Subscribe
Share
Share
Embed
Dr. Zain, Heather, and Courtney discuss how skin functions as an immunologic barrier and how allergy pathways show up in dermatology. They cover seasonal allergies and allergic rhinitis (including eyelid dermatitis and links to the atopic triad), distinguish true food allergies from intolerances, and explain why food allergy testing often doesn’t clarify eczema flares. The episode reviews hypersensitivity types (especially IgE-mediated type I and delayed type IV), patch testing for contact dermatitis, and common contact allergens like fragrances, preservatives, metals (nickel), PPD hair dye, and tattoo ink reactions. They also address drug allergies and severe reactions (SJS/TEN, DRESS/DIHS), risk factors such as atopic dermatitis and hygiene hypothesis, microbiome issues like staph and MRSA, diagnostic approaches including biopsy to rule out CTCL, and treatments ranging from avoidance and topical therapies to antihistamines, steroids, biologics, JAK inhibitors, and practical prevention tips.
00:00 Elevator Germs Story
00:52 Allergies And Skin Intro
01:01 Skin As Immune Barrier
03:11 Seasonal Allergies Signs
05:09 Food Allergy Vs Intolerance
06:53 Hypersensitivity Types Overview
07:49 Contact Dermatitis Patch Testing
09:15 Common Contact Allergens
10:13 Tattoo Ink Reactions
11:29 Drug Allergy Personal Story
15:08 Severe Drug Reactions Risks
16:49 Why Allergies Develop Hygiene
18:25 Back To Germs And Pathophysiology
19:27 How Allergies Trigger Hives
21:15 Anaphylaxis Warning Signs
21:53 Type Two and Three Reactions
22:40 Type Four Contact Dermatitis
23:31 Atopic Dermatitis Pathways
24:43 Staph and MRSA Risks
26:02 Clinical Patterns and Clues
30:22 Testing and Immunotherapy
33:43 When to Biopsy Rashes
35:24 Treatment Toolbox Overview
38:04 Prevention and Daily Habits
40:23 Final Takeaways on Allergies
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
[00:00:00] Default_2026-03-04_1: My husband jokes about that all the time because he, he has a really good immune system and we were walking with my mom somewhere, I think we were in a hotel and we were just talking about how like he rarely gets sick and how like. I think we were walking into the elevator and we were talking about like how there's probably so many germs on the elevator button.
And he was like, I'm not gonna get sick. And he like licked his finger, touch the button, licked his finger. Finger again. Oh my. And he didn't sick, but he was proving a point. Oh my God. His immune system is, that scares me. I know. Well, I just read this book about like. Ebola last time. Oh. I'm like, don't lick any substances.
That's how you get a pandemic. Yeah. Welcome to Skin Side Out. I'm your host, Dr. Zane, with Heather and Courtney. So today we're gonna be tackling allergies and the skin from the inside out. So the first concept I wanna bring up is thinking of skin as an immunologic organ, meaning that's an extension of our immune system.
So Heather, let's go into a little bit of depth about that. I think first and foremost, the skin. Needs to be looked at as the barrier into the rest of our body. And so the epidermal barrier is consisting of the stratum cornium, which is a layer of the skin lipids and microbiome.
And this helps protect us from the external world. And when we see different types of like hypersensitivity reactions, our body reacts to that, and our skin reacts to it too. And we'll go into a little bit of depth of like. Hypersensitivity reactions, but there are different mediations that can happen that can cause your antibodies or antigens to bind or cause a reaction.
And so it kind of really, I don't know how to like surface level tackle that question because there's a lot to that. It's very complex. Yeah. I mean there's a lot of different signaling molecules, a lot of pathways involved. Yeah. Um, but you know, I think just giving just a general overview is probably sufficient.
So what do you want me to do? Like, like how we could scratch that for me. Okay. Like, do you want me to talk about like, I guess, what are you looking for? Um,
so you talked about the barrier hypersensitive reactions and then. Oh, why don't we just say like, you know, why it's important in dermatology? Like in terms of what we see in the office, like as far as different allergies and stuff. Mm-hmm. Okay. Do I pick up? Okay, so I guess there are lots of different types of allergic reactions and irritant reactions that we see that can affect the skin, and I think it's not only our skin reacting to it, but our immunity too.
Absolutely. And we do see a lot of these different types of reactions and it's nice to classify them and their relevance to dermatology. So let's talk about one of the most common ones we see seasonal allergies. So Courtney, I know you suffer with seasonal allergies like I do. So tell us a little bit about how seasonal allergies presents in our dermatology patients.
So, um, we definitely, I feel like get this surge of patients year yearly here in North Carolina. Where are what's happening right now? Right. It's happening right now. My nose is bitching. Thinking about it, we have the yellow snow, AK pollen. Um, and a lot of people do suffer from raw pollen allergies. Um, I'm actually one of the true ragweed sufferers, so more in the.
Fall when we start to see that ragweed. But yeah, this time of year you'll start to see those like itchy eyes and runny noses and on the skin that can manifest as, you know, eyelid dermatitis around the eyes. Mm-hmm. I think sometimes people unaware are, you know, rubbing at their eyes and that is kind of further increasing that, um, sensitivity in the skin.
Um, different things like mold, different types of grasses. I know. I had gotten, um, allergy testing back in high school and they had tested 40 different things. I was allergic to all 40. And of course it's Oh wow. Like oak trees, which again, we're known for in North Carolina, mold, ragweed. So, um, it can be important if you find yourself suffering, especially like seasonally, to maybe consider that it's not so much your skin, it, it's an allergy, but your skin is being related to that.
And the allergic rhinitis is what we call this. Um, it is part of the atopic triad. Mm-hmm. So. It's got its relationship to asthma and eczema, so we kind of see all this kind of happening together. Yeah. I guess meaning if you have allergic rhinitis, you're more likely to get atopic dermatitis or eczema and asthma compared to other people.
Exactly. And it's part of your genetics. Mm-hmm. Yeah, I feel like even this week, um, like I've been waking up with just a little bit of that, like rashness on the cheeks and I think just that change of weather starting the PO Yeah. Um, we also have food allergies. Mm-hmm. So, um, I think there's a big difference between food allergy and food intolerance.
So a true fruit food allergy will cause like hives, angioedema, where you can get like throat swelling and trouble breathing. Um, it can cause exacerbations in eczema, especially in children, but a food and intolerance is more so that your body is not quite breaking down the food very well, and that can cause more.
Like GI issues. Mm-hmm. So common allergens that we see for food, food allergies can include peanuts, tree nuts, shellfish, milk, eggs, soy, wheat. Courtney also has experience with this too. Yeah, we love a, she just got a long list of everything. We actually have a list in our office of Courtney's. We just keep adding medical history, care about hipaa.
But what I was also gonna say too, um, to piggyback on that is I do feel like a lot of our patients. Wonder when they come in with a rash, they think that it could be something that they ingested food wise. And oftentimes what dermatologists might be looking for in correlation to that would be more so maybe around the mouth or on the hands where you've actually touched that food.
Mm-hmm. Rather than something like, um, you know, a full body kind of rash. Mm-hmm. Exactly. And there have been studies that have shown that, you know, these food allergens. Do not lead to these eczema type flares. It's a different pathway. Mm. So that's really important because a lot of people like, oh, I'm having this eczema flare, like, can we do some food allergy testing?
Mm-hmm. I'm like, that's not going to really tell you what's causing it. Mm-hmm. So that's really important to know. And I think it depends on the hypersensitivity reaction that you're having. So there are four different types of hypersensitivity reactions. Um, food allergies are specifically IgE mediated.
Meaning your, so the first time you come into contact with that allergy, your body kind of creates like an alert, and then when you have it the second time. That alert creates the hives. Mm-hmm. And so, um, you may not notice like the first time that you eat peanuts that it happens, but then the second time it happens, it has memory.
It has memory, yeah. And, um, you know, the other types of hypersensitivity like there's type three, which is related to like lupus. Mm-hmm. And we see a lot of type four, which we'll get into, but that's more so like your. Um, immune system is creating this like antibody antigen complex, and so that's very different from the food allergies.
Yeah. Um, so let's talk about topical contact allergens. So this is something we commonly see in our clinic every day, so we are getting exposed to these allergens through direct skin contact. And it goes through a type four or delayed hypersensitivity reaction where over time you develop this eczematous rash, um, because you are sensitive to that allergen and very different than the IgE mediated, um, you know, allergies that we were talking about.
So the food related allergens as well. Um, so this is something that we can test for actually. So we perform something called patch testing, um, where we actually apply. Direct chemicals to the skin, and we see which chemicals your body reacts to. So it presents, as, you know, like a rash. Um, it's usually elevated itchy red.
And we categorize how intense the reaction is, and then we inform our patients, Hey, you're allergic to X, Y, Z. Um, we typically inform them like what products. You know, they can find them in and how to avoid them and hopefully it helps clinically with reducing their symptoms. Mm-hmm. That's very helpful.
Yeah, and there are different types of patch testing. So there's like a standard um, series that we use and then there are more specific ones too. Yeah. And even some of them that are doing photo patch testing as well. So Yeah. You know, related to sun exposure. So that's pretty interesting. Um, what are some common allergens that we see a lot of our patients allergic to?
Fragrance. Fragrance. I was just about say fragrance. The word fragrance could mean like 400 different chemicals. So like specifically like some of the most common ones, like Balam of Peru, Uhhuh the fragrance mixes, Uhhuh. Um, so their particular, your Lang Oil. Mm-hmm. I don't know if I say that right.
Yeah. So like, you gotta be careful, um, you know, about, you know, or fragrances. You're coming in contact with a lot of chemicals, um, preservatives and skincare products, um, are commonly encountered. Metals. Mm-hmm. I mean, we do see that, especially with nickel. I think that's the most common. I actually saw a nickel today.
Oh yeah. Very cool. Yeah. Um, PPD is another really big one. Mm-hmm. Hair D, which is hair dye. Yeah. We see a lot from that are referred from hairstylists too. And then you also have seen, um, tattoo ink, right? Mm-hmm. Yeah. Yeah. You know what's interesting about the tattoo ink and people who have tattoos will tell you this, but at different times you can actually feel your tattoo raised.
It's, it is like a sensitivity in the skin. Like a, like it'll come and go. Yeah. And, um, I'll show you guys next time you see a red. Pretty much, no, it's usually my black lines, but you'll feel it elevated and raised and it's like a histamine response. So it gets worse like around like this time of year, spring and summer.
Mm-hmm. But most people who have tattoos have experienced it, um, at least once in their life. Yeah. It's a really weird phenomenon. I had a lady who had a reaction, but only to the red. Mm-hmm. Tattoo. Yeah. I hear that a lot more than any other color is red. Yeah. Yeah. That's very common. Wonder why? I feel like it has something to do with maybe like the dye, the actual dye.
Yeah. Yeah. Yeah. Yeah, I actually had a patient, um, who had this really cool pirate tattoo and he had a monkey. Like who had some of the red inks, like in his ear and on his tongue. And those are the only places. Oh, no rash. Okay. So it's pretty funny. I imagine it's hard to get out because mm-hmm. The tattoo removal process, the laser normally picks up on the darker colors like the blacks.
Yeah. Dark blues. But the reds and and greens are, are, are hard. Yeah. Hard. I mean, you can, but like it's still very difficult. Yeah. And you're not getting all of it out. Yeah. Yeah. Um, so drug allergies. Mm-hmm. So I find this very interesting because I suffer from drug allergies. So actually it's one of the reasons why I was so interested in dermatology as well, because when I was in college, I found out that I was allergic to Tylenol.
Oh. And it's weird because I've taken Tylenol my whole life, never had any issues, went off, um, you know, freshman year of college and in the dorms and, you know, I, I think I was like sick and I was like taking some antibiotics. Um, and then also taking Tylenol to reduce like my fever. Um, and I was just developing like these weird rashes, blisters all over.
Oh wow. And I was thinking, oh, okay. It's something that maybe I'm exposed to, or maybe it's just from the virus that I have. So I kept taking more and more Tylenol and I was just getting worse and worse. Oh gosh. It didn't make any sense to me and I never thought it made the connection that I had developed an allergy to Tylenol.
Yeah. I went to Sony Dermatologists Student Health. Nobody could figure it out. And eventually I kind of like, this has happened throughout the entire semester and you know, I missed a lot of school too. And I finally like, huh, every time I'm taking this, it's actually getting worse. Mm-hmm. And I would actually start, like the minute I took Tylenol, then I realized, like I started feeling tingling and then shortly thereafter I started developing these blisters and ah, I finally put it together.
But it was kind of a mystery. And yeah, I had never thought that, oh, you could develop. A new drug allergy over time, but you can, yeah. And interestingly, when I was a third year medical student, I saw a kid who had the same allergy and nobody could figure it out. I'm like, huh? Like, do you take Tylenol? I know, like, yeah, it, it was like a bolus fixed drug eruption, generalized uhhuh.
It was like head to toe. Like it's, it was pretty gnarly rash. But, um, I'm glad I figured it out. Um, so that was my first drug allergy. My second one, sulfa Uhhuh. And that was taking an antibiotic in response to me getting cellulitis. Where? On Bactrim? On Bactrim. Oh, wow. Yeah. So yeah, I was being treated for an infection, took Bactrim.
Then a week later I developed this horrible rash. Wow. And then I'm like, okay, this is the Bactrim. Yeah. I think the issue we. Run into a lot is a, a lot of people will say, well, I've taken that for years. Mm-hmm. Or I've used the same shampoo for years and things. Things change, baby. Yes. Your body changes.
The immune system changes. Yeah. Yeah. So it's really important just to kind of always take that history. Yeah. And I remember in training, like the worst patience to take care of, were like the ones that came into the er. Came in with these like head to toe rashes and they're on like 10 million different medications.
I was just about to say that. Yeah. I was just, yeah. I'm like, oh my God. I mean like, it's impossible to know for certain which ones Right. But there are like higher chances of certain medications Yeah. And certain types of mm-hmm. Reactions too. Yeah. But still like it was so annoying. Yeah. And sometimes, like, even just changing, um, you know, most medicines nowadays are generic, so even changing, I mean, pharmacies don't.
Really, they're not apt to tell you that you've had a manufacturer change when you get a different prescription. I know for my prescriptions there's been numerous times where it's changing the manufacturer and you know, sometimes you'll notice like different side effects with some manufacturers. And so I think especially like when you look at the older population and they are on a ton of medications and if they do have a.
Um, you know, rash, then we're going through drug by drug. Okay, well, did you increase cyst dose? Like, did, did the generic change to another manufacturer? Like where is, you know, lot times they don't know. They don't know. Yeah. Yeah. Oh, that's, that's tough. So, kind of speaking on the drug allergies and um, skin reactions.
There's very severe ones like Stevens Johnson syndrome. And, um, TEN, which stands for Toxic? Toxic Epidermal Necrolysis. Necrolysis. Yeah. Did you have either of those? No. No, no. No. Okay. I've actually seen SJS with Bactrim. Yeah, I have too. Bactrim is scary. Yeah, Bactrim is, I actually don't really prescribe it very much.
I don't either. And actually, um, there's another reaction called dress syndrome. I think it's been renamed to dish now. Mm-hmm. Um, a drug induced hypersensitivity syndrome. Um, but I had a pediatric patient who got it to minocycline and that was really scary 'cause she almost died. Oh, wow. And I kind of, you know, was looking at this patient and like, you know, she was doing really poorly, her liver function tests and a lot of her other markers were, you know, very abnormal.
And, you know, with the history and kind of finding out what was going on. I mean, like this was, you know, dish. Yeah. And I do think that a lot of people don't realize that some certain common medications that we use in medicine in dermatology can induce this reaction. Yeah. And that's another reason why I don't really use minocycline in my practice.
Yeah. Um, I just don't, I mean, I know what it can do. And there's just a lot of other bad side effects that are associated with it. I'll take the GI upset. Mm-hmm. Or you know, the photosensitivity of doxycycline. Yeah. Um, over that any day. Yeah. Yeah. Very scary. Yeah. Um, so let's move on. So we talked about.
Some of these reactions. So what are some of the factors that lead to an individual developing these? I think people who are eczema prone or who have atopic dermatitis are very prone to getting this, and there is a genetic mutation that you can have with flagrant that can cause more like susceptibility to certain.
Sensitivities in allergies, um, family history of the atopic triad, so like asthma, eczema, allergic rhinitis is very common too. And I know there's like a very popular theory, the hygiene hypothesis, um, where you know, when you don't have exposure to certain allergens early on in life. Um mm-hmm. We often talk about it with food allergies, right?
Mm-hmm. Um, so we see like people developing a lot more of these nut allergies because they weren't exposed to any of these nut allergens when like mom was pregnant. Mm. And now that we know that people are definitely having a lot more exposure to it during pregnancy and early childhood. So that they don't develop these potential allergies down the road.
Well explain mine then. Yeah. Why did your mom avoid? No, I ate peanut butter up until peanuts and peanut butter and mine developed when I was like 11 mm. Just out of, out of the blue. And then also we think that society's too clean now. Mm-hmm. Like we wash our hands. Oh, agreed. Yeah. You know, we don't get on the dirt anymore.
Yeah. Get some dirt on your hands. Exactly. Like kids need to learn how to play again. Yeah. They're like in there. That's, they all get sick. Mm-hmm. Their immune systems are not, and then when they do get sick, they get really sick. Yeah. Mm-hmm. Yeah. So you need to get exposure to some of these allergens too.
Yeah. Yeah. My husband jokes about that all the time because he, he has a really good immune system and we were walking with my mom somewhere, I think we were in a hotel and we were just talking about how like he rarely gets sick and how like. I think we were walking into the elevator and we were talking about like how there's probably so many germs on the elevator button.
And he was like, I'm not gonna get sick. And he like licked his finger, touch the button, licked his finger. Finger again. Oh my. And he didn't sick, but he was proving a point. Oh my God. His immune system is, that scares me. I know. Well, I just read this book about like. Ebola last time. Oh. I'm like, don't lick any substances.
That's how you get a pandemic. Yeah. Alright, so let's dive into the pathophysiology. So there's, um, you know, several different. Types of allergic reactions. We kind of went through some of them. So type one, let's just kind of summarize that. Yeah. So to break it down, the type one hypersensitivity is the IgE mediated.
We briefly touched on that, but um, so again, what happens is you get exposure to that allergen. Your body produces IG antibodies, which is, um, related to your immune system, and then you create. Mast cell sensitivity. So mast cells are, everybody has mast cells, but mast cells are kind of like that, um, memory warning sign cell.
So they'll be like, Hmm, I don't know. I don't know about this. Let me keep an eye out and see if it comes back. And then you re-expose yourself or you get re-exposed to the allergen and then those mast cells are like, huh, I knew there was something going on. Mm-hmm. And they release histamine. And so histamine is.
Um, contributing to hives, so like urticaria or severely angioedema where you get like the throat swelling and um, swelling of the tongue. And this kind of explains why antihistamines help because they're blocking that histamine release from affecting the skin. Yeah. And I think that if you are able to identify what, you know, things that you're allergic to and you're using antihistamines to kind of suppress the mast cells from releasing histamine mm-hmm.
That can be very, very, um, clinically alleviating for the patient. Mm-hmm. Um, they can really get through some of these symptoms and hopefully not really. Have serious, you know, consequences. And usually this is more of like a quick onset and quick resolution. So the hives will likely, you know, come up pretty quickly after the exposure.
But then typically they'll go away within like 24 hours. However, we should talk about anaphylaxis too. Yeah. 'cause that can be deadly. Yeah. So this is like a very severe form of a type one hypersensitivity reaction. This can be life threatening, you know, you're. Airway can close, you can have a lot of other symptoms, GI symptoms, and you need to act quickly.
You actually use epinephrine or an EpiPen mm-hmm. To treat these patients. And this is a medical emergency, need to go to the er. And typically we're doing antihistamines, we're doing, um, you know, epi, we're doing, um, you know, steroids, all these things to kind of help these patients. Um, so they don't. You know, die.
Mm-hmm. Yeah. Um, so the type two and three are less, um, you know, likely to occur in dermatology. But what is a type two reaction? Type two reaction is cytotoxic. So your cells are kind of attacking themselves. They, um, think that a healthy cell is a dangerous cell, and so they start attacking. Healthy cells when they shouldn't.
Hmm. And type three is the immune complexes. Mm-hmm. That we see. Correct. So this is like lupus. myasthenia gravis I think is a type three, which is not really skin related, but, so yeah, that's why we typically don't see it in dermatology. And on the type four hypersensitivity, um, we talked about that and its relationship too.
Contact dermatitis. So this is a delayed hypersensitivity reaction, T-cell mediated. Um, and you know, this is something that we can test with, um, for patch testing and I think that that can be very helpful. There's a type of cell called longer hand cells. Um, which help with antigen presentation and that kind of contributes to the reaction with T-cells and, um, because it's delayed.
That's a really, um, I guess, important factor to consider, especially if you're having patch testing done because you know, it's, you're not, your skin's not gonna react to it. As soon as we put it on, we have to let it sit. We have to give it a couple days even after it sits to see if your body creates some sort of response.
Yeah. And then let's talk about the chronic inflammation in atopic dermatitis. So we have all these new medications that target some of these signaling molecules. So what are these inflammatory markers? What pathway are they a part of? So most commonly it's IL four and IL 13, which these are different pathways that contribute to.
Causing eczema. And so if we can block those, we can treat eczema. There's a lots coming down the pipeline as far as other, um, pathways, but those are the most common with eczema and. Sometimes if you turn off one pathway, it could turn on a different pathway and maybe cause psoriasis. And so there's a lot of, um, you have to be very careful with different types of medications that you're using so you don't flare something else.
Um, I think the skin barrier gets into this cycle of, you know, being disrupted and then healing. But a lot of times it's very fragile and very susceptible to becoming disrupted again too. So you just have to be really careful. So Courtney with, um, the microbiome, we talk a lot about that in dermatology.
What is the main bacteria that we're seeing causes a lot of issues with these atopic patients? Definitely staff. We see a lot of staff, um, with those chronic like atopic dermatitis patients where their skin barrier is just, um. You know, not effective at that point, you're more susceptible to things like infection.
Um, I think staph is a pretty common infection. Mm-hmm. Um, what becomes scary is when those patients become a little resistant and they end up developing MRSA. We've seen that in patients. Um, and we actually had a patient in my old practice who started becoming resistant to different antibiotics. Um, this was kind of before I think some of these biologics came out.
It might've been like the year Dupixent had kind of come out or kind of before, but he basically had recurring staph infections. Mm-hmm. Got MRSA and then started becoming resistant to antibiotics. Wow. Yeah. Um, that's another reason why we use a lot of like bleach baths. Mm-hmm. Um, hypochlorous spray. I do think that that's a great option 'cause you don't really develop resistance to that.
Literally kills the bacteria. Yeah. Um, without having to, you know, rely on antibiotics. Mm-hmm. So, all right. So how do, um, these present, um, in terms of these allergies, what do we see clinically in the office? It depends on what is causing your issue. So classic like, um, eczema or atopic dermatitis is more of those like dry itchy patches.
Um, they could be anywhere on the body, but there are classic locations you could have. Blisters. I know with like certain contact dermatitis, like poison ivy for example, is a really, um, easy example. This is very likely to cause like a streaking of blisters, and that's where the poison ivy or poison oak rubbed against you.
Um, you can get the hives where it's just like your skin is red and raised in. Um, little patches. You can have lichenification, which is a chronic, like thickening of the skin from scratching. And then, um, angioedema, like I mentioned, is more of a serious thing where you're getting that like throat and tongue swelling.
And sometimes we notice different patterns where these occur. So Courtney, what are some of the patterns that we see in these patients? So when we look at things like maybe like the face for example, we start questioning, you know, any new products, um, any products that have changed, um, things like that.
New cosmetic products I think are a really big offender, um, hands and mouth. We might think about things that you're picking up or things you know, maybe. Some type of food, not in the traditional sense, um, but something that you're coming into contact with. Um, and then different areas, like maybe behind the knees or on the, um, inner elbows, those are places that are kind of, you know, traditionally eczema or atopic dermatitis.
So I think the location gives you a lot of intel as to what's going on, um, because. Again, different things you might be coming into contact with and things that you might not even think about on a daily basis could end up being a trigger for you. I think hand dermatitis specifically, we see a lot with like occupations too.
Mm-hmm. So, um. And it could be like a true allergy or it could be irritant. Like if you're washing your hands very, um, frequently, that could be more of an irritation. Whereas like, um, nail salons, I see a lot of people come in with irritation or, or allergies to the chemicals used. Mm-hmm. During, um. You know, doing somebody's nails.
Yeah. Not me, but No, I was just gonna say, it just reminded me, I had a patient, I was just doing like a facial on her, but she was just talking to me about her medical visit with you and she works, I won't name the popular food chain because I don't want this to get taken down, but she works for a popular food chain and she said that when they are cleaning tables out in the like dining area, that they are not allowed to wear gloves.
Um, why? And they're using different chemicals to clean the tables. Why? I don't know. I asked her and she said she doesn't know. And I was like, well, maybe we can write you like a doctor's note saying, 'cause she had like really bad rashes on her hands and we were thinking maybe it was from cleaning the tables with the chemical.
And she said, yeah, if you're behind the counter you can wear the gloves, but not in the dining room. Does that make sense? It was really bizarre. Huh? Really bizarre. I was like, well girl, let's get you a doctor's note because. Yeah. And especially with like a medical note, I mean, and just presenting like that, why wouldn't you allow, are they just not wanting you to like wear the same gloves in the kitchen that you're wearing out, like cleaning?
I guess that makes a little, I mean, they could switch out their gloves that just Yeah. Get a new pair. Yeah. I don't know if I was like asking, I was like, well, are they just being cheap? Like they just don't want you to like, use like pairs of gloves. Interesting. There's, can you bring your own gloves?
There's like that, um. There was a TikTok that was really popular, maybe like a year ago, where it was like. People cleaning with a cavi wipe and then they like fall over dead or something. Yeah, yeah. That's me. I, I did not have gloves on when I'm cleaning with a cavi wipe. Really? Yeah. Oh man. Yeah. Well you know what?
I don't have any rashes, so I guess that's fine. There you are. You know, when I get cancer in 30 years, well blame the wipes. So let's go into testing. So we did talk extensively about patch testing, uhhuh. Um, so let's talk about skin print testing. 'cause a lot of people. Hear about this and they think it's the same thing.
So what is skin prick testing? I can tell you about that as someone who's had it. Um, but they, they basically, it's more, um. I, it is more like environmental allergies. Mm-hmm. So they're testing more for things like pollen, ragweed cat dog dust cockroach. You can be allergic to cockroach. Mm-hmm. Um, yeah, lots of different, like environmental factors.
Um, normally they'll pick a place like the back, um, sometimes they actually did my arms. Um, but they will essentially give you a small dose of that allergen. Um, and then they kind of wait to see how it presents. My arm was completely swollen and like different, like my ragweed for example, was like the size of like a half dollar.
It was crazy. Wow. So certain allergies will present more than others, um, you know, depending on what you're allergic to. But that gives you kind of intel and what environmental factors are coming into play. Yeah. Do you know when they would do that versus blood tests? 'cause I had blood tests to check my allergies.
Really? Mm-hmm. So some aller. I never had a skin prick. Some allergist. I do the skin prick test first. Ah, okay. And then they do the serum, um, uhhuh allergens. And then what they do is they monitor the serum levels over time. Uhhuh, Uhhuh. 'cause sometimes you can, you know, like immunotherapy. Yeah. Getting immunotherapy.
And, um, that's what we've done with oia, actually with her pistachio and cashew allergy. Oh. Um, and she initially, I think also with her skin prick test showed that she had a hazelnut allergy. So those three, but then she did the serum testing. So that was just pistachio and cashews. And then we've been monitoring her serum levels, um, to see if like, you know, eventually she'll grow out.
Unfortunately, they've been going higher. Oh gosh. And then, um, we've been doing, um, you know, immunotherapy, the serum immunotherapy and I think she might be starting the sublingual, um, yeah. Therapy to slit treatment. So, um, I've heard they work my, um, I know somebody who's done that before and mm-hmm.
They do work. They just take time. Yeah. Yeah. Yeah. I thought about doing it. Oh, what are you allergic to? Lots of grasses. Okay. And cedar. Mm-hmm. I did allergy shots in college. Yeah. And I feel like it was incredibly helpful. Yeah. OIA and Ana both did them. And they're still doing them. Yeah. Yeah. And you can get, um, you can get to a point where they can like train you to do it at home.
Mm-hmm. Instead of having to go in, I actually give them both their shots. Oh, nice. Um, so, and then elimination diets, that's just another tool that we use to kind of. Rule out certain allergens. Mm-hmm. Um, by eliminating them out of our diets. Mm-hmm. I think going back to the blood test, what's interesting is they had offered me the day that I went in for my skin prick test.
I think I had taken like a Zyrtec or something like they're not supposed to. Well, and that, so they were like, we're gonna have to reschedule you or we can do a blood test. Yeah. They said I didn't have to stop any of this week Exactly. But then I was like, Hmm, I'm gonna stop it just in case. 'cause I want, if I wanna accurate, which they said.
Yeah, I was well and I had such a fear of like getting my blood drawn at the time. I was like, I'd rather have like 50 pokes on me than one blood draw, which is like insanely, that's the tattoo girl. Yeah, yeah, exactly. Like it's different, but yeah. Sorry. Yeah. Interesting. And when do we biopsy these patients diagnostically?
Um, I think when. It doesn't present classically as a good time to do it when you can't really distinguish, is it eczema or psoriasis? The hands are very tough. Mm-hmm. I, I think also. The hands are very tough for the pathologist as well to decipher between eczema and psoriasis. Um, if you're doing everything that you think should be helping and it's not helping, I do think it's worth reconsidering or rebiopsying to rule out CTCL, which is a type of cutaneous T-cell lymphoma.
And, um, a very classic rash that that presents with is something called mycosis fungoides, which can look very much like eczema and. Mycosis fungoides or CTCL is, um, it takes, I think, on average three to four biopsies to diagnose mm-hmm. Because of how similar it looks clinically and under a microscope to eczema.
I've had a number of patients who were misdiagnosed as eczema Yeah. For years weren't getting better, progressive. And you know, after doing like several biopsies, then I'm like, oh you have CTCL. Yeah. Um, which is good because they can actually treat it. Yeah. Um, and get it under control and you know, 'cause the traditional eczematous medications don't always work for that.
Not a huge phototherapy proponent. Mm-hmm. But I do think phototherapy does help with enough That's great for CT cell. Yeah, I agree. Um, all right, so treatment strategies. So what do we have in our toolbox to treat these skin allergies? Avoid the allergens. Oh, if you can. Easier said than done. It's like those drug commercials.
It's like, don't take ozempic if you're allergic to, you're like, okay, how do I know that? I'll work on that. It's just a CYA. Yeah. Yeah. Um, topical therapy. So we have a, a number of different medications that we can use. Um, topical steroids. Classic, um, topical calci calcineurin inhibitors, PDE four inhibitors.
And then also just optimizing our barriers, just using cide containing moisturizers and other ingredients to help with our skin integrity. Mm-hmm. Um, oral. So I think. First option is usually an antihistamine. Um, usually for other therapies down the line. They like to see that you've tried and failed an antihistamine.
Um, so like Allegra, Zyrtec, Claritin, Zal, um. Usually for about six weeks before insurance will approve something different. But you can also do like short courses of, um, systemic corticosteroids. So like prednisone or a, an injection of a steroid. Um, I think. People love this because it works so nicely, but it's not something that you can sustain long term.
Mm-hmm. Um, immunomodulators such as cyclosporine and methotrexate. I try to avoid these whenever I can. These are kind of like old school, but also very risky. Lots of side effects too. Um, and then kind of depending on what you have going on, like if you are atopic and if you have, um, comorbidities like.
Asthma. It might be worth considering something like Dupixent or if you don't have asthma, maybe AB gly, and these are different injectables that help kind of calm down that inflammation. Yeah, and with the advent of new JAK inhibitors too, I mean that's been also another treatment option we have for these patients, especially those that.
You know, have taken these biologics like Dupixent and didn't tolerate some of the side effects. Mm-hmm. Especially like the conjunctivitis that we see and the eye irritation. Yeah. Yeah. Now, a lot of times you'll have. Um, urticaria or hives and there's no known cause. And that's a whole separate condition.
Mm-hmm. Called chronic spontaneous urticaria. And there are some really good medications out zola's, kind of like the trying and true rapsodo we've seen really good success with. So there's lots of different options depending on what your issue is. Okay. Um, so we're always big on patient education and prevention, right?
So what are some practical tips for our patients, Courtney? Um, definitely avoiding the heavy fragrance products, um, which is hard for, I think, the female population. I love my bath and body work is what everybody always says. So mna, I mean, not amna, SIA has been asking for this. Princess set from Bath and Body Works.
Oh, each princess has their own like, set like, daddy, daddy, I want this. I'm like, no, start M Young. And Body Works is the devil. Yeah. I do feel like Bath and Body works and I feel like gain, um, laundry detergent is like the biggest offender, Uhhuh. Um, so I will say like my clothes, I definitely have switched to fragrance free, um, detergents.
My wash is fragrance free. But your girl loves perfume. Um, so just being cognizant of what you're using.
Um, I think, you know, making sure, um, especially in times where your skin is dealing with more, um. You know, skin barrier disruption, making sure you're adding in like a good barrier cream, especially during like the winter. Um, again, just as we kind of talked about earlier about, you know, once you have that disrupted skin barrier and infections can kind of get in there more, more easily.
So making sure you're well moisturized. Um, avoiding, we say this probably every episode, avoiding like the really hot showers. Mm-hmm. And, um, you know, avoiding like extra heat to, to the skin is really important. Um. Yeah, those are my tips. Yeah. And I think just remembering that this is likely gonna be something chronic.
Mm-hmm. There's not really a cure. I mean, we're having good success with immunotherapy, controlling, or, or, um. I'm blanking on the word, but like making you more or less sensitive to allergens, but there's no true cure for allergies and honestly, I feel like lately I've just been a proponent of like just everyone taking a daily Zyrtec, like just get on the daily antihistamine.
Like I am kind of riding the antihistamine. I tell my cosmetic patients to take it just because it helps with the puffiness around your eyes. Yeah. I'm like, just take it every day. I'm like, I don't have allergies. Just take it. Yeah. Feel. I don't care. You'll thank me later. Just take it. I mean, everyone's got a little bit of swelling, I think.
Yeah. Um, especially in the mornings. Yeah. Yeah. So allergies are clearly an important part of dermatology. We see it in our clinics all the time, and it kind of reflects the, you know, complex immune barrier interactions that we have with the environment. Um, so it's really important to determine what type of allergy that you do have.
Because there are different types and treatment can differ between the different types. Um, and then it's important to personalize the treatments and, you know, using certain good practices like barrier repair, um, avoiding allergens and using targeted therapies to really get your skin healthy again. And it's just been an exciting time in the past decade.
We've been, you know, blessed with having new medications that were. Not available before. And a lot of patients used to suffer in silence and now we are making huge progress. We're having new medications that patients are responding to beautifully. So I think that that's really refreshing and it gives us a lot of options to help our patients.
So that's been really great. Um, any closing thoughts on allergies? No, I think you hit it all. Fantastic. So. If you guys have any questions, um, please feel free to reach out to us. Um, please follow, like, comment, and until next time, skin side out out.