Capsaicin for Nonallergic Rhinitis

February 5, 2021 by Alan Khadavi

Here’s the full update and thank-you Alan for sharing

Capsaicin nasal spray may be an effective treatment for patients who have nonallergic rhinitis. A significant proportion (25-30%) of patients suffering from rhinitis have nasal symptoms without an infection or allergies, this is referred to nonallergic rhinitis. Up to 50% of these patients have idiopathic #rhinitis after excluding work, elderly, gustatory, hormonal and drug induced rhinitis. Nasal steroid sprays are ineffective for this condition. Astelin, Atrovent are nasal sprays that have also been used for this condition and they have showed some improvement. But for others, these treatment options have failed. Capsaicin is the active ingredient of chili peppers. It is available as an over-the-counter nasal spray (ei, Sinus Buster, Sinus Plumber, others).

Capsaicin is another treatment option available for patients with idiopathic rhinitis. This treatment has limitations though, it can be uncomfortable, time consuming and incompletely understood in terms of its working mechanism. Research for better capsaicin treatment is needed.

A recent study looked at 2 different dosing of #capsaicin nasal sprays to see if it could suppress nasal symptoms. Daily nasal administration of low-dose capsaicin was well tolerated and reduced nasal symptoms. The study also evaluated the levels of Substance P which has been shown to be higher in patients with idiopathic rhinitis.

Symptom reduction was seen between 70-80% of patients with idiopathic rhinitis. Daily administration of low dose capsaicin was well tolerated and reduced nasal symptoms. Levels of Substance P were reduced and there was a positive correlation between Substance P and nasal obstruction, suggesting that rhinitis symptoms result from abnormally increased Substance P levels. As Substance P increases mucus secretion, suppressing it might represent a novel approach.

This study looked at different concentrations of Capsaicin nasal spray. There are various different manufacturers of Capsaicin spray, although the exact concentration isn’t well defined. As always speak to your doctor before beginning any treatment.  Patients who participated in this study were excluded from any allergies or infections prior to beginning treatment.

In conclusion, capsaicin low dose is effective in suppressing nasal symptoms and it may be a good, novel option for patients with non-allergic rhintis.

I have several reasons to write about “non-allergic” rhinitis.

  • Granted, this is the allergy season, but not everything that sneezes is allergy. Patients are always confused when skin testing is negative, yet they have consistent “allergy symptoms”. Heck, I even use the term “allergy” when I’m writing about non-allergic rhinitis.
  • Allergy has to have IgE (that’s the molecule binding to both allergens and subsequently to the mast cell causing histamine release). No IgE, no allergies and unfortunately, no allergy shots will work.
  • As Alan has mentioned, the typical nasal sprays such as Flonase and other nasal steroids don’t work well for this condition. Much of what you see advertised on TV is designed to encourage you to buy intranasal steroids, but many of those conditions are “non-allergic” rhinitis and listening to the TV ads won’t do you a bit of good.
  • I would disagree with the incidence of “non-allergic” rhinitis @ 30%–it’s more like the majority of rhinitis sufferers at ~70% and maybe more during the winter.
  • It is true that treatment of “non-allergic” rhinitis is frustrating because of lack of good nasal sprays, but PLEASE don’t give yourself capsaicin or hot pepper sauce in the nose before getting a prescription to dilute those hot babies down or you’ll be swearing at me all the way to the ER. Pepper spray will reduce that runny nose only if you compound the formula by an experienced pharmacist and deliver it into the nose carefully. Police grade pepper spray will get you into a whole lot of trouble!
  • As a research project, I’m looking into using nasal challenges for patients who have local allergic rhinitis and this may provide some additional use of desensitization even though skin testing and blood work is all negative for IgE. More on that later.
  • Bottom line: Not all that sneezes is allergy and a significant number of patients have runny nose, sneezing and sinus infections without having the opportunity to use allergy shots for desensitization.
  • If this is you, there is hope. See your local allergist for discussion about Astelin, Atrovent (hardly ever used), and if needed, I can work in conjunction with a local compounding pharmacy to get some capscaicin spray to help with that sneezing.

In the meantime, enjoy your tacos!

#if-not-allergy

Reddit Has It All

Not sure I want to rinse my nose everyday for sinus problems, but here goes. I advise rinsing the nose for chronic sinusitis every day, but patients initially turn their nose up at this suggestion (pun intended). I find myself intrigued at the interest in nasal irrigation, flushing, or whatever else you want to call it. So who did I turn to but #Reddit Allergy. So what to my wondering eyes did appear, but questions abound for the right sinus rinse! Google search for sinus rinse yields > 7,000,000 hits and searching PubMed 750–you think there might be a problem there? Misinformation abounds and of course every advertiser/company has the best product! Who do you believe? I’m about to give you some guidelines that you can rest assured have at least been studied in one published article. And by the way, to answer your question below, if the water doesn’t come out the other side, you’ve got nasal congestion that needs further evaluation by your allergist or ENT. My comments are highlighted in RED in the lists after each article. There is no test at the end, but maybe next time….

For the Reddit Junkies
One of the few articles published on the true effects of nasal irrigation!
  • Budesonide is a steroid that can always be added to ANY device you use to flush the nose
  • When you hear “double-blind, placebo-controlled, randomized clinical trial” you’re on the right track to some real (and reliable) research. In this study participants didn’t know if they were getting budesonide or placebo; now remember, in any study the placebo effect can be as high as 30-40% and this is why you can’t make recommendations only based on your treatment “experience”.
  • SNOT-22 score–really? Let me know if you want more information on this one. No takers yet!
  • The results? Budesonide was better than saline for the sinuses, but it’s difficult to measure clinically meaningful benefits to sinus treatment. And who’s going to admit to a better SNOT score?
  • The good news: no side effects noted with the irrigation; so it may look bad, but won’t hurt you!

Here’s the abstract from the above study–>

IMPORTANCE: Recent studies suggest that budesonide added to saline nasal lavage can be an effective treatment for patients with chronic rhinosinusitis (CRS). PARTICIPANTS: This double-blind, placebo-controlled, randomized clinical trial was conducted at a quaternary care academic medical center between January 1, 2016, and February 16, 2017. A total of 80 adult patients with CRS were enrolled; 74 completed baseline assessments; and 61 remained in the trial to complete all analyses. Data analysis was conducted from March 2017 to August 2017. INTERVENTIONS: All study participants were provided with a sinus rinse kit including saline and identical-appearing capsules that contained either budesonide (treatment group) or lactose (control group). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the change in Sino-Nasal Outcome Test (SNOT-22) scores, pretreatment to posttreatment, in the budesonide group compared with the control group. Secondary outcome measures included patient-reported response to treatment, as measured with a modification of the Clinical Global Impressions scale, and endoscopic examination scored by the Lund-Kennedy grading system. RESULTS: Of the 74 participants who completed baseline assessments (37 in each study arm), mean (SD) age, 51 (14.7) years, 50 (68%) were women. Of the 61 who remained in the trial to complete all analyses, 29 were randomized to budesonide treatment, and 32 to saline alone. The average change in SNOT-22 scores was 20.7 points for those in the budesonide group and 13.6 points for those in the control group, for a mean difference of 7 points in favor of the budesonide group (95% CI, -2 to 16). A total of 23 participants (79%) in the budesonide group experienced a clinically meaningful reduction in their SNOT-22 scores compared with 19 (59%) in the control group, for a difference of 20% (95% CI, -2.5% to 42.5%). The average change in endoscopic scores was 3.4 points for the budesonide group and 2.7 points for the control group. There were no related adverse events. CONCLUSIONS AND RELEVANCE: This study shows that budesonide in saline nasal lavage results in clinically meaningful benefits beyond the benefits of saline alone for patients with CRS. Given the imprecision in the treatment effect, further research is warranted to define the true effect of budesonide in saline nasal lavage.

Adults have chronic sinusitis too!
  • Inflammation is once again the key to sinus problems even in the adult population.
  • 1-2% of total physician visits, not just allergists or ENTs. Very impressive.
  • Evidence-based approach to assist in optimizing patient care is the “Holy Grail” of being a doctor. If only we had this for COVID-19. Truth of the matter is, it takes years to analyze and accumulate enough data to make statements about evidence-based medicine, so for some issues, you’ll just have to wait.
  • I won’t bore you with the details, but these results come from HUUGE databases such as MEDLINE and Cochrane. It’s nice to be able to “mine the database” and combine multiple studies in the analysis of your final conclusion.
  • Compared with no treatment, saline irrigation was good, “add-in” topical steroids were better; leukotriene antagonists (Singulair) and oral antibiotics also showed improvement in not just sinusitis, but also resolution of nasal polyps.
  • And now let me introduce DUPIXENT! Approved for use in treatment of nasal polyps even without steroids. That is the problem with research–shelf life isn’t the greatest.

I’ve included the abstract below for easier reading–>

IMPORTANCE: Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the Sino nasal cavities lasting longer than 3 months. It accounts for 1% to 2% of total physician encounters and is associated with large health care expenditures. OBJECTIVE: To summarize the highest-quality evidence on medical therapies for adult chronic sinusitis and provide an evidence-based approach to assist in optimizing patient care. EVIDENCE REVIEW: A systematic review searched Ovid MEDLINE (1947-January 30, 2015), EMBASE, and Cochrane Databases. FINDINGS: Twenty-nine studies met inclusion criteria: 12 meta-analyses (>60 RCTs), 13 systematic reviews, and 4 RCTs that were not included in any of the meta-analyses. Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42 [95% CI, 1.01 to 1.84]; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]; a negative SMD indicates improvement), improved polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]). Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P < .001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P < .01). Macrolide antibiotic for 3 months was associated with improved QOL at a single time point (24 weeks after therapy) compared with placebo for patients without polyps (SMD, -0.43 [95% CI, -0.82 to -0.05]). CONCLUSIONS AND RELEVANCE: Evidence supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis. A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps. A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps.

  • Fungus among us–we don’t think very often about fungal sinus infections, but in this study, symptoms improved with antifungal treatment. Fortunately, this is topical amphotericin B as the IV route was called “amphoterrible” for good reason.
  • IgE is an antibody used for diagnosis and treatment of allergic rhinitis (one of the biological measurement of IgE is skin testing), but can also be used to measure inflammation due to infection.
  • In this study, almost 25% of ALL participants had recurrence of chronic sinusitis, but it was improved in the amphotericin B rinse group. IgE went down as well. It’s nice to know that something works for sinus problems, but now that we have DUPIXENT, the results are probably even more of a game changer!

OBJECTIVE: To determine the effect of topical antifungal irrigation fluid containing amphotericin B on nasal polyp and their recurrence pattern, and to study the association of serum IgE in predicting the presence of fungus along with the nasal polyps. METHODOLOGY: All adult patients having nasal polyps, who had not undergone any previous nasal surgery, were included in the study. Patients aged under 18 years, history of granulomatous diseases, immunosuppression, invasive fungal sinusitis, and pregnant ladies were excluded from the study. The ratio was kept as 1:2; one receiving irrigation with amphotericin B and the other only saline nasal irrigation without the medicine. Serum IgE level of more than 250 ng/ml was taken as a high value. RESULTS: A total of 87 patients were inducted. Overall 22 (25.3%) patients had recurrence of symptoms at six-month followup visit. Twelve (13.7%) of these were in the placebo group and 10 (11.5%) were in the amphotericin B nasal irrigation group. Serum IgE level preoperatively ranged between 52 – 9344 ng/dl; postoperatively it ranged from 13-1050 ng/dl. CONCLUSION: Amphotericin B improved the CT scan score of the patients. The nasal irrigation of amphotericin B did not show significant change in the recurrence pattern of chronic sinuses with polyps. Serum IgE can be used as marker for the presence and response to treatment for non-invasive fungal sinusitis.

  • Bacteria have evolved sneaky ways to protect themselves from death by antibiotics. Thus, bacterial infections in the form of adherent biofilms are frequently implicated in the pathogenesis and recalcitrance of chronic rhinosinusitis. You dirty rat! That’s for you Jimmie Cagney from “Taxi” (actually a misquote, but that’s for another time!)
  • Lots of methods to suck out your boogers from battery powered to suction from your own mouth into a separate “trap”. Oh parents will do anything to suck out moist mucous!
  • Who would be recruited for this study? Yuck
  • We are left with that SNOT score again to measure any benefit from our treatment with the Snot Sucker.
  • Battery powered nasal irrigation (snot suckers) came up with 2.5 million hits on Google–it’s popular.

I copied parts of the above abstract for details–>

The Hydrodebrider, a disposable powered irrigation and suction device, has been developed specifically to remove biofilm from the paranasal sinuses. We conducted a prospective study to evaluate the tolerability and efficacy of the Hydrodebrider in the office setting with the use of local anesthesia. Of the original 13 adults we recruited, 10 completed the entire study protocol. All enrolled patients had previously undergone sinus surgery that involved the creation of a maxillary antrostomy large enough to allow placement of a Hydrodebrider device, and the endoscopic findings in all patients were consistent with chronic sinusitis. In conclusion, powered irrigation with suction is a well-tolerated procedure in the office setting and might be a useful short-term adjunct in the management of recalcitrant chronic sinusitis.

Surely, there has to be some conclusions from all this?

  • Don’t get overwhelmed with all of the choices for cleaning out your nose.
  • Using nasal irrigation can include antibiotics, topical steroids, anti-fungal medication, baby shampoo just to name a few. Every doctor who deals with this has their own cocktail.
  • Although clinical research shows that nasal irrigation has a place in the treatment of chronic sinusitis & nasal polyps, you may just want to see your allergist for more aggressive measures such as allergy immunotherapy (AIT), Dupixent, Fasenra, Xolair or many of the other biologics available to treat nasal polyps and chronic sinusitis without using all of those steroids.

#chronic-sinusitis, #nasal-flush, #neil-med-irrigation, #netti-pot, #sinus-irrigation

The Cat’s Out of the Bag!

As the holidays approach, our travel will be limited by #COVID-19, but we still may visit relatives with #cats, and you’re allergic! Researchers from Nestle Purina Research in St Louis MO may have part of the answer. As cats groom (which they do all the time), Fel d 1 is distributed within the hair coat and can then be shed with the #cat hair and dander. Not good news if you suffer from cat allergy. And worse news for your relatives!

Continue reading

It’s a scam to our patients

Much of my medical office day is explaining to patients what they DON’T have rather than treating #allergy. Allergy has become the explanation for all medical disease. For instance, it’s rare for allergy to cause lack of attention, abdominal cramping (because of food allergy), or even constipation, but patients want allergy testing nonetheless. What are some “non-allergy” conditions that you’re likely to spend money you don’t need because of excessive testing?

Continue reading

#allergy-shots-2, #food-allergy, #myths, #sinus-infections

Scientists “Speak” on Mold Allergy

Background

  • Allergic bronchopulmonary aspergillosis is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, and rarely other Aspergillus species, and is characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.
  • An ABPA-like syndrome called allergic bronchopulmonary mycosis is indistinguishable from ABPA but is caused by other fungi.
  • The condition occurs almost exclusively in patients with cystic fibrosis (CF) or asthma.
  • The global prevalence of allergic bronchopulmonary aspergillosis is reported to be 2.5% (range 0.7%-3.5%) among adults with asthma and reported to be 2%-15% in patients with cystic fibrosis.

Evaluation

  • Suspect allergic bronchopulmonary aspergillosis (ABPA) in patients with asthma or cystic fibrosis who have symptoms consistent with ABPA, such as:
    • difficult-to-control asthma
    • new or worsening cough
    • dyspnea
    • increased sputum production
    • expectoration of brown-black mucus plugs
    • wheezing
    • hemoptysis
  • ABPA may also be suspected in patients with computed tomography (CT) findings of bronchiectasis, especially central bronchiectasis.
  • Multiple sets of diagnostic criteria exist, all of which include a combination of clinical signs, imaging findings, and serologic features.
    • Rosenberg-Patterson diagnostic criteria for patients without cystic fibrosis (most commonly used):
      • major criteria for diagnosis (at least 6 required for diagnosis):
        • asthma
        • transient pulmonary opacities on imaging (fleeting shadows)
        • positive skin test for Aspergillus (type 1 immediate hypersensitivity)
        • peripheral blood eosinophilia (> 1,000 cells/mcL)
        • precipitating antibodies (immunoglobulin [Ig] G) against Aspergillus fumigatus in serum
        • elevated total IgE > 1,000 units/mL
        • central/peripheral bronchiectasis with normal tapering of distal bronchi
        • elevated A. fumigatus-specific IgG and IgE
      • minor criteria:
        • Aspergillus in sputum
        • brownish black mucus plugs in expectorate
        • delayed type III skin reaction to Aspergillus
    • Cystic Fibrosis Foundation diagnostic criteria for patients with cystic fibrosis:
      • classic case (all criteria required):
        • acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, increased sputum, decrease in pulmonary function, exercise-induced asthma) not attributable to other cause
        • serum total IgE > 1,000 units/mL (2,400 ng/mL) in patient not on corticosteroids
        • immediate skin reaction to Aspergillus (wheal > 3 mm diameter with erythema in patient not on antihistamines) or positive serum IgE antibody to A. fumigatus
        • precipitating antibodies to A. fumigatus or serum IgG antibody to A. fumigatus
        • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest computed tomography (CT) that does not clear with antibiotics or chest physiotherapy
      • minimal diagnostic criteria:
        • acute or subacute clinical deterioration not attributable to other cause
        • serum total IgE > 500 units/mL (1,200 ng/mL) (if disease suspected and serum total IgE is 200-500 units/mL, repeat testing in 1-3 months)
        • immediate skin reaction to Aspergillus or positive serum IgE antibody to A. fumigatus
        • 1 of following:
          • precipitins to A. fumigatus or IgE antibody to A. fumigatus
          • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest CT that does not clear with antibiotics and standard chest physiotherapy
      • diagnosis of ABPA in cystic fibrosis should not be based in serology and skin tests only(2)

Management

  • Treatment goals include:
    • control of symptoms of asthma and cystic fibrosis
    • prevention or treatment of pulmonary exacerbations of allergic bronchopulmonary aspergillosis (ABPA)
    • reducing or remitting pulmonary inflammation
    • avoiding progression to end-stage fibrotic or cavitary disease
  • No large randomized trials have evaluated efficacy of various treatment options as of September 20, 2017.
  • Refer patients with suspected or known ABPA to a pulmonologist or an allergist-immunologist.
  • Systemic corticosteroids are considered the cornerstone of therapy for ABPA.
    • In patients with asthma:
      • typical initial therapy is prednisone 0.5 mg/kg/day (or equivalent) with tapering dose as symptoms improve
      • for patients with mild exacerbation – inhaled corticosteroids and bronchodilators may help control symptoms
      • for patients with acute exacerbation – prednisone 0.5-1 mg/kg/day for 1-2 weeks, then 0.5 mg/kg every other day for 6-12 weeks following remission, then tapering dose to preexacerbation dose
      • for patients with refractory disease with multiple asthmatic exacerbations – chronic corticosteroid therapy suggested, usually > 7.5 mg/day
      • dosing may be increased based on findings from routine monitoring of serum immunoglobulin E (IgE) levels, pulmonary function tests, and chest imaging, such as:
        • significant increase of IgE levels (such as doubling of baseline IgE level)
        • imaging evidence of infiltrates, mucoid impaction, fibrosis, worsening bronchiectasis, or worsening physiology
    • In patients with cystic fibrosis:
      • oral corticosteroids indicated for all patients except those with corticosteroid toxicity
      • typical initial dose prednisone (or equivalent) is 0.5-2 mg/kg/day orally to maximum 60 mg/day for 1-2 weeks, tapering to 0.5-2 mg/day every other day for 1-2 weeks with attempt to taper completely within 2-3 months
      • in patients with relapse, increase corticosteroid dose, add itraconazole, and taper corticosteroids when clinical status improves
  • Inhaled corticosteroids and methylprednisolone IV pulses may be used in some situations.
  • Consider antifungal agents in adults with severe, poorly controlled asthma and ABPA (Weak recommendation).
  • Combination antifungal/corticosteroid (nebulized amphotericin B and nebulized budesonide) may reduce the incidence of exacerbations.
  • Omalizumab may reduce exacerbations but may not improve or affect lung function or quality of life.
  • For refractory cases, consider evaluating the patient’s environment for significant mold exposure that can be modified (Weak recommendation).
  • Consider adjunct leukotriene antagonists for some patients (Weak recommendation).
  • Follow-up could include imaging at 4-8 weeks and total serum IgE monitoring.
 2017 Aug;13(8):823-835. doi: 10.1080/1744666X.2017.1324298. Epub 2017 May 17.

Mold allergy: is it real and what do we do about it?

 

Abstract

fungi produce substances that contain pathogen-associated molecular patterns (pamps) and damage-associated molecular patterns (damps) which bind to pattern recognition receptors, stimulating innate immune responses in humans. they also produce allergens that induce production of specific ige. Areas covered: In this review we cover both innate and adaptive immune responses to fungi. Some fungal products can activate both innate and adaptive responses and in doing so, cause an intense and complex health effects. Methods of testing for fungal allergy and evidence for clinical treatment including environmental control are also discussed. In addition, we describe controversial issues including the role of Stachybotrys and mycotoxins in adverse health effects. Expert commentary: Concerns about long-term exposure to fungi have led some patients, attorneys and fungus advocates to promote fears about a condition that has been termed toxic mold syndrome. This syndrome is associated with vague symptoms and is believed to be due to exposure to mycotoxins, though this connection has not been proven. Ultimately, more precise methods are needed to measure both fungal exposure and the resulting health effects. Once that such methods become available, much of the speculation will be replaced by knowledge.

Lips Like Strawberry Wine…

 

Sometimes even I get surprised by a clinical problem that may not be due to allergy. Every 2-3 months, a patient will come in to the office wondering what has caused the redness, swelling, and cracking of their lips, a condition called chelitis. Of course we many times think this is due to #food allergy, but think again. I wish it were as easy as food allergy. 

Yes, it’s true that foods go past your lips in order to be swallowed, but that may not have anything to do with food allergy or fixing your problem. 

Let’s get it on with those not so strawberry lips….

Background

Evaluation

  • Patients with irritant or allergic cheilitis may present with dryness, scaliness and/or fissuring, with or without erythema or edema of the vermillion border.
    • Ask about common allergens, such as lipsticks, cosmetics, nail polishes, and oral hygiene products; and common irritants, such as wind or cold weather exposure, irritative topicals (lip cosmetics, antiseptics), repeated lip-licking behaviors, and musical instrument contact.
    • For allergic contact cheilitis, consider patch testing if the culprit allergen is not identified by history.
  • Angular cheilitis (also called perleche) may occur in young children or in adults with dentures or dental appliances. Erythema, scaling, fissuring, bleeding, or ulceration is seen at the angle (corner) of the lip, and may be unilateral or bilateral.
  • Actinic cheilitis (also called solar cheilosis) typically presents in older adults (aged > 40 years), more commonly in fair-skinned individuals, and is more common in men. Actinic cheilitis may be seen as dryness, scaliness, color variation on lip, atrophy, leukoplakia, erythema, solitary papule or nodule, and/or with blurring of the vermilion border. Consider biopsy to rule out cutaneous squamous cell carcinoma.
  • Consider other differential diagnoses of lip lesions, such as cutaneous squamous cell carcinoma, basal cell carcinoma, melanoma, salivary gland tumors and metastatic tumors of the lip.

Management

  • Management for any identified infection should follow usual, advised treatment.
  • Management for any identified generalized or systemic causes of cheilitis, such as atopic dermatitis or lichen planus should follow usual, advised treatment.
  • For allergic or irritant cheilitis, advise patients to avoid the culprit agent or exposure. Consider short-term topical steroids for symptoms of pain or pruritus.
  • Management of actinic cheilitis may depend on the type of lesion.
    • For lesions with suspicious features of cutaneous squamous cell carcinoma, obtain biopsy.
    • For well-circumscribed nodules or papules, consider surgical excision.
    • For larger focal lesions, prolonged ulceration, and areas of atrophy, consider topical 5-fluorouracil or imiquimod, or ablation with cryotherapy or electrosurgery.
    • For diffuse disease, particularly if the vermilion border is involved, consider topical 5-fluorouracil or imiquimod, photodynamic therapy, vermilionectomy, or laser treatment.
  • Management of angular cheilitis (perleche) depends on the cause.
    • For idiopathic angular cheilitis, consider application of an emollient barrier such as petroleum jelly.
    • Advise correction or elimination of any sources of irritation, such as ill-fitting dentures.
    • For Staphylococcal infection, use topical mupirocin or fusidic acid.
    • For Candidal infection, use a topical antifungal, such as ketoconazole 2% cream.
    • Replete nutritional deficiencies if present.
  • For cheilitis glandularis, consider intralesional steroid injection, topical tacrolimus or pimecrolimus, or vermilionectomy.
  • For plasma cell cheilitis, consider topical fusidic acid, topical pimecrolimus, or tacrolimus.

Is This Really Corona virus? 

We’ve been so caught up with the #Coronavirus pandemic, that we’ve missed two important developments in the field of allergy:

  1.  The FDA has now approved the use of Palforzia for taking care of peanut allergy.  Guess when this was released? January 2020, about one month prior to the outbreak of COVID-19; the affect on our practice and most other medical clinics across the country was predictable. Nothing happened except to try and avoid COVID-19 as long as possible. Hopefully, our efforts will pay off, but the viral pandemic isn’t over yet, even though the panic has appeared to lessen.
  2. I won’t talk more about COVID-19 because many of us (including myself) are suffering from Corona fatigue and plenty of good information about COVID exists on YouTube channels such as MedCram and ZDoggBe prepared to devote some time to listen to these experts, because they won’t give you just a brief summary. They drill down to the ever evolving truth about COVID-19. (definitely worth your time)
  3. Back to the peanut story. #Palforzia is designed to give minute (very small) powder of peanut protein a little bit at a time so you don’t develop anaphylaxis with every ingestion. The company making this product spent large amounts of money to train professionals such as allergists with Zoom! conferences and field representatives to make sure we launched the program of desensitization without a hitch. Then came Coronavirus and knocked that one out of the park. So where does that leave us:
  4. Palforzia or peanut desensitization still works and is available to those patients who make good candidates. And who wouldn’t be a good candidate?
  5. Palforzia is associated with some risk and a consultation just to focus on this new treatment is required before starting the process.  Can you believe, patients have to pass a certification as well?
  6. For more information, call our office at 918-495-2636 to schedule a consultation for peanut desensitization.

FDA Gives OK to Peanut Allergy Oral Immunotherapy

What else did we miss because of COVID-19?

IT’S THE SPRING POLLEN SEASON!

In years past, everyone lived their life (or especially free time) outdoors because we live in Tulsa for the Spring & Fall, right? Well, this year, it was hard to live outside when you’re quarantined. Hopefully, you avoided exposure to the Coronavirus, but you also avoided exposure to the outdoor Spring allergens (good for you). What you’ll find when we relax the “stay-at-home” rules is more sneezing, runny nose, and typical allergy symptoms. Just a great case in point at how exposure really plays a significant role in your allergy symptoms. So don’t make fun of me when I tell you to cover your mattress and pillows with a substance that isolates the dust mites! Let’s review how allergies work, because a “pollen grain” and IgE look a lot like COVID-19. the video below is a pollen grain that attaches to IgE and the process of “allergy” begins. Notice that whatever process happens in the body occurs because a receptor (suction cup on the cell) binds to a virus or IgE. Every reaction (both good and bad) happens because of this union between body cells and external molecules. Listen to the video below to see how this actually works–and BTW, infection with COVID-19 works the same way.

So how do I tell if I’m having allergy or a nasty virus?

  1. As is usual for me, I like to give you academic information on topics that I really want you to understand–don’t just take my word for it. Too many hits come up searching for “corona virus or allergy,” so I will make it simple and give you the best video to watch.
  2. Patients with allergy are always sneezing and coughing, and many stories this year involve allergy patients who were suspected of having “the virus”. One patient said, “the isle cleared at Wal-Mart when I sneezed”. Another patient found she was ostracized at a friendly get together because of her runny nose and cough–it wasn’t Corona, only spring allergies. She told me later, that she felt embarrassed and wanted to leave the party immediately. You shouldn’t have to experience this rejection and embarrassment if you know what separates virus (any type) from allergy.
  3. Viral infections will often have fever, sore muscles/joints, and in the case of COVID-19, significant shortness of breath. Most likely, this is your first experience with rhinitis, whereas allergy patients have sneezing, coughing, and runny nose year after year.
  4. If you have any questions, please ask your doctor if you need further testing. Testing for both allergies and viral infections (not just Corona) are readily available and you should take advantage of knowing how best to treat your symptoms by correctly diagnosing your problem. Now, don’t show up at your allergists’ office if you think you have COVID-19 before calling first! Don’t take my word alone, watch the video from Dr. Skoner at West Virginia — 3 minutes long and will give you the peace of mind to know “is this allergy or virus.” Your health depends on it!

 

#allergy-symptoms, #asthma, #tulsa-oklahoma

Peanut allergy treatment is finally here!

#peanut-allergy

Do I really want that? Shared decision making and how this applies to allergy.

As #Christmas time approaches, it’s clear that Americans want choice. When I ask patients what they would like for Christmas, “I don’t know” is usually not their answer. Children’s eyes filled with sparkles at Santa’s coming, parents’ smiling at me and thankful I haven’t ruined their stories about Santa dominate our discussions about the holidays. Of course, I’ll always review medications and made sure that #asthma won’t ruin a perfectly good Christmas.


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Myth-busters in Medicine

As an allergist  in Tulsa, the myths that surround asthma, food allergy, hives, hay fever abound and patients often come in to the office telling ME what they are allergic to or how to fix the problem. Let me give you some examples:

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#allergies, #asthma, #board-certified-allergist, #dave-stukus, #food-allergy, #lynn-wiens, #tulsa-oklahoma, #zdogg