BBC – Radio 4 – Case Notes Transcript 06/06/2006

Crabs, officially called pubic lice, affect more than 3 million Americans every year. An analysis by Middelveen et al. “Does it look like…that?” She carefully avoided giving me a direct yes or no, but explained that herpes takes on many forms. There were so many possible remedies but I decided to start with the one I thought made most sense to me and that was this post even though I had very regular bowel movements, hardly ever constipated, still suspected it might have something to do with my colon and skin being irritated. When I itch it little raised bumps appear (like small hives), it itches and itches. It is not really a burning or stinging and it feels as if it is under the skin. So, for example, we know that patients who get a – common for dermatologists – condition called bullous pemphigoid where they get lots of blisters, tends to happen in the elderly.

However, if you look hard enough you should see some flat, brown or white insects crawling around in your hair. “Driven from Pasture-Raised animals, fed on organic diet, Free of HGPs, Preservatives, Gluten, and non GMO. Eventually they either seem to sink back into the skin, or they’ll break open and you’ll have a round, shiny wet spot. I know there is a solution out there for everyone, it’s just about finding the right one for you. And then after we’ve taken a history from our patient then we’d want to have a look at the skin and there maybe things that will give us guides to what is the underlying cause. Thank you in advance for thought you might have. And we’d certainly look at the nails, quite often the nails can give you quite a lot of information about what’s going on internally within the body, so we can look to see whether there’s any evidence of any iron problems or any thyroid problems or any kidney problems or any liver problems.

Nymphs mature in about 10 days and, as adults, will live for about 30 days. That’s why our strictly controlled selection process starts with healthy, Pasture-Raised animals, fed on nature. They itch until they eventually break open, and at that point they’ll weep, crust over, and begin to heal. We also want to test the kidney function, so we’d want to look at the urea and the creatinine. We want to do liver function tests, thyroid function tests and then we’d also for completion sake check the blood sugar. They’re quite a diverse range of underlying problems and I suppose it stresses that itching can be quite an important symptom, there can be some quite significant underlying causes but is there a common pathway or are all of these causing itching in a different way? Well the short answer to that question is that we don’t know what causes itch and we know that itch has been a symptom for just millennia, so we know from ancient Egyptian scripts that itching was something that was recognised many, many, many years ago.

You may also notice dark spots on your skin or underwear. And so far he is right. My best guess is that it was a small blister or bump that broke open either on its own or when I absentmindedly scratched it. And the whole point of raising that sensation of itch in our consciousness is that we then have something that will relieve that itch and that’s usually scratching. Absolutely. I mean the reflex of scratching, of course we all know that lots of animals scratch, so dogs, for example, might scratch when there’s an insect within their coat. So we do know that scratching is probably beneficial to some extent, so in our ancestry we may have developed this reflex to try and get rid of insects or parasites or mites that might have been on our skin.

If you notice pus in the area, or any open sores, consult your doctor. we don’t get the same results. SORES/ULCERS: These show up on the inner labia, on what I think of as either pink skin or wet skin. And it was just like rampant pins and needles in those areas, which caused me to scratch and then scratching developed across my scalp, across my shoulders, down my arms, round my lower back to the backs of my knees. And within a very short period of time I was hugely scarred and really from that date I had a sleep pattern that was hugely out of whack, I’d wake up for an hour at night with this itching, then take time to go back to sleep, wake up again at say 9 in the morning but sort of really drugged out, as if I’d lived two days and two nights in 24 hours. Dr Christopher Bridgett is a psychiatrist with a special interest in the relationship between itch and scratching. He works alongside dermatologists in the skin clinic at the Chelsea and Westminster Hospital where he teaches habit reversal techniques to try and help patients control their scratching.

It’s linked with picking, squeezing, rubbing, cutting and touching the skin. There are expensive deluxe models that need an auxiliary oxygen tank that you would get at a medical supply store. The natural reaction may be to drink less, and thus pee less, but it’s actually better to drink more so that the urine is less acidic and hurts them less. They’re associated with a variety of common experiences like frustration, boredom, stress, tiredness, idleness, even thinking – the cartoonist will draw somebody thinking and the character will be scratching his head. Yeah I mean that’s something that I do myself, I often scratch my head when I’m thinking. But can that get – I mean can we do that sort of scratching subconsciously so much that it actually causes problems in the skin? Certainly in our – with our experience helping people with age atopic eczema, which is one of the common skin conditions, when it’s acute, when it flares up is very itchy, leads then to reflex scratching but the scratching becomes an issue on its own, insofar as scratching is part of the human repertoire of behaviours associated with all those experiences I mentioned – frustration, boredom, stress, tiredness – and if you go into the scratching behaviour of an individual with atopic eczema you’ll discover that they scratch about say 50% of the time due to itch and the other 50% will be due to circumstances.

And if you give them a hand tally counter to measure the frequency of their scratching they then can see how the scratching will predominate at the end of the day, for example, or when they’re taking their clothes off or when they’re in the bathroom and at those times the skin isn’t necessarily itching at all. I do think it was the flu because I never got sick like that again. I scratch it without thinking, even in my sleep, and at times find it almost impossible to stop. And this has already worked, I’ve been to see him now – I’m in day 10 and I have a clicker which I use every time I feel that I go to make a scratch on the place where it’s itching and this has really flagged up for me just how often I was doing this. The number that I started with and the number I’m now on now are hugely different, I was something like 630 and I’m now on 25. The first substitute behaviour is to tuck the nails of the hands into the palms, making a fist lightly, and to fix the arms by the side for 30 seconds. At the end of which if there’s an itch the patient is taught to touch the skin that’s itching with a nail or to pinch the skin that’s itching until the itch has gone.

We spoke to Edward Donald, one of your patients, who when he initially saw you was scratching 600 times a day, now he’s down to just 25 episodes and that’s just 10 days into his treatment, how representative is that of the sort of response that you can get? I wasted a lot of time and money trying things that gave me little to no results. I would normally expect people to reduce their scratching by 50% over two weeks but clearly he’s rocketed on and it goes to show in his case a great deal of his behaviour was habit and we’ll be looking at this when I next meet him. From my point of view 60% of patients who complete the programme do well. Another 20% do reasonably well and there’s a final 20% who fail and they fail for various reasons, some of those come back for another treatment course later. Dr Christopher Bridgett talking about habit reversal techniques – sometimes known as the Noren habit reversal system – about which more information will be available on the Radio 4 action line and our website – contact details at the end of the programme. I work in eastern London and many of the Asian patients are young women who have a young family and are still having regular menstrual flows and so their intake of iron may be less than the amount of iron that they’re losing.

And over time that leads to their body being relatively iron depleted. If you are interested in trying it you will have to join the FB group to be able to download the free PDF files that Kandy has made available to everyone at no charge. And you’re confirming the diagnosis of iron deficiency presumably – I mean we’ve talked about the techniques that you’re using, the person might have other symptoms such as anaemia, a pallor, breathlessness or whatever but the acid test is going to be a blood test. Absolutely so, we sit down with the patient and we’d explain that we were worried that they may have low iron stores and it does seem to be low iron stores that is relevant. So many of these patients will not be anaemic, so they will not be pale, but their iron stores are very low indeed. One of the things that we know if you’re low in iron is that your skin gets very itchy and that your nails can be rather fragile and now grow quite so well and actually that in fact your hair doesn’t grow quite so well. So we find that younger women who find that their hair is getting a bit thinned it may be because their iron stores are really rather low.

We know that the best way to absorb the iron is to take iron supplements or have an increased amount of iron in your diet. I am happy to say that my fibers are now nearly all gone. But if they want to take tablets we say fine take some tablets and take it with a glass of orange juice and you may find that that puts up your iron levels. What about the response rate – how quickly would the itching get better because presumably I mean you’ve identified this as the cause, it may not be the cause, you’ve found iron deficiency therefore you treat it, how quickly would you expect to see the response? What’s astounding is that these patients get better so quickly and they’re so happy and so relieved and they come up to us and almost – but don’t – give us a big kiss. Well iron deficiency isn’t the only hidden cause of itch that’s most common in women of childbearing age. Itching is a common complaint in pregnancy too.

As many as one in four pregnant women complain of it – mainly around their expanding tummies. Carley has made a video in her need to educate others on this as yet unacknowledged  disease. Obstetric cholestasis often runs in families and if a woman develops the problem in one pregnancy, then it’s almost sure to happen in future pregnancies. Caroline Swinburne reports. Suzanne McDonald plays with her younger daughter, three-year-old Grace. Grace and her older sister Shona were both born prematurely and Suzanne’s first child was stillborn. Although Suzanne displayed clear symptoms the condition was undiagnosed throughout her first and apparently straightforward pregnancy.

No morning sickness, no aches, pains, absolutely nothing until I was in the second trimester and started to have very severe itching on my nipples. Mycoplasmas have been found in ticks, fleas, scabies and other mites, mosquitoes, lice, flies (including dragonflies), biting flies, and midges. So it was very, very intense, under the skin, couldn’t get to it type of itch. I did mention it to a midwife who explained to me that was very common in pregnancy and to try some E45 cream. The midwife couldn’t find the heartbeat with the monitor. She then got the sonic aid, tried to do it that way and at that point then obviously realised that there must have been a problem and they then brought in a portable ultrasound machine and it was then that they advised us that they could find no heartbeat. And I do recall my husband saying so what does that mean then and they explained to us that the baby had actually died.

No reasons why, they didn’t understand why, they couldn’t tell me why and it was just absolute devastation and disbelief and it was during part of this that my husband was explaining that the only thing that I’d ever complained about during the pregnancy was this itching and then obviously alarm bells started to ring with the registrar, liver function tests were carried out and they then realised that my liver count on the liver function test was extortionately high and that’s the first time we heard the condition of obstetric cholestasis mentioned. So at this point I still don’t know what exactly I have/had but the supplements are working regardless. When a woman has OC this flow is reduced and this leads to a dangerous build up of bile acids in the blood. It’s been shown that prematurity and foetal distress occur more frequently in women with high bile acid levels in the blood, possibly because they interfere with the baby’s heart and cause cardiac arrest. At Queen Charlotte’s Hospital in West London consultant physician Dr Catherine Williamson cares for women with medical problems in pregnancy. She says if a woman suffers itching it’s vitally important she’s tested for OC. The standard liver function test checks chemicals that are released by the liver if there’s any harm done to liver cells.

If they are abnormal I think it’s important to check the bile acids or if somebody continues to have the same itch, even if their liver tests are normal, I would recommend in my own practice checking bile acids. Plus it is great as an immune modulator so if you have any autoimmune issues it can be quite helpful. They could have intervened and everything could have been oh so different. When the condition is correctly diagnosed women can be prescribed creams to help relieve the itch. There are also drugs which may help to improve the liver function and return bile acid levels to normal. A few months ago there was a big study from a Scandinavian group that compared two drugs, one is called ursodeoxycholic acid, might be easier to call it Urso and the other is dexamethasone which is a steroid. And their results indicated that women who have raised bile acids, above a threshold level, which we think may relate to complications, that group respond well to Ursodeoxycholic acid in terms of improved itch and improved liver tests and reduction in the bile acids.

They didn’t have such encouraging data for dexamethasone and most of the other drugs that have been tested in studies haven’t been so obviously useful. Many feel that it is everywhere in our environment and everyone is exposed to it on a regular basis. Because this is a liver disorder it may affect the way the liver makes the factors that help us clot when we have a bleed and therefore it seems a sensible idea to give vitamin K. Although again no big comprehensive study has been done to prove that. Essentially women with the condition must be carefully monitored and if necessary may be delivered early. When Suzanne McDonald became pregnant for a second time she insisted on a referral to the team at Queen Charlotte’s. Here she had regular blood tests and was treated with Urso.

All the same her condition soon gave cause for serious concern. I tested negative twice for Lyme from a regular lab. Within our own group we’re mainly trying to understand what causes the condition. So we’re looking at genetic factors and we’re looking at how the female hormones can cause abnormal handling of bile acids by the liver. You see even on the television all these pregnancies – preeclampsia and other conditions are taken so seriously on the soap operas even, I’ve never yet seen anybody on the television with cholestasi. And all the mums that I’ve met from the nurseries and playgroups and schools, mother and toddler groups, none of them have heard of obstetric cholestasi. Suzanne McDonald talking to Caroline Swinburne.

As I said before that report, itching is a common complaint in pregnancy and normally nothing to worry about – but always mention it to your midwife or doctor, especially if it affects parts of the body other than your tummy, particularly your palms or soles, a common complaint in women with OC. Certain products from that program from Nutrimedix did nothing and others helped to move things out but the Morgellons was still active. So in young adults we know that the oil production is rather high and that can lead to even problems such as acne. And we know that the oil that the skin produces is not uniform all over the skin, so we know that we’re much more oily on our face and in the middle of our chest and we’re much less oily on our lower legs. So one of the commonest places to get itchy skin in the elderly is on the lower legs. And then that compounded with Western culture, where we all shower about a million times a day and use lots and lots and lots of soaps and detergents and wash away the small amount of oil that our skin is producing then that can lead to relative loss of even the small amount of oil, so the skin gets dry and when the skin gets dry it gets unbearably itchy. It started about five years ago.

First in my scalp, identify my scalp starts itching, especially the front of my forehead. In some women it can cause tender and swollen breasts. And the front of my head it’s getting so tender, you know, very tender from this – from the continuous itching. And I don’t scratch, I try not to scratch, I give it a pat sometimes when it’s too bad because I can imagine if I scratch it, it will all get sore. As it itch the hair it falls out, which if you notice you can see that – how the hair – and I’m a person who used to have a lot of hair in the front and it’s gone all thin from the itching. And then at the bottom of my feet – both feet – right at the soft part of my feet start itching and you know if you scratch it you get all blistery, so I try not to scratch which makes it even more frustrating. Sometimes I’m out at the movies if I’m out at the pictures and sitting down and my two feet are itching and my scalp is itching it’s very uncomfortable, very embarrassing.

Sometimes I go to bed at nights and I can’t sleep, my scalp’s itching, the bottom of my feet itching. Woodland Essence has a product called C.S.A. The lotion for the scalp, the cream for my feet and the rest of my body. But using these creams and things it helps a little bit but it doesn’t stop it, that’s the thing. And you don’t have to spend hours putting moisturising creams on the skin, it’s very simple you just – couple of minutes and you quickly smear some nice moisturising cream onto the skin, making sure that you move down the skin in the direction of the hairs rather than against the direction of the hairs because we know if you go against the direction of the hairs you can force moisturising cream into the hair follicles, which can lead to spot formation or follicle – folliculitis formation. And if you do that very quickly a couple of times a day, say, for example, when you step out of a shower or before you go to bed at night then that will give you excellent barrier function and give you a really nice smooth skin. If it doesn’t settle though we have got other tricks up our sleeve and that can be antihistamine tablets, some of which can make you feel a bit sleepy but some patients who have had itch for a long period of time are rather sleep deprived and they like the idea that something’s going to give them a bit of relief from their itch and actually make them feel a bit sleepy so that they have a reasonable night’s sleep.

He decided to prescribe some antihistamine tablets for me, they didn’t really help very much to start with but he said you had to take them for quite a long period of time for them to make any difference. It is suggested for systemic staph that does not respond to antibiotics. I’ve been on them on and off about four months or so. But you can actually take antihistamines indefinitely. And if that doesn’t work then we have other tricks up our sleeves like sunlight treatments, what we call photo therapy, where a patient can go into a specialised cabinet and have what’s called narrow band UVBs. So sunlight treatment with all the more nasty wavelengths of sunlight removed and just the relatively safe wavelengths exposed to the skin. We know that it can help the skin cells to mature more evenly and more effectively, we know it can promote greater oiliness of the skin and so repair some of the skin’s barrier function.

We know that it can thicken the skin and again repair some of the barrier function of the skin. I have even been using the Cryptolepis on the nails on my feet and it seems to be reducing the fiber bundles there too. Unfortunately, despite all our sitting down with patients and examining the patient and doing the appropriate tests there are a group of patients for whom we can find absolutely no cause for their itching and that’s not that rare. We say okay we can’t find a cause for your itching but we have got ways of making this better. And patients for whom – who have had this intractable itch for a long time again are often so relieved to have the itch settled that they don’t mind the fact that actually doctors don’t know what the cause of their itch is. If you have any queries arising from the issues raised in today’s programme then please call the action line or visit the website – details of both in a moment. Next week’s programme is all about arthritis.

Non steroidal anti-inflammatory drugs, like ibuprofen and diclofenac, are the mainstay of therapy for most people with arthritis, but recent research has suggested that some types may double the risk of heart attack. My favorites are coconut oil mixed with castor oil. And if you are taking anti-inflammatories, and have been worried by the recent reports in the press, then we’d like to hear from you – I’ll be putting your queries direct to consultant rheumatologist David Eisenberg.