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Hand foot and mouth.....a disease nobody wants

Well things seem to come in threes, and this week was no different. In keeping with are continuing look at all things rashy, today I will bring you to story of a rash that occurs on the hands or feet and the mouth.

Hand-foot-and-mouth disease is a common viral illness that typically affects children below the age of 10. They can occur in outbreaks and epidemics, in which case it’s most often the "coxsackie" virus that does it. It is contagious, and unfortunately spreads by that age-old route of fecal-oral (in other words the virus is shedding your poop and somehow find its way back into the mouth).Click to enlarge

Given the way it spreads, and should be no surprised that most of the patient’s that we see who get this disease are the kids... the young kids... the toddlers. Thankfully it’s not tremendously contagious, there is a one and 3 chance of passing it on from one toddler to the next within a family (or daycare) and usually it is 3 to 5 days before you start to see symptoms. Typically the child will remain infectious for about 7 days, and it’s usually one day or two before the child starts having symptoms once they are infected.

So what are the symptoms? If typically begins as a fever, decreased appetite, possibly belly pain, and just generally feeling grumpy and unhappy. The fever typically last 3 to 4 days if the patient’s going to have a fever, and the rash typically begins around the third day.

Click to enlargeSo what about this funny rash? Yes I know, one more rash. This begins with small ulcers in the mouth typically on the insides of the cheeks, the roof of the mouth, and these can be fairly tender and uncomfortable. Sometimes they involved the sides of the tongue as well. This rash typically precedes the arrival of the rash on the hands or the feet.

So what we do about a sore mouth? While my first advised to be try not to get one, but given that were talking about hand-foot-and-mouth disease, let’s assume that we have the mouth part of this process. Unfortunately there is not a great deal of science to tell Click to enlargeus what to do, but I have found aloe vera juice seems to help the sores in the mouth. Now, you have to understand, that there is absolutely no scientific basis for this recommendation, just my observation that when I have patients gargle with 100% aloe vera juice they seem to have less pain from these kind of ulcers. Additionally, I have found that the use of Peridex (a dilute mouthwash made from chlorhexidine) seems to shorten the duration of this disease.

So how to we prevented in the first place? That one is easy, wash you hands!


Man that has to itch!

As is often the case in the summer time, certain illnesses seem to pop up again and again. The disease of the week this week, comes to you courtesy of the Toxicodendron family of plants.

(cue the theme song- "poison ivy" by the Coasters)

That’s right, this weeks installment of What Is Going on in Clinic This Week is brought to you by that summer plant known as poison ivy.

Now the oil in the sap of poison ivy is a common cause of "contact dermatitis" which is an allergic skin reaction to chemicals. This is certainly not the only chemical that causes contact dermatitis, but is the Click to enlarge This picture appears in Skin Disease : Diagnosis & Treatment, by Thomas P. Habif et al, Second edition, 2005one I saw the most of this week (for a fuller list please click here) Typically these chemicals get absorbed into the skin and they change the outside of the skin cells so that these cells look different to your body. You should understand that in the human body, different is foreign and must be destroyed. So, these innocent skin cells are now subjected to the full fury of the immune system because they are different. 

So what exactly happens? Well, this is called a delayed type hypersensitivity reaction. This means that you initially require an exposure to the offending substance (in this case the oil from the plant) which sensitizes your body’s immune response. The next time that your exposed to the same chemical, this immune response fires up and starts attacking the cells that have been exposed to the oil.

Why does it seem to spread? The duration and the intensity of the reaction is dependent upon how much of the oil gets onto the skin in the first place, the thickness of the skin, and the amount of time that it sits there before is brushed or washed away. So, you pet your dog whose recently rolled in a patch of poison ivy getting a big dose on the palms of your hands. You then scratch your nose (spreading a little bit), swat a fly on your forearm (spreading a bit more), scratch your leg (spreading a bit more), scratch her head (spreading a bit more), you get the point. Now with each subsequent scratch, brush, or rub, you deposit a little bit less oil on the skin because you are taking it off of your hand. The areas where the skin is thinner (under your eyes, back of your hands, inside of arms) it will take less of the oil to generate a large response. Where the skin is thicker, it will take more oil to generate a response. Additionally, the timing of this response will also vary based on the thickness or toughness of the skin the oil is sitting on. So you will likely see the reaction on the thinner skin before the thicker skin.

Can I spread it when I pop the blisters? No, the oil is what is irritating, and after it has that on the skin for a period of time it is no longer spreadable. Usually the blisters occur over a period of 24 to 48 hours after exposure and so the fluid they contain will not spread the oil. The blisters represent the damage to your skin by the immune response and the fluid they contain is fluid from this response.

How long the last? Unfortunately, once the reaction starts it usually runs for two to 4 weeks. Again this is dependent upon how many times you have been exposed to the oil previously, how big a dose you were exposed to, and how quickly we start you on medications to help turn it off.

Is there anything I can do to prevent it? Avoidance is the best strategy. However, if you are going to be working around known patches of poison ivy, you want to make sure that you wear long sleeves, long pants, and gloves. Also you will want to be sure that you don’t stay around the poison ivy for more than a few hours before you go inside undress and shower off with soap. The key is to remove the oil before it has a chance to irritate your skin and start the immune reaction.

Click on the link to see pictures of poison ivy so that you may identify it readily when your out and about on the island.


That is an interesting rash

It is interesting how things seem to come in threes.  You go for a long period of time without seeing something, and then, you see it all the time.  Well, this was rash week in the clinic.  It has been a while since I have seen anything other than sun damaged skin, but this week saw an outbreak of itchy rashes. Chickepox Click to enlarge Shingles Click to enlarge 

So, what kind of rash is it?

Well, that is the rash of Varicella zoster.  In an adult it is commonly known as shingles, and in children, chickenpox.  Both of these rashes are caused by the same virus, Varicella zoster, and that virus has an interesting life cycle. 


The virus usually enters humans either through the respiratory tract or directly through the skin (but the respiratory tract is most common).  It usually is spread form infected fluid from the eyes of individuals with the disease, or the droplets form their coughs and sneezes.  Once it is in the victim, the virus replicates in the lymph nodes of the throat, and then starts shedding.  It travels in the bloodstream to the liver and spleen where it repeats the replication.  It returns to the blood stream where it ends up on the skin where the characteristic rash develops in waves form the head to the feet.  Most people start shedding the virus before they get the sore throat, fever and rash.  These folks continue to shed the virus until all the lesions have crusted over.

Now here is the interesting part, this virus can hide!

After your body has fought off the infection, some of the virus hangs out in the roots of the nerves as they exit the spinal cord.  It can stay there out of sight for years, and then, one day, it travels down the nerve root to the skin and erupts in a painful rash.  This rash is unusual in that the pain or irritation often precedes the rash, and the rash is very localized.  It will only show up along the route of the nerve in which it was living.  This means that it usually is only on one half of the body, and one small section in an band form the back to the front.  The rash itself looks like a cluster of chickenpox, and like the rash of childhood, it is contagious.

Treatment for these illnesses is pretty similar.  In children, if there is a significant underlying medical problem (asthma, diabetes, cystic fibrosis, etc) then we often will give antiviral medications to the children to help decrease the duration of the illness.  For the fever, it is Tylenol or anti-inflammatory medications to help.  For adults with shingles, it is important to get antiviral medication in the first couple of days so that you can decrease the likelihood of developing post-shingles nerve pain. 

Treatment is great, but prevention is even better, and that is possible for children and adults.  There are vaccinations for chickenpox that are available through the public health department for children, and the vaccines are very effective.  They are a ‘live attenuated virus’ vaccine, so they will induce a mild case of the illness they are trying to prevent.  The value of the vaccine is that is virtually eliminates the likelihood of complications for children who get infected in the future.  The vaccine does not prevent infection, but it provides enough immunity that if the child gets infected they are less likely to get really sick.  For adults, the shingles vaccine is about to be available from the public health nurses.  This vaccine is exceptionally good at preventing the occurrence of shingles in the adults who receive it. 

For more information on shigles, shingles vaccine, chicken pox, or the chickenpox vaccine, click on the links.

So there it is….and itchy week in clinic.

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