Topical Cortiscoteroid Therapy’s Lesser Known Side Effects

A long time patient of mine made an appointment with me just to ask some questions about his topical corticosteroid therapy. He had read the package insert, and had become concerned. The side effects stated that the medication could potentially make his diabetes worse. His “sugars” were higher after applying the medication for a couple of weeks.

I have to admit, I was dismissive at first. But when I researched my patient’s question, I found that that he was correct. I also discovered that potent topical corticosteroids can cause significant pituitary gland suppression. 20% of patients using these drugs for more than 3 weeks suppress the release of cortisol from their adrenal gland. The dose can be as low as 2 grams per day.

So sometimes, I find I need to rediscover things that I used to know. Thanks to this patient’s perceptive question, I can help others avoid side effects from these frequently prescribed medications.

What Good Does Niacinamide Do?

I prescribed a patient Niacinamide for prevention of actinic keratosis (premalignant tissue) as per a study done in the NEJM in December 2015. “First of all, they look like horse pills,” the patient said. “How does this work? Is it really necessary?”

Niacinamide is structurally related to Niacin (Vitamin B3), and is converted into other substances (NAD, NADPH). These substances are crucial in regulating cellular energy levels. NAD is bound by the enzyme poly-ADP-ribose-polymerase 1 (PARP-1). This enzyme has important roles in DNA repair and expression of inflammatory messengers.

Niacinamide exerts an anti-cancer effect after it converts to NAD and activates PARP-1. Whether all patients who have significant history of skin cancer and premalignant tissue should take niacinamide is not clear. If a patient is niacin deficient, then they are more likely to develop a wide range of cancers. Giving individuals excessive Niacin levels may not accomplish anything as is often the case with”supra physiologic” doses of vitamins.


Australas J Dermatol. 2014 Aug;55(3):169-75. doi:10.1111/ajd.12163.

 J Med Chem. 2016 Jul14. [Epub ahead of print]

J Nucleic Acids 2010 July 25

Healthcare Progress Wasn’t Made in a Day

Rome wasn’t built in a day. Neither was the current state of healthcare progress in the US. While watching the film Ben Hur last week, the subplot of Leprosy in the ancient world impressed me. The fear of contagion and social isolation is reminiscent of some recent epidemics: syphilis, TB, and HIV. Now, Ebola and Zika trigger the most panic.

What struck me is how much healthcare progress the global medical community made in the last century. We’ve been able to eliminate and control so many infectious diseases. The USA is the primary leader in this effort, with investments in basic medical research. Shoutout to taxpayers!

Although many see large pharmaceutical companies as “robber barons”, they have also played a major role in drug development. They conducted well-crafted clinical trials that were necessary to healthcare progress. So while there is much to gripe about in the current state of healthcare in the US, what we can cure would amaze a citizen of Ancient Jerusalem.

In conclusion, we have much to be thankful for in the way of healthcare progress. But while we are arguing about healthcare delivery, let’s make sure we invest heavily in the basic research of disease. Collectively, I think it is one of the costs we must bear.

Surgical Technique From The Western Frontier to Present

I recently watched The Revenant and am now reading the book. Wound care in the 1800s Western frontiers shocked me. I’m sure surgical technique was different in big city hospitals. But out in the wilderness, all people had were crude remedies. There was no local anesthesia. People treated wounds with poultices of pine tar and Native American astringents.

In 200 years, we have come so far with surgical technique: we’ve developed anesthesia (circa 1850), sterile technique (circa 1860), and antibiotics (circa 1930). Now, major trauma centers (circa 1980) are a large part of the medical world.

Doctors learned many of the innovations in military field hospitals. As a result, these techniques made their way to general practices. Looking back, this is an area where necessity is the mother of invention. The medical community has advanced significantly in helping the body to do its job. This is truly an impressive feat in a short amount of time.

Can Apple Cider Vinegar Clear the Skin?

Many patients tell me that apple cider vinegar helps reduce wrinkles and signs of aging. Since I’ve never heard of any scientific research done on it, I decided to look it up. I found nothing in any medical database.

There is a rumor circulating that apple cider vinegar enhances the skin. But there’s no scientific evidence just yet. We’ll just have to wait and see.

Does Circumin Have Anticancer Purposes?

A patient asked me about circumin. Circumin is a chemical that is found in Turmeric, a plant indigenous to Asia and some parts of Africa. Turmeric’s primary use is in spices, food products, and clothing dyes, but it’s not prominent in the medical field.

While laboratory studies suggest that circumin may have some anti-inflammatory and anticancer uses, there are no reports of these findings in people yet. Hence, the research on circumin and its medical benefits remains in progress.


Medicines to Reduce Breast Cancer Risk. 2014.

Turmeric. NCCIH. Published March 2007. Accessed July 7, 2016.

What Allergen Causes Caterpillar Dermatitis?

Moth and butterfly caterpillars can sometimes cause an allergic reaction known as caterpillar dermatitis (lepidopterism). So after human skin comes into contact with the hairs on a caterpillar’s legs, symptoms begin to show up. While I’ve seen frequent cases of caterpillar dermatitis, I’m still not sure about one key aspect: what specific allergen in the hairs causes the dermatitis?

It turns out that, like porcupines, caterpillars have venomous quills. These spines, called verrucae, contain poisonous fluids, and are nestled beneath the leg hairs. When they penetrate skin, these verrucae introduce the venom into the bloodstream. Hence, an allergic reaction ensues. While the venom is usually not life threatening because of the caterpillar’s small size, it’s still irritating.

Caterpillar dermatitis manifests in hives, itching, and rashes, to name a few. Treatment is relatively simple and non-invasive due to the reaction’s topical nature. If you or your child should develop mild caterpillar dermatitis, use topical corticosteroid cream in addition to an oral antihistamine. As a result, the lesions usually heal within one week without scars.


Caterpillars: MedlinePlus Medical Encyclopedia. U.S National Library of Medicine. Published July 14, 2015. Accessed July 7, 2016.

Foot NC. Pathology Of The Dermatitis Caused By Megalopyge Opercularis, A Texan Caterpillar. Journal of Experimental Medicine. 1921;35(5):737-753. doi:10.1084/jem.35.5.737.

Müller CSL, Tilgen W, Pföhler C. Caterpillar dermatitis revisited: lepidopterism after contact with oak processionary caterpillar. BMJ Case Reports. Published April 20, 2011. Accessed July 7, 2016.

Mother Dirt Nurtures the Good Bacteria in the Skin

I heard an advertisement for a brand called Mother Dirt the other day. I had never heard of their products, so I figured I would do some research. I found out that it’s a new skincare line that nurtures the good bacteria present in the skin.

Most skincare products kill all of the germs on our skin, including the good bacteria living there. Researchers claim that this is more harmful than healthy for us, as it disrupts that natural order. We are sterilizing our bodies, which strips the skin of essential bacteria and leaves it prone to infection. In short, we are too clean!

Mother Dirt’s products are full of Ammonia-Oxidizing Bateria. AOB is healthy for the skin in the same way probiotics are healthy for the digestive system. Good bacteria will balance out cleanliness, health, and natural order.

You can check out Mother Dirt’s website and product line here.


Mother Dirt | Rethink Clean and Health Skin. Mother Dirt | Rethink Clean and Health Skin. Accessed June 30, 2016.

Collagenase Santyl Ointment for Chronic Wound Care

A visiting nurse suggested Collagenase Santyl Ointment for a patient who had chronic leg ulcers. I had never heard of this chronic wound care product before, so I decided to do some research on it. It turns out Santyl Ointment is a prescription medication that removes dead skin from chronic surface wounds. Dead skin buildup interferes with the healing process.

The ointment is prescribed for many kinds of chronic wound care: diabetic ulcers, venous ulcers, and areas that have been severely burned.

How to use Santyl Ointment:

  1. Clean the affected area.
  2. Apply the amount of ointment instructed by your doctor.
  3. Cover the area with a clean gauze bandage.  


What is Collagenase SANTYL Ointment? Collagenase SANTYL Ointment. Accessed June 30, 2016.

Spironolactone and Photosensitivity

A patient asked me if spironolactone caused photosensitivity. After careful research on the subject, I found that photosensitivity was not a side effect of spironolactone specifically. But it can be caused by hydrochlorothiazide, which the other chemical ingredient in Aldactazide® tablets. The short answer is not directly. But if the patient is taking Aldactazide® tablets, photosensitivity could be a side effect.


Aldactazide® spironolactone and hydrochlorothiazide tablets . Published January 14, 2016. Accessed June 29, 2016.