A patient recently came to me with complaints of excessive sweating from the scalp. This is an unusual form of hyperhidrosis called cranial facial hyperhidrosis. It is similar to people who have sweaty palms and sweaty armpits.
In this particular patient’s case, it was interfering with the quality of their life. It was not related to their being overheated, and it was getting worse. The patient did not want to have an excessively sweaty scalp for no reason at all.
I’ve been consulting with this patient’s internist on the best course of treatment. I will most likely prescribe an oral agent called Glycopyrrolate.
Recently, a pediatrician consulted me on a 13 year old with shingles. The patient had been vaccinated with the live attenuated vaccine as a younger child. Patient responded nicely to a course of valacyclovir (antiviral medication).
The case got me thinking about two things: first, in my experience, shingles in children is very unusual. Epidemiologic data supports the rarity to about 1 case for every 1000 people aged 1-25 per year.
Second, it got me thinking about the pathogenesis (how the process works). It must be that the latent live attenuated virus can set up shop in the spinal cord. Over time, the patient’s ability to detect varicella zoster may wane. In these cases, the virus escapes local control, resulting in findings called shingles.
This patient’s pediatrician and I ran the case by an infectious disease specialist. The specialist thought that it would be wise to check the patient’s CBC, specifically the lymphocyte count. We wanted to make sure there were no underlying conditions.
Albrecht MA. Epidemiology and pathogenesis of varicella-zoster virus infection: Herpes zoster. Hirsch MS, Mitty J, eds. http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-varicella-zoster-virus-infection-herpes-zoster?source=search_result&search=Epidemiology and pathogenesis of varicella-zoster virus infection%3A Herpes zoster&selectedTitle=1~150. Accessed May 19, 2017.
Oral contraceptives are an established part of acne management, especially in post adolescent women. However, I have seen a few cases where some oral contraceptive brands exacerbate acne and hair loss.
The progesterone components of some OCPs have androgenic (testosterone-like) properties. Androgenic properties can make acne worse. For example, they can cause hair loss in individuals genetically vulnerable to alopecia. I have been recommending orthotricyclen with 35 micrograms of estrogen for female adult acne patients for years. But I failed to realize that the progesterone component is less androgenic.
While reviewing a recent case of a young patient with significant alopecia, further history revealed that she had been on oral contraceptives for years. I had done a full work up on her three years ago, but failed to get the history of birth control use. Some patients don’t consider it a medication. The progestin in this particular brand is in the mid range of androgenicity; it has been associated with hair loss in about 2% of women. I have contacted this patient’s PCP to see if she can be prescribed a contraceptive with less androgenicity.
Osathanondh, R, Stelluto, MR, Carlson, KJ. Contrception. In: Primary Care of Women, Carson KJ, Eisenstadt(eds), Mosby, St. Lois, 1995. In UptoDate
My advice to all patients is to use sunscreen (SPF 50), which is available at most stores. Apply to the face, ears, back of the neck, hands, exposed legs, and feet. Reapply ever two hours, and immediately after sweating or water exposure.
It’s important to know the key ingredients in the sunscreen product itself, and how safe they are.
Zinc oxide and Titanium oxide are common ingredients found in many products. These micronized particles are for the most part safe, and don’t penetrate unbroken or undamaged skin. However, there are some concerns about these substances being absorbed into damaged areas. They should be avoided when the skin barrier is impaired. For example, if you have eczema or even a sunburn, don’t apply sunscreen directly to the wound site. Make sure you have an alternative method of protecting the site.
Products that contain benzophenone pose risks to the environment: they are harmful to coral reefs. They may also cause hormone complications: theoretical absorption may lead to estrogen-like effects, based on a rodent study. Benzophenone is most commonly found in organic sunscreens.
How you apply sunscreen has a direct effect on how well you are protected. While using sunscreen:
- Apply generous amounts of sunscreen fifteen minutes before going outside. For optimal protection, apply your sunscreen before you get dressed.
- It’s important to reapply every two hours, and to do so immediately after swimming or excessive sweating, even if the bottle promises water resistance.
- Just because it’s cloudy doesn’t mean you don’t have to sunscreen. Clouds don’t protect you from damage, as UV light passes through them. Apply sunscreen as you would if it were sunny.
- Keep in mind that sand, water, and snow are reflective surfaces.
The sunscreen product itself doesn’t protect you from serious complications such as heat stroke and dehydration. Don’t stay in the direct sunlight for too long, drink plenty of fluids, and reapply.