Bracelet that Measures Your Sun Exposure

June is being worn on this model's wrist.

At the CES 2014, an interesting bracelet made an appearance that purportedly is able to measure sun intensity in real time and monitor total daily sun exposure. Even better, it is able to provide sun protection advice via smartphone app based on your habits and skin type, get notifications when you need to apply SPF, wear a hat, or put on sunglasses…

Made by Netatmo, the bracelet is called "June" and may be beneficial for those individuals who are prone to sunburn,  out in the sun a lot, and/or concerned about skin cancer due to UV exposure.

It comes in three different colors and will soon be available for purchase.

Watch a video about this product.

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Medical Translator Commercial...

I'm sure many patients would like a medical translator like this one shown in this humorous commercial. In case you haven't seen it yet...

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Diagnose Cancer with Flash of a Light!

Traditionally, cancer is diagnosed by a surgical biopsy with pathology results taking days later. Supportive evidence for a cancer is also determined based on visualizing the lesion as well as radiological studies (CT, MRI, Ultrasound, etc).

However, there is a very exciting breakthrough technology that may be able to make a cancer determination under 1 second with only a flash of a light... meaning no biopsy with associated pain and scar to go along with it.

Called Verisante Aura, a probe emits a light that non-invasively analyzes a lesion by scanning 21 different cancer biomarkers at the cellular level using Raman spectroscopy.

Raman spectroscopy (RS) is a technology that involves shining a laser onto a material and interpreting the reflected light to learn more about its biochemical composition.  Healthy cells have a different reflected light "fingerprint" compared with diseased cells. Although this technology won the Nobel Prize in 1930, such RS units used to be huge and complicated machinery to operate. Fortunately, only recently has RS units been miniaturized and made robust enough to be idiot-proof to operate by Canadian researchers.

How accurate is it?

It has up to 99% accuracy leading to potential reduction in unnecessary biopsies by 50 to 100 per cent [link]. Given each scan is under 1 second, a complete body scan can also be accomplished in a single office visit. However, in order to obtain sensitivities between 95% and 99%, the specificities did range between 15% and 54% which is comparable to clinical examination and other optical-based methods.

The one caveat is that the probe needs to be able to shine a light directly on the suspicious lesion... meaning it is applicable only for lesions found on the skin and body cavities (mouth, colon, esophagus, etc)... not lesions under the skin (like a thyroid nodule). The lesion also needs to be larger than 3.5mm in size.

With such instant diagnostic accuracy, it would not only revolutionize in the diagnosis of cancer, but also in treatment! The big question mark for any surgeon is "did you get all the cancer out"? Well, with this probe, one could just scan the wound bed after excising the cancer and see if there's any residual cancer left behind that needs to be removed further. In essence, every surgeon can now perform a Mohs-like resection instantly and without need for pathology assistance with frozen sections.

Verisante Aura is currently approved for use in Canada, Europe, and Australia... but not yet available in the USA pending FDA approval.

Source:
Simply Amazing! Instantly Diagnose Melanoma with the Flash of a Light. Forbes 3/14/13

Reference:
Real-time Raman spectroscopy for in vivo skin cancer diagnosis. Cancer Res. 2012 May 15;72(10):2491-500. doi: 10.1158/0008-5472.CAN-11-4061. Epub 2012 Mar 20.

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Kim Kardashian Gets Allergy Testing

Celebrity Kim Kardashian of Keeping up with the Kardashians reality TV show underwent allergy testing with Dr. Mirmelli. Allergy testing was accomplished via skin prick (our office performs allergy testing by blood draw instead called immunocap).

She apparently was allergic to her pet cat...

Kim apparently decided to let her pet cat Mercy go... a decision in contrast to what most cat-allergic people do.

Watch the video.

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The Facial Triangle of Danger (Even Death)

Image by SpooSpa from Wikipedia

If you draw a line between the eyebrow to the corners of the lip, a triangle is created which delimits a region esoterically known as the "danger triangle".

Why is this region considered dangerous?

It's because infections within this region can lead to infections of the brain (rarely). Why? The blood supply within this triangular area communicates with the cavernous sinus found at the bottom of the brain. This anatomic structure is a major source of venous drainage of the brain.

If the cavernous sinus gets inflamed/infected due to a rip-roaring pimple of the upper lip, it could lead to multiple facial abnormalities due to injury of the numerous cranial nerves that go through it including:

• Inability to move the eyeballs (CN3, 4, 6)
• Numbness, pain of the skin over the forehead and cheeks (CNV1, V2)
• Loss of pupillary constriction (CN3)
• Visual loss/changes (CN1)

The cavernous sinus could also become thrombosed.

Cavernous Sinus shown by red arrow. Taken from Sonoworld.

From there, the infection can spread to the rest of the brain and potentially can even lead to death if not treated promptly and aggressively.

Of course, tiny infections like a small pimple or a small laceration due to biting a lip is not going to cause problems.

However, rapidly progressive major infections of the skin with abscess formation do need to be treated cautiously.  Typically, such patients are hospitalized on IV antibiotics until definite and significant improvement can be seen at which time patients can be discharged home on oral antibiotics.

At which point a "minor" infection becomes "major" requiring hospitalization is a judgement call.

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Why Can't Some Contact Dermatitis Be Diagnosed by Blood Test, EVER?

I often see patients for allergies who desire allergy testing due to mysterious hive-like rash on the skin, and given many are fearful of needles, they opt for a blood test like RAST or immunoCAP to diagnose what they are allergic to. Some would even argue that skin prick testing would not be diagnostic.

Though such blood tests have become remarkably accurate (skin prick is still the most accurate way to diagnose what a person is allergic to), there are profound and significant limitations.

In order to understand why, first a little biology lesson.

In "classic" allergy (Type 1 hypersensitivity), there are antibodies called IgE floating around in the blood. When such antibodies come into contact with what a person is allergic to, it causes mast cells to explode releasing bioactive chemicals that triggers the classic signs of allergy including runny nose, sneezing, and hives.

The timing of exposure to reaction is very short... within minutes.

In this scenario, the allergy blood testing is appropriate... because such testing measures the amount of IgE antibodies floating around in the blood.

Unfortunately, not all contact dermatitis is due to this biologic response.

There is another type of allergic reaction that can cause skin manifestations that is NOT mediated by IgE antibodies at all!

Known as Type 4 Hypersensitivity, special cells called macrophages initiate the "allergic" reaction when it detects an allergic substance.

This type of reaction occurs hours to days AFTER exposure.

Obtaining a blood test for allergies will NOT diagnose this type of allergic reaction because the test measures the level of IgE which is not involved in this type of reaction!

The ONLY way to test for Type 4 Hypersensitivity is skin patch testing, typically performed by dermatologists.

Patch testing is performed on skin where the dermatitis is not apparent (typically upper back). The allergens are mixed with a non-allergic material (base) to a suitable concentration which is then placed in direct contact with the skin within small aluminium discs. Adhesive tape is used to fix them in place. The patches are left in place for 48 hours. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light. After 48 hours the patches are removed and an initial reading is taken one hour later. The final reading is taken a further 48 hours later. Additional readings beyond 48 hours increase the chance of a positive test patch by 34 per cent. The patient should refrain from washing until the last reading is taken.

Some chemicals produce an allergic reaction only when exposed to light (usually ultraviolet type A). If this scenario is suspected, patch testing is performed, one while exposed to UVA light and the other hidden in darkness. A positive light-reaction is made if the patch exposed to UVA light causes a skin reaction whereas the one hidden in darkness looks fine.

What are some common chemicals/substances that cause Type 4 skin reactions?

• Balsam of Peru: an aromatic mixture made from resins and essential oils. It is found in the haemorrhoid preparation Anusol, some perfumes and certain spices. 
• Caine mix: local anaesthetics found in preparations for sore throats, sunburn remedies, haemorrhoid preparations, Wasp-eze. Used by dentists and doctors for minor surgical procedures. 
• Carba mix: rubber 'accelerators' (chemicals used to speed up the polymerisation process in the manufacture of rubber). It is found in rubber gloves, shoes, bandages and elastic. Of those allergice to carba, 85 per cent are also allergic to thiuram. 
• Chlorocresol: a substituted phenol preservative that kills bacteria. It is widely used in medications and some cosmetics. It cross-reacts with Dettol, which you should also avoid if you have a chlorocresol allergy. 
• Chromate: a metal used for plating other metals to prevent rusting and in the manufacture of stainless steel. It is also found in cement and tanned leather. 
• Cobalt: found in jewellery, dental implants, artificial joints, jet engines. Most patients are also allergic to nickel, and some are also allergic to chromate. 
• Colophony: present in adhesives, plasters, paper, printing inks, medicated creams, glue tackifiers (stamps, labels), and cosmetics. 
• Epoxy resin: plastics, used mainly as adhesives in the industrial setting but also by DIY enthusiasts. Found in two-component glues, such as Araldite. 
• Formaldehyde: preservative frequently used in household products and in industry. Often found in cosmetics and shampoo. 
• Fragrance mix: used in patch testing, this collection of eight individual fragrances detects about 75 per cent of patients allergic to perfume. If you have perfume allergy, you will not be allergic to all fragrances, but you cannot tell from the label which fragranced cosmetics are safe. Avoid all cosmetics listing 'parfum' as an ingredient on the label. Also found in air fresheners, washing powders and candles. 
• Lanolin: produced by sheep to protect the fleece from the results of weathering. It is widely used in cosmetics, medical creams and bandages. 
• Latex: most commonly found in gloves used by healthcare professionals.
• Mercapto mix/thiazoles: a rubber accelerator found in rubber shoes, insoles, gloves and elastic. It is also a component of balloons and bandages. 
• MBT (mercaptobenzothiazole): another rubber accelerator. Neomycin: an antibiotic commonly used in ear and eye drops and creams to treat infected skin problems. Cross-reacts with other antibiotics. 
• Nickel: 10 per cent of women and at least 1 per cent of men are affected by nickel allergy. Nickel is released from metals such as alloys or electroplated items. Found in jewellery, keys, coins, zips and buckles, pacemakers and batteries. 
• Parabens: preservatives found in cosmetics and topical medical products to inhibit the growth of fungi and prevent slow deterioration. They are commonly used in cosmetics, household products, glue, shoe polish, shampoos and conditioners, sunscreens and medical creams. 
• PPD (paraphenylenediamine): a permanent hair dye that is very frequently used in hair salons and at home. Dyed hair cannot cause an allergy but the dye may do during application. Also found in skin paints, such as 'henna' tattoos, and occasionally in fur and leather dyes. Primin: a substance produced by the plant Primula obconica, a common houseplant. 
• PTBPF resin (para-tertiary-butylphenol-formaldehyde): a synthetic polymer used as an adhesive. It is often combined with leather or rubber to make shoes, handbags, watchstraps, hats and belts. 
• Thiuram (tetramethylthiuram disulphide or TMTD): another rubber accelerator that is also found in pesticides. People who are carba allergic often react to thiuram. Patients who react to the drug disulfiram (Antabuse), used for alcohol dependence, may also be allergic to thiuram. 
• Toluene sulphonamide formaldehyde resin (TSF resin): the commonest polymer in nail polish and a frequent allergen.

Given a patient often has no idea why, how, when a hive reaction occurs, it is important to obtain a good history to see if a reaction is immediate or delayed as it may influence what type of allergy testing may be required.

BUT, the key thing for people to remember is that allergy blood testing and skin prick testing can NOT diagnose all allergies due to intrinsic factors.

Skin patch testing may be the ONLY test to determine what that mysterious hive reaction is due to.

AND, now you know why!

For physicians, skin patch testing supplies can be purchased at www.dormer.com. However, your local dermatologist should be able to perform such patch testing (our office does not).

In our area, Dr. Moshell at Georgetown is the expert in this field.

Phone: 301-951-2400
5530 Wisconsin Ave, Suite 730
Chevy Chase, MD 20815

Another dermatologist in Northern Virginia who performs patch testing is:

Kurt Maggio, MD
7512 Gardner Park Dr
Gainesville, VA 20155
Phone: 703-753-9860

Robert Gurney, MD
11315 Sunset Hills Rd
Reston, VA 20190
Phone: 703-437-7744

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Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found... in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting
• Pimple/Acne Formation
• Scabbing
• Ulcers

People often try applying lotion, neosporin, or cortisone cream... which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either... but... if one must...

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say... Use an electric nasal hair cutter! That's a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones...

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I'm sure there are other good ones, but it may also come down to personal preference.

Now, if there's an active recurrent nasal sore that's not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.

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