Breaking Out in Hives?

Hives- the very thought of these itchy, raised, red splotches make me start to squirm and scratch. With our oak allergy season in full bloom here in Austin, we see the full spectrum of allergic complaints- from sneezing, sore throats, dry coughs and itchy eyes to skin reactions such as hives. The medical term for hives is "urticaria". These lesions come and go, and often cause a burning sensation along with the itch.

In the previous blog entry about allergic eye problems, I mentioned that histamine (the substance that causes the redness and itch of allergic reactions) is stored in cellular level containers called mast cells. With urticaria, the basic problem is that these mast cells degranulate, releasing their highly inflammatory contents. The good news is that typical lesions resolve within 24-48 hours, but the bad news is that they can quickly reoccur and become a chronic problem.

But Doctor, what caused my hives? Was it the shrimp I ate yesterday?
Unfortunately, identifying the triggering cause for hives can be extremely challenging, because there are so many different potential culprits. Infections (especially from Strep and mononucleosis), drugs, foods, pollens, chemicals, metabolic disorders (like thyroid) and even rarely underlying cancers can all be to blame. Additionally, urticaria can be triggered physically, from cold or heat, pressure, or sunlight.

Treatment focuses on antihistamines initially, and often this is all you will need- especially if this is the first time you have ever had hives. Non-sedating antihistamines are used for daytime, and our old standby diphenhydramine (Benadryl) works well at night for those who need help sleeping. If these medications are not enough, clinicians have stronger medications such as steroids or other histamine receptor blockers that may be added.

What can you do as well? Avoid extreme or sudden changes in temperature, including hot showers. Avoid alcohol and NSAIDS (ibuprofen, naproxen), both of which can aggravate hives. Stay out of the sun. Applying topical calamine lotion provides relief to some people. If you develop a chronic problem, consider keeping a diary to help identify potential triggers. Happily, approximately 70% of people with first time hives will have resolution of their symptoms within three days, regardless of which treatment they use.

BOTTOM LINE: If you break out in hives, start with OTC antihistamines and be assured that it is okay to give yourself a couple days before you head to your doctor, as long as your itching is tolerable. 

Seeing Red This Spring?

What should you do if your primary allergy symptom is not sneezing, runny nose, or sore throat, but burning, itching, watery, red eyes? Will over-the-counter products help with eye symptoms?
The short answer is yes- oral antihistamines (like Benadryl, Allegra, Claritin & Zyrtec) can help with allergic eye symptoms, but if you are really only having eye issues, you may get better relief from some prescription eye drops.

Many of my patients try to use over-the-counter eye drops that "get the red out"...only to discover that they need more and more of these drops to accomplish the same results. The only time that I recommend these OTC products (which have vasoconstrictors to eliminate red eyes) is for extremely short-term use, such as if you are giving a presentation or taking pictures. If you use these products for more than a couple days, you will develop rebound symptoms of increased redness, and risk getting pulled into the vicious cycle of red eyes, use drops, worse red eyes when drops "wear off", more drops, etc.

Prevention is key for allergies in general, and especially helpful with eye symptoms. While avoidance of the allergen is your first choice, often that is not possible or practical. There are a variety of both over the counter and prescription eye drops that can greatly reduce eye irritation and discomfort from allergies. Some are antihistamines, but others are more pro-active prevention. Histamine (the substance that triggers the redness and itch) is stored in "holding tanks" called mast cells. Mast cell "stabilizing" drops were designed to keep the histamine staying in the holding tanks, rather than being released to cause havoc.  There are also prescription combination antihistamine and mast cell stabilizing drops, which can be applied only once or twice daily. Finally, there is another class of medication that is purely anti-inflammatory.

What "home" remedy helps? For quick relief of itchy eyes, try wrapping a dampened washcloth around  some ice cubes, and hold this cold compress up to your eyes for a few minutes. Heat is NOT the answer for this eye problem! Heat releases histamine, and simply ramps up the problem.


BOTTOM LINE: If your eyes are driving you crazy during allergy season, don't suffer in silence, but schedule a visit with your family doctor or eye doctor to find out your treatment options!

Itchy Eyes, Runny Nose...Achoo!

No April Fool's...here in Austin, Texas, we are fully into OAK ALLERGY season. Our cars have a dusting of yellow pollen, and the streets are strewn with oak droppings. Is it time for a trip to your family doctor or allergist? Maybe, but there are several remedies you can try on your own first.

What are signs and symptoms of allergies?

At the risk of sounding like an antihistamine commercial, it's sneezing (often in fits of sneezes), itchy eyes, itchy throat, scratchy throat, drainage down the back of your throat (which creates early morning sore throats that often fade mid-morning), stuffy eyes, ear pressure and the lovely dark circles under your eyes.

What is recommended for treatment?

Typically we start with the non-sedating antihistamines,which used to be prescription but are now available over the counter (OTC). These include Loratadine (Claritin), Fexofenadine (Allegra), and Cetirizine(Zyrtec), to name a few of the most popular. Which is BEST? In my experience, they are equally effective overall. However, what works for you this year may not work as well next year, and there is not great science to explain why. Antihistamines will DRY you up and STOP ITCH. If you are mainly stuffy, you are better off with just a decongestant such as phenylephrine (Sudafed) or if you have both, grab a combination product.

If you are suffering regularly in a particular season, or perhaps year-round from something like molds, your doctor may recommend more preventative therapy such as nasal steroid sprays. These sprays are prescription, and they are not "addictive" like the OTC ones. The OTC sprays that give immediate relief are fine for a day or two, but beyond that, you will get rebound nasal congestion and be chasing your tail with symptoms/spray/more symptoms/more spray. Nasal steroids are minimally absorbed (so no turning into Arnold, gaining weight, or weakening your bones.) They are very safe, and decrease swelling while creating kind of protective barrier against entering irritants, so you don't turn on the histamine system that causes allergy symptoms.

What more prevention can you do?

Well, it's April 1st, so like every first of the month, I recommend changing out your home's air filters! Even the "central" or "media filter" type should be changed at least three or four times per year, despite manufacturer recommendations of annual replacement. Yes, that is expensive, but cheaper than many allergy medications, and no other side effects! Consider posting a reminder on your calendar to change your filters every few months. HEPA air cleans and vacuum bags are of unclear efficacy, but may help. Limit your outside exposure (get on the exercise bike or treadmill indoors.) If you really suffer, consider getting rid of carpet and drapes in your home, and restricting pets to outside the bedroom.

BOTTOM LINE: If you can't stop sneezing or are having other signs of seasonal allergies, schedule an appointment with your doctor and find out what she can do to help! There are many interventions before considering allergy shots- though for severe sufferers, those shots may be an excellent option.

Getting a Base Tan for Spring Break?

Here in Texas, we are alternating hot days of wearing shorts with chilly days or grabbing jackets, which means it's nearly time for SPRING BREAK- hooray! Many students and their families head to the beach for spring break, and before the women don their bikinis, the quest for a "base tan" to avoid a sunburn begins. I have had many patients ask my advice on what is better- going to a tanning booth or braving the capricious weather outside. My answer? NEITHER.

The entire notion of a "base tan" has no scientific basis, nor support from dermatologists. In fact, the American Academy of Dermatology (AADA) testified last year at FDA hearings about the risks of indoor tanning. These devices have shared the same low risk category as bandaids and tongue depressors, yet we have had medical evidence for years that they clearly cause skin cancers.

Melanoma rates are increasing across the board, and melanoma is now the number one cancer in young people aged 25-29, and the second most common cancer in 15-29 year olds. Use of a tanning bed before the age of 35 increases your risk of developing melanoma by a whopping 75%! I can personally attest in my own practice that I have diagnosed multiple cases of melanoma in the last couple years, primarily in people younger than I am- which really hits home. (I'm 47.) Having lost a friend to melanoma many years ago, I am very aware that skin cancers are not simply cosmetic nuisances.

Please be aware that tanning beds are not "safe", and they target young people (especially women) with their ads. Many tanning salons promote their "safe" or "harmless" type of UV radiation, but the UVA rays cause damage in the same fashion as UVB rays- only a bit more slowly and more deeply. Any change in skin color is a sign of damage from UV radiation. Period.

The American Academy of Dermatology hopes the FDA will ban indoor tanning devices all together, but at the least, should require a minimum age of 18 for ANY indoor tanning and should mandate obtaining informed consent from clients AFTER educating them about the real risks of skin cancer. The AADA also strongly recommends changing the risk category of these machines to match the health risks they create.

BOTTOM LINE: TANNING is NOT SAFE and "base tans" don't help! Use sunscreen, wear protective clothing and stay away from tanning beds all together.

What Did You Give Up?

Lent came early this year- tough to have Valentine's Day the second day of this season if you gave up chocolates! While certainly not everyone practices Lenten observances, I think most people are familiar with the general concept of offering some sort of self-discipline as part of a religious practice, so this is a good opportunity for me to share a thought about the mix of religion and medicine.

As a physician- especially as a Catholic one- I really appreciate Lent. Just as New Year's resolutions for healthy changes are fading away, in comes Lent to save the day! All kidding aside, while many of us have wonderful intentions of limiting sweets, sodas, alcohol, nicotine, or you-name-it in the name of HEALTH, a good portion of us need that extra nudge of discipline that comes when these intentions are linked to a higher good. One way to do this is indeed the traditional practice of a "fast"from an earthly pleasure. If every time we start to reach for or simply crave our "off-limits item", we instead check ourselves and take a minute for prayer or reflection, how great is that? Not only are we not harming our body with an unnecessary substance or calorie load, but we gaining the peace and lower blood pressure that comes from meditation. Definitely a win-win! (Of course, if we gripe and grumble and feel extremely self-deprived every time, that's a whole different ballgame...)

Whether it is fasting, prayer, meditation, or acts of service for others, religious practices can be a wonderful asset to our health- both physical and mental. In my practice, I have seen tremendous success  when patients combine their spiritual and physical efforts in a very practical manner.

BOTTOM LINE: Harness the power of your religious strength to give you that extra push to stick to healthy life-style choices!

Till We Meet Again...A Special Note to my WLFP Patients

To my wonderful patients from West Lake Family Practice,
This note is a month overdue, not from neglect, but from the inadequacy of my words each time I sat down to write. I simply cannot express what a privilege it has been to care for you and your families. Many of you have been trusting your healthcare to me for almost two decades- first at my practice on 38th street and then in Westlake. I truly cherish our friendships and shared experiences- through occasionally bewildering medical challenges and with your "real life" experiences, both the joyous and the sorrowful. When I think about the practice of medicine, it's not about cancer, diabetes, weight, heart attacks, depression or sore throats- it's about the complete person dealing with these challenges, and his or her stories and relationships. That is why I love family medicine.

When I took what I had hoped to be a six month leave of absence last year to finish up two writing projects, I had every intention of returning to WLFP. Unfortunately, publishing world turnover created chaos in one project, extending my leave to a full year. Meanwhile, medical care is obviously in the midst of upheaval and evolution, and primary care practices in particular have been swept up in these changes. WLFP is no exception, as I am sure you are aware. Like any business, our practice both gained and lost personnel as the ownership changed hands.  I believe many of these changes in healthcare will push the practice of medicine in the right direction (such as electronic medical records)  but patience is required, as the growing process can be challenging for all of us. With all of these changes, however, the timing is right for me to make another transition in my career.

Although I miss the patients, co-workers and staff at WLFP, I am truly enjoying being back at the University of Texas, seeing students in the urgent care area of the health center. (The reflection from my Aggie ring makes all that burnt orange look maroon...) Seriously, though, please make sure your current Longhorn students know I am available for them! Additionally, many of you know that I have been working with our Bishop Emeritus, John McCarthy, on his book (very near publication), and I am excited to bring my life full circle soon by joining the team at Seton's McCarthy Clinic (named in his honor.)

A special thank you to Cary Douglass, MD, for inviting me to work at WLFP a decade ago, and always supporting my editing, writing, publishing, and media adventures. To Scott Gaertner, MD, & Kristyn Fagerberg, MD, I miss you both and wish you success at West Hills Family Health Center.
To Mary Sue and the front office staff, thanks for juggling my schedule without complaint. To Deana and Lorie, I know you will keep taking great care of our patients, thank you! To Virginia, all the best...until we meet again.

BOTTOM LINE: My dear patients, I will not say goodbye, but only "till we meet again"...and many thanks for your trust and friendship. 

P90X- Bring It!

Okay, my post about the FB pledge to better health with P90X has generated lots of questions for me (and I suppose smiles for the makers of the DVD- and NO, I do not have any financial or other ties to them!) I will explain what it is and why I personally enjoyed it, but more importantly, I want to encourage you to find what will push YOU a bit out of your comfort zone.

P90X is a series of exercise DVDs. To be honest, I learned about it several years ago when I was in a hotel exercise room and the infomercial was on the locked-in TV channel, so I was a captive audience. Time seems to be my scarcest resource, so exercising at home is my preference. That being said, both my body and my mind get bored with simply walking the dogs or riding the exercise bike, and I am not one to spontaneously drop in to push ups or heaven-forbid, sit ups! Each DVD in this series is different, from old-fashioned calisthenics (though who knew their were over a half dozen kinds of push ups??) to yoga to kick-boxing. I am generally in good shape, but the first week of this program, I literally felt like a truck had run over me- and that was with only being able to do maybe 10% of the exercises! I'm happy to say that in several weeks, I could do everything (okay, except the yoga, which I never mastered.) And, for full disclosure, I developed a shoulder injury that was aggravated with the pull ups, so I had to put P90X back up on the shelf, but I did so with vastly improved upper body & torso definition and strength, and I went back to a self-modified version of this program after I rehab'd my injury.

Would I recommend P90X for you? Maybe. From my standpoint, this type of program is best for the person is at or within roughly ten pounds of their ideal body weight, is already doing some kind of cardio consistently, but wants to get serious about changing their body shape and strength, AND will commit to the hour per day that this program demands. Talk to your doctor and see what she recommends.

The take home message here is that if you stay in the same exercise program for prolonged periods and expect different results, you are setting yourself up for disappointment (especially if you are walking or running.)

BOTTOM LINE: I have always encouraged cross-training for this reason, but pushing yourself to the next level- more intensity, more muscle groups, or simply different muscles- is the best way to break out of a body plateau.