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

Patient Regrets

Patient: If I would have known I would live this long, I would have taken better care of myself and not smoked so much.

Me: Patients will tell you all kinds of things! And Covid-19 never crossed his mind.

Where Do You Get Your Medical Information?

I recently found an article on the accuracy of #medical information on #Facebook–it was 85% (wrong that is).  With this much misinformation at our fingertips, no wonder medical advances seem to be muted…obesity, cost of medical care, gun violence, heart disease. If you’re relying on the internet for your medical information, perhaps this link on how to counteract medical-misinformation might be helpful.

Take a survey for me at the end of the article: I want to know your thoughts.

Continue reading

When You Just Can’t Fight It Anymore

I’m often asked about #immunodeficiency–does my body fight infection like it’s supposed to? Is this baby’s immune system normal? Obviously, probably not. Fortunately, #Stevens Johnson syndrome is quite rare, but antibody deficiency is NOT rare and many strategies can be performed to improve the situation.

example of Stevens Johnson syndrome

I often start the conversation about #immunodeficiency: “are you worried about how well you fight infection?” Since immunodeficiency comes in many flavors, there are no absolutes to checking the immune system, but here’s some pointers that are helpful. Remember, the body fights infection in compartments, so test for something in each compartment and you’ll hit a home run with the bases loaded.

Continue reading

#antibodies, #gamma-globulin, #immunology, #lymphocytes, #neutrophils

Katy Perry has Sleep Apnea!

No not really, but one of her hits has a slight twist!  I don’t usually digress to humor on a very serious topic, but you might enjoy the break.  Just remember, Shaq has apnea too.

#sleep-apnea-2

The Hidden Gem

Tulsa has often been chided as the “Oklahoma step child” in comparison to Oklahoma City, but I think this article refutes that myth.

Tulsa is on the listhttp://www.medscape.com/features/slideshow/best-places-to-practice-2015?src=wnl_edit_specol&uac=45399FY#page=4

#Oklahoma boasts a low cost of living, and #physicians responding to the Medscape survey also reported high incomes: an average of $304,000. At 8.5%, the average state and local tax burden is well below the national average of 9.8%.

Oklahoma doctors may have trouble finding adequate staff support. Continue reading

#community, #tulsa-oklahoma

Drug Reps Will Give You Asthma

I know you’ve been there before….waiting in the doctor’s office for your appointment and some smartly dressed man or woman barely has to say hello to the receptionist and walks right by your seat, straight to the doctor’s office. “Hey, that’s not fair,” you say to yourself as you dig your nose into that outdated magazine trying to mask the irritation.  “My time is just as valuable as theirs is, put me to the front of the line!”  As a patient, my frustration with the #health care system only percolates at the injustice.  Isn’t the cost of #medication so high in America because of all the drug companies?  If there were no drug reps, wouldn’t my doctor have a better and certainly more unbiased selection of medications?  Granted, the goal of any #pharmaceutical company (employer of drug reps) is to make profit, but they can’t do that unless a product (medication) works well and is taken as directed.  In the end, drug companies want you to be adherent to medications prescribed so they’ll work, you get better, all of which is good for the bottom line.  Almost sounds too good to be true when everybody wins, but hang on and I’ll show you how this is possible. Continue reading

#allergies, #asthma, #immunoglobulin-e, #wheeze

The Future of Medicine

I don’t normally stray from the trail of #allergy topics, but this issue is so important for doctors and ultimately patients that it’s worth investigating. If the doctor shortage becomes severe based on a dwindling supply of physicians, and increased utilization with the Affordable Care Act (ObamaCare), where will you get care when you need it? As #Tulsa County Medical Society (TCMS) president, I am privileged to write about our initiatives in the community and this one is of great importance not only now but for future generations. Here’s the President’s letter from the most recent newsletter:

President’s Letter

I had just finished my training in allergy and was ready to conquer the world. Setting up a practice was no big deal; I just didn’t know what I didn’t know! Small town hospital to the rescue. If my practice didn’t succeed or if my revenue didn’t cover my expenses, I would have the local hospital guarantee my salary for the first 3 years of practice. How comforting and reassuring is that? What I didn’t know is if I was more successful than I anticipated (which most of us are), I had to share the profits with a hospital that literally did nothing to earn the cut. Rookie mistake, but very costly and could have been avoided with a few well-placed stories from my mentor….oh yeah, I didn’t have one either.

So here at TCMS, we tell you we’re more than just a political organization looking out for the practice of medicine. We are involved in watching out for your backside, to be sure, but the summer months allow an opportunity to reach out to our #medical students and residents to let them know about life after residency. You mean there is life after residency? In the grand scheme of life, most of the time you spend practicing medicine will be outside of your time as a resident or medical student.

Bright eyed and bushy tailed for those med school lectures!

Bright eyed and bushy tailed for those med school lectures!

Think about your importance as a physician mentor knowing that #doctors of the next generation will be ill prepared for what lies ahead in their practice careers. Now before you jump up and down in protest at having to attend one of the resident/medical student events, consider the following: Continue reading

#allergy-blogs, #medical-students, #tulsa-county-medical-society, #tulsa-world

What Else About Allergy is Out There?

It’s difficult to find good material on the internet related to the practice of #allergy. Here is one such blog site: http://blogs.medscape.com/garystadtmauer.  This blog originates from New York and the practice website is www.cityallergy.com.  I will periodically post comments & articles from Dr. Stadtmauer’s blog and I’ve included one below about the coexistence of systemic allergy (that’s a positive skin or blood test) and LOCAL allergic rhinitis which has all the signs & symptoms of allergy, but guess what–skin & blood testing is all negative.  Very frustrating for #patients to experience allergy symptoms, but go in to their local allergist and find nothing. I wish treatment would be more satisfactory, but as you can imagine, it’s unknown what allergens to mix up for your allergy recipe if all testing is negative.  Continue reading

#allergy-blogs, #allergy-shots-2, #medscape