

To most dermatologists, the concept of "a health tan" is heresy. However, the sun is not everyone's enemy. This article, written, by a red-headed female investigative science reporter gives important information and insights. It was published in the prestigious magazine Science.

"A dark natural tan offers unparalleled protection against skin cancer. So scientists are developing compounds that trigger tanning without the sun’s damaging effects.

"Anyone who relies on sunscreen knows it is  sticky, inconvenient, and easy to forget. But  sunscreen has a lesser known, and more serious, downside:  It doesn’t adequately protect  against the deadliest form of skin cancer."   To read on, please go the the Download Tanning.pdf

Post-Herpetic Neuralgia

A Personal View

David Elpern -- Dermatologist

Around 15 - 20% of patients who have shingles will develop pain that lasts for months after the acute lesions subside.  By definition post-herpetic neuralgia (PHN) is the term used for pain that is present six weeks after the blisters have resolved.  Wikipedia has a fine section on PHN .  So does The National Library for Health's Prodigy system if you want more in-depth and evidence-based information.

I would like to add some ex-cathedra comments.  I have helped care for patients with PHN for over 30 years and read about this disorder with great interest. It is unusual in young persons who have had shingles.  These individuals seem to perceive pain differently.  In patients who are depressed, sad or chronically ill initially the incidence of PHN is higher.  These people seem to focus on their pain and don't let go of it.  Understanding the Gate Control Theory of Pain helps one to understand this.

"In their seminal  paper "The Tragedy of Needless Pain," Melzack and Wall assert that pain is a fundamental human experience, and requires an integrative understanding of that whole experience, and every choice we have made, that has formed our own "gates". They frame the choice to deal with pain or ignore it as moral: if the brain can control pain, we who know that must make use of that capacity, and in turn take control of pain.  Only by doing so can we achieve control of the larger causes of all of the pain that humans cause each other by carelessness, hatred, and failures of empathy - which might extend beyond humans.

The impact of this theory on medical treatment for pain has been profound, and has made it a multi-disciplinary field. A major advantage of the theory is that those being taught pain control techniques can actually be told why they work. This seems to play a major role in achieving results - which is explained most readily by psychoneuroimmunology, in which the nerves are seen as the link between the immune system and sensory and cognitive experience."

Please read about the Gate theory if you are interested.  But what does this mean for post-herpetic neuralgia?

In my opinion PHN is a scourge for people who focus on the pain of shingles and then believe they will not get better.  In some cases, this is a self-fulfilling prophesy.  The media, pain clinics and some physicians nurture this fear by promising interventions which inadvertently may actually prolong the pain.  It is very important to work with shingles patients early on to help prevent them from focusing on the pain.

I tell them to be active.  To go to work if they can.  To keep one's mind off the pain.  Watch funny movies, get out if they can, go to dinner with one's partner or friends.  Don't sit around feeling sorry for yourself.  Yes.  This is difficult, but there does seem to be something to this.  It may well explain why older individuals (who are retired and can sit around if they need to) or people with chronic disease suffer more than active busy people.

I know this is controversial and there have been few or no studies.  These have been my observations and I think they explain why kids and young adults rarely develop PHN (most are just to busy to do so!).  Besides, these techniques are benign, cheap and have no down side.

Shingles

Shingles aka Herpes zoster

Herpes zoster, or shingles, is a common skin disease characterized by a painful, one-sided band like blistering eruption. It may occur at any age, but is more common in the elderly.

The disease represents reactivation of the chicken pox virus which remains dormant in the body after that infection. It is estimated that by age 85 at least half of the population will have had one attack of Herpes zoster. Second attacks, although uncommon, may occur  in around 1% of individuals.

Patients with shingles are infectious to people who have not had chicken pox; thus an immunologically naive person may contract chicken pox from a person with shingles. Patients with advanced cancer may also be at risk and should be isolated from patients with Herpes zoster.

The first symptom of shingles is pain or an abnormal sensation in the area which will later develop the rash. This may last for a few days before the rash occurs, and may be mistaken for a number of medical or surgical problems: such as, pleurisy, heart attack, ulcer disease, appendicitis, disc problems, and others.

The rash, when it occurs, is distinctive. It is band-like and does not cross the mid-line of the body, being entirely on the right or left side. It is made up of blisters which vary in size from patient to patient, some being quite small and clear, others being large and occasionally blood-filled. The rash spreads for 1-4 days, dries, and crusts for 7-10 days, and heals over 2-3 weeks. It tends to be more severe in older patients.

Treatment:
The uncomplicated case requires no special treatment. Pain medications (aspirin, acetaminophen, or codeine) are sometimes necessary. Cool compresses and calamine lotion may speed up drying of the blister, and the application of olive oil to the crusts will help to loosen them. In the 1980s, it  was demonstrated that acyclovir (and more recently Famvir and Valtrex) can  shorten the duration of zoster. This is only true if the drug is started within three days (72 hours)  of the onset of the rash. It is important to keep in mind that acyclovir are not very effective in preventing post-herpetic neuralgia and that for thousands of years people have recovered from herpes zoster without any therapy.

Complications:
1. Pain may last for months to years after an attack. This is rare in patients less than age 50, but more common in patients over 60.  The name for this syndrome is "Post-Herpetic Neuralgia."
2. Dissemination: 2 to 10% of patients with H. zoster may have many blisters outside of the original band covering wide-spread areas of the body. This is usually not serious.
3. Secondary infection may occasionally occur in zoster lesions. This is by no means the rule, but one must look for it.
4. When shingles occur on the forehead and especially the tip of the nose, the possibility of eye involvement exists. Your doctor will know when to refer you to an eye specialist, as involvement of the eye with H. zoster requires prompt treatment.
5. There are a number of other rare complications which may occur. Most of these are related to the muscles and nerves. Consult your doctor if anything unusual occurs with or shortly after your zoster.
6. Zoster may be more severe in HIV positive patients. Special attention should be given to zoster patients at risk for HIV infection.

Common Warts

WARTS AND ALL -- Festina Lente

Warts are benign growths on the skin which are the result of a specific viral infection. Although they may occur at any age, they are most common in the 10-20 year-old age group. It is estimated that 10% of teenagers have warts. Almost everyone will get one or more warts in their lifetime. As with other infections, warts may be transmitted from one individual to another. They may also be contracted from inanimate objects (for example, the cements around a swimming pool).

Warts may occur on any location of the skin. In different locations, they have different appearances. This accounts for the many confusing names given to warts. For instance, the plantar warts are merely warts found on the soles (plantar area) of the feet.  Genital warts are called "condyloma."

"The strangest thing about warts is that they tend to go away. Fully grown, nothing in the body has so much the look of toughness or permanence as the wart, and yet, inexplicably and often very abruptly, they come to the end of their lives and disappear." *  Warts resolve because the body's immune response destroys them as it does with other infections. Thus, an immunity to the wart virus develops. Because warts vanish without treatment in most cases, the routine treatment of every wart is unnecessary, undesirable and can be traumatic for some patients, especially young children.

In general, the therapy of warts is nonspecific, destructive, and often painful. For these reasons, it is often wise to proceed slowly and with gentle methods at first, especially in children. Some of the methods we use are the destructive chemicals (Duofilm, Canthardin, and for genital warts, Podophyllin). Liquid nitrogen, an electric needle, and Zonas tape occlusion. Recently, there have been some studies on Duct Tape Occlusion (some positive, others not).  Some people believe suggestion or hypnosis may cure warts. No matter what treatment, 1 in 3 treated warts will recur. However, in most cases, after a few treatment sessions, the patient will be free of warts.

*From : "On Warts" Lewis Thomas, The Medusa and the Snail Download ON WARTS

Dr. Austin's Head Lice Treatment

Dr. Melanie Austin’s Homeopathic Lice Treatment

This is a picture of eggs (called "nits") on the hair.

For background material go to: DermNet

Don’t Panic!
You or your child did not get head lice because of your hygiene or anyone else’s. You got unlucky, that’s all!

Here’s a simple treatment that works.

1. Go to your local supermarket or pharmacy and get a long metal hair pick called a lice or nit comb.
2. Combine a 50:50 mixture of baking soda and thick crème rinse
3. Divide hair into 6ths
4. Pull nit comb through crème rinse mixture then through a small section of hair starting at the scalp…..repeat until entire head is done
5. Wash hair out thoroughly
6. Apply small amount of Cetaphil cleanser to hair and comb through
7. Then blow Cetaphil dry – this works to suffocate the lice (you hair will feel as if you have a light styling gel dried in it)
8. Wash nit comb daily by pouring boiling water over it….if you boil the comb, the teeth will loosen and fall out
9. At night rub small amount of extra virgin olive oil into scalp – if there are active lice this will prevent them from adhering to the hair shaft and getting a nightly “blood meal.”

Repeat this process daily until no further lice or nits are present
Continue this process then every other day for 7 days
If nits are present...continue process until all nits are gone then every other day for 7 days

Check all family members for nits – treat everyone who is infested

Check in your local community if there is a “Nit Picker” a professional who removes lice. If you can see the “nit picker” its well worth the money in the time and effort spent.  But if you’re fastidious about the plan you can manage yourself. Keep in mind, it is labor intensive, but WORKS!

Other Management:
So you know what to do with your head…..
Now we have to prevent re-infestation
1.    Wash all sheets, blankets comforters and pillowcases in hot water and dry in dryer
2.    For those items that can’t be washed, toss in the dryer for 20 minutes
3.    For those items which can’t be washed or dried, seal in plastic bag for 2 weeks
4. Pillowcases, sheets and towels should be washed daily until no nits are   
    present
5. Carpeted areas should be vacuumed
6. Upholstered furniture should be steam cleaned once you’ve see a “nit
    picker” or as soon as no further nits are present

Your pets can not carry lice and thus should not be treated!

A Poem – attribution unknown

Share a thought
Share a ride
Share a feeling …deep inside
But never share a hat or comb
Or lice will make your head their home!

Melanie Austin is a native New Yorker. She is a graduate of Smith College, Suny Downstate in Brooklyn (M.D.)  and a well-respected mid-western pediatric residency program.  After residency Dr. Austin indulged her wanderlust and worked for year as a locum tenens in places like Dodge City, Kansas.  She now understands the true meaning of "Git outta Dodge!" She also volunteered with the Maryland Militia and went to New Orleans during the aftermath of Hurricane Katrina.  The armed forces put up with Major
Dr. Austin for two weeks, and then gratefully accepted her letter resignation. She was HONORABLY discharged. In June 2006 Dr. Austin finally married her fiancée, Greg. They are both living happily in the Boston area with their cat Brooklyn and their rescue doggy Katrina. 

Dry Skin

Dr. Ben Barankin's* Dry Skin Handout

DRY SKIN AND DRY CRACKED HANDS AND FEET


Skin dries out for a variety of reasons. The environment plays a big role. Dry air will dry out your skin, particularly in the winter in institutions or homes that are heated with wood stoves or electric heat and have very low humidity.

As age reduces skin oil production, our skin becomes more susceptible to drying. Certain skin diseases make skin more susceptible to drying and irritation   eczema, psoriasis, ichthyosis.. Harsh detergents and soaps further irritate us. In the winter there is a tendency to want to take nice long hot showers that further degrease the already dry skin, aggravating the situation. Using detergents and soaps with the hot water and its degreasing action adds insult to injury.

As the skin dries, it cracks and feels rough. Areas of redness develop. Scratching or rubbing the skin causes burning and itching sensations, leading to more itching and scratching.

The object of treatment is rehydration (basically wetting the skin). This is done with a good soak (three to five minutes) in plain water. The water should not be too hot, just comfortably warm. Little to no soap should be used. If a cleanser is needed one can use Cetaphil liquid cleanser, Spectroderm/jel or Dove unscented cleansing bar.

After the soak, while the skin is moist, a lubricant is needed. This is applied after patting the skin to remove the excess water but must go on while the skin is still moist. Excellent lubricants include Lipikar Balm, Taro base, Vaseline Creamy Formula, Eucerin cream, or Glaxal base. Consider adding bath oil to your baths, but careful not to slip.

The idea is to form a film or coating to keep the real moisturizer (water) in the skin.


Hands and Feet

Your hands and feet can be particularly difficult.  Because the feet are in warm, moist, occlusive footwear for most of the day when the shoes are removed, the soggy skin rapidly dries out and cracks. Keep socks and slippers on in the house so the feet do not dry out too much.  A special plain water soak for the feet may be necessary, followed by Vaseline or Cetaphil Therapeutic Barrier Cream or Cetraben Emollient Cream or Neutrogena Foot Cream or Aquaphor Healing Ointment. These types of products should be left on overnight, with or without socks. Take your socks to the bathroom with you and wear them immediately after applying oinment to prevent slipping on your floor as well as tracking ointment through your house, and for enhanced penetration.

Hands that are in and out of water are damaged by repeated cycles of over-drying. No wonder the fingers crack! To protect hands, use thin cotton gloves under vinyl gloves for all wet work. Around the fingernails and for deep cracked areas either plain petrolatum (petroleum jelly) or Lipikar hands or Aquaphor Healing Ointment is best. Cleansing the hands with Cetaphil cleanser rather than soap is often much safer. For a light hand moisturizer, try Neutrogena’s Norwegian Formula hand cream (unscented).

Many of the over the counter "moisturizer" products are light lotions. Avoid these. They may be adequate for lubrication in the southern parts of North America but are not adequate for harsh Northern winter climate with prolonged low humidity. Indeed, they often make matters worse.

For moisturizing the face, consider Toleriane riche, Impruv, or Hydronorme.

MOISTURIZE, MOISTURIZE, MOISTURIZE!!!      

The author, Dr. Benjamin Barankin, is a board-certified dermatologist and widely published author. Dr. Barankin has published more than 200 articles related to dermatology and has gained international distinction as the author of 5 books related to dermatology. He regularly educates dermatologists, family physicians, medical trainees, and the public on dermatology and his expertise is frequently sought by the Canadian Press. Dr. Barankin combines his interest in the humanities with his knowledge of medical, surgical and cosmetic dermatology to optimize the skin care needs of his patients.

Erythematous Rosacea

This is a difficult variant to treat. 
Brenda Dintiman is a dermatologist who has broad experience in this area.  Here are her thoughts.

These patients are definitely challenging.  We actually see a fair amount of this erythematous only rosacea.

I like to switch them to Vanicream products - preservative free, fragrance free, lanolin free. and their sunscreen

I also use Noritate cream instead of Metrogel since many of my patients say that Metrogel stings.

I would use doxycyline for about 6 weeks also to calm the inflammation.

We will also use the VBeam pulse dye laser on non-purpuric settings and treat the entire red area.

Cold seems to be an important factor and dryness can be a trigger.
Citrus is the other biggest trigger we see.
We also inquire about any meds that could be producing flushing.
Rule out carcinoid syndrome and  photosensitivity from medication.

Actinic Keratoses -- The Truth

Actinic Keratoses (AKs) are rough scaly spots which appear on the sun-damaged skin. Especially common in fair-skinned persons, they result from repeated sun exposure. Photo-damaged skin is dry and wrinkled and may form persistently scaly spots, actinic (solar) keratoses, even though the crust or scale is picked off.

The standard treatment of a AKs calls for removal of the defective skin cells with liquid nitrogen, topical fluorouracil or imiquimod. New skin then forms from deeper cells which have escaped sun damage. However, there is no evidence that treatment of most AKs is of any value. Removal of all AKs is quick and easy and very lucrative for a practicing physician in some countries.

While textbooks of dermatology state that around 10% of AKs progress to skin cancer (squamous cell carcinoma, SCC) if left untreated, this number was derived from no study and crept into the literature without factual basis. The only study on the malignant transformation of AKs was performed in Australia by Professor Robin Marks, a research dermatologist.

This is an abstract of Robin Marks' study:
Br J Dermatol 1986 Dec;115(6):649-655
Spontaneous remission of solar keratoses: the case for conservative
management.
Marks R, Foley P, Goodman G, Hage BH, Selwood TS

One thousand and forty people aged 40 years and over, 616 (59.2%) of whom had solar keratoses, were followed for 12 months. Two hundred and twenty-four people (36.4%) had a spontaneous remission of at least one  of their solar keratoses. A total of 485 lesions (25.9%) underwent spontaneous remission out of the 1873 lesions that were present at the  first examination of these 224 people. There was no significant difference between the number of lesions present at the initial
examination in those who had a spontaneous remission compared with those  who did not. There was a 21.8% increase in the total number of solar keratoses in the 1040 people studied in the 12-month period, due to new lesions forming at the same time as remissions were occurring. The incidence rate of squamous cell carcinoma occurring in the people with solar keratoses was 0.24% for each solar keratosis present at the original examination. With a substantial proportion of solar keratoses
remitting spontaneously, plus the low rate of malignant transformation and the low potential for metastasis to occur from squamous cell carcinoma arising in a solar keratosis, the rationale of treating all solar keratoses appears questionable.

Comment: Robin Marks could not get his study published in the United States or Australia. The reason was that dermatologists derive a significant proportion of their income from these usually banal lesions. The image of the dermatologist running from room to room with a spray bottle of liquid nitrogen is all too familiar to elderly patients in the United States.

There are lesions which look like AKs which need treatment. These are the hypertrophic AKs which can be indistinguishable from early squamous cell carcinomas. An experienced dermatologist will be able to tell the banal from the worrisome in most cases. However, it will be a long time before the average practitioner will give up income for the pursuit of truth - so it is caveat emptor.

A retired physician we know saw a dermatologist for routine care.  The latter froze ~ 15 lesions with liquid nitrogen and the bill to Medicare was > $1000 for the ten minute office visit.  The retired doctor wrote to the dermatologist and said if this wasn't fixed he would be reported for fraud.  Was it?  You be the judge.

The take-home message is that most actinic keratoses are innocuous.  They can be observed.  A small subset will progress to squamous cell cancer -- but these behave and look different.  What is important is that AKs are markers for persons at risk to develop skin cancers (squamous cell, basal cell and melanoma) and these individuals need to perform regular self-skin exams and visit a dermatologist periodically.  There will be dermatologists who disagree with this.  However, we are entitled to our reading of the literature, too.

Duct Tape for Molluscum

Molluscum contagiosum is a common viral infection which can occur at any age, the greatest incidence occurs in children.  See Dermnet NZ for particulars.

Recently the efficacy of duct tape was compared to cryotherapy in the treatment of common warts. We opted to try duct tape occlusion in the treatment of recurrent molluscum contagiosum.  This is the report on one case -- it may not be applicable to you or your child, but it is worth trying if you want to proceed with a safe inexpensive approach.

Method:
Duct tape was cut to the size of each lesion and applied after the patient bathed and towel dried. It was reapplied after each bath or if it fell off. After 3 weeks of therapy, most of the lesions were crusted over. Occlusion therapy continued for 2 months. By the end of therapy  the lesions had disappeared. This treatment was very well tolerated, with no reported pain or irritation. Compared to topical salicylic acid or glycolic acid therapy minimal scarring occurred.

The use of duct tape occlusion therapy for molluscum contagiosum has several advantages over conventional treatment. Treatment is nondestructive and painless or
minimally painful. Duct tape is widely available and affordable compared to the costs of traditional over-the-counter and prescription medications. The tape is applied at home, obviating office visits. Molluscum contagiosum is self- limiting and can remit spontaneously. However, when  lesions persist, the use of duct tape occlusion may be a
more acceptable, nontoxic treatment option, especially for  young children.

This was adapted from a letter in the medical literature by:
MARK S. LINDAU, M.D.
MYRNA Y. MUNAR, PHARM.D.
Portland, Oregon