Posts for tag: corticosteroids

By Robert J Weiss MD PC
February 15, 2015
Category: Uncategorized

Many of us have had the uncomfortable itching experience of hives or wheals(the medical term is urticaria)in

our lives. Hives result from the release  of a body chemical called histamine from mast cells.Ordinary individual hives

typically last 24 hours or less. However,the coming and going of hives persisting for more than 6 weeks is called

chronic.And,from my clinical experience in the office it becomes much more difficult to elicit their cause.

               The etiology of hives can be divided into several classifications: these include:

                  1)anti-inflammatory medications such ibuprofen,naproxen,and aspirin as well as narcotic medications

including codeine,hydrocodone,and oxycodone.

                  2)the ingestion of certain foods as well as the diluents and preservatives they contain. These foods include


                 3)physical causes such as heat and cold,water and pressure,sun and cholinergic(due to physical exertion

and sweating)

                 4)chronic causes of hives such as the autoimmune diseases of lupus and the thyroid gland(Grave's disease).

In addition,chronic infections including dental cavities,urinary tract and vaginal infections.

                5)stress and nerves-I have listed this last since it is easy to blame everything on this.

               But,patients with chronic hives in particular need a complete  history,physical exam,and lab work to rule out

internal causes (comorbidities).

             The mainstay of treatment is to correct any underlying medical disorder and the use of non-sedating 

antihistamines whenever possible.However,in my clinical experience acute exacerbations sometimes require

sedating antihistamines(especially for patients kept awake all night from the itching)and/or a short course

of corticosteroids for the worse flare-ups.

             The injectible drug omalizumab initially approved for moderate to severe persistent and allergic

asthma is now available for chronic recalcitrant and idiopathic(ie,cause unknown)urticaria.The drug opposes

the immunoglobulin antibody in the blood known as IgE which mediates allergic reactions.It is approved

for patients over 12 years old.

             However,when the monthly injections are stopped the hives recur.The good news is that the drug is still effective

when restarted.



                A few years ago one of my male patients presented with a groin rash of several months duration

which was unresponsive to various topical antifungals and topical corticosteroids  prescribed by his health care


              The rash was red and scaly encompassing his groin and extending to his scrotal area.There was

associated itching and burning at times. The most important clue here was that the rash had been  chronically

unresponsive to the above measures.

             Consequently,I suspected a condition called extra mammary Paget's disease (EMPD) which

fortunately is a rare  cancerous condition of apocrine gland-bearing sites.

             In addition,two types of EMPD have been described:the primary type thought to arise from a stem

cell within genital skin and not associated with an underlying internal malignancy involving the rectum

and/or other internal body areas.However,the primary type is still a carcinoma of the skin and needs to

be treated.

             Secondary EMPD is the more dangerous type since it is associated with an underlying adnexal

(connected) adenocarcinoma or an underlying visceral(internal) cancer and is the same as mammary

Paget's disease  of the breast(nipple). 

           Fortunately,I referred my patient to a general surgeon for a deep excisional biopsy which confirmed

my clinical diagnosis.The presence of a cellular protein called cytokeratin 20  helps to differentiate

between the primary and secondary types on biopsy.

           In addition,the presence of a gene called HER-2  in the biopsy specimen may indicate a high risk

for lymphatic spread and the need to follow the patient very diligently.

          EMPD most frequently involves the vulva in women,the perianal area,perineum,scrotum,penis and

axillae(armpits). Treatment includes wide surgical excision,radiation therapy,and several topical(external)