The Case of the Mysterious Rash

Posted 11/30/2010

Although dermatologists are very good at what they do–glance at a rash, make a diagnosis, and write a prescription–it has always (very mildly) irked me that they do this so quickly.

“Of course,” they would argue, “Skin is right up front, isn’t it? No stethoscope needed, no peeking into various body openings. Ask a couple of questions, like how long have you had this, and what brings it on. Take a look-see. And viola! Next patient, please.”

That’s true. Even when dermatologists take a biopsy or remove a skin cancer it takes only a couple minutes. Still, the young man I saw a few weeks ago had seen several dermatologists since his particular rash first started seven years earlier. He was getting no diagnosis and now the rash was beginning to dominate his life.

Yet once I heard his entire story, not only did I make a diagnosis, but so did a couple of my non-medical staff members when I presented his tale at our weekly patient conference. This fulfills the old medical school dictum, “If you listen carefully enough and long enough, your patient will to tell you the diagnosis.”

Let’s see if you can make an accurate diagnosis as well
Ron had always been an allergic sort of kid. As a child, he had both hay fever and asthma, as had his father and brother. Before age ten, he’d been through allergy shots (ineffective) and although his symptoms began to diminish as a teenager, a common occurrence, he carried an asthma inhaler with him well into his twenties.

And, in fact, like many allergic people, Ron’s twenties were his best decade, symptom-free for the first time in his life. In his late twenties, he moved to Hawaii and then one day seven years ago, a strange thing happened.

He was walking along the beach in his flip-flops when he noticed the bottom of his feet were beginning to itch–really itch–and turn red. It’s hard to scratch an itch on the bottom of your feet, but Ron was able to get some relief by soaking them in cold water or scraping them on carpeting.

Things improved, but then, a few days later, Ron noticed another very itchy rash where his underwear rubbed against his rear end. And he had yet another rash where his surfboard rubbed against his thighs and chest when he carried it. This rash spread very quickly and he felt major allergic symptoms, including a swollen tongue and tightening in his throat.

Ron got himself to the emergency room, where he was given steroids and antihistamines to reduce the swelling. The doctor told him he had hives (urticaria), recommended Ron avoid whatever was triggering them, and to use the antihistamines if the hives recurred.

Return of the hives And that would be the problem over the next seven years–the hives kept coming back, seemingly anywhere pressure was applied to his skin: underwear, elbows after placing them on furniture, even after playing his guitar or golf. Three years after his initial flip-flop episode on the beach, Ron’s hives were now virtually a daily occurrence. Moreover, he began to develop hives after eating certain foods, but nothing seemed consistent. He told me it seemed like no day went by without hives somewhere on his body.

By this time Ron had moved back to Chicago and was seeing one dermatologist after another. He heard the same litany: in almost half the people who have hives, we never find the culprit that triggers the rash, and some people, like Ron, pretty much need to take antihistamines every day.

At this point in my telling, a couple of our staff people hazarded a guess, and they were right. Care to try?

Mystery solved The rubber tree is the source of latex, and some people–especially those who easily develop allergies—can become significantly sensitive to latex. If fact they can become so sensitive that, like the peanut allergies you read about, even the tiniest exposure, such as latex dust moving into the air when a nurse opens a box of rubber gloves, can trigger major problems.

To develop an allergy in the first place, you’re likely an allergy-prone person with a significant exposure to a “culprit molecule.” In Ron’s case, this occurred when the sand he was walking on abraded both his skin and his flip-flops, which were made of rubber. Once the culprit molecule latex made its way inside Ron’s body, his exceedingly sensitive immune system created huge numbers of antibodies against it. With every subsequent exposure to latex molecules (via his underwear, surfboard, guitar, and golf clubs), a massive release of the chemical histamine was triggered. It’s histamine that causes rashes, makes your eyes water, and makes you sneeze or wheeze. Hence the treatment for allergies are anti-histamines.

The problem with a severe latex allergy, though, is that latex is everywhere: in the elastic of underwear, on surfboards, golf handles, guitar necks, mouse pads, keyboards. And, like a poison ivy allergy, if you inadvertently touch with your fingers one area where latex rubbed against you, you can spread it elsewhere.

Although it’s a good idea to carry an epi-pen if you have a severe latex allergy (antihistamines will help with symptoms), the real treatment is avoidance, and this can be very challenging. Click through to this latex allergy support site and prepare to be astonished by the number of everyday products containing latex. Latex-sensitive people in the healthcare field have been known to change careers because latex is ubiquitous in hospitals.

Ron is currently on a latex-avoidance quest and is finally noticing some improvement.

I asked him what to me was an obvious question that might have led him to making his own diagnosis: had he every used latex condoms? Turns out his wife is on the pill.

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