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.

The Government Gets It Right!

Supersize Me!

Supersize Me!

Food allergy is a constant source of anxiety to parents of children who could in fact die or suffer a severe reaction to foods.  Believe it or not, the government has done a nice job with information pertaining to public safety, in this case, food allergy in schools.  In case you think I’m kidding about the severity of food allergy, the YouTube link below should change your mind.  The second link from the CDC is the “official word” on food allergy in schools. 

 

http://www.cdc.gov/healthyyouth/foodallergies/index.htm

#center-for-disease-control-and-prevention, #food, #food-allergy

Contradictory skin test and ImmunoCAP results–which is better?

This question comes up in my office almost everyday….should I do skin testing or blood work?  As you can see from the response of national experts, it depends.  There is NO test that can boast 100% accuracy to predict whether or not you will react to a food.  In fact, the gold standard if you will, is still the oral food challenge.  Here is some food for thought (really, do you have to pun)

  1. Clinical history is very important in determining food allergy.  If you can eat a food without difficulty breathing, rash, or hives, you are most likely not allergic.  You may have a positive test, but that only means you’ve had previous exposure to the food.
  2. I will often obtain both skin testing and ImmunoCap (blood work) to clarify the presence of IgE-mediated allergy. If both tests are negative, you may have an adverse reaction to a food, not the severe life-threatening anaphylaxis.  Very important distinction!
  3. If in doubt, a food challenge is always a procedure to consider.  Here’s why.
  4. Sometimes the food in question just isn’t worth the trouble to challenge.  No one says you have to eat strawberries!
  5. If you challenge peanuts for example, in the doctor’s office and experience anaphylaxis, better there than at home.  Epinephrine is more readily available and in many cases, IV access and full resuscitation is available within minutes of your reaction. 
  6. This is another reason why a single test or treating allergy without experience is not a good idea.  Read the link below and tell me just how complicated things can become!

Contradictory skin test and ImmunoCAP results.

#allergy, #anaphylaxis, #food, #immunocap, #immunoglobulin-e

5 Tips for Dodging Frightful Food Allergies this Halloween

From the College of Allergy, Asthma, and Immunology–always a great source of support for allergy treatment.  Click on the link below BEFORE Halloween!Trick or Treat? (safely)

5 Tips for Dodging Frightful Food Allergies this Halloween.

#allergy, #food, #halloween

Why Doctors Order Too Many Tests

A good lab test will solve everything!

A good lab test will solve everything!

You blurt out an insult to your girlfriend, the quarterback throws for an interception, I bought a stock that tanked….if only I could take back decisions I’ve made.  We all feel that way at times, but how can a lab test be a bad decision? Continue reading

#food, #immunoglobulin-a

Have We Lost our CommonSense?

Schools are quite paranoid about giving any medication on their watch.  The liability for giving sunscreen when you don’t need it?  Zero.  This is very similar to the use of epinephrine in a school aged child with food allergy.  You certainly don’t want to withhold epi and risk anaphylaxis or death, when the risk of giving the EpiPen is negligible even if you don’t need the drug.  Maybe our policies in schools will change after a large malpractice case gets media attention for NOT giving epinephrine at the appropriate time for peanut allergy. 

http://www.usatoday.com/news/health/story/2012-06-27/sunscreen-policies/55877080/1

#allergies, #allergy, #epinephrine, #epinephrine-autoinjector, #food, #food-allergy, #health, #new-york-city

Are We Beating a Dead Horse?

Ok, another study about the dangers of food allergy (yesterday in USA Today).  You would think the occurrence of food allergy to KNOWN allergens (peanut & milk) would decrease given all the attention given to accidental ingestion.  Evidently, this is not the case.  Explanations?  Maybe we’re afraid of giving epinephrine.  In my personal experience, giving epinephrine is analogous to “waving the white flag.”  It doesn’t have to be nor should it be when treating children with suspected food allergy.  As I tell my nurses, “give the epi, then call the doctor!” 

http://www.usatoday.com/news/health/story/2012-06-25/kids-food-allergies/55797696/1

#allergen, #allergies, #allergy, #epinephrine, #food, #food-allergy, #health, #usa-today