Esketamine: a promising new treatment for depression

Depression is a mental illness. It is estimated that depression will affect 15 percent of all people at some point in their lifetime. The condition is caused by imbalances in certain brain chemicals called neurotransmitters. These neurotransmitters play an important role in controlling your mood. In addition to directly affecting depression, neurotransmitters have other bodily functions.

Continue reading Esketamine: a promising new treatment for depression

Combating the opioid crisis

This alarming epidemic requires everyone’s help to counteract

The opioid crisis has been national news for the past several years, affecting thousands of people throughout the country, with seemingly no end in sight. It involves an increase in opioid addiction and overdose caused by misuse of opioids, such as prescription pain relievers, heroin, and synthetic opioids like fentanyl. 

Opioids trigger the release of endorphins, the “feel good” neurotransmitter, which numb your perception of pain and boost feelings of pleasure. When the drug wears off, you can have a desire to experience those good feelings again. Continuous use of this drug can lead to dependency and, eventually, addiction.

While the epidemic has peaked within the past five years, it has been gaining momentum since the late 1990s. This was a time when prominent pharmaceutical companies reassured members of the medical community that patients wouldn’t become addicted to prescription opioid pain relievers, resulting in widespread misuse of these medications by physicians before it became clear they were highly addictive. 

The statistics showing the prominence of opioid misuse and overdose warrant immediate attention from consumers and legislators. According to the Centers for Disease Control and Prevention (CDC), more than 130 people in the U.S. die every day after overdosing on opioids.

From 1999-2017, more than 700,000 people died from drug overdoses. That is more than 10 times the number of people who died in the Vietnam War.

Opioids are often prescribed for chronic pain; however, roughly 25 percent of patients prescribed opioids for chronic pain misuse them. Approximately five percent of people who abuse prescription opioids will transition to heroin.

The most common states of the country experiencing this opioid crisis are in the Midwest—including Ohio, Wisconsin, and Minnesota.

The CDC says the economic burden of this crisis is $78.5 billion a year, including costs of healthcare, loss in productivity, addiction treatment, and criminal justice involvement.

The significant magnitude of this national crisis is quite apparent. Here, we will identify and examine current approaches to correct the opioid crisis and what you can do in your community to combat the opioid crisis.

What government is doing

With all of these startling statistics, what is being done about it? Several government agencies are brainstorming new ideas and programs to counteract this growing crisis. For instance, the U.S. Department of Health and Human Services (HHS) has several approaches including:

  • Developing treatment programs that optimize the use of opioid treatment medications such as Buprenorphine, Naltrexone, Clonidine and Methadone.
  • Continuing to research the use of cannabis as a new tool in the treatment of opioid addiction. Cannabis and opioid systems in humans interact very closely. Perhaps this will open a door for the development and utilization of cannabis-related medicines to treat opiate addiction. Although promising, much more research needs to be done. Cannabis will not be the solution, but it may be a significant component in the war against the Opioid Crisis.
  • Improving access to treatment and recovery services.
  • Promoting the use and widespread availability of overdose-reversing drugs such as naltrexone (Narcan).
  • Strengthening understanding of the epidemic through more public health surveillance data.
  • Providing up-to-date research on pain and addiction.
  • Advancing better practices for pain management by healthcare professionals.

The National Institute of Health (NIH), a research branch of HHS, echoes these initiatives by conducting research for new non-addictive strategies to manage chronic pain, as well as meeting with pharmaceutical companies and healthcare professionals to prevent the snowball effect of opioid misuse.

The CDC plans to take it one step further by partnering with public safety, such as law enforcement, to address the growing illicit opioid problem. Officials are also considering attacking the source to reduce opioid availability. This includes targeting the opioid manufacturers who produce much more medication than is actually needed.

Purdue Pharma, the manufacturer of Oxycontin, is currently involved with lawsuits from over 30 different state attorneys general (including Minnesota’s) and over 1,500 personal liability suits. We are just at the beginning of these legal challenges.

Also, legal minds have discussed the possibility of prosecuting the large pharmaceutical distribution companies that make sure that the supply is plentiful across the country by delivering opioids to every drug store in the country at quantities that appear to be ridiculously high.

What local communities must do

An important question to ask is what you can do at a community level. You must realize that anyone who takes opioids is at risk of developing an addiction. The public must be made aware of this. An individual’s personal history and the length of time opioids are used both play a role, but it is impossible to predict who’s vulnerable to eventual dependence and abuse of these drugs.

Another thing you can do for your family and community is become aware of the signs of addiction, which include but not limited to:

  • Irresistible craving for a drug
  • Compulsive use of the drug
  • Continued use of the drug despite repeated harmful consequences

If you are prescribed an opioid by your physician to manage acute pain, such as after a surgery, opioids are safest when used for three or fewer days. Try to avoid using opioids unless you absolutely have to for recurrent chronic pain.

If you do need opioids, ask your doctor for the lowest possible dose for the shortest time required, and use it exactly as prescribed. The key is to have a discussion with your doctor on the proper pain management specific for you.

You can help prevent addiction in your family and community by disposing of unused opioids properly, specifically by contacting local law enforcement or using the Drug Enforcement Administration (DEA) medication discarding and take-back programs. If there are none in your area, contact your pharmacist on how to properly discard the medication.

It is critical to realize that anybody who uses opioids, either prescribed or illegal, are at risk of developing dependence and possible addiction. Therefore, we must educate ourselves and our community of this matter to combat this evolving crisis one neighborhood at a time.

Charles E. Crutchfield III, MD is a board-certified dermatologist and Clinical Professor of Dermatology at the University of Minnesota Medical School. He also has a private practice in Eagan, MN. He received his M.D. and Master’s Degree in Molecular Biology and Genomics from the Mayo Clinic. He has been selected as one of the top 10 dermatologists in the United States by Black Enterprise magazine. Dr. Crutchfield was recognized by Minnesota Medicine as one of the 100 Most Influential Healthcare Leaders in Minnesota. He is the team dermatologist for the Minnesota Twins, Vikings, Timberwolves, Wild and Lynx. Dr. Crutchfield is an active member of both the American and National Medical Associations, and president of the Minnesota Association of Black Physicians.

 Alexis E. Carrington is a senior medical student at St. George’s University School of Medicine and a graduate of Pepperdine University. She is currently applying for a dermatology residency and research fellowship.

Hidradenitis suppurativa: hard to pronounce, live with, and treat

Dr. Crutchfield, my cousin had a skin problem where she developed pimples in sensitive areas that would get bigger, become painful, turn into boils and break. The areas would smell bad. She saw a dermatologist and was diagnosed with a condition called “hidradenitis suppurativa.” What is hidradenitis suppurativa?

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that may be caused by an inappropriate response of the body’s immune system.

No one knows for sure what exactly causes HS. One theory is that HS is the result of an abnormality in hair follicles. HS tends to occur when hair follicles become blocked, leading to a clogged hair follicle. When the follicle is blocked, pressure builds up in the follicle, causing a rupture and leakage to the sides of the follicle, deep into the skin. The leakage produces a response by the immune system to the material in the skin. The immune response is in the form of inflammation.

This cycle can repeat itself over and over and in many areas, producing a chronic medical condition. The lesions of HS appear as boils in the skin. The medical term for a boil is an abscess. The abscesses of HS can be mild, moderate, or severe.

  • Mild: This means a single abscess or a few abscesses that don’t connect or drain. They can be very painful.
  • Moderate: Commonly, several abscesses are widely separated. These are painful. They may connect and drain with pus and blood.
  • Severe: Multiple abscesses that are close together and cover large areas. These are painful and drain profusely. The common areas are the scalp, on the neck, around the ears, under the arms, under the breasts, in the groin, and on the backside. These areas coincide closely with hair-bearing areas.

HS starts as pimples in sensitive hair-bearing areas that enlarge and turn into large abscesses that can be extremely painful, connect and rupture, and smell foul. The connection between abscesses is called a sinus tract.

HS is an inflammatory skin disease. It is a chronic medical condition, meaning it lasts for a long time, maybe even a lifetime. Some people mistakenly think that HS is an infection. It is not an infection, but is actually a malfunction of one’s immune system.

There are a lot of misconceptions about HS. Here are some other things you should know:

  • HS is not the fault of the person who has it.
  • HS is not transmitted sexually.
  • HS is not caused by poor personal hygiene.
  • HS is not contagious.

What are the symptoms of HS?

The lesions of HS are boils or abscesses. They form under the skin in areas where hair grows and the skin may rub together. They are painful and fill with pus and blood. When they get big, the lesions can rupture and release a very foul-smelling fluid. The amount of fluid produced can be quite significant, and in severe cases they can drain all day long, causing the person to have to wear absorbent pads in the areas that need to be changed often.

Larger regions can connect by tunnels in the skin known as fistulas or sinus tracts. Over time some areas can form scars, and new areas can form. The constant drainage of bad-smelling drainage can lead to a foul odor that travels with the affected person.

As one could imagine, the condition is terribly embarrassing and can interfere or prevent normal personal social interactions, leading to an inferior quality of life. As a result, many dermatologists believe that HS is one of the very worst skin diseases to have.

In some cases, HS may temporarily subside, but it often comes back. It may start out as mild but rapidly progress to severe. Being overweight and smoking are two factors that can be managed and have an impact on the severity and progression of the disease.

Treatment

Physicians will recommend smoking cessation and weight reduction. In addition, these treatments are available:

  • Antibiotics (as anti-inflammatories, not to treat infection)
  • Steroids
  • Surgery
  • Hormone therapy
  • Immunosuppressant medications
  • Biologic medications

HS can be devastating for self-esteem and lead to profound depression. If HS is impacting social relationships, self-esteem, and/or depression, it is important to talk to experts in the fields of mental and sexual health. It also may be helpful to join a support group so you can share feelings and information with other people who have HS. 

For stubborn or severe cases, you should visit a dermatologist who specializes in HS. These dermatologists are medical doctors who have experience in diagnosing and treating inflammatory conditions of the skin. They understand what you’re going through and can recommend treatment options that are appropriate for you.

There are good treatments for HS, and no one should have to suffer from this terrible condition. Fortunately, there is an FDA-approved biologic treatment (named ‘adalimumab’) for HS.

To find a dermatologist who specializes in the treatment of HS and for a list of national support groups to join, visit www.noBSaboutHS.com.

That dry, itchy scalp might not be dry at all

Dr. Crutchfield, I seem to be having a problem with dandruff and a dry, itchy scalp, especially this winter. Can you help me?

Your concern over a dry, itchy scalp is a very common one. In fact, I see several patients every day with the same complaint.

I tell patients that when it comes to treating dry, itchy scalps, I have good news and I have bad news. The bad news is that there is no cure for the condition, but the good news is that it can be managed and controlled to the point where it seems like it does not exist.

The surprising fact is that the condition that everyone seems to think of as dry, itchy scalp is not dry at all. It is a unique type of eczema (also known as dermatitis) that makes the scalp seem like it is dry because it produces lots of flakes.

 The flakes are not a result of the skin being dry; rather, the skin grows too fast as a response to inflammation in the scalp. Sheets of skin pile up because they can’t be shed quickly enough. The inflammation is driven in part by the oil production or sebum in the scalp.

This massive amount of skin flakes tricks us into thinking it is dry skin when it really is not. It is a very common skin condition called “seborrheic dermatitis.” The condition is so common that it probably affects 25 percent of all people to some degree. It can occur on the scalp, face (especially sides of the nose), eyebrows, ears, chest, belly button, groin, armpits, and even the backside’s “gluteal cleft.” 

For now, I will only talk about seborrheic dermatitis when it occurs on the scalp. The familiar, non-medical name of seborrheic dermatitis when it happens on the scalp is dandruff. It is a common skin disease that causes the skin to be red, itchy and flakey.

Seborrheic dermatitis can wax and wane and appear and disappear at any time. Sometimes the condition will resolve without treatment, but more often than not it may require medical treatment.

Seborrheic dermatitis can occur in all people. In babies, it is commonly called “cradle cap.” It can also occur in a baby’s diaper area. It tends to occur most often in infancy and adulthood and in men more than women. It is more common among family members, in people with oily skin, and for some odd reason in people with Parkinson’s disease and HIV.

The condition is harmless and not contagious, although it certainly is a nuisance. The constant itching and abundant skin flakes can be extremely problematic and embarrassing. 

Interestingly, the exact cause of seborrheic dermatitis is still not completely understood. Perhaps the excess oil in our skin serves as a food source for yeast that commonly live on everyone’s skin. The yeast grow, and for some unknown reason some people have a brisk reaction to the larger population of yeast on the surface of the skin. This response comes in the form of inflammation (redness, flaking and itching).

The yeast component is only a part of the problem. The other part is purely genetic, and the common areas are prone to inflammation with or without yeast. The diagnosis can be made easily by an examination by a doctor, especially a dermatologist.

As mentioned earlier, there is no cure for seborrheic dermatitis. The goal is management and control of the condition until it is unnoticeable and no longer a nuisance.

For scalp seborrheic dermatitis, I have a two-part treatment plan. First, let me say that I am not a big fan of using a hair shampoo to treat a skin condition. I recommend a medicated oil applied once per week to reduce and maintain scalp inflammation. This part is the maintenance program.

Washing one’s hair weekly is also very important. I recognize that weekly hair washing may be a challenge for some, but it is essential to clean the scalp skin and wash away the dead skin and flakes that are continually building up.

Secondly, I have a very potent topical treatment to use for five days if the condition should flare up and break through the maintenance program. Three two-treatment steps work exceptionally well.

If you or a loved one has dry, itchy scalp, talk to your doctor to see if it really is the medical condition called seborrheic dermatitis. If it is, rest assured there are excellent treatment programs to make the embarrassing and troubling situation much better to the point of seeming not to be there at all.

Six tips for staying healthy in a world of germs

Dr. Crutchfield, it seems like everyone at work is sick. What can I do to protect myself from getting sick at work?

Here are some tips on protecting your health in the workplace in spite of all the germs that may be lurking there.
 


Tip 1: Wash your hands.
As you entered your office, you probably touched one of many common surfaces just teeming with germs. These common surfaces include elevator buttons, escalator railings, and door handles. Whenever possible after such contact, wash your hands for 15 seconds with warm, very soapy water.
I was at a professional sporting event this weekend and the men’s bathroom was extremely full. I counted 30+ people. I paid very close attention, and half the people did not wash their hands.

The ones who did attempt to wash their hands did so in such a poor manner that they really only wasted their time. Many just splashed or rapidly rinsed their hands under the water for less than five seconds. No soap. It was almost like a theatrical performance or a gesture of washing hands so as not to look bad in front of the other bathroom patrons. They did not engage in a significant, worthwhile, useful hand-washing event. 

Remember, you should engage in at least 13-30 seconds of hand washing with warm, soapy water. True story: When I did wash my hands, I did it properly, and the man behind me commented, “Dude, you’re washing your hands like you’re a doctor!” Wow, did that bring a smile to my face.
Also, be sure to keep a bottle of hand sanitizer handy. Make sure it contains at least 60 percent alcohol. It can be almost as effective as washing your hands with warm, soapy water.

When it comes to your desk, the area is mainly contaminated with your own germs, so they are unlikely to make you sick unless you brought germs in with you (as from doorknobs, elevator buttons) and did not clean your hands.

Also if you have other people who may work in your personal work area, like an IT person working on your computer, then you should clean your area. This is best done with commercially available disinfectant wipes. Keep these handy and use daily or whenever someone else works in your space or uses your computer.
 
Tip 2: Try not to touch your face.
This is much easier said than done, but with practice and concentration, you can minimize or decrease how much you touch your face. Studies have shown that most people touch their face 60-100 times per day, and some people even much more.
Your hands carry germs, and they can enter your body through your mouth, eyes and nose. Minimizing the number of times you touch your face will minimize how often you get sick.
 
Tip 3: Keep your distance.
Maintain a safe distance from your co-workers. You can’t control if your co-workers arrive sick, but you can control the distance between you. Most germs, including the flu virus, are unlikely to spread beyond three feet.
For good health, be sure to stay three feet away from co-workers, especially anyone who is sick. Wearing a mask may seem safe, but in most work environments it is not practical.
 
Tip 4: Sneeze into your elbow. 
In the old days, we were taught that when sneezing we should do so into our hands to prevent propelling germs into an aerosolized cloud that could contaminate those around us. Unfortunately, our hands subsequently touch many surfaces like telephones, coffee pot handles, refrigerator door handles, doorknobs, vending machine buttons, etc.
Sneezing or coughing into our hands just allowed germs to spread differently, not to mention transmission by shaking hands. Coughs and sneezes should be done into one’s elbow or a tissue.
 
Tip 5: Get vaccinated.
Vaccination is one of the best things that you can do for your good health. It protects you and also those around you, including people who can’t get vaccinated, like infants or those with weakened immune systems.
Sure, there are all kinds of cold medicines that can make you feel better if you are sick, but the best strategy is to prevent getting sick in the first place. Eat a healthy diet rich in fruits and vegetables that will help boost your immune system — and get vaccinated.
 
Tip 6: If you are sick, stay home.
You will recover faster at home and not spread your illness to your co-workers. The rule of thumb is that if you have a fever, do not go to work. If you are ill but not feverish and can work, this is the one time to wear a mask and keep your distance from coworkers.
 
Remember, you can’t completely eliminate getting sick at work, but you can do many things to minimize your risk of getting sick that will protect both you and your coworkers.

New technology could revolutionize food safety

Rarely does a month go by that there is not some national recall or warning about tainted foods. Food contamination is a worldwide problem. Recently, there was a nationwide ban on romaine lettuce in the U.S.

In 2008, for another example, 50,000 babies were hospitalized in China after eating infant formula contaminated with melamine, an organic chemical used in the manufacture of plastics. Melamine is toxic when present in high concentrations.

In April of last year, more than 90 people died and many others were blinded in Indonesia after drinking alcohol contaminated with methanol. Methanol is a toxic and cheap alcohol that is frequently used to dilute and extend liquor that is sold in black markets around the globe.

Here are some other facts bearing on the issue of food safety:

  • 48 million Americans get sick every year from the food they eat.
  • 128,000 Americans are hospitalized with illnesses that come from contaminated food.
  • Hundreds go blind from contaminants in bootleg alcohol.
  • 3,000 Americans die every year from contaminated foods.

If you have ever gotten sick from the food you have eaten or thought the food in the fridge smelled a bit off or wondered about the freshness or date printed on a food product you were about to consume, help may be on the way.

Researchers at the Massachusetts Institute of Technology (MIT) are using artificial intelligence to develop a wireless sticker system, called RFIQ (Radio Frequency IQ), that can check foods and drinks for a wide variety of illness-producing organisms and other tainted products. It would give consumers direct control over detecting contaminants in their food and drink.

They have developed a special, small, and very precise and accurate sensor that can attach to your smartphone and check for contaminants in food and beverages. The system should be able to:

  • Detect E. coli and other germs in produce and foods
  • Detect lead and mercury in water
  • Detect contaminants in alcohol and milk

MIT scientists are excited that they are developing a system that could revolutionize the field of food safety. Eventually, the device would be the size of a phone charger and plug directly into a smartphone. It would then interact with an app that directs the detection.

This technology has the potential to be a groundbreaking advance. There are thousands of people who have become critically ill from foodborne illness. As a result, many have a terrible relationship with food and live in constant fear, dreading every day doing something as essential to life as eating food.

The new system would enable people to test the food in grocery stores, farmer’s markets, restaurants and at home. For commercial foods and beverages, there could be a standardized, unique identifier code on the label that is scanned. If any contaminants are detected, not only would the device’s owner be alerted, but so would the product manufacturer, and even safety organizations like the Centers for Disease Control (CDC), for potential early and widespread warnings.

Ideally, the device will first serve individual consumers. Eventually, the MIT team’s goal is to scale-up the technology for commercial applications and then adopt it nationally, and even globally, so it becomes part of an invisible, seamless, food and beverage production infrastructure. Foods and drinks would then be scanned automatically before they ever hit the shelves or are sold in markets or served in restaurants.

Think about the profound effect this food safety technology can have; we could soon have the ability to check any food or liquid, before we eat it, making sure that they contain no contaminants.

The scientists are also developing additional technologies so the scanner can detect sugar, calories and other components. These additional capabilities would be extremely beneficial for people with diabetes, those watching their weight, or with food allergies.

Researchers say that the devices could be in consumer’s hands in as little as three to five years. The U.S. Food and Drug Administration has also expressed an interest in the project.

When it comes to food safety, the future looks bright.

For more information, read MIT’s RFIQ project report at bit.ly/2X2hXAC.

How safe is CBD oil?

From bath oils and soft drinks to skin creams and coffee bars, everywhere you look, you can see what looks like the next hot product: CBD oil.

CBD, or cannabidiol, oil is a member of the cannabinoid family of molecules found in marijuana and plants closely related to marijuana, such as hemp. Although CBD has been around since the 1940s, CBD’s popularity has dramatically increased along with the legalization of medical and recreational marijuana across the United States.

There are over 100 different cannabinoids found in marijuana and hemp plants. CBD and tetrahydrocannabinol (THC) are the most commonly studied cannabinoids. CBD oil is extracted from the buds and flowers of marijuana and related plants, such as hemp. But, unlike THC, which is psychoactive marijuana derivative oil, CBD does not produce a “high” or intoxicated feeling.

CBD does have medicinal benefits, however. Proponents of CBD claim that it can treat a variety of conditions including seizures, pain, anxiety, inflammation, insomnia, acne and other skin diseases, and even some forms of cancer.

Experts are not quite as enthusiastic because solid scientific research has not verified most of these claims, yet. That has not stopped marketers and producers. In addition to CBD-infused products popping up in bath and body stores and local coffee shops, many malls now have “CBD stores” dedicated to selling a variety of products containing CBD oil. You can even search “CBD oil” on Amazon.com and well over 1,000 products are displayed – all touted to treat a wide variety of health concerns.

Read on to learn more about the different types of cannabinoids and safety and effectiveness of CBD.

Three types of cannabinoids

Phytocannabinoids

These compounds, like CBD, are found in plants like marijuana and hemp.

Endocannabinoids

These are found in the human body, discovered as a result of studying phytocannabinoids. They are derivatives of a chemical called arachidonic acid. Many tissues and organs contain receptors for endocannabinoids, which are released by human tissues in times of pain and inflammation. It is well-documented that receptors for endocannabinoids are located throughout the human body, including skin cells and the nervous system and brain.

The endocannabinoids in the skin can regulate cell growth which can be used in cancer treatments. The endocannabinoids in the nervous system and brain may affect thinking and understanding, memory, body movements, and pain control.

Synthetic cannabinoids

These are man-made cannabinoids used for research purposes and in some currently available products. They may eventually be employed in pharmacologic preparations and drug treatments used for cannabinoid-responsive conditions.

The rest of this column will focus on the phytocannabinoid, CBD.

Is CBD safe?

Unfortunately, most CBD is being produced without regulation. As a result, purity and quality can vary greatly.

In a recent study, 70 percent of products evaluated contained a different amount of CBD than listed on the label. Most products examined had less CBD, but some had more. Also, about 15 percent of CBD-containing products had measurable amounts of THC. This derivative can cause anxiety, just the very thing CBD is reported to calm, and THC should not be in CBD products.

Additionally, CBD is poorly absorbed. Only about 20 percent of CBD gets absorbed, so the quality and purity of CBD products are critical for their effectiveness.

Some studies have shown that CBD can have adverse effects on the liver. This seems to be the case in about five percent of all people. Other studies need to be done to see how CBD affects a person if the person consuming CBD is taking other medications. This is extremely important.

In general, there are relatively few side effects. So, the downside in using CBD-containing products is relatively low, but liver and other possible drug interactions must be considered.

Is CBD legal?

This is really a grey and ever-changing area. It appears to be legal in the 30+ states where marijuana is legal, but the overall national legal status has not been challenged yet, and the FDA has taken a very quiet and conservative stance.

Recently, a farm bill was proposed and is expected to pass that will make hemp-derived CBD legal. Keep in mind that just because something is legal does not mean that it is FDA-approved to treat anything or everything that is printed on the label.

Is CBD effective?

There are CBD receptors in our bodies. In the presence of bound CBD, our bodies can produce physiologic responses. In fact, CBD is FDA-approved to treat certain epileptic seizures in children.

There is emerging research that CBD may be useful in treating anxiety, and there are countless anecdotal reports that it helps muscle aches, joint pain, depression, psychiatric conditions, and insomnia. The number of human trials for other diseases is small but promising.

In fact, CBD’s use as an anti-inflammatory may be the next area for future FDA investigation and approval. As mentioned, many cells in our bodies have CBD receptors, so it stands to reason that CBD can have other physiologic effects in humans, such as on pain, inflammation, anxiety, and sleep.

Unfortunately, due to the murky legal status of CBD, research to uncover these physiologic responses has been sparse. As for other health claims, much more research, especially on humans rather than animals, needs to be done. Unfortunately, due to lack of regulation, manufacturers of products that contain CBD can print just about any health claim that they want on the product label, and buyers, desiring a relatively inexpensive, natural treatment, may just believe it.

As the new farm bill clears, legality issues over research should move forward at a much faster pace. Additionally, the best method of CBD delivery (oral, topical or inhaled) should be studied for the best treatment results.

Should I use CBD?

CBD is a promising product for a variety of challenging medical conditions, but more research needs to be done. If one is considering the use of CBD when other tried-and-true treatments are not working, don’t just buy something off the shelf because the label says it will help you.

I would strongly suggest using CBD-containing products with the guidance and care of a physician knowledgeable about and familiar with CBD-containing products. The future appears bright for CBD-containing products, but its ultimate success will depend on the production of high-quality products with safe, proven and approved results.

Treating skin of color

First of a three-part series

Most skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This column and the two that follow will consider these problems and their treatments.

Skin tones
Variations in human skin tone

Variations in skin color

Skin color is determined by cells called melanocytes. Melanocytes are specialized cells within the skin that produce a pigment known as melanin. Melanin is produced and stored within special structures known as melanosomes, contained in the melanocytes.

The melanocytes make up only a small percentage of overall skin cells. In fact, only two to three percent of all skin cells are melanocytes. The variation in skin color we see across all people is determined by the type and amount of melanin produced by the melanocytes.

All people inherently have the same number of melanocytes. A recent theory indicates that the differences in skin color are really a reflection of the skin’s ability to protect against ultraviolet radiation.

Persons living closer to the equator produce more melanin because the ultraviolet radiation is more intense and ultraviolet protection is required by the human body. Groups of people living further away from the equator produce less melanin, resulting in lighter skin color.

One reason treating pigmented skin can be somewhat tricky is that traditional textbooks have had only black and white photographs. Additionally, many lesions have been described as red, pink, salmon, or fawn-colored. This certainly is true in Caucasian skin; indeed, many of the textbooks that were written had this as the majority patient type.

However, in tan, brown, or dark-brown skin, inflammation can look grey, copper, or violaceous in color. Additionally, certain conditions will have a slightly different presentation in pigmented skin.

Post-inflammatory hyperpigmentation and hypopigmentation

Melanocytes can either stop producing color or produce excessive color in cases of inflammation. Generally, in children, the cells stop producing color, especially in irritation of the diaper area. (I explain to parents that the cells tend to go to sleep.)

It is very common for a child of color to have a very light area of post-inflammatory hypopigmentation. This is where the inflammation of diaper irritation causes the melanocytes to stop producing color, leaving light or white patches.

With the appropriate treatment, the color almost always returns to normal within a few weeks. In older patients, inflammation can lead to post-inflammatory hyperpigmentation. This is most commonly seen in areas where acne blemishes heal, leaving a dark spot behind. These, too, will fade with time; however, it can be quite persistent.

Vitiligo

Vitiligo is a skin condition that occurs in all people, but it is most noticeable in patients with tan, brown, or dark-brown skin. I believe that vitiligo is really the end stage of several different disorders.

In some disorders, the melanocytes are attacked by the immune system, and they die. In other conditions, the melanocytes are pre-programmed to die early. No matter what the cause, ultimately, patches of vitiligo are white spots devoid of melanin.

Because these areas lack natural protection, vitiliginous patients must wear sunscreens to prevent ultraviolet radiation exposure and subsequent cancer later in life. In the majority of cases, vitiligo is probably the result of an auto-immune or inflammatory attack on melanocytes.

In these cases, topical anti-inflammatories and phototherapy, most notably narrow-band ultraviolet B, tend to be most effective. We have a success rate of approximately 75 percent in our clinic. In the remaining cases, these are probably related to a genetic program in the melanocytes where they die prematurely. Usually, with the appropriate treatment, signs of vitiligo can be reversed in one to two months.

Pityriasis alba

Pityriasis alba is a condition where white patches occur on the arms, trunk and, most notably, on the face. This is a widespread condition seen primarily in adolescent patients of color. It is a result of very mild irritation and/or eczema leading to post-inflammatory hypopigmentation where the melanocytes temporarily stop producing color.

Gentle topical anti-inflammatory lotions, mild cleansing bars, and ultra- moisturizing lotions can be used to treat pityriasis alba. The loss of color in this condition is usually only temporary and is most notably seen on the cheeks of adolescents.

Dermatosis papulosa nigra

This most commonly occurs in African American patients. Some people call them “flesh moles,” “Bill Cosby spots,” “Morgan Freeman spots,” and, more recently, “Condoleezza Rice spots.”

It tends to occur slightly more frequently in women than in men. These are tan to brown to black, raised papules that can occur on the forehead, cheeks, and neck. Under the microscope, they resemble other benign growths known as seborrheic keratoses.

We use a unique surgical technique in our clinic that can achieve excellent results in treating dermatosis papulosa nigra. Indications for treatment can be pain, itching, irritation, and cosmetic reasons.

Treating skin of color: part three

Conclusion of a three-part series

Most skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because it affects skin color. This column completes our consideration of these problems and their treatment in this series.

Pseudofolliculitis barbae

This condition is also known as “razor bumps.” Hair is made of a protein called keratin, and it can be extremely inflammatory to the skin. It is called “pseudo” folliculitis because the hair can actually come out of the follicular opening and penetrate nearby skin, causing it to look like inflammation, or folliculitis, of that pore.

However, because it is just nearby the actual follicle, it is “pseudo” folliculitis. This is most often seen in persons with curly hair or hair that grows at an oblique angle to the skin.

Sometimes, if curly hair is cut extremely close, it never even exits the skin surface, instead penetrating the sidewall of the follicle (known as transfollicular penetration), or it comes out of the follicle and pokes the skin (known as extrafollicular penetration). The results are the same: The keratin invades the skin, producing a brisk inflammatory reaction that causes itching and the formation of pustules.

When pseudofolliculitis is mild to moderate, many topical treatments can be implemented, including a very gentle oatmeal-based shaving cream, and a non-electric razor with a safety guard, so the hairs are not cut too short. Shaving after a shower is also recommended when the hair is hydrated, so the final tip is soft as opposed to sharp.

Also, using a soft-bristle toothbrush to make circular motions in the beard area before bedtime can prevent the hair from penetrating as it grows throughout the night. Topical anti-inflammatory aftershave lotions and oral anti-inflammatories can also be used if necessary. In the majority of cases, this can provide satisfactory relief.

However, in certain instances in which relief is not achieved through these means, the best treatment is to remove the offending agent. In this case, I recommend laser hair removal.

Pseudofolliculitis barbae has been a vexing problem throughout history and can even interfere with occupations that require a clean-shaven face, such as military officers, peace officers and firefighters. Thankfully, this condition can be addressed by implementing appropriate treatments and techniques.

Tinea capitis

Tinea capitis, also known as ringworm, is endemic in African American children. Any child with a scaling, itching scalp should be thoroughly investigated for tinea capitis.

One of the clues to this is enlarged lymph nodes in the nape of the neck. I recommend a topical anti-itch anti-inflammatory lotion in addition to an oral antifungal agent. No matter what agent is used, it is essential that treatment occurs for at least eight weeks at a somewhat high dose, as advised by a board-certified dermatologist.

It is also recommended that all objects that touch the hair, such as combs, barrettes, rubber bands and pillowcases, be replaced or treated to prevent re-infection. I also advise all members of the household to use an anti-fungal shampoo throughout the treatment period for two months.

This is a prevalent yet easily treatable condition in young children. I believe that as people get older, the milieu of their scalp sebum changes, preventing an active infection. However, many adults can be carriers and pass it to their children, who are prone to the infection.

Melanonychia striata

This is a condition where brown to black longitudinal bands occur in many, if not all, the fingernails and toenails. This is a common, benign condition that is often seen in multiple family members. However, if one band should occur spontaneously without a family history, this should be evaluated for an underlying mole or melanocytic malignancy.

Voigt or Futcher lines

These are lines seen most commonly on the upper arms and sometimes thighs and are normal variations. They were named after a physician and anatomist who first described these near the turn of the century. They are harmless.

Melasma

Melasma is a common and vexing problem that I see on a regular basis in our clinic. It presents as hyperpigmented patches occurring on the cheeks, upper lip, forehead, and sometimes dorsal forearms. It can be extremely challenging to treat, and I inform patients that 25 percent of the time there’s not much we can do about it.

I also tell patients that it is a lifelong battle and something that we’ll always have to treat and use preventive measures to keep from coming back. It’s usually a result of hormones, genetics, and sun exposure. Commonly the hormones can include the initiation of oral contraceptives and/or pregnancy and childbirth.

I often tell patients that it’s a very rapid, uneven suntan occurring in the areas described. It’s exacerbated by sun exposure and, we discovered recently, heat exposure. So, people who enjoy saunas, hot showers, steam baths, and warm climates should know these can exacerbate the condition.

I had one patient who we had difficulty treating, and I asked if heat might be a potential factor in his melisma. He looked at me with a frown and said, “I’m a chef. I’m over a hot stove and opening ovens all the time.”

So, patients with melisma must consider meticulous sun protection and heat avoidance. I tell patients that they need to apply sun protection before they leave the house. Any amount of sunlight that touches their skin while walking from a car across a parking lot into a building, even on a cloudy day, is enough to trigger its occurrence.

Treatments include topical lightening agents, deep skin peels, and newer laser treatments. In three-quarters of patients, we certainly can see satisfactory results, although it’s one of the most challenging conditions that I treat. I see it almost on a daily basis in my practice.