It’s Only Skin Deep

https://www.reddit.com/gallery/q58hrk

Severe allergy and can’t find what’s causing it. Literally have tried EVERYTHING. Have been on 5 rounds of steroids in the past 2 months. Saw an allergist and having a patch test done so have to stop steroids and that’s the only thing giving me relief. I will try anything at this point.

After swelling goes down skin is dry, itchy, feels hot, and red. Nothing is helping. I want to crawl in a hole and never come out–I think I hear this story every day and definitely feel for those of you that suffer from CONTACT DERMATITIS. Click on the link if you want more information from American Contact Dermatitis Society. As this gal is appropriately pursuing, you must do patch testing for better answers.

Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011 Mar-Apr;24(2):229-39. doi: 10.1111/j.1529-8019.2011.01398.x. PMID: 21410612.Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma. It is a common diagnosis in both inpatient and outpatient dermatology, as well as in the primary care setting. Cellulitis classically presents with erythema, swelling, warmth, and tenderness over the affected area. There are many other dermatologic diseases, which can present with similar findings, highlighting the need to consider a broad differential diagnosis. Some of the most common mimics of cellulitis include venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis. History, local characteristics of the affected area, systemic signs, laboratory tests, and, in some cases, skin biopsy can be helpful in confirming the correct diagnosis. Most patients can be treated as an outpatient with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern–and yes, sometimes you have to treat with the antibiotic and see if the condition improves. That’s why we call this the “practice of medicine”

Roy S, Chompunud Na Ayudhya C, Thapaliya M, Deepak V, Ali H. Multifaceted MRGPRX2: New insight into the role of mast cells in health and disease. J Allergy Clin Immunol. 2021 Aug;148(2):293-308. doi: 10.1016/j.jaci.2021.03.049. Epub 2021 May 4. PMID: 33957166; PMCID: PMC8355064.

Mast cells are getting lots of attention these days and many mystery diagnoses are labeled as “mastocytosis”. For the unfortunate few with true mastocytosis, your life will be filled with hives, flushing just like the above picture. At times, you may need chemotherapy if your tryptase levels get too high. But most patients (and doctors alike) who think they have mastocytosis really don’t.

Cutaneous mast cells (MCs) express Mas-related G protein-coupled receptor-X2 (MRGPRX2; mouse ortholog MrgprB2), which is activated by an ever-increasing number of cationic ligands. Antimicrobial host defense peptides (HDPs) generated by keratinocytes contribute to host defense likely by 2 mechanisms, one involving direct killing of microbes and the other via MC activation through MRGPRX2. However, its inappropriate activation may cause pseudoallergy and likely contribute to the pathogenesis of rosacea, atopic dermatitis, allergic contact dermatitis, urticaria, and mastocytosis. So here’s the link between normal cells in the body and disease of any kind: inappropriate activation causes a rash you don’t want to deal with. Gain- and loss-of-function missense single nucleotide polymorphisms in MRGPRX2 have been identified. The ability of certain ligands to serve as balanced or G protein-biased agonists has been defined. Small-molecule HDP mimetics that display both direct antimicrobial activity and activate MCs via MRGPRX2 have been developed. In addition, antibodies and reagents that modulate MRGPRX2 expression and signaling have been generated. In this article, we provide a comprehensive update on MrgprB2 and MRGPRX2 biology. We propose that harnessing MRGPRX2’s host defense function by small-molecule HDP mimetics may provide a novel approach for the treatment of antibiotic-resistant cutaneous infections. In contrast, MRGPRX2-specific antibodies and inhibitors could be used for the modulation of allergic and inflammatory diseases that are mediated via this receptor.

So for contact dermatitis, remember the following:

  • You can always have an infection that mimics contact dermatitis–don’t forget to at least ask about antibiotics.
  • Facial rosacea is treated with topical metronidazole among other creams, but it often hangs around for a long time. It will mimic contact dermatitis many times.
  • Patch testing is crucial for diagnosing the culprit causing contact dermatitis, and I would recommend having this procedure done at a clinic familiar with patch testing and even consider customizing your own patch test. We do this in our clinic with use of a Finn Chamber which allows you to test for anything in a semi-liquid or pasty consistency.
  • Autoimmunity can always cause a rash, especially on the face and upper body. Anyone see a butterfly rash that looks like this?

I hope she gets some answers and I’d love to hear about your stories re: facial rash and contact dermatitis.

#allergies, #american-contact-dermatitis-society, #contact-dermatitis

This Can’t Be Right

So what is going on with persistent allergy symptoms when the pollens are NOT very high? This patient is using the term “allergies” to describe “symptoms” of allergy that may not be IgE-mediated allergy at all. Doesn’t mention skin testing, but this testing can be completely negative in this scenario. How frustrating!

Positive skin tests look like this….


In fact, often I am tested for allergy and had no reactions even though I sneeze my head off during the fall season?
You cannot assume that pollens are the only cause of persistent rhinitis. Various conditions are called infectious rhinitis, vasomotor rhinitis, that have nothing to do with allergy but still because lots of nasal drainage and congestion.
In fact we are now entering into the time of year (late fall and winter) when many symptoms of sneezing, coughing, asthma are thought to be due to allergy but are really due to infection or cold air. Your body does not tell you when triggers change, but that is actually what is happening.
This writer from Reddit also complained of more symptoms that would suggest asthma during the fall pollen season, but yet low allergy counts.
Again, allergies are not the only cause of asthma even though the highest time of admissions for asthma occurred during the third week of September. Certainly, not all these patients have allergy. We have been inundated with COVID-19, and this virus shares many similarities with the common cold–do not be surprised if sneezing congestion, nasal drainage during the winter makes you think of Covid-19, but is actually rhinovirus induced asthma.

Look at the examples of sinus infection below. Slide a is the only normal CT scan as all of the others have some evidence of sinusitis. Any sinus infection is bound to cause problems with PND, congestion, and even sneezing–allergy can be involved, but many patients with chronic sinusitis have no allergy on skin testing. Asthma during the winter is often exacerbated by sinus infections just like the ones shown below.

What to do with this conundrum?

  1. Take your regular medications as prescribed by your doctor–do not stop using your inhaled corticosteroids just because the seasons change.
  2. It may even be beneficial to increase your dose of inhaled corticosteroids to 2 puffs 4 times a day when you are ill
  3. Always use a spacer device for your asthma
  4. Be open to “nonallergic” trigger for your nasal congestion sneezing, coughing. It is not unusual for patients to have both allergy and sinus infection for instance.
  5. Treating sinus infections may require oral corticosteroids and antibiotics for up to 1 month at a time. 10 days just won’t do it with chronic sinusitis
  6. Take your regular medications as prescribed by your doctor–do not stop using your inhaled corticosteroids just because the seasons change.
  7. It may even be beneficial to increase your dose of inhaled corticosteroids to 2 puffs 4 times a day when you are ill
  8. Always use a spacer device for your asthma
  9. Be open to “nonallergic” trigger for your nasal congestion sneezing, coughing. It is not unusual for patients to have both allergy and sinus infection for instance.
  10. Treating sinus infections may require oral corticosteroids and antibiotics for up to 1 month at a time. 10 days just won’t do it with chronic sinusitis

#allergies, #allergy, #respiratory-disorders

New medications for Asthma–are we at the end of the line?

Watch my FOX 23 interview about new asthma meds

Jane (fictitious name, of course because of HIPPA regulations) is now 56 years old and just last year was diagnosed with #asthma. She thought, “no big deal, there are plenty of inhalers for me to use so I don’t wheeze”.  Little did she know that 2019 would put her in the hospital 3 times and multiple visits to the emergency room because of asthma. In fact, she even missed her grandson’s graduation from kindergarten because of her asthma. Now if that doesn’t motivate you, nothing will! Continue reading

#allergies, #tulsa-oklahoma

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:

Continue reading

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

Dear Doctor…..

                             

Dear Doctor,

Thanks for all your help with my #allergies, but I have a bone to pick with you.  A few minutes into my visit and you’re talking about “rhinitis” and “IgE” and “desensitization”.  By the time my brain catches up with you, our visit is over and I don’t feel like I really understand what condition I  have.  Could you slow down and explain what you mean by all that medical riff-raff?

Signed,

Confused and a bit rushed Continue reading

#allergy-shots-2, #allergy-testing, #ige

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

Tulsa is the Allergy Capital of the Nation

Tulsa is the #allergy capital of the nation.  You wouldn’t believe how many times in a day I hear that!  and it makes sense…countless numbers of patients return to Tulsa and find their #allergies are now out of control. But is this really true?  Does anyone even keep track of which city in America has the highest pollen counts and can thus claim to be the most miserable #pollen city in America? Continue reading

#asthma, #pollen-counts, #respiratory-disorders, #runny-nose, #sneezing

It’s allergy season and what can I do?

The following YouTube video describes a process called “Rush Immunotherapy” conducted in Ohio.  It’s now a more common way to deliver #allergy shots and reduces the total number of shots required to achieve clinical relief from your #allergies.  Some caveats about #RUSH Immunotherapy need to be included and your bullet list is below the video.

I would make the following corrections to this video:

1.  Unfortunately, you can’t answer all questions about immunotherapy (allergy shots) in a 3 minute news clip.

Continue reading

#allergen-immunotherapy, #allergy, #american-academy-of-allergy-asthma-and-immunology, #american-college-of-allergy-asthma-immunology, #oklahoma, #tulsa-oklahoma

Wacky Oklahoma Weather

I love  weather! Growing up on a farm in Kansas brought a variety of weather right to my front doorstep, and that must be one reason I became an allergist.

Nothing like the harvest!

Nothing like the harvest!

You have to be part botanist to do this job anyway, with monitoring pollen counts, making allergy recipes for allergy shots, and knowing what is pollinating at what time of the year. Oklahoma makes predicting weather patterns quite a challenge.  One minute it’s 80 degrees outside and 24 hours later the temperature has dropped back to 50.  We fluctuate from drought to 5 inches of rain in 1 week.  How are you supposed to take care of your lawn, much less predict the pollen counts?  Here’s some clues that might help you anticipate “bad pollen” days based on the weather patterns in Tulsa; and better yet, you might do better than the weatherman! Weather plays an important role in how much pollen is produced, its distribution and how much pollen is in the air at a given time.  (for the full article on weather and pollen counts go to: http://www.weather.com/health/allergy/news/how-weather-impacts-spring-allergies) Allergy symptoms are often reduced on rainy or windless days because pollen does not circulate as much during these conditions. Pollen tends to travel more with warm, dry and windy weather, which can increase your allergy symptoms. Pollen counts vary by time of day, season and weather conditions. Rain, wind and temperature are all important factors to consider when determining if pollen counts will be high, moderate or low on a particular day. Overall, pollen counts tend to be higher in the morning, as well as on warm, dry and windy days. Conversely, lower pollen levels are also typically observed during a stretch of cold and wet days. The National Institue of Heath Medline Plus recommends saving outside activities for late afternoon or after a heavy rain when pollen levels are lower. First, if we’re measuring pollen, what is it we’re measuring? The American Academy of Allergy Asthma & Immunology defines pollen as tiny grains needed to fertilize many kinds of plants.

This is ragweed pollen floating around in the air

This is ragweed pollen floating around in the air

Pollen from plants with colorful flowers usually do not cause allergies. Plants that produce a powdery pollen can easily be spread by the wind and can cause allergy symptoms. Spring allergies are often caused by tree pollen, summer allergies by grasses, and fall allergy by weed pollen. Pollen is transported in the air and enters our respiratory system, triggering an allergic reaction technically called allergic rhinitis. According to the National Institute of Allergies and Infectious Diseases, a branch of the National Institute of Health, approximately 35 million Americans complain of upper respiratory symptoms related to pollen. So how does weather conditions impact spring, summer, and fall allergies? Continue reading

#allergies, #respiratory-disorders, #weather

Spring is Right Around the Corner!

#allergies, #american-college-of-allergy-asthma-immunology, #asthma