Educate the world, one person at a time.

Today was the Education Council meeting for McMaster’s Family Medicine Teaching Centre and it inspired some thoughts as to how education (both medical and general) has changed over time.  There are a lot of other people that are far more qualified to speak on this topic, but I wanted to put “pen to paper” and just mention a couple of things.

I still have a “certificate” from my elementary school class trip to the Old Britannia Schoolhouse, where we learned how kids were educated and disciplined.  Education as a theme is ageless as people have passed down information from parent to child, teacher to student and possibly as below.

 

In discussion with a colleague of mine, who was telling me about his father who started a charity called Asha Jyoti, which gave a scholarship to a student who was underprivileged and yet showed promise as an excellent student.

It seemed to go well with EveryDayChild‘s motto of Learn, Earn, Return, allowing students with excellent potential the chance to succeed despite unsurmountable odds.

The evolution of education has continued to grow, especially in the way that it is developed.  Child psychology and behaviour has been analyzed in multiple articles and this is being used to avoid the use of discipline involving physical harm to children.  There is good literature that discipline should be focused on being based on what is appropriate for the child’s developmental stage and age.  A 2 year old will not understand a dissertation about why finger painting on the wall is a bad thing.  As such, discipline needs to be based on clear instructions with set rules of punishment and positive reinforcement to allow for rewards for good behaviour.  Interestingly, the use of “Time outs” when used on young children has been shown to be effective in studies and can be used effectively.

It is important to have the goal of discipline be directed at the behaviour and not at the child and that it should taught with respect and patience, not to punish or belittle the child.  As such, it is important for the child to have the punishment be as soon as the behaviour occurs and it needs to be consistent.

There are studies that physical punishment (whether thought to be “minor” or “child abuse”), has been noted to have issues with poor self-esteem, increased risk of drug abuse and depression/anxiety.

Newsflash: Jumping from side to side doesn’t help with this.

Paronychia or Ingrown nails are extremely common, so much so that current literature does not have actual data collected on how common it is.

It is defined as a infection that is specific to the nail bed and is present on the superficial layers of the skin.  In order to understand where the infection is taking place, it is helpful to see the nail in a cross section to get a general sense of the vocabulary. Source: footdoc.ca

The main causes for paronychia is nail biting, frequent manicures, excessive moisture and sucking one’s finger.  Certain medications can also be causative agents such as growth factor inhibitors and antiretrovirals.

Certain occupations can use cotton gloves to be placed under vinyl or nitrile gloves if they will commonly come in contact with water, but practically this is quite difficult for some professions, and other mechanisms have been utilized to protect people.  A perfect example of this is a bartender who would find it difficult to don and doff gloves constantly and can instead use a automatic glass washer where his hands won’t be immersed in water.  Working in combination with motivational interviewing can be helpful in breaking the nail biting habit (SORT C).

When patients come to the physician for advice, it is usually because the toe is tender, swollen especially on the edge of the nail bed or on either side.  As the need to decrease unnecessary antibiotic prescriptions is mounting, it is vital to have patients try conservative measures such as warm soaks or compresses prior to starting antibiotics.  There is evidence that compresses or warm soaks may be all that is needed (SORT C), though more studies and critical reviews are needed to hash out the risks and benefits, as well as the recurrence rates.  If the patient has a fluid filled area, an incision and drainage may also be required, though there is no clear cut evidence that antibiotics are better or worse than incision and drainage.  It should be noted that unless there is a coexisting cellulitis (skin infection), there is no role in giving antibiotics after the toe nail removal.

Use of topical steroids (much better than use of anti-fungals) are helpful in cases that last over 6 weeks and should be monitored as the nail folds may be come thick and/or discoloured.  Typically patients do not present with symptoms of fever or fatigue with this disease and if these are present, consider alternative diagnoses.

If toe nail removal is to be performed, it is preferred that there is a phenolization of the nail bed base to decrease symptomatic recurrence, though it is possibly to have increased chances for infection after the procedure (SORT A).  The risks, benefits and alternatives need to be discussed prior to beginning the procedure.  

In the end, the old adage of ‘ounce of prevention’ is probably worth more than a procedure that also runs a risk of infection.  Therefore, it is important to dry the hands well and to show you how… here’s a TED talk on how to use just one paper towel to dry your hands.

Cantankerous men might all have canker sores!

Apthous Ulcers aka Canker Sore typically do not require medical treatments and there is no preventative therapy.  In most cases, patients can use over the counter ointments to help with the pain.

These can be found in groups or single lesions may be noted, and in most cases they are painful.  They are usually found on the gums, tongue and cheeks.  Some patients may find that they get these quite often, and are diagnosed as recurrent aphtous stomatitis (RAS).

Apthous Ulcers are broken down into 3 main categories:

1. Minor type – single lesion usually smaller than a centimeter
2. Major Type – More than 1 lesion and/or over a centimeter in size
3. Herpetiform – More than one lesion AND has the appearance of a blister or vesicle

Normally, this is a problem that starts in childhood and most people that get apthous ulcers have a family member with the disease as well.  To date, there are no known infectious agents that cause these ulcerations though there are medications which can be a causative aetiology.  Some diseases can be predisposed to having them, such as patients with celiac disease or patients with iron, vitamin b12 or folic acid deficiency (about 1 in 5 patients).

Benzocaine (Orajel) is typically available over the counter and can work for most people, but in others, medication treatments are required.  The first FDA approved treatment was Amlexanox or Apthasol and was shown to be quite helpful in RAS (SORT B), while steroids and tetracycline have also been noted to be quite helpful as well.  It should be noted that using anti-septic mouthwashes have been shown to be ineffective, and silver nitrate applications may help with the pain but not in shortening the duration of disease.  Using liquid nitrogen has not been proven to be effective.  Regarding complementary/alternative (CAM) therapy, myrtle paste was proven to be effective for those that would like to use an alternative route.  The possible triggers that have been noted to date include: wheat, barley, cow’s milk and oats.  If symptoms are too overwhelming or simply become unmanageable, a referral to dermatology can be helpful.

Hair, hair everywhere, even on my chinny chin chin

Polycystic Ovary Syndrome is diagnosed in approximately 5-15% of women who are of reproductive age.  A previous NIH criteria was used to state that increased levels of hormones (called androgens) and having multiple cysts on the ovaries was used until about 2004, when the Rotterdam criteria was utilized.  This created the current criteria of two of the following three (SORT C):

1. Enlarged ovaries with at least 12 follicles each
2. Increased levels of androgens noted clinically or through blood work
3. Changes in menstruation, either in the form of lack of ovulation or decreased menses.

Typically, PCOS has multiple factors, though is commonly a problem with excessive production of androgens.  There are theories that state that insulin resistance play a role in this androgen excess and this plays a role in treatment.  There is a possible genetic link due to polymorphism and there is one study that looked into a possibility that elevated bisphenol A (BPA) levels may be related as well.

Risk factors include obesity, family history, using some medications (especially seizure medications) and the highest risk comes from being born small for gestational age.

Typically blood work is only done to rule out other causes and not to rule in PCOS.  The disease is suspected based on the above Rotterdam criteria.

Androgens are hormones, which are produced out of the adrenal glands (DHEA & DHEA-S) and the ovaries (androstenedione and DHEA).  The skin, liver and fatty tissues house the remaining androgens, such as testosterone and dihydrotestosterone (DHT).  Typically, the symptoms of androgen excess include acne, increased facial and body hair growth (hirsutism), male pattern baldness, deepening of the voice (virilization).  Embryonically, the role of androgens is to form male external genitalia in the growing fetus, and when they are absent, this leads to female sexual characteristics.

It should be noted that loss of hair and acne alone are not consistently seen in androgen excess and therefore should not be sole reasons to diagnose PCOS.

Adolescents get a very strict criteria including:

1. Decreased menses for over 2 years or lack of menarche after age 16
2. Blood work showing that there is clearly signs of androgen excess
3. Multiple cysts with the ovaries noted on ultrasound

Laboratory testing should be done to rule out diabetes and high cholesterol, given the high likelihood of these being present but should be noted that checking fasting glucose and fasting insulin ratios can be falsely negative.  A two hour glucose tolerance test is usually required (SORT C).  Checking for total testosterone and DHEA-S will be helpful, while looking for LH and FSH may not be as useful, given their changes related to menstruation.

Regarding treatment, oral contraceptives aka birth control pills can be used to help regulate menstrual cycles and decrease hair growth (SORT A), and in some cases improve acne (SORT C).

Clomiphene and metformin can be effective with the ovulatory issues which the research seems to favour clomiphene, more so because of possible issues with ovarian hyperstimulation syndrome with use of metformin (SORT A).  However, a study in May 2012 noted that use of metformin in obese women seem to improve the chances of becoming pregnant by 1.6 times.

Is it snowing in here, or is it just me?

Seborrheic Dermatitis AKA Dandruff is a very common condition, which causes people to form white flakes that are usually present on the scalp, but can also occur on the ears and nasolabial folds.  Infants can form a similar scaly appearance and this is commonly referred to as “cradle cap”.

The exact cause is not well understood, but a couple of the leading theories include:

1. Inflammation caused by the Malassezia furfur and others within the Malassezia species (none with names as fun to say).
2. Hormonal Imbalances (usually male hormones causing overgrowth within the hair follicles)
3. Environmental/Nutritional and Medical factors (Especially in HIV and AIDS patients where it is present between 40-80% of patients)
4. Overgrowth of the skin causing increased sloughing

Diagnoses is based on history and it’s classical appearance.  History of itching that occurs some of the time, scaling and burning sensation, especially when involving the forehead, behind the ears, nasal bridges and chest.

Different treatments have been used for dandruff, with different levels of success.  One interesting study in the Journal of American Academy of Dermatology 2002, 47: 852-855. noted that 5% tea tree oil could be used with statistically significant results.  There was actually less complaints of greasiness or scaliness in the tea tree oil group as compared to the placebo (a shampoo with similar consistency but didn’t have the distinct odour of tea tree oil, which likely means that group realized they were in the treatment group).

Ketoconazole 2% (found in some brands like Nizoral) can be used in combination with desonide gel to help improve dandruff specific to the face.  Regarding the scalp, cicloprox shampoo 1% and betamethasone valerate foam were found to be quite helpful, safe and well tolerated (both with SORT A).

Regarding selenium containing shampoos (enter popular brand here), can be effective in treating dandruff, however the selenium sulfide shampoos had all of the side effects in the study, when compared against ketoconazole treatments.

Long day = Sleepy Blog.

Some days are far more tiresome than others and can really take a toll on anyone.  In most people, regardless of how tired they may feel there are a significant amount of things that must be done prior to turning in for the night.

In turn, this causes people to feel a difficulty with getting to sleep.  Our minds are wired to constantly work on a constant basis, whether or not we are sleeping. Below is a great TED talk regarding mindfulness and meditation.

Insomnia is a very difficult problem for a great deal of people.  Approximately 50% of patients will experience occasional insomnia while almost 1 in every 5 patients may suffer from chronic insomnia.  This can be quite stressful and there are 4 main predictors noted how likely a patient would go to their physician for help.

1. How a patient felt about their own physical health
2. The number of years they had dealt with their insomnia
3. Age (Increasing age physiologically and psychologically changes sleep patterns due to “medical and psychiatric illness and circadian changes.”)
4. Income level – typically lower income families had worse sleep than higher income, likely related to increased financial burdens, less comfortable sleeping arrangements and lower likelihood for shift work.

Female gender also seems to play a role in worsened sleep patterns, although more studies can help us figure out exactly why that is.

There is a clear link between mental health disorders and insomnia as well as medical illnesses but sometimes it can be secondary to another sleep disorder.

According to the National Sleep Foundation, the number of hours of sleep depends on the age of the patient, as below.

Typically someone complaining of insomnia will have trouble either starting to sleep or maintaining sleep.  Some will state that the sleep is poor in quality while others state that they just get up too early.  Whatever the type, most will state that it will lead to day time fatigue, decreased attention and poor concentration (something confirmed in studies involving sleep deprivation).

There is no good diagnostic test for insomnia and is based off history given by patients and a sleep study AKA polysomnography is really meant for patients who might have obstructive sleep apnea or periodic limb movement disorders.

There are a significant amount of medications that can cause insomnia and a periodic health exam with one’s physician may help find out if there is a need for all of the medications someone is taking.

What can be done about insomnia?  The first, second, third and fourth line of treatment should be behavioural.  This includes Cognitive Behavioural Therapy (SORT A), a good sleep hygiene and a sleep log.

The usefulness of these depend on the person and it should be noted that the strength of the recommendation for the CBT is based primarily on patients with sleep maintenance type insomnia, but has been seen in Cochrane reviews to be helpful in patients over the age of 60 as well.

Sleep Hygiene is typically a lists of Do’s and Dont’s that are based on quality studies.  There are a few major universities, i.e. Mayo Clinic and Tuft’s University with good quality sleep hygiene handouts that patients seem to really like.

Remembering that Alcohol can actually worsen sleep is important as some patients use alcohol as a “night cap” to get to bed.  This actually stops the body from getting into a proper stage of sleep.

In order to understand this, I’ll provide a very quick recap of the sleep cycle:

Sleep is broken down into Non-Rapid Eye Movement sleep (Stages 1-4) and Rapid Eye Movement (REM) sleep – Stage 5.

• Stage 1 – This is the first time the body moves from a state of alertness to a state of sleepiness.  The brain produces “theta waves”, which are very slow high spike waves.  This stage lasts about 5-10 minutes and if you awaken someone in this stage, they might say ‘I was just resting my eyes!’
• Stage 2 is where the body starts slowing things down.  Heart rate and core temperature start to decrease and the body creates quick bursts of activity called “sleep spindles”.  This stage lasts about 20 minutes and if you awaken someone in this stage, they might be just a bit disoriented but able to “shake out the cobwebs” quickly.
• Stage 3 is where most people will start to get to after about a 1/2 hour.  People will vary how long as they start to form deep, slow wave state called delta waves.  Waking a patient here might cause someone to feel very drowsy but able to wake, they might turn over and say ‘I’m sleeping, leave me alone.’ and go back to sleep.
• Stage 4 is known as delta sleep as the previous discussed delta waves take full formation and start to create deep sleep.  Typically, this lasts about 30 minutes and is the stage that people will speak in their sleep, have episodes of bed wetting and start sleep walking.  Waking a patient here can cause significant disorientation and can cause a patient to be VERY angry.  After all, they were just about to dream.
• Stage 5 AKA REM sleep is where dreams are born.  It is sometimes called “paradoxical sleep” as it is typically the time that patient’s body and brain function is at its peak, though muscles are typically quite relaxed.

Patients usually follow typical patterns with their sleep, where they start out in stage 1 and progress through, but can have “poor sleep efficacy” where they break from the cycle and go backwards, causing an awakening.  This can be from medical reasons, such as obstructive sleep apnea or from external source, someone making loud noises nearby the bed.  Typically, REM sleep will start approximately 90 minutes into sleep and last initially a very short time.   Then as patients move back and forth through the sleep cycles, they start spending more and more time in REM sleep.  This allows for dreaming and the more REM cycles, the more vivid and the longer the dream will become.

Below is an image from the Mayo Clinic, which summarizes this quite well.

As such, it is important that alcohol and for that matter sleeping pills, keep patients from being able to get into that stage 5 sleep.  Typically, what sedative hypnotics do, is that they will help patients speed through stages 1-3 and get to stage 4 and then as they cycle through they will stay between 3 and 4 and this causes patients to feel like they are sleeping deeply but in actual fact they are missing out on the REM sleep, which is where the brain consolidates the information it learned that day.

Exercise was found to be quite effective for patients if they did not do it near bedtime and the biggest thing that can be done to help improve sleep is to do two simple tasks.

1. If someone wakes up at night, do not start watching the clock.  The best thing to do is go somewhere quiet and do something unstimulating.  This does not mean, watch TV or start planning a major trip with a lot of little details.  It might mean; writing a quick blog (on paper) or reading a book (maybe not “50 shades”).
2. Use the bed for only sleep and sex.  This is crucial as it allows the brain to associate the bed with a key feature in life.  We spend 33% of our lives where we should be sleeping, we should work to keep it as restful as possible.

Have a good night sleep.

It burns, it burns!!!

Urinary tract infections (UTIs) are a very common issue, seen in all areas of healthcare.  It is about 4 times more common in women than in men, usually between the ages of 20-24.  However, there is also a spike noted in men over the age of 84.

The urinary tract is made up of (moving from the entry up) urethra, bladder, ureters and kidney.  Each site has it’s own name for when it is affected, i.e. urethritis, cystitis, ureter infection and pyelonephritis, respectively.    The information below should not bypass any diagnosis given by your physician as individuals feel pain and discomfort in different

The reason urinary tract infection are more commonly seen in women is that the typical female urethra is approximately 4 cm in length while the male urethra’s length will vary from 15-29 cm (depending on the study).  Nevertheless, the women’s urethra is substantially shorter allowing it to be at higher risk for ascending infections.

Typical symptoms include pain or burning sensation when urinating (called dysuria), a sense of needing to frequently urinate (frequency), passing small amounts of urine when the urge to urinate is high (urgency) and lower abdominal pain can be present.  Cloudy urine can either be a sign of purulent material (bacteria) in the urine or a sign that someone is dehydrated.  Commonly during urinary tract infections, blood is present in the urine.  This may be visible in the urine (called hematuria) or it may be invisible to the naked eye, requiring use of a urine dipstick (normally present in most physician offices).

It should be noted that these typical symptoms may not be the ones present for all patients but a patient self diagnosis was noted to have a positive predicted value of 85.7% in a high quality study by Bent and al. noted in JAMA 2002, 287:2701.  What this means is that when patients said, “Hey Doc! I think I have a urinary tract infection, 85.7% of the time, they were right.”  In comparison, having blood in the urine gave a positive predictive value (PPV) of 75%, and having pain when urinating gave a PPV of 69.2%!  “When you know, you just know.”

Now having said that, the more serious pyelonephritis (kidney infection) may show up differently with symptoms of fever, chills, nausea and vomiting and complaints of pain in the back along the side (“flank pain”).  On exam, health care providers can assess costovertebral angle tenderness.  These signs and symptoms, with or without signs/symptoms of urinary tract infection increase the likelihood that there is a pyelonephritis.

When men (especially elderly men) present with infection, they will present with symptoms of foul smelling odour, nausea and gross hematuria (meaning you can see the blood not the other kind of gross…. though both work.)

As alluded to previously, some of the more common tests that can be done include the “urine dipstick”, which can give a quick hit answer in the office.  It has essentially replaced the use of in office microscopy and there is no need to have patients do a “clean catch urine”, which is where the patient will start urinating then start catching the urine mid stream.  Messy work, and so most patients are happy to be done with it, and also it commonly was not done completely accurately, making them more of a false sense of security that the specimen collected is a proper specimen.

Having either a positive “Leukocyte Esterase” or “Nitrite” or both can be enough for a diagnosis and usually is enough to initiate treatment.  Based on the work by Deville and al. in BMC Urology 2004, 4(1): 4, it was noted that there is a high chance that a child, pregnant woman or elderly patient does not have a urinary tract infection if both the nitrite and leukocyte esterase is normal.  In everyone else, having these tests showing as negative, does not rule out a UTI.   Usually, the confirmatory test is a urine culture.

The urine culture is quite an interesting test, as it can provide with great information as it not only states what the bacteria is, but also with the names of the medications with which it is sensitive.

Seventy to ninety percent of the time, the causative bacteria is E. Coli, while the others involved include Staphylococcus saprophyticus, proteus, klebsiella and enterococcus.  Sometimes there are also mixed samples noted as well, which typically mean that the sample has been contaminated, usually by a non-sterile container.  This is usually the case when people bring in samples from home, understandable as they would like to limit the amount of time they will be urinating until treated.

There is a phenomenon called asymptotic bacteriuria, in which bacteria is noted in the urine on “screening” tests or because the urine was checked for another reason and there is no symptoms associated with it.  This practice should not be done unless it is on a pregnant patient where the bacteria can cause problems with the pregnancy.  The only other exception is if there is subtyping done on the bacteria, which notes that the E. Coli has O or K subtype, which is notorious for causing pyelonephritis.

Treatment is with a myriad of antibiotics and the choice is usually more dependant on provider choice and patient allergies.  The biggest qualm I have is with providers that still give long courses for women with uncomplicated cystitis.  Antibiotics should be given for 3-5 days (unless it is nitrofurantoin which should be given for 7 days).  This is based on high quality studies and SORT A.

Exceptions to above will be in men and in pyelonephritis, the course should be for 7-14 days for men with UTIs and 10-14 days (SORT C) for pyelonephritis.   If the pyelonephritis is severe, it may require hospitalization and possibly intravenous antibiotics.  It should be noted that patients that can tolerate medications by mouth, should use as such, as there are no less effective than taking the medication through an intravenous route.

So what about just preventing them all together?  Eat a lot of cranberries, right?  At this time, cranberry juice has not been shown to be effective in treating UTIs, however there is some evidence that women that drink cranberry juice may have less symptomatic urinary tract infections.  It should be noted that the same studies have high numbers of dropouts which might mean that using cranberry juice long term may not be a feasible choice.  As always in medicine, more studies are required.

Garbage in, even worse out… of your medical record.

There has been a great deal discussed regarding the rise of electronic medical records, which for the remainder of this article will be referred to as EMR.

The spectrum lies in one end stating that they have no need for electronic records as medicine has gotten along famously without it and can continue doing so in the future.  While the competing side of the spectrum states that the future is with the EMR and that we will only be able to move forward, if all physicians decide to move forward and every patient have their medical information readily available.  There are some very intriguing ways that this has been discussed; using a USB device, having it on apps on one’s phone or possibly using a barcode on the health card which links to a cloud storage (patent pending).  All have drawbacks and their own benefits, but come with the same flaw.

What is the information present?  Is it information that the patient ascertained from their physician appointment and scrawled on a piece of paper, or that their family members placed in the notes section of their smartphone?  Is it a typed progress note that their health care provider printed out and gave to them (i.e. complete patient profile)?  This variety changes how likely the information will be helpful and the other side is simply, who reads the information.  When information is given in an unfamiliar format, things can be pushed aside as extraneous.  This will cause confusion and often lead to mistakes.

Don’t get me wrong, I am clearly on the side of the spectrum that states that EMRs are here to stay and that every patient should have their medical records handy for any new physician that they see (whether it’s an emergency room physician, specialist or heaven forbid, walk in clinic physician.  For these physicians, or any health care provider to actually have useful information so that good, sound clinical decision making can occur is critical.

But this is not new, this has been an issue that has been wrestled around with for a while.  The Canadian government attempted to help move EMRs forward using eHealth with …. interesting results.  OntarioMD continues to work forward using Peer Leaders, some of whom I follow on twitter to keep my ear to the ground.  I personally have been a Physician Practice Champion, working with both eHealth and OntarioMD, piloting the Ontario Laboratory Information Service (OLIS) using our EMR, which will likely allow for a smoother roll out.

So what’s the problem?  Unfortunately, the issue as with all things is the bell curve.  Any student will recognize the bell curve, this one is about innovation.

The “laggards” (recently this slide was shown at FM rounds, and I got a kick out the verbiage) will cause significant issues.  Not because things will hinge on their decision of when to come onboard to getting an EMR, but more about what they do when they get there.

The biggest issue with someone that is not fully invested in moving forward with a good EMR is that the information that they put into it, will simply be… garbage!

So what does that mean?  If we take the Complete Patient Profile (CPP) as an example, we will note that there are a few sections where information may duplicate.  If there is no standardized way of displaying data, what will happen is some people might put the fact that a person is a smoker in the “Medical History” or “History of Problems”, while others may place this in “Social History” or “Lifestyle”.  This may seem confusing to think of abstractly, but take this as an example.

Medical History – Tobacco Abuse – 1 pack per day for 14 years.

vs.

Social History – Smoker – 1 ppd – started 1998

 

Both give the same information with different presentations.  To a reader, it might be quite easy to pick up the fact that both are the same, however, the purpose of EMR should not just be a cleaner looking chart, but something that can pull data out and use it in a way that can benefit patients, individually and as a whole.

Other providers may put that a patient who has never smoked a day in his life as a “Smoker” with a negative check box or as a Non-Smoker.  Again, in this instance, both say the same thing.

However, in order for EMRs to be more helpful for a physician and eventually larger entities, this information needs to become standardized, because the information is likely going to be read by automated queries which will be looking for specific phrases and if the information is haphazardly thrown into the system, with abbreviations and with a complete lack of standardization, the EMR will be as worthless as a sticky note that was used to make a quick diagram for a patient.

Information needs to be usable, readable and searchable.  Standardization is the key.  Our office is working on a way within our Family Health Team but there will likely need to be a larger scale approach, and I am afraid when that comes that the steps we make, may end up being extra work.  “All’s well that ends well.” – Shakespeare.  Let’s hope so.

Out darn zit, out!

But does it??

It would not be a surprise to find out that Acne Vulgaris is an extremely common problem, especially for people between the ages of 15-24.  It is a disease process in which can be present as obstructive lesions, i.e. open (blackheads) and/or closed (whiteheads) and/or also as inflammatory lesions, i.e. papules, pustules and/or nodules.

A secretion from the sebaceous gland called sebum starts getting produced too heavily causing the gland to grow.  This is usually in the face of increased levels of androgenic hormones within the body.  This then causes a increase in the level of skin cells called keratinocytes which blocks the opening.  After this point, there is an overgrowth of a bacteria that normally is found within the follicle called Propionibacterium acnes.  The sebum then causes inflammation which moves to the surrounding skin.  Therefore, anything that causes obstruction to the sebaceous follicle is going to be a nidus for acne.

If a picture truly does say a thousand words, then I believe my word count will be incorrect.  The following images were taken directly from Google Image searches and have been linked to their respective sites.

The follicle that now has become blocked will enlarge at the base and if the pore opening is closed, it is referred to as a closed comedo aka whitehead.  However, if this opening is present, air is exposed to the trapped sebum and oxidizes it, giving it the dark appearance known as blackheads, scientifically known as an open comedo (comedones, if multiple, which is usually the case).

Acne is typically graded based on it’s severity (Source: FPE Skin Therapy Letter):

It is important to know about the other inflammatory lesions that are discussed:

Papules/Plaques

Papules are well defined, raised areas of the skin, which has no visible fluid, but can become infected and drain, if scratched or picked at.  These are typically smaller than 1 cm.  Plaques are groups of papules that are present sometimes in a scale-like appearance.  

Vesicles/Bullae

Vesicles are also well defined lesions that are fluid filled and again are usually less than 1 cm in size.  If a fluid filled lesion is larger than 1 cm, it is typically referred to as a bullae.

Pustules are inflammed, pus filled blisters which typically contain dead inflammatory cells and cain be quite painful.  They can be either red or white.

A quick internet image search of each of these lesions will give you a whole host of these lesions present on people’s faces.

The causes of acne can be hotly debated by many people, but the ones that have been noted in studies include endocrine disorders, use of steroids, blocking of pores with cosmetics or psychological stress.

Chocolates and other sweet tooth favourites were charged with causing acne as far back as the 1930s and as time went on studies came out and placed the shadow of doubt on the link.

One very interesting Harvard study in 2005, noted that high school students who drank skim milk had an increased prevalence for acne, while this was thought to be due to the “hormones and bioactive molecules in milk”.  They also noted that “Instant breakfast drink, sherbet, cottage cheese, and cream cheese were also positively associated with acne.”, albeit at a lower prevalence.  This restarted some of the controversy in the case of Diet v. Acne.

In 2010, a careful review of the available evidence was performed and published in the Journal of American Academy of Dermatology!  This combed through all the data available as far back as 1930s and reviewed them to bring us what we know now about the link between diet and acne.

Wait for it….

The wait is over, we found out that we need more randomized controlled trials to help figure out what the link is.  The study did report that there is compelling evidence that high glycemic index diets can worsen acne.  In addition, there is a weak link between dairy products and acne and that we need to look more into “omega 3 fatty acids, antioxidants, zinc, vitamin A and dietary fiber” before making any recommendations about their use.

Easy enough?  Stay away from high glycemic index foods.  It’s obviously not that simple and this will continue to be a problem despite what products come out for acne in the future.

Regarding treatments, there is significant evidence that topical retinoids are effective (SORT A) as well as topical antibiotics, but the combination works synergistically (SORT A).  Use of benzoyl peroxide (any dose will do but the lower the strength, the less adverse effects) with an antibiotic is effective (SORT A).  Interestingly, a review of 57 randomized trials of oral tetracyclines were done and found no difference as to which worked best.  Given this information and the fact that there is a mounting amount of resistance to antibiotics, use of this class of oral antibiotics probably should be limited (SORT C).

A study using ayurvedic formulations has been attempted, specifically “Bhavprakasha Nighantu and Charak Samhita” but is of limited use as it was not tested against any other current strategy.

Face washing and increasing UV exposure has found mixed results but chocolate appears to not have a role in making acne worse.  However, these cannot be taken as hard and fast rules as there is still need to have more studies in the field of Acne Vulgaris.

Why is my face drooping?

Bell’s Palsy is an interesting disease.  It affects the 7th cranial nerve AKA Facial Nerve, causing paralysis of facial muscles in a very specific way.  It is typically temporary but can be very distressing, especially as many patients will think they have had a stroke.

The seventh cranial nerve runs through a narrow canal called the Fallopian canal, which runs beneath the ear, to the muscles on each side of the face.  Each nerve controls the muscles on the same side, and for most of its course, it is completely covered by bone.  When the facial nerve is affected, there is a disruption in the message that the brain gives to the muscles that it innervates.  Typically this allows for the ability to make a frown, smile, show one’s teeth, wrinkle the brows, close the eyes tightly or purse the lips.  Inability to do this leads to the downturning of the mouth on the affected side, drooping of the eye and cheek.  See the picture below from a Google Image search.

This facial paralysis can also lead to lacrimal and salivary gland problems as well.

The cause of Bell’s Palsy is still not well understood, but certain risk factors include:

1. Diabetes
2. Pregnancy
3. Viral Exposure
4. Cold Exposure
5. Age over 30
6. Family History
7. Obesity
8. Previous Bell’s Palsy

Most diagnosis are made usually with history and physical exam and typically testing or screening is not needed unless the physician finds other neurological issues associated.  History of one side of the face which happens suddenly and is present for 1-7 days is a typical history.

If other risk factors are present, screening for diabetes can be performed as 10% of patients with Bell’s Palsy, may also have diabetes.  Lyme titers can be checked if exposure is suspected.

Specialist care may be required if the duration is longer than 2 weeks, if there is paralysis on both sides of the face or if the paralysis is unresponsive to treatment within 2-3 weeks.

Use of 10 days of steroids (not the kind the baseball players are in trouble for) will increase the chances that the paralysis will clear completely.  Especially if used within 3 days of the start of symptoms (SORT A).  The number needed to treat is 10.  Use of anti-viral medications are no longer recommended based on careful review of the evidence (SORT B).  Also given the drooping of the eye, the eyes can dry out causing injury to the cornea, and frequent use of artificial tears and lid taping or eye patching is sometimes recommended (SORT C).

Use of accupuncture has not shown enough evidence to be recommended widely.  Facial muscle exercises may improve facial function in patients with moderate paralysis (SORT C).

Approximately 85% of people will have full resolution within 3 weeks, and so it is important to follow patients and prevent complications.  Interestingly, surgical options provide minimal improvements and hearing loss is a possible complication, while steroids and antiviral use do not have many complications because of the short duration of treatment.