Skin Problems

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Questions Received:

  1. I am mid 40s: about 2 years ago I developed a hive problem. The V A hosp. in Cleveland Ohio call it pressure hives. Done bi-ops-blood-cat.ect....been on pregnazone,quick-set?33-22-11-1/2stop all that did was cause a heart attack sym.check ekg-chest x-ray all neg.all blood-stool-internals-o.k. If so much as sit on a hard surface - stand on rough toilet paper so on (hives) approx. 2-4 hrs later. I have tried changing food, detergent, life!! Started with itchy palms-soles of feet. Bloomed into hives. Hoping to be submitted to university hospital in Sept 99 derm. convention. At wits end!

  2. My roommate has had an ongoing problem for years now. On certain areas of her skin, particularly around the neck, armpits, and inner thighs, her skin has darkened, almost to blackness (she is white, 24 years old) and the skin is rough and very creased. She is very embarassed about it and is reluctant to seek help. This problem seems to have started about 5 years ago when she started putting on a lot of weight. What is this and should she be concerned?

  3. My husband has had a rash off and on since April of 1999. In April, he had surgery on his finger for a high pressure injection injury from an airless paint spray rig. He injected lacquer thinner and oil based paint into his finger. Is there a suitable medication?

  4. Two years ago I developed a fungal infection on the side of my neck to which the doctor gave me canneston cream to relieve this but as the fungal slowly disappeared from then on I have had this burning and "trickling" feeling from my neck as if there was something under my skin. My doctor said because I am 78 years old that it is wear and tear of the neck!! and then prescribed painkillers. This has been dreadful to cope with at times and is wearing me down. Can you please help me!! What is it and what can I do?

Responses:

I am mid 40s: about 2 years ago I developed a hive problem. The V A hosp. in Cleveland Ohio call it pressure hives. Done bi-ops-blood-cat.ect....been on pregnazone,quick-set?33-22-11-1/2stop all that did was cause a heart attack sym.check ekg-chest x-ray all neg.all blood-stool-internals-o.k. If so much as sit on a hard surface - stand on rough toilet paper so on (hives) approx. 2-4 hrs later. I have tried changing food, detergent, life!! Started with itchy palms-soles of feet. Bloomed into hives. Hoping to be submitted to university hospital in Sept 99 derm. convention. At wits end!

8th June 1999

Pressure hives is one of a group of skin disorders known as urticaria. These disorders are characterised by transient whealing or swelling of the skin and they can be extremely distressing. In some cases the cause can be identified - an allergen, or a drug being given to treat another condition - and removal of the cause produces a cure. Recently a possible link between a micro-organism that inhabits the stomach (Helicobacter pylori) and chronic urticaria has been investigated (Ring et al, 1999). However, in many cases of chronic urticaria a specific cause cannot be identified and treatment is symptomatic.

For many patients with urticaria of unknown cause, treatment with antihistamines is effective. This is because in urticaria histamine is being released by mast cells in the tissues and initiaties the irritation and accumulations of fluid. Other inflammatory cells, including lymphocytes and polymorphonuclear cells, have also been implicated (Tharp, 1996). Antihistamines inhibit this inflammatory process. There are several antihistamines to choose from, including cetirizine, astemizole, loratadine, terfenadine and acrivastine. Some of the original antihistamines caused sedation and anticholinergic effects, but the newer drugs do not cross the blood-brain barrier and are largely free of these unwanted side-effects (Juhlin and Landor, 1992; Ormerod, 1994; Monroe, 1997).

ometimes, antihistamines are ineffective. This is especially the case with pressure urticaria, and there is evidence that this may be because of the nature of the molecular mediators operating in this condition (Greaves, 1992). If antihistamines do not help, then several second-line treatments are used. The most effective are corticosteroids such as the prednisolone that you received. There are others: doxepin, dapsone, attenuated androgens, calcium antagonists, antimalarials, gold, and methotrexate.

Recent research has shown that some forms of chronic urticaria have an autoimmune origin. That means that in about 30% or so of this group of patients the immune system is producing antibodies against normal substances in the body and triggering the release of histamine by the mast cells (Hide et al, 1993; Black, 1997; Tong et al, 1997; Greaves and O'Donnell, 1998; Sabroe et al, 1999). This suggests that more active immunosuppression may benefit people with urticaria who have autoantibodies in their blood against the immunoglobulin-E receptors or immunoglobulin-E carried by mast cells. However, this approach would probably require plasma exchange and the administration of toxic drugs such as cyclosporin, so would only be undertaken if the attendant risks were warranted clinically (Sabroe and Greaves, 1997).

Hopefully, a resolution to your problem will be found during the September dermatology convention.

References

My roommate has had an ongoing problem for years now. On certain areas of her skin, particularly around the neck, armpits, and inner thighs, her skin has darkened, almost to blackness (she is white, 24 years old) and the skin is rough and very creased.

She is very embarrassed about it and is reluctant to seek help. This problem seems to have started about 5 years ago when she started putting on a lot of weight. What is this and should she be concerned?

2nd December 1999

It is unfortunate that your roommate has suffered for so long with this problem. Try to reassure her that she does not need to feel embarrassed or worried about her problem and that a visit to her doctor can almost certainly result in an improvement. The regions of skin that you mention may be affected by an infection that prefers the slightly damper conditions in those regions, and it is possible that the darkening is due to prolonged scratching and rubbing because of itching and irritation. Another possibility is that there may be an underlying metabolic disorder, but either way the doctor will most likely be able to bring about a significant improvement.

My husband has had a rash off and on since April of 1999. In April, he had surgery on his finger for a high pressure injection injury from an airless paint spray rig. He injected lacquer thinner and oil based paint into his finger, thankfully they got it all out...during his 3rd surgery a skin graft, he had an allergic reaction to a medication.... I cannot remember the name of the medication and the plastic surgeon does not feel the need to let us know the name... Anyway, off and on since those surgeries, he has had a hive like rash that has been treated with shots of steroids, steroid pills, and topical steroids.

It goes away for a few days then pops back up... We have seen 3 different general practitioners, an internist/allergist, and a dermatologist... they all tell us the same thing. You have bad skin... he has tried herbal remedies... and frankly we are at our wits end with this rash... Maybe you can tell me about another medication that might help my husband, because, frankly, he is driving me nuts and I know this rash is driving him nuts.

13th March 2000

Even though it is more than a year since your husband’s injury, it is possible that his immune system is still sensitised to the paint/thinner mixture that was injected into his finger. There may be small residues of these substances in his tissues that are still being dealt with by inflammatory tissue reactions. If this is the case, the skin rash should become less of a problem as time goes by. You did not mention whether or not he has returned to the same work since the accident. If he is sensitised to those substances, then any additional exposure via skin contact or through breathing contaminated air could aggravate the problem. The ability of various steroid-based treatments to reduce the rash for a while does seem to indicate that the immune system is involved. It may help to remember that although the symptoms are distressing for you both, they are probably a consequence of an ongoing protective mechanism.

High-pressure injection injuries to the hand are potentially very disabling, so it is reassuring that your husband received comprehensive and effective treatment. Airless paint sprayers, high pressure grease guns, and fuel injection apparatus deliver materials at pressures ranging from 600-12,000 psi, and at these pressures substances penetrate through a small skin wound with great kinetic energy and spread widely within the tissues. Here they compress blood vessels, cause severe chemical irritation, and introduce bacteria (Mrvos, Dean, and Krenzelok, 1987; Ebelin, 1994). The index finger on the non-dominant hand is most commonly involved (Jebson et al, 1993). Injuries to digits are potentially more disabling than those to the palm of the hand (Hayes and Pan, 1982).

Paint is very toxic and causes considerable tissue inflammation (Lewis 1985; Zook and Kinkead, 1979). The potential hazards are death of tissues aggravated by infection, with the result that amputation becomes necessary in up to half the cases (Lewis et al, 1998; Schnall and Mirzayan, 1999). At first sight the injury may look relatively benign, but this appearance is deceptive and there should be no delay in surgery to reduce pressure within the tissues and remove the contaminating fluid (Karlbauer and Gasperschitz, 1987; Neal and Burke, 1991; Flotre, 1992; Jebson et al, 1993). An open wound technique with delayed closure has been found to be beneficial (Pinto et al, 1993). Antibiotics are given routinely after such an injury to reduce the risk of infection, and although steroids are commonly given to limit the severity of inflammatory response (Phelps, Hastings, and Boswick, 1977; Edlich, Rodeheaver, and Edgerton, 1978), there is still discussion about whether this is necessary (Sirio, Smith, and Graham, 1989).

References

Two years ago I developed a fungal infection on the side of my neck to which the doctor gave me canneston cream to relieve this but as the fungal slowly disappeared from then on I have had this burning and "trickling" feeling from my neck as if there was something under my skin. My doctor said because I am 78 years old that it is wear and tear of the neck!! and then prescribed painkillers.

This has been dreadful to cope with at times and is wearing me down. Can you please help me!! What is it and what can I do?

14th April 2001

Canesten (Clotrimazole) is used topically to treat fungal skin infections but quite commonly produces a side effect of local burning or stinging. It is an indication that your skin has heighted sensitivity to the agent and if the fungal condition has cleared up, it might be useful to treat the area with either an antihistamine or antiseptic cream containing a local anaesthetic. Canesten is best avoided in future and it is possible that other imidazole antifungal agents such as Miconazole might produce similar symptoms as well. If the fungal condition recurs in future it might be best to use a different antifungal agent, preferably a topical drug like Nystatin (Tinaderm, Mysteclin, Dermovate are trade names), especially if the fungal condition is candidal in origin.

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