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The Itching Games, Part 2: "Catching Ivy"

Posted on Wednesday, August 27, 2014, by Ashley Snyder

by Dr. Kathryne Buege

Well, the odds were not in you favor and you have been thrown back into the ring. This time, the plants of the Anacardiaceae family have your name and number. They are prepared for this match and guarantee an exciting conclusion to the “Itching Games.”

With what are we dealing? In the United States, the most important members of this family are those of the genus Toxicodendron (“poisonous tree”). Common or northern poison ivy, western poison ivy, eastern poison oak, western poison oak, and poison sumac comprise this genus.

How do we identify the plant?

“Leaves of three, let them be” is a helpful reminder in helping identify these types of plants. Poison ivy and poison oak are often identified by three leaflets with flowering branches arising from axillary positions on a single stem. The leaves may be green or green-reddish and are smooth, fine-toothed, or lobed margins. They have small, yellow green flowers and cream colored fruit, which look like berries and are most often seen in the fall.

In contrast, poison sumac more often forms leaflets of five, seven or more that angle upward toward the top of the stem.

One may also find characteristic black dots on all of these plants; this black lacquer is oxidized urushiol found on the plant leaves within 10 minutes of exposure to oxygen. Many people are sensitive to urushiol, the allergic component. It is a sticky oil, and causes the rash by contact.

  • You can get the rash from touching or brushing against any part of these plants and then contacting the skin.  This can include clothing, sporting gear, gardening tools or even pet fur – 
    YES, pet fur. My mother had poison ivy dermatitis on her abdomen, and it was not from wearing a bikini in the woods (sorry mom)…her fluffy white dog Mimi was the culprit!
  • The rash is only spread through the oil. You CANNOT catch a rash from someone else by touching them or their blister fluid.
  • The rash is an allergic reaction to the oil. You become allergic to it through contact and your immune system may start to react to the oil as though it’s a harmful substance.
  • Symptoms of poison ivy dermatitis in sensitized individuals generally develop within 4-96 hours after exposure and peak between 1 and 14 days after exposure.

How do I get a rash in places I did not contact the plant/urushiol?

  • Lesions may present at different locations at different times after exposure based upon the amount of urushiol present and thickness of the skin involved. This can give the impression that the poison ivy is spreading from one region to another. Blister fluid is not antigenic (contagious). Also, new lesions can present up to 21 days after exposure in previously unexposed individuals.
  • Rebound dermatitis (recurrence of rash) may occur if too short a course of steroid is used, for instance, a six-day course in a Medrol dose pack. Basically, your body has cells that react and activate an immune response, leading to a rebound rash when steroids are stopped.

Presentation

Intense itching and redness are the most common presenting signs of poison ivy dermatitis. Patients may develop blisters or papules, arranged in linear or streak-like configurations where the oil has contacted the skin.

  • Involvement of the face and genitals may cause significant edema (swelling) and discomfort.
    • Runners, campers, and outdoor-enthusiasts: beware of what you come in contact with if nature calls unexpectedly.
  • The rash may take more than a week to show up the first time you have a reaction to the oil. If develops sooner with later contacts after your initial exposure. You will only get a rash where the oil touched your skin, but as I mentioned earlier, there are a few exceptions.

What to do? Treatment and Prevention

The most important and effective treatment for poison ivy dermatitis is identification and avoidance of toxic plants and related allergens.

  • Protective clothing is useful, but patients should be reminded that clothing, pets and fingernails can harbor the allergic resin for many days. The oil can seep through clothing and can penetrate rubber or latex gloves, but not heavy-duty vinyl gloves.
  • Burning poison ivy is not recommended. The oil is stable at high temperatures and the plant particles dispersed in smoke are allergenic and irritant.
  • After a known exposure, patients should remove any contaminated clothing and gently wash skin with mild soap and water ASAP. Vigorous scrubbing is not useful and can exacerbate the impending dermatitis.
  • Chemical in-activators to prevent poison ivy (Tecnu) and oil removing compounds (Goop) are helpful, but expensive. Most healthcare providers suggest washing with an inexpensive mild detergent.
  • Barrier creams are controversial. Most studies suggest Ivy Block, an organoclay compound, is useful for preventing poison ivy. It must be reapplied every four hours and leaves a clay residue on skin.
  • DO NOT USE: Antihistamines applied to skin (topical – cream, spray or gel), topical anesthetics (benzocaine/Lanacane), or topical antibiotics that contain Neosporin/neomycin.
    • These may cause an allergy problem of their own in certain patients.
    • Mild rashes may be treated with calamine lotion, oatmeal baths, and cool, wet compresses.
      • Weeping lesions may be treated with topical astringents such as Burow’s solution or Domeboro used under occlusion to help dry the lesions.
      • A soap misture of Zanfel may benefit.
      • Corticosteroid pills, injections or creams may be prescribed for more severe reactions/rashes.
        • An oral dose of prednisone should be tapered over 14-21 days, but is reserved for more extensive cases of poison ivy dermatitis.
        • Sedating antihistamines (Benadryl and sometimes Zyrtec) are used to help people with severe itching to sleep. However, the itching in poison ivy is not caused by histamine release and there is little to no evidence to support their use.

The most important advice is to prevent exposure. Learn to identify these plants. Use protective clothing and use heavy-duty vinyl gloves. Wash with a mild detergent soap ASAP after exposure. For more severe or persistent rashes, seek medical attention with your primary care provider or MASH Urgent Care. Having said this, hopefully your name won’t get picked for the “Itching Games,” but if it is – you will be prepared for battle. Enjoy the rest of your summer, Buffalo.

The Itching Games, Part 1: "Bee-ware"

Posted on Tuesday, August 05, 2014, by Ashley Snyder

By Dr. Kathryne Buege

You have arrived at a summer picnic and, unbeknownst to you, your name has been picked by the Phylum Arthropoda to participate in their annual "Itching Games."  Here are a few survival tips to navigate their playing field.

What is Phylum Arthropoda?

It is the largest division of the animal kingdom. Bees, wasps, mosquitoes, fire ants, black widow and brown recluse spiders, ticks and scorpions, to name a few. This post is dedicated to the bee and insect stings that inevitably cross our paths this time of year.

Toxic reactions to multiple stings by Hymenoptera (wasps, bees and ants) and severe systemic allergic reactions to one or more stings or bites of other insects such as deer flies, black flies, horseflies, and kissing bugs can all present emergency, life-threatening situations. "Bee" aware of what to do when stung by an insect or bee and take appropriate action.

What you need to know about Hymenoptera:

  • The most important venomous insects known to humans
  • This order of species includes honeybees, bumblebees, yellow jackets, hornets, wasps and ants.
  • Honeybees and bumblebees are usually docile and only sting when provoked.
    • Males have no stinger! Yes, ladies - the females pack the punch, but are only able to sting one time and then die.
  • Wasp, hornet and yellow jacket stings cause most of the reported allergic reactions.
    • They nest in the ground, in walls and have volatile tempers.
    • Like honeybees and bumblebees, the females have the stinger, but have the ability to withdraw their stinger, allowing for multiple stings. OUCH!
  • Sting signs and symptoms:
    • Pain, slight erythema (skin redness), edema (swelling) and itching at the sting site
    • In some cases, more serious reactions may develop (anaphylactic reaction).

What to do if you are stung:

  • Remove the stinger and wash the affected area with soap and water. Older conventional methods recommend scraping the sting site with a flat surface, like a credit card.
  • Apply cold compresses.
  • Elevate the affected limb.
  • Control any itching with anti-histamines, such as Benadryl (sedating), Zyrtec (sedating for some), or Claritin and Allegra (non-sedating).
  • NSAIDS (non-steroidal anti-inflammatories) for pain relief
  • H-2 blockers (Zantac) for any gastrointestinal symptoms

Signs & symptoms of anaphylaxis:

  • The majority of reactions occur within 15 minutes, and nearly all occur within 6 hours of the sting or bite.
  • There is no correlation between the number of stings and the systemic reaction.  Typically the shorter interval between the sting itself and the onset of symptoms, the more severe the reaction.
  • Watch for facial flushing, tongue swelling, generalized urticaria (hives), dry cough, throat constriction, vomiting, diarrhea and bluish discoloration in the extremities.
  • Seek immediate medical attention/call 911.
  • If available, use an EpiPen, injected into the muscle, massaging the injection site to hasten absorption.
  • Patients should be monitored/observed for several hours in an acute care setting.

Uncomplicated local reactions typically consist of redness and painful swelling at the sting site, and resolved within a few hours. Occasionally, swelling may last one to two days.

Large, local reactions may have exaggerated redness and swelling that does not resolve until 5 to 10 days later. Most stings do not become infected, although this can occur. An infected sting must be differentiated from a large local reaction, so contacting your medical care facility or MASH Urgent Care for evaluation is a great idea if you experience prolonged or unusual symptoms.

Remember, talk to your health care provider about what treatment regimen is best for you, and "may the odds be ever in your favor!"

How to Tame a Tick

Posted on Tuesday, June 17, 2014, by Ashley Snyder

By Dr. Kathryne Buege

As I mentioned in an earlier blog post, I live in Erie, PA.  We have had an increased incidence of Lyme disease in recent years, and this past spring we have had twice as many ticks reported to the Erie County Department of Health.  Why?  Despite a cold spring, the ticks are hungry and looking to feed.  Yes - the ticks are on a feeding frenzy.  You and your pets are the targets, and I have written this in order to help protect you and provide some insight into the symptoms of Lyme disease.

What should you do?

  • First, protect yourself when you go outdoors.  Wear long pants and tuck them into your socks.  (Not the most fashion forward, but worth the embarrassment compared to contracting Lyme disease!)
  • Use bug spray that contains at least 20% deet.
  • Do a thorough check for ticks when you return home.
  • Take a shower immediately after walking trails or doing yard work. You should also wash and dry your clothes right away, as the the dryer is what kills any ticks.

If you have a tick, how do you remove it?

  • Use fine, flat tweezers and grip the tick as close to the skin as possible.
  • Pull backwards gently but firmly, using an even, steady pressure.   Do not jerk or twist.
  • Do not squeeze, crush or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms.
  • After removing the tick, wash the skin and hands thoroughly with soap and water.
  • If any parts of the tick's mouth remain in the skin, these should be left alone - they will be expelled on their own.  Attempts to remove these parts may result in significant skin trauma.
  • DO NOT use a smoldering match, nail polish, petroleum jelly (e.g. Vaseline), liquid soap, or any other folk remedies, as they may irritate the tick and cause it to behave like a syringe, injecting bodily fluids deeper into the wound.

What are a tick's characteristics?

It is helpful when a patient can provide information about the size of the tick, whether it was actually attached to the skin, if it was engorged (full of blood) and how long it was attached.

  • Deer ticks are brown and approximately the size of a poppy seed or pencil point.  They may transmit Lyme disease
  • Dog ticks are brown with a white collar and are about the size of a pencil eraser.  These ticks DO NOT transmit Lyme disease.
  • Lone star ticks aren't exclusive to Texas, as its name might imply.  This type of tick is brown to black in color with a white spot on its back.  They may be transmitters of STARI (southern tick-associated rash illness), which causes a rash similar to Lyme disease, but has no other similarities.

Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease.  A tick that is not attached, easy to remove or just walking on the skin, and still flat, tiny, and not full of blood when removed could not have transmitted Lyme disease or any other infection, since it has not yet taken a blood meal.

When treatment is needed:

  • If the attached tick is identified as a deer tick
  • If the tick is estimated to have been attached for 36+ hours, based on how engorged the tick is and the amount of outdoor exposure

Treatment involves antibiotics, often administered within 72 hours of tick removal.

What are the symptoms of Lyme disease?

  • In the days and weeks after a tick bite, you may experience:
    • a red rash that may develop and expand, however some infected people may not develop a rash. This rash may be uniform in its coloring and is usually salmon in color, but can be an intense red. The rash tends to expand over the span of a few days or weeks, and can reach over 8 inches in diameter.  As the rash expands, the center can become clear with concentric rings appearing around it, giving it a "bulls eye" appearance.
    • flu-like symptoms, such as fatigue, chills, fever, stiff neck, body and head aches
    • swollen lymph nodes
    • additional rashes on the body
    • swollen and painful joints
    • neurological disorders, such as numbness or leg weakness
    • loss of muscle tone in the face
    • heart palpitations
    • dizziness
  • If a small bump or redness at the bite site goes away in 1-2 days, it most likely is not Lyme disease. 
  • Confirmed cases of Lyme disease are treated within 3-6 weeks with antibiotics, which may be given intravenously in more serious cases.

Don't get "ticked" off if you can't remove a tick or are unsure what to do.  When in doubt, seek medical attention immediately at your local MASH Urgent Care or your primary care physician.  Enjoy the outdoors this summer!