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.
A patient said that I was “saddled with Mitchell’s disease,” which I had never heard of. After doing some research, I learned Mitchell’s disease is another name for Erythromelalgia. Erythromelalgia is a clinical syndrome that often goes unreported.
Erythromelalgia is a rare pain disorder characterized by a burning ache in the hands and feet. Severe redness and raised skin temperature are also symptoms. Erythromelalgia was called Mitchell’s Disease, named after Silas Weir Mitchell. Mitchell discovered and named the disease in the late 19th Century.
Presently, the cause of Erythromelalgia is unknown. There are a few theories floating around, but researchers think the underlying root is dilation and contraction abnormalities in blood vessels in the hands and feet.
Symptoms can manifest quickly or slowly. Some report a sudden, rapid onset of crippling pain over weeks. Others say that they’ve had relatively mild symptoms for years. Theories suggest that Erythromelalgia does get worse as it goes on. Some cases have even started in the feet, and spread up from the toes to the face and ears. Erythromelalgia is nonfatal, but it is chronic, which can cause interferences with a patient’s daily life.
Some suggest that patients relieve their symptoms by putting their extremities in a colder environment (e.g. ice water). However, in several cases, repeatedly immersing in ice water actually triggered an episode. Most doctors advise patients to stay in a cool environment, but that makes it more difficult for people who live in warmer areas. Topical medications appear to be more helpful, such as a local anesthetic like lidocaine.
As mentioned before, the disease is nonfatal, and most patients can live a normal life. Research into cause and treatment for Erythromelalgia is ongoing.
Erythromelalgia – NORD (National Organization for Rare Disorders). NORD (National Organization for Rare Disorders). http://rarediseases.org/rare-diseases/erythromelalgia/. Accessed August 12, 2016.
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.
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. https://www.nlm.nih.gov/medlineplus/ency/article/002860.htm. 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. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3082058/. Published April 20, 2011. Accessed July 7, 2016.