This is one of my more clinical posts, addressing common skin disorders. If you are interested, feel free to suggest more topics in the comments section.
Cold Sores
As a small child, I developed what our local GP called impetigo on my lips. My mother put this yellow salve on it. I still remember its slightly sweet taste and grainy consistency. I couldn’t stop licking it off. Salve – it’s such a medieval-sounding name. I’ve not sure if she got it by RX or if it was something the pharmacist just whipped up. As I remember, it did nothing but dry out the lesions which took about a week to go away. (If you look online for yellow salve, it seems to be making a comeback as an alternative treatment, but I’m not sure it’s targeted towards cold sores or even whether it is indeed the same yellow salve.) Trouble was, this wasn’t impetigo, it was herpes labialis, or your common cold sore. Kids can develop this in infancy, often by being kissed by someone infected, or contact with the lesions of a playmate. It’s caused by a virus related to chicken pox and shingles, hence the blisters, and has cycles of dormancy and recurrence. It can be brought on by illness, i.e., a cold, stress, or too much sun. If you’ve had it, you become hypervigilant about the first sign of a tingle, the harbinger or “prodrome,” as we say in the biz, of an outbreak. Best way to diagnose it is through a viral culture. If the clinical presentation is not obvious, I do both a bacterial and viral culture and see what grows out. Treatment has come a long way, and if begun at that first tingle, goes a long way towards stopping a full-blown outbreak which can be very painful, disfiguring, and embarrassing.
For adults, I prescribe valacyclovir (generic Valtrex), the huge 1000 mg lozenge-shaped pills. Take two of them at the first sign and then another two 12 hours later. So four should treat an outbreak, which is a good thing because they are very expensive, over $10 per pill. Insurers prefer the cheaper anti-viral, acyclovir, which does not work nearly as well. I also recommend OTC Abreva (www.abreva.com), a cream that can be applied as often as you like. Since it is white, you might want to save this for when you are not out in public. You can also buy an OTC clear lysine gel which you can use when you are out and about. Why would you want these extra measures? If you are already a cold sore sufferer, you know. Those lesions hurt and are unsightly, and you just want to do everything you can to make them go away. Health care providers are not immune to this desire to overtreat their own outbreaks. A dermatologist once told me she herself used a topical steroid cream to reduce inflammation. This is controversial because a steroid can decrease immunological response. Her point was that a lot of the pain and swelling is caused by inflammation and the steroid addressed that. If you are unlucky enough to suffer from cold sores, make sure you have your provider write you a script for the 1000 mg valacyclovir pills, maybe eight, with a lot of refills. And always carry two pills around with you.
Preventing Skin Cancer and the Problem of Vitamin D
What I (often) tell my kids about skin care is wear sunscreen every day, at least 30 SPF, limit exposure from 12-3pm, wear a hat and sunglasses when in bright sun, and get a yearly full body check by a dermatologist. Some posit that this kind of vigilance against skin cancer – a good thing – has led to a widespread Vitamin D deficiency – a bad thing.
Vitamin D is a fat-soluble nutrient essential for calcium absorption, bone health, heart health and especially important for those with autoimmune diseases. It has been advised to get at least 10 minutes of unprotected sunlight daily so your body can make vitamin D. This is controversial because of the association of sun exposure with skin cancer. Medicine is seldom black and white. We don’t know how much sunlight is safe, and most dermatologists will tell you, no amount is safe. I always advise it’s best to get your vitamins through food in most cases, although that’s difficult with vitamin D. Web MD lists food sources of vitamin D: http://www.webmd.com/osteoporosis/features/the-truth-about-vitamin-d-vitamin-d-food-sources), some of which include fortified foods (where the vitamin is added). For a while, most primary care providers were checking vitamin D levels as part of regular screening blood work. You might recall lots of people were deemed deficient and were advised to take megadoses for a period of time. (I was shown to be mildly deficient but chose not to do this. Not a fan of megadoses of anything.) Now the USPSTF (United States Preventative Services Task Force) recommends against this screening, citing there is not enough information to assess benefits vs harm in testing of adults without symptoms.
Acne
When teens are just breaking out a little bit, simple solutions are the best. I tell them: don’t overwash, and use a mild cleanser like Cetaphil (www.cetaphil.com). Don’t scrub or use harsh astringents. First try benzoyl peroxide cream (Clearasil: www.clearasil.com) applied to the zits at night. Takes about six weeks to see results, so be patient. Next step is adding a prescription antibiotic cream, like clindamycin, and mixing the two together. There are premixed creams such as Duac and Benzaclin but insurers are getting less inclined to pay for them. Some people do well with Differin (www.differin.com) which is a retinoid, similar in the way it works to Accutane or Retin A, but milder, and with fewer side effects. Now you can buy it over the counter. After topical creams, providers try six-week courses of oral antibiotics such as doxycycline, minocycline, or azithromycin. These can work well, but like all antibiotics, they have potential side effects. If the RX topical treatments are not working after six weeks, I recommend seeing a dermatologist.
Diaper Rash
Diaper dermatitis happens to all babies at one time or another, usually after a bout of diarrhea. At home, treatment is frequent diaper changes, using a diaper balm, allowing the area to air-dry when feasible. Sometimes, though, the rash is severe, beefy-red, causing obvious discomfort. This is when your child should be seen by a provider. Often, when it gets this severe, there is a fungal component. Usually I can see the rash is deep red, with small affected areas in addition to the main one, called “satellite lesions”. I prescribe the anti-fungal nystatin cream, and sometimes a steroid cream as well if there is particular discomfort. I advise using the nystatin after each diaper change for 3 days, cleaning with warm water instead of wipes, exposing the diaper area to air as much as is possible. Not too often, but sometimes, the problem is a bacterial infection, the impetigo I mentioned in the beginning of this post. In the diaper area, it can manifest with rather large blisters and is called bullous impetigo (which can also appear in other places). The treatment is antibiotics, usually oral if a large area is affected.
Eczema
Eczema or atopic dermatitis, usually starts in infancy, manifesting as rough dry, reddish patches which can be itchy. It can be mild or severe and is an allergic response to the environment or food and linked to other allergic disorders, such as asthma. Severe cases are very itchy and can result in secondary bacterial infections from scratching. Steroid creams are used to treat the outbreak but prevention is best and here’s why: steroids can adversely change the appearance and texture of the skin, making it thinner and at times, darker, which can be permanent, if used for more than two weeks, twice a day. At times parents need to be educated about this because the steroid cream works so well, they want to use it all the time to keep their child comfortable. If the steroids aren’t helping, there are newer topical meds, such as Elidel and others in this class, approved for children over two years old. At this point, though, I advise having the child seen by a dermatologist. There have been some safety concerns about these newer drugs, including a possible link to certain cancers, but nothing has been proven at this point.
For prevention, I advise only using mild unscented soap, such as Dove for sensitive skin (www.Dove.com), every other day, washing with only water on the days in between. Moisturizing is key. A&D ointment works very well, but some people dislike the rather medicinal smell; others actually prefer it because it makes it seem more like a healing medication. Also good is Aquaphor (www.aquaphorUS.com) or plain old petroleum jelly, which is basically the same thing. The good news is you can use these ointments as much as you want (or can stand, since they can be messy). A little goes a long way. The problem with scented baby oils or lotions is that the scent itself can cause an allergic reaction. Also important is using a detergent for bedding, towels and clothing that is free of perfume and dyes and not using dryer sheets, which can cause a reaction to predisposed people. If you notice you or your child has an outbreak following a certain food, cut it out. You can get allergy testing down the road but most allergists prefer to wait until children are aged three or older.
There are plenty more skin conditions that could be addressed, but I will stop here. If you have any skin topics you’d like me to cover (or any other clinical topics), put your suggestions for future topics in the comments section below. No promises, though, and please, no personal medical queries – see your own provider for that. If you prefer more “Tales From the Clinic” patient stories, let me know that too.