Tag Archives: Skin

DR. C’S JOURNAL: WHAT IS AUTOIMMUNE DISEASE?

Our immune system contains cells that are part of us, and they evolved to protect us. They generally do a good job of this, as witnessed by our survival in a sea of viruses, microbes, and parasites.

However, just like our police force, occasionally the protective function goes awry and damage is done to our own body, in the protective act. For many years I was a practicing allergist, and observed this protective function misfiring. In allergic rhinitis and allergic asthma, tiny harmless particles in the air are interpreted by the body as a threat. The TH2 immune system, initially evolved to fight parasites, is activated, and causes considerable disease and misery.

Some of the antigenic determinants on the surface of the pollen, animal dander or dust particles are interpreted as being dangerous by the immune system, which causes chronic inflammation with acute allergy attacks.

Autoimmunity is a similar misreading, in which our own cells are deemed dangerous. In this case the immune agency is the more powerful Th-1 system, which often causes crippling or even fatal results.  

Millions of people are sickened by an immune system that is supposed to defend them.

An article in the September 2021 issue of the Scientific American lists 76 of these disorders, and classifies them as to frequency, patient gender and age of onset. It is worth reviewing, at least for the listing on page 32 and 33.

Auto immunity must be considered as a possible cause in any illness that is not easily diagnosed, common, and well known to your doctor. Many patients have to be their own advocates, and persist in trying to get themselves diagnosed.

Celiac disease, Lupus, and Addison’s disease come to mind as tricky customers. Although “autoimmune disease” in toto is common, many of the individual diseases occur in less than one in 1000 patients, and are not high on the diagnostic list of most doctors.

The skin, nervous system, endocrine system, and digestive system are the most common areas involved. Recent advances in blood and antibody testing offers to give needed diagnostic help to the medical profession. These illnesses must be detected early to avoid functional loss in the tissues and organs affected.

Treatments are improving. In the past, immune suppressing cancer drugs and cortisone were the main drugs available. With increasing knowledge of the mechanisms of the separate diseases, treatment can be directed towards the specific causative antibody, receptor, or interleukin involved, hopefully with less side effects than the shotgun drugs previously available.

As with medicine in general, these modern treatments are excessively expensive as a rule, because much money and research went into their development. Prevention is obviously preferable. A healthy diet, with its attendant healthy microbiome comes to mind, as well as the avoidance of cigarette smoking and environmental toxins.

Proper sleep, exercise, and stress relief should also be helpful.

—Dr. C.

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INFECTION: OPPORTUNISTIC INVASIVE FUNGI EXPLAINED

Fungi are in the outside air, the inside air, and even the air of isolation units In hospitals. The normal human respiratory tract is able to breathe these fungi in, have them deposited on the mucous membrane surfaces and have no problem. The normal respiratory membranes, with their associated cleansing cilia and normal mucus production are able to sweep the invaders out without sustaining any harm.

Problems arise when the respiratory tract is functionally or structurally abnormal, such as in cystic fibrosis, bronchiectasis and COPD. Immunocompromised conditions have been increasing in frequency with the improvement in medical care in recent years. Intravascular catheters and sensors can provide a resting place for pathogens including fungi, as can cavities, scars and other damage to the lung. The immune system may require suppression to accommodate an organ transplants or ameliorate autoimmune conditions.

Cancers, especially of the hematologic or lymphatic system, such as lymphomas, pose a definite problem. Severe burns and  malnutrition may weaken the immune system, as may Viral infections, especially AIDS, and more recently COVID-19. More subtle immune problems may arise with diabetes, Obesity, or even a lack of sleep and exercise.

These and other conditions give the fungal infections the OPPORTUNITY to invade the body, and a few dozen of the thousands of species of fungi proceed to do just that. Opportunistic fungi often have special features, depending upon the species. Most prefer the respiratory tract, and if they get in to the bloodstream can go to their favored spots.

Aspergillus, and coccidiomycosis , for instance, prefer the lung. Mucormycosis often involves the sinuses and eyes. Blastomycosis can involve bone. Sporothrix is often found infecting the skin.

Symptoms depend upon the area involved. Of course if it’s a respiratory tract, you have coughing, mucus production, sometimes shortness of breath. With the central nervous system you have headache and confusion. You can see the involvement in the skin.

The number of drugs available to fight fungal infection is fairly limited, and currently involves only three different classes. Many fungi are resistant to one or two of these classes, and can be problematic.
However, fungi do not as a rule spread through the air from person to person, and a true epidemic would be unlikely.

—Dr. C.

HEALTH: VALUE OF A HEALTHY ‘SKIN MICROBIOME’ (VIDEO)

Our skin is home to billions of microorganisms, the vast majority of which are bacteria. Much like the microbiome in our gut, these microbes play a crucial part in keeping us healthy. They are part of a finely balanced ecosystem of friendly or ‘commensal’ bacteria, which protect our skin by creating an inhospitable environment for would-be invaders, bolstering the physical integrity of the skin, and training the immune system to distinguish commensal inhabitants from pathogens. A number of skin conditions are now understood to be influenced by a breakdown of this microbial ecosystem. Researchers are working out whether restoring the balance can treat these conditions. Understanding the ecology of this rich community is likely to be an important part of both dermatology and the study of the microbiome. Read more in https://www.nature.com/collections/sk…

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #30: ACNE (Vulgaris)

ACNE is almost a rite of passage in adolescents, although it is not totally restricted to the teen years; women may experience acne during pregnancy, or at the time of menopause. It afflicts about 90% of kids during their PUBERTAL growth spurt, though is moderate or severe in only 15%.

Acne is caused by PLUGGING of the sebaceous glands of the skin. Infection by certain skin BACTERIA follows. Check the accompanying video for a description of the battle between the “Good guys”, Staph epidermidis and Cutibacterium acnes, vs. the bad guy, Proprionibactrium
acnes.

Acne tends to run in families. The steroid HORMONES like Testosterone and Cortisone promote Acne. STRESS tends to chronically raise Cortisol and is a factor in Acne, and many chronic illnesses as well.

A person who is having trouble with Acne should avoid sweets and greasy foods, which is a good idea for everybody. Skin cleansers, using salicylic or azelaic acids and benzoyl peroxide may help, and creams containing retinoic acid derivatives may be useful..

The doctor may prescribe an antibiotic like tetracycline in resistant cases. Cystic acne may be scarring, but otherwise “the zits” depart with the pubertal years.

–Dr. C.

Further reading at Mayo Clinic

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #18: SKIN INFECTIONS

The skin is the protective barrier between the inside of our bodies and the outside world of microorganisms, parasites and toxins. It is often the site of inflammation and infections.

In past times, before the advent of cleanliness and antibiotics, mankind was plagued by erysipelas, boils, carbuncles, and other severe infections of the skin, which are rarely seen now. The beta hemolytic streptococcus and Staphylococcus aureus were ubiquitous in the past, and mostly are contained today.

Severe Infections presently require some skin abnormality, immune deficiency, neglect, animal bite or other breach of skin integrity to be a problem. Antibiotic resistance, however, is allowing some organisms like MERSA to make a comeback.

ECZEMA. or Atopic Dermatitis, was common in my medical practice. This condition weakens the skin barrier, allowing Staphylococcal infection to gain a foothold. In my day, If there were a flare of eczema severity, antibiotics would often help. Leg edema and swelling. such as from heart failure, especially coupled with diabetes and blood vessel disease is also an invitation to infection, such as cellulitis.

Redness, swelling, warmth and pain- the classic rubor, tumor, calor and dolor- as well as swollen local lymph nodes and fever often betray infection of the skin. Please see the recently posted infographic on celulitis.

IMMUNE DEFICIENCY raises the likelihood and risk of severe skin infections. Infection from “flesh-eating bacteria”, often beta hemolytic streptococci in deep tissue planes , is a medical emergency. Immediate surgery is often needed.

Disproportionate PAIN after injury or surgery is often a clue. Certain age groups have characteristic skin infections, such as the scalded skin syndrome of infants, and the acne of adolescents. Viruses, molds, and arthropods can also infect the skin.

Viruses, such as herpes in particular can simulate bacterial infection. Ringworm from fungi is easy to distinguish, but arthropod bites, and especially bee sting can look very much like bacterial infection. Scabies and mite infestation are so itchy as to be distinct.

Topical antibiotics applied on skin breaks like cuts or breaks are useful in preventing infection. These ointments and creams are like “artificial skin”. Once again, prevention is key.

–Dr. C.

CDC INFOGRAPHICS: ‘HEAT STROKE & HEAT EXHAUSTION’

COMMENTARY:

THERMOREGULATION, preservation of the normal body temperature, is well developed in humans, and monitoring the body temperature has been useful since the development of thermometers.

Indirect measurement by Infrared detectors is being widely used today to detect FEVER as a sign of Covid in gatherings such as schools. Reactive increase of body temperature in a cool environment is a body defense mechanism that I have discussed earlier. Contrary to general practice, Fever, in my opinion, should be left untreated unless excessive, such as above 103 degrees F., or even 104 degrees.

Excessive environmental temperature, such as in a closed car, Jacuzzi, or heat wave can defeat the body’s ability to defend the normal temperature. Children, with their high body surface to mass ratio, are particularly at risk, as periodic newspaper articles testify. HEAT STROKE is the most serious of heat-related illnesses, leading to high and increasing body temperature, mental symptoms, even convulsions, and is a MEDICAL EMERGENCY.

The treatment is to call 911, and to lower the body temperature by removing insulating clothing, and immersing in cold water. There are a variety of other conditions based on excessive exertion, water or salt loss.

These include HEAT EXHAUSTION. Older Workers are particularly susceptible, and medical clinic attention may be needed for fluid and electrolyte replacement. MUSCLE CRAMPS and even damage( Rhabdomyolysis), FAINTING (this has been discussed before) and Heat Rash can result from too hot an environment. Furry Animals Pant instinctively to get their highly vascular Tongue to “air condition” their bodies. Humans should dress and exercise appropriately when the environment requires it.

–Dr. C.

THE DOCTORS 101 CHRONIC SYMPTOMS & CONDITIONS #18: ACTINIC KERATOSES

Red hair and freckles are associated with MCR-1 gene variants, and large areas of skin with lowered melanin protection against the adverse effects of the sun. I have red hair and freckles, for which I was teased. My response was that I had a lot of Iron in my blood, and that the freckles were Rust. This is ironic (no pun intended).

Since becoming an Octogenarian, I have had trouble keeping my Iron levels normal. I live in a beach area, where all the young ladies are sunning themselves to promote the socially desirable “bronze goddess” effect, and all of the older ladies hide their leathery skin and wear broad-brimmed hats.

The sun has a good reputation as a health-giver. Being outside does correlate with a lot of beneficial effects, such as enhancing production of Vitamin D. My recommendation, however biased, is to get your Vitamin D in capsule form, and reduce sun exposure.

SUNSHINE, however salutary, is accompanied by invisible, high energy photons capable of breaking DNA strands, and ultimately causing SKIN CANCER. Not accidentally,Visible light has insufficient energy to break bonds, although the rhodopsin in rods and cones do release electrons if stimulated by light.

Actinic Keratoses are the roughened plaques of skin, often on the face, which have a small but definite risk of turning into Cancer. I have a dermatology check every 6 months for precancerous areas to be frozen and destroyed by CO2 spray.

PREVENTION of UV Skin damage is advisable. I wear a broad brimmed hat and UV-blocking sunglasses (UV can promote cataracts and retinal damage as well) when outside in the sun. When swimming I wear a “rashguard” shirt with UV protection in the fabric.

Also, I try to limit my exposure to the Evening and Morning sun, because the light is warmer, and contains less UV. Even with these precautions, I use Sunscreen creams and lotions. I always wondered how a transparent lotion can block UV light.

The explanation lies in the chemicals contained. Such chemicals as Avobenzone and Homosalicylate actually absorb the energy of UV light. Protect yourself now for later health.

–Dr. C.

TELEMEDICINE: THE RISE OF TELEDERMATOLOGY (AMA)

From AMA.org (June 12, 2020):

Teledermatology

“There’s an aging population, and there’s a lot of skin out there,” said Dr. Isaacs. “One in five people in the country develop skin cancer, but there is a plethora of benign skin conditions that also require the expertise of the dermatologist. So, you have increasing demand and a limited supply of dermatologists.”

A basic example of how the TPMG teledermatology program works involves a patient who is concerned about a suspicious lesion or mole on their body. The patient can take a picture of the location in question and send it to their primary care physician for review. The physician can request the patient come in for a more thorough evaluation, or if the physician determines that a dermatologist should be involved, they can send the photo to an on-call dermatologist to review.

If the patient does an in-person evaluation, the physician can also take a higher-quality image and forward that to a dermatologist. The dermatologist can then decide whether there is a problem, if a prescription is needed, or if there should be an in-person evaluation and potential biopsy.

A study in the Journal of the American Academy of Dermatology in 2019 found that when TPMG dermatologists had the chance to look at well-photographed skin lesions, they were able to identify nearly 10% more cancers with almost 40% fewer referrals to the dermatology department.

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COMMENTARY

A high quality I-phone picture of a skin lesion can provide the dermatologist with 90% of the information needed for a diagnosis.

Melanoma diagnosis depends even more on the visual. In fact, Artificial  Intelligence evaluation of Melanoma may be  overtaking dermatologist expertise.

Size can be indicated by including a dime in the photo.

It is true that the roughness, softness or hardness may be important in diagnosis, but perhaps these characteristics could be described by the Patient.

This week, I started worrying about an itchy, rapidly growing lesion on my back. I sent a picture of this to my dermatologist, hoping he would call it a wart and reassure me. It was very regular, soft, and had a rough surface like warts I have had in the past.

However, he saw some redness and had me come in for removal. We will see what the pathology shows.

Dermatologists are in short supply, and making more efficient use of their expertise attractive.

Calling the Doctor’s office, arranging for e-mail Photo transmission, and a talk with the Doctor on the phone could save a visit. The Primary Doctor could send you directly to the dermatologist, or might be comfortable with watching and waiting.

Dermatology is indeed a field ripe for Telemedicine.

—Dr. C.