Month: February 2018

Allergies to Moisturizers

Excessive dryness of the skin is a feature of many chronic dermatological disorders and contributes greatly to itchy skin.  Regular application of a moisturizer is critically important in the prevention and treatment of atopic dermatitis (i.e., eczema) or eczematous-like conditions such as contact dermatitis.

There are hundreds of different moisturizing products available over the counter. A recent article published in the JAMA Dermatology journal offers some guidance on how to choose the right product for most individuals

A total of 174 unique best-selling moisturizer products were identified in the cohort study.  The median price per ounce was $0.59 with a wide range varying between $0.10 and $9.51 per ounce.  This represents a tremendous range of 9,400%.  The most popular type of moisturizers were lotions (59%), followed by creams (13%), oils (12%), butters (8%), and ointments (2%).

Contact dermatitis is the condition that results in chronic inflammation of the skin, triggered by exposure to a chemical allergen or irritant. The study found that some moisturizers contain common chemical allergens, potentially worsening the very condition it is designed to treat!

The North American Contact Dermatitis Group (i.e., NACDG) publishes a list of most of the chemical allergens that play a role in the causation of contact dermatitis.  The three most common allergens in moisturizers were fragrance mix, paraben mix, and tocopherol (i.e., DL-a-tocopherol).  Most of the moisturizers contained more than one allergen.  In fact, 43% of the moisturizers contained three to four allergens while 13% contained five or more allergens.

Even products with a claim of “fragrance free,” 45% of the moisturizers had at least one fragrance cross-reactor or botanical ingredient.  When an individual is allergic to one fragrance, the risk of having a reaction to other fragrances is much higher because of the chemical similarity between ingredients.

Lotions were statistically less expensive per ounce than butters, creams, and oils. Products without any ingredients in the North American Contact Dermatitis Group’s list of allergens were not statistically more expensive per ounce than products with one or more allergens.

The most common potential allergens of the 174 best-selling moisturizer products are as follows:

  1. Fragrance mix
  2. Paraben mix
  3. Tocopherol (i.e., DL-a-tocopherol)
  4. Phenoxyethanol
  5. Formaldehyde releasers
  6. Propylene glycol
  7. Benzyl alcohol
  8. Iodopropynyl butylcarbamate
  9. Cocamide diethaholamine
  10. Methylisothiazolinone
  11. Compositae mix
  12. Lanolin
  13. Lavandula angustifolia oil
  14. Ethyl acrylate
  15. Benzophenone-3
  16. D-Limonene
  17. Melaleuca alternifolia

The study also found that the three most affordable moisturizers that were free of ingredients listed by the North American Contact Dermatitis Group included Ivory raw unrefined shea butter; Vaseline original petroleum jelly, and Smellgood African shea butter.

In addition to a comprehensive history and physical examination, diagnostic patch testing is often performed in order to identify the allergen(s) that may be causing any skin manifestations such as redness, dryness, itching, burning, peeling, scaling, and/or blistering.  Identifying the allergen is very important, since treatment is aimed at avoiding contact with the offending allergen found in a moisturizer.  Patch testing can also identify other chemicals and metals typically found in an array of products and used in various industries.  These products may include cosmetics, hair dyes and other dyes, shampoos, rubber products, fragrances and perfumes, caine medications (e.g., benzocaine, tetracaine, dibucaine), industrial chemicals, topical antibiotics, topical anti-fungals, soaps, metals, jewelry, adhesives, sealants, paints, pine oil cleaners, dermatological creams, bandages, flavoring agents, glues, leather goods, shoes, pesticides, creams, lotions, ointments, oils, sunscreens, coolants, plastics, building materials, vaccines, corticosteroids, and textiles.

The board certified allergists at Black & Kletz Allergy see patients of all ages and have over 50 years’ experience in the field of allergy, asthma, and immunology.  Skin disorders such as eczema, contact dermatitis, poison ivy, poison oak, poison sumac, hives (i.e., urticaria)generalized itching (i.e., pruritus) are common skin ailments that we routinely diagnose and treat.  Black & Kletz Allergy has 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and all locations have on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To make an appointment, please call us or alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy are happy to answer any questions or concerns you may have about any allergic, asthmatic, or immunologic issue.

Self-Injectable Epinephrine Devices

Woman injecting emergency medicine into her leg

Self-injectable epinephrine devices or epinephrine autoinjectors have been in the news quite a lot recently due to their high cost.  In recent months, generic versions have become available which are much less costly.  Epinephrine (i.e., adrenaline) is a medication that is used to treat individuals who have systemic allergic reactions (i.e., anaphylaxis) among other disorders such as cardiac arrest, asthma, and superficial bleeding.  Regarding asthma, epinephrine is occasionally used in emergency rooms to treat acute severe exacerbations of asthma.

Epinephrine is a naturally occurring hormone that is made in both the adrenal glands and certain nerve cells.  Epinephrine causes increased cardiac output, increased blood flow to the muscles resulting in increased muscle contraction, increased heart rate, dilation of the pupils of the eyes, smooth muscle relaxation causing dilation of the bronchial tubes, increased respiratory rate, and increased glucose production.

The side effects of epinephrine are numerous and may vary.  Some of the side effects may include rapid heart rate, increase in blood pressure, anxiety, dizziness, headache, nausea, vomiting, sweating, trembling or shaking, difficulty breathing, stroke, chest tightness, chest pain, blurred vision, decreased sense of touch, hives, numbness, rashes, jaw pain, arm pain, and/or restlessness.  Most patients experience a rapid or pounding heart rate and a shakiness feeling.  Typically these symptoms generally last less than 30 minutes.

Epinephrine is usually administered intramuscularly (i.e., IM) when given to individuals that require it due to an allergic reaction.  Commercially available preparations come either in vials, bottles, or self-injectable devices.  Patients that are prescribed epinephrine by their physicians are usually given prescriptions for a self-injectable epinephrine device.  There are several brands that exist in the U.S. with the most common brand being an EpiPen.  Other self-injectable device brands include Auvi-Q, and Adrenaclick.  There are generic brands available as of late and they are labeled epinephrine on the autoinjector.  The generic versions are generally much less expensive than the brand name self-injectable devices.

Self-injectable epinephrine devices come in two different strengths of epinephrine.  In adults and children weighing more than 66 lbs., usually the 0.3 mg. strength is prescribed.  In children that weigh between 33 lbs. and 66 lbs., there is a 0.15 mg. strength that is typically prescribed.  In the case of EpiPens, there is a regular EpiPen which contains 0.3 mg. of epinephrine and there is an EpiPen Jr. which contains 0.15 mg. of epinephrine.  Auvi-Q also comes in two strengths and they are referred to as Auvi-Q 0.3 mg. and Auvi-Q 0.15 mg. depending on the amount of epinephrine they contain.  Adrenaclick is labeled either Adrenaclick 0.3 mg or Adrenaclick 0.15 mg.  Likewise, the generic versions are labeled Epinephrine 0.3 mg and Epinephrine 0.15 mg.

The technique of using a self-injectable epinephrine device may vary depending on the brand.  In general, the devices contain a fixed dose of epinephrine and a spring-loaded needle that exits the tip or edge of the device and penetrates the individual’s skin, to deliver the epinephrine via an intramuscular injection.  EpiPens, Adrenaclicks, and the generic epinephrine autoinjectors all look like long magic markers and when used should be administered by forcefully pressing the tip of the autoinjector to the outer thigh and holding the device in place for at least 3 seconds.  Auvi-Q’s are smaller in size and are more of a rectangular-shaped device that can be put into a pocket.  The Auvi-Q device also has a retractable needle as well as automated voice instructions to assist the user(s) on how to correctly use the autoinjector.  It also should be administered by forcefully pressing the edge of the autoinjector to the outer thigh and holding the device in place for the audible countdown heard from the Auvi-Q device.

It is very important that the adult patient or parent/caregiver of the allergic child who has been prescribed a self-injectable epinephrine device understand how and when to use it as well as understand that he/she should go immediately to the closest emergency room after using it as the beneficial effect of the epinephrine may wear off or not be effective.  If the epinephrine effect wears off and the systemic signs or symptoms begin to reoccur in the patient, a second dose of another self-injectable epinephrine device should be given on the way to the emergency room.  It is also important to realize that self-injectable devices have expiration dates marked on them and they should be checked regularly and replaced if they have expired.

It should also be noted that epinephrine self-injectable devices contain the preservative known as sodium metabisulfite.  In the EpiPen package insert, it says “The presence of a sulfite in this product should not deter administration of the drug for treatment of serious allergic or other emergency situations even if the patient is sulfite-sensitive.  Epinephrine is the preferred treatment for serious allergic reactions or other emergency situations even though this product contains sodium metabisulfite, a sulfite that may, in other products, cause allergic-type reactions including anaphylactic symptoms or life-threatening or less severe asthmatic episodes in certain susceptible persons.  The alternatives to using epinephrine in a life-threatening situation may not be satisfactory.”  This implies that if someone is having a serious life-threatening allergic reaction, it may be worth the risk of using the self-injectable epinephrine device rather than do nothing about it, since the anaphylactic reaction is life-threatening on its own.  One should check with their physician and discuss whether or not to use an autoinjector in the case that individual has a sulfite allergy.

The board certified allergists at Black & Kletz Allergy have been treating anaphylaxis and prescribing self-injectable devices for many years.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and they are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you or someone you know have an allergic condition that predisposes you to anaphylaxis (i.e., food allergies, insect sting allergies, medication allergies, idiopathic anaphylaxis), please make an appointment so that we may help you.  Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergists at Black & Kletz Allergy have been treating both adults and children in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years and would be happy to provide allergy relief for you in a caring and professional atmosphere.