Sneaky skin cancers

I’ve been fooled recently. I’ve been fooled by abnormal skin lesions of patients, and I’m not afraid to admit it. I see a good bit of dermatology in my practice, as I’m usually at the front line of diagnosis for my patients.

Here are three recent cases that surprised me.

The first is of a longstanding patient of mine – an elderly white gentleman with a rash on his scalp that we’d frozen lesions off of before, and treated as a combination of “cradle cap” and actinic keratosis, which is essentially sun damaged skin. He returned for evaluation of one lesion on the scalp that seemed to be growing much larger than the others. It was mountainous, yellow and greasy, just like a severe case of cradle cap, and similar to what some babies have.

However, since it was bothersome to him, we decided to take it off by doing an excisional biopsy. We numbed it up and cut it off and sent it to the pathology lab to grow. It returned showing squamous cell carcinoma in situ. This is a precancerous type of lesion that potentially can become cancer. Squamous cell carcinoma in situ has a high probability of becoming true carcinoma. We sent him to a dermatologist for follow up, and he is doing well.

The second patient is an elderly black gentleman I saw with our physician’s assistant. She brought him to my attention for a fairly normal-looking mole on his forehead. He’d had it for years, but it recently started changing in size, shape and color. He had no family history of skin cancers, but due to the recent changes, we agreed to do an excisional biopsy.

Guess what it turned out to be? Squamous cell carcinoma! Not in situ again but true carcinoma. That was truly surprising, particularly since he is African-American, a group that skin cancer doesn’t normally affect, and he had no family history.

The last one is actually a patient of my colleague that he brought to my attention. This is a young, white gentleman who came in for what he thought was “pink eye.” There was a dark spot beginning in the sclera or the white part of the eye, moving into the inside of the lower eyelid. It wasn’t painful, but it was new and had increased over the last couple of weeks. He had no family or personal history of skin lesions or cancers.

The first person that saw him in our practice thought enough to send him to an eye doctor that biopsied the lesion. When he returned to my colleague, guess what it turned out to be? Melanoma!

I never would have imagined skin cancer beginning in the eye. He had no other lesions on the skin that would have sparked the thought of skin cancer. I was able to see the patient and see the original lesion in the eye that was biopsied. I’ll never forget that case, and I’ll now pay even more attention to everyone’s eyes when I examine them.

The point is, skin lesions can be sneaky, and are more often more than meets the eye nowadays. This is not to say every mole, spot or skin tag is cancer, but if there is significant change in color, shape or size over a matter of months, it needs to be evaluated by your doctor. Don’t ignore your body. It may be trying to tell you something.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at www.durhamfamilymedicine.net.

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Deer ticks, and dog ticks, and mites….oh my!

Tick season seemed to start earlier this year than usual. One of my partners in our practice in March said she awoke one morning with a deer tick, and we knew the season was here. This month alone, June that is, I’ve treated 3 cases of RMSF, or Rocky Mountain Spotted Fever, which is one of the common tick‐related illnesses we treat here. Tick‐borne illness is one of the interesting things I’ve learned about since practicing in North Carolina, as these illnesses are more common in the Southeast. But apparently they are an issue all over the US during this time. The illnesses include the above‐mentioned RMSF, Ehrlichiosis, Tularemia, and Lyme disease.

Lyme disease is actually very rare in North Carolina, because the tick that carries the disease is rarely found here. I had to refresh my memory on the different kinds and flavors of ticks, so that I could identify them on patients more easily.

The usual season for ticks is now, during the spring and summer months. The different types of ticks vary from dog ticks to deer ticks to Lone Star ticks. The American dog tick is generally a reddish‐brown color and becomes large and red after it’s attached itself and fed. Deer ticks are usually smaller and darker than dog ticks. The Lone Star tick is also small and reddish‐brown in color but usually also has a white spot on the back. Clear as mud? If confused like I was, you can go to the CDC website (Center for Disease Control and Prevention) to see pictures.

I also have a hard time identifying which is which, so I’ve posted a picture of types in my examination rooms for patients to point them out. Lone Star ticks are probably the most common type in this area, and they cause symptoms such as fever, headaches, myalgias (body aches), and possibly a round, “bulls‐eye” rash where they have bitten. This is the classic rash called erythema migrans, and it’s very helpful to see when trying to diagnose the illness. Not all tick bites will cause the illnesses if caught early enough. The best way to remove them is with tweezers and picking the whole body off, but most importantly the head. If you don’t know whether you’ve removed the entire body, don’t play around with it, have you doctor look at it and remove the rest as quickly as you see it. Don’t use matches or ointments, because they don’t work well all the time.

Once symptoms have been identified, your doctor may go ahead and start treatment, or do blood work. Labs that are affected by tick‐borne illnesses include white blood cell count, platelet count, liver labs, and sodium. There are also antibody tests for RMSF, Erhlichiosis, and Lyme disease. Once I generally have a good idea that a person has been affected, I usually will start treatment with Doxycycline, which is the most common antibiotic that treats all the common types of tick‐borne illnesses. The medicine is prescribed either for 1 or 2 weeks, depending on the severity of symptoms.

Now, to say a word about Lyme disease in North Carolina‐‐‐it’s present, but not very common. In 2008, the CDC reports 16 cases were reported in North Carolina versus 2000‐3000 cases in the upper north states of Connecticut and Minnesota. Because of its long term effects and consequences, such as arthritis and neurologic effects, Lyme disease is taken seriously, but the other types of tick‐borne illnesses are far more common than Lyme disease here in North Carolina. Be careful this summer!

Be Healthy and Be Blessed, Dr. Swiner

*Reference: www.aafp.org (American Family Physician), www.cdc.gov(Center for

Disease Control and Prevention)

Autism and Children’s Vaccines-still puzzling?

One of the joys of being a Family Physician is I have the opportunity to care for the entire family. With this, I care for many babies and children in my practice, giving physicals, providing school vaccinations, and seeing them when sick. So, of course, the conversation arises often of potential side effects of vaccines, and the most recent concern is that of Autism. It’s a difficult and passionate debate to have, and I try to present the information that I know and come to an agreement with the parents of my patients. I’ll try to briefly explain where the debate comes from below.

Autism is a devastatingly difficult mental condition that affects approximately 1 in 150 children per year in the United States (stats from http://www.cdc.gov). It is a puzzling condition for all involved, including the families and caretakers of these children. In fact, if you see the ribbon magnets on the cars of people that advocate research for Autism, it’s in the form of a jigsaw puzzle.

I believe that puzzle represents both the variety of signs and symptoms that can occur with this condition and the controversial factors and arguments that surround the causes and treatment of the condition. Autism is described as a “spectrum disorder” in that it breaks down into 5 different types and can vary from minimal to severe ranges of effects on the human brain and psyche. These types include autistic disorder, Asperger disorder, disintegrative disorder, Rett disorder, and pervasive developmental disorder. Studies haven’t shown a clear cause yet, although a genetic link has been found. Autism in general is usually diagnosed by age 3years old and is 4 times more prevalent in boys than in girls. It spans all socioeconomic and racial lines, and lasts a lifetime for both the patients and their families.

And so begins the debate-There has been a lot of controversy surrounding vaccines and Autism. You’ve probably seen or heard the story of actress, Jenny McCarthy, whose son was diagnosed with Autism and her concern with the administration of shots containing the preservative, thimerosal. The vaccine containing antibodies for measles, mumps, and rubella (MMR) is one vaccine that has received the most blame in the argued link. The MMR shot is given at age 12months during a well child physical, and now recently, is repeated at age 4-6years old for kindergarten physicals. As mentioned above, most children are diagnosed with Autism around age 2 or 3 years old.

Until 2001, thimerosal was used as a preservative for many vaccines, and it is a mercury-containing chemical. After Jenny McCarthy’s story came out, many parents became worried about the effects of this ingredient and how it might affect their children.

I have had this conversation with some parents in my practice and what we discuss is the following. Studies were done and reviewed on thimerosal by the Institute of Medicine. None showed conclusive evidence that the chemical caused Autism. However, even with these favorable studies, after 2001, levels of mercury and thimerosal were reduced if not taken out of most vaccines altogether.

Because we still don’t know for sure what the etiology of Autism is, the best screening tool we have is the monitoring of development of speech and social interaction by parents at home, along with routine well child physicals done with medical professionals. The discussion of vaccines and possible side effects likely will continue for a while between doctors and patients, particularly about Autism. But, it’s a healthy one to be had, as we continue looking for the key and solution to this huge puzzle.

Be healthy and be blessed,

Dr. Price

‘Tis the season: Allergies vs. Sinus Infections vs. Colds

‘Tis the season for pollen, mold, and trees. Yesterday in clinic, I think half of my 20 visits involved complaints of “I think I have a sinus infection”. The answer to my “Why?” included many common truths and misconceptions, ranging from “because I’ve congested for a week” and “because I have green and yellow mucus” to “because this happens every year to me”. The truth is all of these signs of symptoms may be present, but I’d bet money that patients are correct less than 30% of the time when trying to self diagnose themselves with infection versus inflammation. Would you know the difference?

Let’s first review the common cold, which I’ve talked about many times before. A cold is a viral infection, which means there’s no great cure. There are ways we can shorten the duration of symptoms, but if I had the cure to a cold, I’d be a retired millionaire. If you read a medical textbook, it would say symptoms of a cold include, headache, muscle aches, low‐grade fever, runny nose, and cough, which can last for about a week. By day number 7, symptoms generally begin to dissipate. Because it’s a viral infection, antibiotics are not the treatment. Let me repeat myself—antibiotics do not treat colds. I can imagine what the next question might be after the last statement, and the answer is that you’re right. Doctors do and might prescribe an antibiotic when you present with a “cold”. However, this is incorrect and should not be done. This helps to produce super‐bacteria that are resistant to the drugs we currently have and create monsters, such as MRSA or methicillin‐resistant Staph aureus and other resistant bugs. This means it will be harder to treat you if and when you do have a bacterial infection in the future.

I hear the mumblings of the next question—then why do antibiotics seem to work when taken for a “cold”. I put cold in quotes on purpose, because what patients often think is a cold isn’t really a cold. It may be a bacterial sinus infection, walking pneumonia, or Strep throat. Or, what I believe is the most common reason, is that the cold was going away on its own, and it was coincidental that you were taking the antibiotic at the same time. In other words, it probably would have gone away without you doing anything. You just happened to be taking an antibiotic at the time.

What does help and what has been proven in studies to help includes, taking Zinc (such as Zicam) or eating chicken noodle soup at the first start of symptoms to cut your sick time by 2 days. Notice I didn’t say cure but shorten the amount of time you’re sick. After trying to shorter the duration of the cold, we treat the individual symptoms with antihistamines, cough medicine, menthol, tea, salt water gargling.

During the allergy season, it becomes even harder to differentiate, because symptoms are similar. Classic allergy symptoms include sneezing, runny nose, itchy, red eyes, congestion, and headache. Allergies don’t occur with fever and are treated with antihistamines, such as Zyrtec or Claritin. Other important treatments include steam, nasal saline and washes (such as Neti pot or saline spray), and cleaning one’s filters in the house and car. A chronic cough can be caused by allergies.

Another million‐dollar question is “Does green mucus mean I have an infection?”

Yes and no. It could mean an infection, but it doesn’t mean it’s bacterial. It is a sign of white blood cells fighting something, and that something could be an allergy or a virus. A bacterial sinus infection is when one‐sided facial pain, runny nose, fatigue,

congestion, tooth pain, and sneezing begin and is prolonged. Talk to your doctor about concerning symptoms.

Be healthy and be blessed,

Dr. Swiner

Back to school‐‐ADHD

Back to school‐‐ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a condition I see and treat often

in my practice as a Family Physician, and it is a controversial and passionate topic

for a lot of my patients. I have those parents and children who do not agree with the

opinions and impressions of teachers and school leaders who suspect the condition,

seemingly too quickly and too frequently. And in terms of treatment, I have those

parents who question the safety and effectiveness of the medicines used to treat the

condition.

A fairly representative depiction of this discussion usually goes as follows:

Elementary school aged child is brought in my Mom or Dad, frustrated by their

behavior at school and constant comments or calls made to them by his or her

teacher. He or she was doing well in school until 2

nd or 3rd grade, when Teacher

began to notice what she described as “fidgetiness.” Now, a perfectly intelligent,

previously well‐behaved child is slipping in his or her grades and is earning

demerits for bad behavior. He or she has begun interrupting class by talking, passing

notes frequently, and keeps forgetting his or her homework assignments. Teacher

has suspicions for ADHD and suggests an evaluation.

Or this: Mom or Dad brings elementary school child into the office to ask about his

or her being “yperactive” He or she won’ listen to directions, talks back, and can’

sit still. He or she does well in school otherwise, and the parents have become

frustrated when usual discipline no longer works.

There are 3 general types, including inattentive, hyperactive‐impulsive, or

combined. It was originally thought that boys have it more than girls, but more

recent studies have not shown a clear predominance. There are nine following

criteria must be present in both the home and outside of the home, must be present

for at least 6months, and must be identified before the age of 7. They also need to

have clear disruption of school or social functioning and cannot be due to another

mental or emotional condition, such as anxiety, depression, or a personality

disorder of some sort. These criteria are too many to list, however, they include:

‐difficulty paying close attention to direction

‐difficulty maintaining a level of attention

‐being “n the go”and talking excessively

‐interrupting or intruding often.

From recent studies, ADHD is a chronic disorder that may be associated with levels

of dopamine, nor‐epinephrine, and serotonin chemicals in the brain. (Am Fam

Physician. 2009;79 (8): 657‐665) Due to the imbalance of these chemicals, patients

with ADHD may suffer from academic, behavioral, emotional and social issues. Also,

because these chemicals have been identified, the medicines used to treat ADHD are

directed toward these chemicals. Most medications are called “timulants” which

are the medicines that interestingly have a calming effect on the child. These

include, Ritalin (methylphenidate), Concerta, and Adderall, among others. If used

correctly at the smallest needed dose, these medicines are very effective but can all

come with possible side effects of appetite suppression, weight loss, insomnia and

headache. I often am asked about their effect on growth of kids, and I explain it has

been shown that these medicines have had association with the trajectory of

growth, but not the amount of growth. This means, if a child’ growth spurt is to be

1‐2feet within a year, it may take a little longer for him or her to reach that 1‐2 foot

growth spurt yet it does not mean he or she will only grow half as much.

Non‐stimulants include Strattera and then other medicines you may have heard of

in treatment of depression or anxiety, such as Wellbutrin (bupropion), Clonidine,

and Imipramine, among others. The other important part of treatment is the nonmedication

based methods, or behavioral methods. Evidence has shown great

benefit from behavioral approaches with reward and consequence methods,

support groups for parents and patients, and parenting skills training. These things

should be done under the guidance and support of clinical providers. Studies show

the combination of both medicine and behavioral therapy of some sort has much

more success than either method alone.

This is how I usually proceed with most of my patients:

1. A patient and parent(s) present with one of the 2 questions I noted at the

beginning of this discussion.

2. I ask if there is any family history (parents, brothers, sisters) of ADHD and

what treatments helped them.

3. Can they identify problems starting before the child turned 7 years old?

4. I make sure there are no problems with hearing, vision, or other medical

issues (anemia, diabetes, thyroid disease among others) with the child. Are

they overeating sugary or caffeinated snacks or beverages?

5. Has there been any other traumatic event (death or illness of loved one,

divorce, abuse) to which the child is responding? Any signs of depression or

other emotional condition?

6. How much sleep does the child get at night? Is it restful, do they snore or wet

the bed? (Bed‐wetting and ADHD seem to occur often together. Snoring or

sleep apnea in kids can cause daytime fatigue and sleepiness).

7. Does the child like school and his or her teachers? If not, why?

8. If ADHD seems plausible, I then ask parent to answer a questionnaire about

patient’ behavior at home (there are various versions, such as Connors

Rating Scale, Vanderbilt Assessment Scales, etc.). Then, we give one to

patient’ teachers.

9. If there is concern from these questionnaires, I then refer to Child

Development and Psychology professionals to confirm our diagnosis, test IQ

and for learning disabilities, and offer treatments options.

10. If parents are comfortable, we can try a medication. If not, we can try

conservative methods and re‐evaluate.

Notice that number one was not “ut child on medicine” This is rarely the right first

thing to do without a thorough investigation. Seek medical advice if concerned

about your child.

Be healthy and be blessed (Have a good school year!),

Dr. Swiner

Is every dry, flaky rash from “eczema”?

It would certainly seem like it, wouldn’t it? Eczema, also called atopic dermatitis, is the most common skin disorder I see in practice, particularly in the African-American population. Eczematous rashes are all generally dry, itchy, flaky, bothersome lesions that occur most frequently in the elbow area (antecubital fossae), knees (posterior patellar regions), and behind the neck. I’ll often see lesions on the anterior abdomen, surrounding the ear or belly button, which can be complicated by allergies to metal, like nickel. Nickel is usually present in buttons on pants (one can try putting tape or cloth between the skin and the button to avoid touching), watches, or earrings, causing a similarly annoying itchy, sometimes sensitive and occasionally painful rash. Eczema, and possibly nickel allergy, is hereditary. Why does it also appear to be more prevalent in black patients? Unsure. My theory is it may be due to the allergies from which we suffer in our homes, products, and environments.

Dyshidrosis, or dry skin, is a cardinal symptom of eczema, so directing attention to keeping the skin moist is paramount. This is why it seems harder to control the rash either in the winter when it’s cold, or during the heat of the summer when we sweat profusely. Interestingly, although we want the skin moist, we don’t want it wet, which is also when eczema becomes worse. Counter-intuitive, right? I think the hardest piece of advice, I’ve found, for my patients to follow is cutting the time in the bathtub or shower short. If a child spends 20 minutes twice daily in the water, cut if half if you can. Also, while in the tub, the more lukewarm the water, the better. No one likes a cold shower, so keep the temp reasonable. As soon as he or she jumps out of tub, dry quickly and moisturize even more quickly. One can imagine how difficult this would be for those of us who feverishly wash our hands in scalding hot water every 5 minutes or use alcohol hand sanitizers to keep clean. It all dries the skin out. I’ve prescribed the strongest, highest strength steroid creams there are, but I’ve had it confirmed by Dermatologists that good old petroleum jelly (ie. Vaseline) is as good as gold. Cocoa butter and shea butter are ok alternatives as well for twice daily moisturizing. Over the counter, my other favorites to suggest are Eucerin and Aquaphor for their thickness and staying power. The thinner, fancier lotions seem to evaporate right into the air after putting onto the skin. Children, and adults for that matter, with history of allergies, eczema, or asthma, often have one of the others or all 3. This comes from atopy * (explain definition). So, when I know one of patients has asthma, and they call with complaints of a dry, itchy rash in one of those special areas, I can pretty much put money on what it is.

With all of the great, sweet smelling soaps, washes, and shower gels out there, it isn’t a good idea for a patient with eczema to use any of these. Because of the allergy rationale, the more pure and simple one’s soap, the better it is for sensitive skin type. I generally recommend regular and plain Dove, without scent or color, for its gentle nature on the skin. Sorry to all of the Bath and Body and Victoria Secret lovers (like me).

If decreasing water exposure and temperature, soap, and lathering from head to toe in lotion won’t help, in comes the steroid treatment. The steroids work by helping the body to decrease the atopic response that occurs. I explain their action by saying they help the body to stop reacting against itself, similar to how antihistamines and allergy medicines work. The simplest one to use is an over the counter (OTC) steroid. There are forms of generic steroid or allergy creams and ointments of varying strengths of hydrocortisone you can buy from the store without a prescription. The 2% strength is available OTC, and it’s a good start. You use it twice a day, sometimes mixed in with your lotion or petroleum for better absorption, for no more than 2 weeks in a row. If the rash is something that recurs regularly, I’ll have patients skip 1 or 2 weeks between their 2 week treatment to give the body a rest from the strong steroids. The body seems . This is also why I usually suggest the ointments instead of the cream, because the ointments remain on the skin longer usually. However, some complain that it’s messier on clothing. If the OTC doesn’t help, we can prescribe a variety of types depending on the severity of the rash and whether it’s occurring on the body versus the face. Names include Triamcinolone, Elidel, or Desonide.

Now, back to my original question. Does this mean that every flaky rash is eczema? No, certainly not. Others that come to mind include candida (yeast), psoriasis, or tinea (fungal). Candidal or tinea rashes are typically more moist or wet in nature, occurring in the creases of skin, and psoriatic rashes have more of a shiny patch appearance on the surface of the elbow or knee. Just another friendly reminder to see your local doctor to help determine the right diagnosis and treatment.

Be healthy and be blessed,

Dr. Swiner

*As of October 1, 2010, we are happy to announce UNC Durham Family Practice becoming Durham Family Medicine. We welcome our new patients to call us at 220-

9800, and visit us at our same location, 2400 Broad St., Ste. 1 in Durham. We are conveniently located across the street from the Costco and Kroger shopping areas. Come see us!

Healthy Women, Sound Minds

During this past winter, I spoke to the ladies of Triumphant Tabernacle Church in Durham for their Empowered Women conference. I was given the theme of “Healthy Women, Sound Minds,” which was a timely topic to speak on and around. We had some fruitful conversations and I thought I’d share a bit about what these wonderful women shared with me.

To review, I’m a Family doctor, which means I care for the entire family, from newborns to the elderly. Since practicing in the Durham community for the past 2 years, I’ve seen a large amount of young and older black women for a variety of reasons. Recently with the economy failing and making a slow comeback, I’ve seen a rash of women, married and single, young and old, who all feel the weight of the world on their shoulders right now. Some of the medical and emotional trends that seemed to have spiked at this time include: domestic abuse, sexually transmitted disease, high blood pressure, depression, and anxiety. The STDs in particular seemed to be at a high during the summer for some reason. Because of my frustration and sadness as I saw these women and attempted to help in some way, I took a step back to see if I could find similarities with these patients and what research there is on the link between emotional and medical health.

I began my talk with the women at the conference about depression and anxiety and reviewed the cardinal signs and symptoms of depression in particular. You may have heard of the “SIGE- CAPS” method before as a screen for depression (using each first letter of the list to make up the acronym). Because we were discussing women specifically, I put a star (*) next to those that seem to appear in women more–

Sleeping problems*

Interest decreasing in social activities

Guilt and self-worthlessness*

Energy decrease or fatigue

Concentration problems

Appetite or weight changes (up or down) *increased appetite

weight gain

Psychomotor slowing (moving more slowly, decreased motivation)

Suicidal thoughts

1 out of 10 all Americans admit to some form of mental illness-depression, anxiety, schizophrenia, etc.-each year. Women suffer from depression 2 times more than men, which means 2 out of 10. Why is there a difference? Studies say a definitive answer is unknown. However, with research, I found similar theories, including the following: higher incidence of physical or sexual abuse in women, use of birth control and having hormones in general, and persistent psychosocial stressors (such as loss of job) affecting women more.

Untreated emotional or mental illness can lead to suicide attempts—more women attempt suicide, but more men complete it. The likelihood is 4 to 1 that a man will be “successful” with suicide. Why? My theory is women use it more as a cry for help than men do. Women also use self- poisoning or drug overdose as the usual tactic, and that’s 70% of the time. However, that does not mean we should ever take threats of suicide from a female patient any less serious than from male.

So what can we do to have healthy bodies and more sound minds? Together, with research and our discussion at the conference, we identified a couple of ideas.

a. The majority of medical studies confirm that spirituality or religion is associated with better outcomes in many cases.

b. Have your annual check ups! Take care of yourself!

c. Have a great support system—family, friends, faith group/community d. Get more exercise and movement.

e. Eat “happy foods”—less caffeine/alcohol, more omega 3 fatty acids (salmon, cod, sardines, nuts help brain and nerve cells), reduce intake of refined carbs that cause sugar highs and then severe crashes, and eat more veggies and vitamins.

f. Pay attention to yourself and your moods. Recognize your symptoms early!

Resources

: Am Fam Physician 1999;60:225-40, Depression in Women: Diagnostic and Treatment Considerations.

BIO–Dr. C.Nicole Swiner is currently a Family Physician in Durham, NC, and has worked in a clinic owned by the University of North Carolina since 2007, after completing her residency training there. She received her undergraduate degree from Duke University. She also serves as an Associate Professor at UNC and

has interests in minority health, gynecology, and pediatrics.

has interests in minority health, gynecology, and pediatrics.