Cold Sores

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

“You went camping?  Outside?  In the snow?”  Yes, Pat from the pharmacy and I went camping on the long weekend in February.  We’ve done it for a few years now.  It’s fun.  For the past couple years, Pat’s son from Ottawa has gone with us.  This year, my son Eric slept one night in the tent too.  Yes, we heat the tent with a wood stove.  However, when you go to sleep, the wood stove goes out and you better have a good sleeping bag, or you will get cold.

Despite the name, cold sores have nothing to do with temperature.  They can occur anywhere on the body, but most often appear on the gums, lips, inside of the cheek, nose and fingers.  Cold sores are caused by the Herpes Simplex Virus (HSV).  There are different types of Herpes Simplex Virus.  The one that most often causes cold sores is called Herpes Simplex Type 1 (HSV-1).  Most of us will get at least one cold sore in our lifetime.  A HSV-1 infection happens when the virus gets on the skin or mucous membrane. It eventually makes its way into a nerve cell and stays there for life.   So, the percentage of us that have HSV-1 goes up as we age.  In young adults 20% to 40% are infected. Each year beyond age 29, another 1.5% of patients reportedly contract the infection, up to age 50.  By age 70, 90% of us will be infected.

About half the people who get cold sores know when one is coming.  They will describe a tingling, burning or stinging sensation in the area where the cold sore is going to erupt.  We call this feeling prodromal symptoms.  The first visual sign is usually fluid filled blisters.  Next the blisters break and ooze liquid that is just teaming with millions of viruses.  Finally, the broken blisters scab over and start to heal.  The entire batch of cold sore symptoms usually lasts 7 to 10 days.  After the symptoms have resolved, the virus goes back into the nerve cells and hides until the next outbreak.

Outbreaks can be triggered by trauma to the skin, menstruation, sun exposure, stress, illness, fever and anything else that reduces the body’s immune system.  Most people only have two occurrences per year, but 5-10% of patients can have more than 6 episodes per year.

We can’t cure cold sore infections.  There are a few prescription and over the counter medications that can help reduce the number of days an outbreak lasts.

Valacyclovir 2000 mg twice a day for 1 day can be very effective if it is started within 6 hours of the beginning of symptoms.  As valacyclovir an anti-viral medication, we believe it suppresses how fast the virus can replicate.  The study I read found the valacycolvir group’s cold sores healed 1 day or 24 hours faster than the placebo group.  The downside is valacycolvir is a prescription product and expensive.  You would almost need your doctor to prescribe it to you ahead of time so you would have it when you feel the first symptoms of your next outbreak.

There is a new prescription cream for cold sores.  It is called Xerese.  It is not that new, really.  It has hydrocortisone and acyclovir in it.  We have been using prescription acyclovir cream on cold sores for years.  Both Xerese and plain acyclovir cream need to be applied 5 times a day.  The new one, Xerese might reduce the length of cold sores by a day and a half and the plain acyclovir cream might reduce them by 1 day.

There are two over the counter products I recommend for cold sores.  They are Abreva and Lipactin.  Abreva is the newer, and more expensive product.  Abreva is the only OTC approved by the FDA to heal cold sores.  Abreva contains docosanol 10% and is supposed to prevent viruses from entering the cells and thus reduce their ability to reproduce.  Abreva should be started as soon as someone has symptoms and also applied 5 times a day.  If the cold sore doesn’t go away in 10 days, the person should see a doctor.  There was a fairly large, double blind placebo controlled trial with Abreva.  In the study 370 Abreva treated patients had their cold sores heal 18 hours faster than the 367 placebo patients.

Lipactin contains 17.8 units of heparin and 0.56 mg of zinc sulfate per gram.  As with Abreva it should be used as soon as the person notices symptoms and again it should be used about 5 times per day.  Apparently there are studies backing up lipactin’s use as well, but I couldn’t find them.  What I do know is it is cheaper than Abreva and anecdotally many people have used it and been happy with the results.

Winter camping is fun.  You should try it.  We spent our time snowshoeing, skiing, ice fishing and skidooing.  Sometimes we build an igloo.  Spending time in our tent at night is not much different than spending time in an ice fishing shack.  So go out and enjoy winter!  And if someone asks you why you camp in the winter, tell them. “No bugs and no crowds!”

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

We now have most of the articles published in the Parkland Shopper on our Website www.dcp.ca

WINTER SKIN AND LIP CARE

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

I like being a pharmacist because I like meeting and helping people.  It turns out those are great reasons to join a service club as well.  Service Clubs have names like the Lion’s Club, the Rotary Club or the Community Foundation.  I happen to belong to the Kinsmen Club of Dauphin.  I really enjoy it.  When I first moved to Dauphin, what I liked most about Kinsmen was that I met people outside of health care.  Now my favorite Club activities include our yearly trip to Yorkton for the Yorkton Kinsmen’s Perogy Cup hockey tournament and when we give money to worthy groups like the Parkland Crisis Center.  The motto of the Kinsmen is “To Serve the Community’s Greatest Needs”.  Right now, I think one of those needs is dry skin and cracked lips.

News Flash!  In Dauphin is gets cold in the winter!  Cold air holds much less water vapor in it than warm air.  When we warm up this cold air in our houses, its relative humidity drops and it sucks up water from our lips and skin.  The same thing happens outside.  The cold air gets warmed up as it enters our bodies through our mouth and nose, its relative humidity drops and it sucks the moisture out of our lips.

Have you ever seen your daughter walk out of her room and all the hair on her head was standing on end?  I have and it is not because I am a scary father (I hope).  It is because the air in my house was so dry it promoted the build up of static electricity.  The first place you may want to go is a hardware store.  You want to keep you house’s relative humidity near (but not over) 50%.  Most hardware stores will sell you a relative humidity meter.  To increase the relative humidity, you need to evaporate water.  The least expensive way is to leave out containers of water.  This is slow, but it will help.  A more pricey option is to buy a humidifier.  I recommend a cool mist one, because there is no danger of spilling hot water on yourself or others.  You can buy small ones for a room or small apartment in your pharmacy.  Hardware stores will have larger ones.  Again, aim for 40-50% relative humidity.

Next, before exposing your skin to the harshness of winter, take a few extra minutes to “winterize” your skin and lips.  To counter dry, flaky skin you can apply a moisturizing cream daily, especially after bathing.  I know the ads for the creams talk about all the moisturizers in them, but really, the creams work best at holding in the moisture that is already there.  So, as soon as you step out of the tub, towel off (by patting, not rubbing) and apply the cream.  Moisturizers do not have to be expensive to be effective.  But, it is best to avoid products with perfumes because they may irritate the skin.

Because dry skin and lips are caused by water loss to the air, an important thing to remember is to drink lots of water.  For most people, 8-10 glasses of water per day are recommended.  There are other products which remove water from your body, and should be avoided like excessive alcohol, and caffeine.  Some prescription medications like diuretics dry you out as well, but don’t stop them without consulting your doctor.  People with certain heart, lung, and other conditions should avoid excess fluid intake.  If you think you are fluid restricted, but are unsure, ask your doctor before drinking lots of water.

Windburn is a common complaint in winter.  You can apply sunblock to your face and lips before an outdoor winter activity to help prevent windburn (it will help sun burn too, which can happen in bright winter sun).  Even a thin film of moisturizer will act as a good windscreen.

Dry, cracked lips can to be bothersome.  Also many people bite or pick at them and which makes them worse.  Lip balms and protectants are available in cream, ointment, or stick formats to ease application.  Lipsticks can also be used as a good indoor moisturizer.  Again, drinking lots of water will help.

Whichever product you use, for skin or lip moisturizing or protection, repeated application is a key factor in maintaining your body’s natural moisture and protecting it from the harsh winter elements.

Dry cracked lips and dry skin may be two of Dauphin’s Greatest Needs, but I believe there are others.  Saturday, February 22 has been designated Kinsmen’s National Day of Kindness.  A little birdy told me the Dauphin Kinsmen will be doing something special for people in Dauphin.  That same little birdy said to watch for the Kinsmen on Main Street.  Stay tuned….

As always if you have any questions or concerns about these or other products, ask your pharmacist.

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Peanut Allergy Treatment

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

This isn’t a mile high club story, but I was once in an airplane bathroom with a young, cute blond girl.  It was my daughter Emily and she was about 4 months old.  Her diaper needed to be changed.  So I kinda wedged myself in such a way that my back was against the toilet and my knees were against the bathroom door.  I did this so I could change Emily on my lap.  The diaper change went okay, but after it was over I realized my legs had cramped and gone numb in this awkward position.  I was now effectively trapped in an airplane bathroom with my infant daughter.

People with allergies to foods like peanuts can feel trapped too.  Allergy to peanuts is thought to affect 0.5-1.4% of children in high-income countries.  Peanut allergy is the most common cause of severe and fatal food allergies.  It is hard to determine ahead of time which people with peanut allergies will have the most severe reactions.  Although it is possible that someone’s peanut allergy will go away over time, it is still uncommon.

When we talk about severe and fatal food allergies, we are usually talking about anaphylaxis.  Anaphylaxis is a severe, sudden and potentially lethal allergic reaction.  It is most often an allergic reaction to foods, medications or insect stings.  After exposure to the allergen, anaphylaxis starts when white blood cells called mast cells and basophils release large amounts of chemical signals into the blood stream.  One of the chemical signals is histamine, but there are many others.  These chemical messengers affect almost every part of the body.  They can cause all the blood vessels of the body to open up at once which means  there is now not enough blood to fill all the blood vessels.  This leads to there being not enough blood for your heart to pump around.  Some of the fluid in the blood may also leave the blood vessels and leak into the tissues.  Between these two problems the patient gets hypovolemic shock which can be fatal.  In addition to the heart and circulation problems, anaphylaxis chemical signals can affect the lungs and airways.  Anaphylaxis can cause the upper airway, the mouth and throat, to swell shut.  Anaphylaxis can also cause the lungs to spasm.  So with the potential to shut down the breathing and the blood flow it is easy to see why anaphylaxis can kill and kill quickly.

If you or your child has an anaphylactic reaction to a common food ingredient like peanuts, the first thing you are told is to avoid the allergen.  This is easier said than done.  My niece has a peanut allergy.  She is 8 and an expert on telling you what things have peanuts in them.  She also won’t eat anything new unless her mother double checks the label to make sure it doesn’t have peanuts in it.

If you have severe food allergies, like an allergy to peanuts, you have to carry an EpiPen.  An EpiPen will let the child or caregiver give epinephrine to the person with the severe allergy before they die.  Yes it is that serious.  Yes, when in doubt just give the EpiPen.  There is very little chance of harm from an EpiPen.  There is a very great chance of harm from anaphylaxis.  And anaphylaxis can progress from nothing to death in minutes.

So, although manageable, you can see how life with serious peanut allergies like my niece has can be daunting.   Unfortunately, there can be near constant worry and anxiety over food choices.  Accidental exposure to allergens does happen.  The quoted rates say from 14-55% of people with peanut allergies get accidentally exposed to peanuts and have some kind of reaction every year.  So it would be great if we could modify the disease so accidental exposures to peanuts weren’t such a big deal.  The answer may be immunotherapy.

Immunotherapy isn’t new.  It has been around for people with allergic rhinitis and insect venom allergies for years.  At our pharmacy we get small vials of insect venom sent to us from a specialized lab.  The venom is diluted according to direction from the allergist and the patient gets injections on a regular schedule.  The idea is that under the tight control of an allergist, a doctor with post graduate training in immunology and allergies, if we give the patient tiny amounts of the insect venom they are allergic to, their immune systems will get used to it.  The if the patient is then stung by the insect, his/her immune system won’t immediately freak out and go into potentially lethal anaphylaxis.

In the January issue of the Lancet, Katherine Anagnostou et al. published a study in which they did immunotherapy on peanut allergic children in Britain.  The researchers used oral immunotherapy instead of the injections that are used in insect venom immunotherapy.  Oral treatments are more convenient and previous attempts at injections under the skin to desensitize patient to peanuts had problems.

The researchers took 99 children aged 7-16 who were allergic to peanuts and gave half very small doses of peanut protein in a peanut flour and the other half got nothing.  This was not a blinded trial, so patients knew if they got the treatment or not.  The treatment group had their peanut protein dose slowly increased from 2 mg to 800mg.  The peanut protein flour was mixed in with food and eaten.  This oral immunotherapy treatment lasted 26 weeks.  62 % of the treated children had no reaction to 1400 mg  of peanuts at the end of the trial.  This was the primary outcome, desensitization.  84% of treated children were able to tolerate 800 mg of peanut protein at the end of 26 weeks.  That means they could eat about 5 peanuts and not have anaphylaxis or other really severe reactions.

So this is a good and promising trial, but it is not the end all and be all.  99 children is still a small trial.  The trial wasn’t blinded.  Only 64% of the children were completely desensitized.  Even if desensitization worked, it has to be continued every day, or the fully fledged anaphylactic reactions will come back.  This study gives us another small piece of the peanut allergy puzzle.  It also gives hope that one day people like my niece won’t have to obsessively read food labels and carry an EpiPen everywhere.   But it is still too early for all people with peanut allergies to be tried on oral immunotherapy.  Unfortunately, my niece will be in her food allergy trap for a while longer.

As my daughter is now 12 years old, it is very fortunate that we are not both still trapped in an airplane bathroom.  I really thought for a while I was going to have to scream for help and get a flight attendant to release us from that airplane bathroom.  But I did manage to slowly wiggle myself free from in between the toilet and the door.  I didn’t even drop infant Emily.  On more recent plane trips, I have noticed folding change tables in airplane bathrooms.  Although they came in too late for Emily and I, they are fantastic safety features to protect new dads and their children from bathroom entrapment.

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

As always if you have any questions or concerns about these or other products, ask your pharmacist.

Lancet article – www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62301-6/abstract

Health Canada Peanut Allergies – www.hc-sc.gc.ca/fn-an/pubs/securit/2012-allergen_peanut-arachide/index-eng.php