Wednesday, November 28, 2012

Creams and Ointments, what's the difference, which is best?

Many medicines intended for skin application are packaged both as creams and ointments. Examples of these topical medications include corticosteroids and antibiotics. Many moisturizers also come in both a cream and ointment form. Is there a difference in a medication that comes in a cream as compared to an ointment? Is one or the other preparation better to use?

First, some definitions are in order. Creams are a mixture of roughly half water and half oil. They spread easily, are well absorbed, and wash off with water. Creams are usually packaged in a tub or tube since they are too thick to be dispensed in a pump like a lotion. Most ointments are 80% oil and 20% water. The oil component is made from hydrocarbons, such as mineral oil or petroleum jelly. Ointments feel greasy and are "occlusive", meaning they stay on the surface of the skin and are not well absorbed. The water and oil components of creams and ointments serve primarily as a "vehicle" to carry an active ingredient or medication.

When is it best to use a cream? In general, people prefer using creams to ointments since they are less sticky and heavy on the skin. Even though we think of creams as being moisturizing, given their higher water content and the evaporation that occurs following application, creams are better than ointments for treating oozing or "wet" skin conditions. Since the viscosity (thickness) of creams is less than that of ointments, they also work better for covering large areas of skin.

When is it best to use an ointment? Ointments are best used on dry skin. They are ‘occlusive,' which means they trap moisture and are not well absorbed into the skin. Thus, they are able to keep the skin moist for longer periods of time. Ointments also promote more complete absorption of the active ingredient or medication. Because of preservatives used in creams, ointments are less likely to cause an allergic reaction.

Here are a few topical medications that come in both a cream and ointment form:

Topical steroids - Corticosteroids are the most commonly used topical medication. They are most often used to treat inflammatory skin conditions, such as poison ivy or eczema. Corticosteroids are different than "anabolic" steroids, such as testosterone, that promote muscle development. Weaker corticosteroids are available over-the-counter (Cortaid, 1% hydrocortisone, Cortizone 10, others) while stronger preparations (0.5% triamcinolone, Kenalog, Diprosone, others) are only available by prescription. The potency of a given corticosteroid may change depending on whether it is in cream or ointment form. Being occlusive, an ointment will allow the medication to enter the skin more completely than a cream. At the same dosage, most topical corticosteroids will be classified as being stronger when packaged as an ointment as compared to a cream.

Moisturizers - Ointments, with their higher viscosity, are generally the best moisturizers. They form a barrier that helps to seal moisture into the skin. Examples of ointment-based moisturizers include Eucerin, Aquaphor, and Vaseline. If a less greasy preparation is desired, cream-based moisturizers that come in a tub or tube are usually better than lotions.

Antibiotics - Neosporin and Polysporin are popular topical antibiotics that come in both a cream and ointment form. Neosporin consists of three different antibiotics, neomycin sulfate, polymixin B sulfate and bacitracin. Polysporin is a combination of two antibiotics, bacitracin and polymixin B sulfate. Generic versions of topical antibiotics are also available, usually marketed as "triple antibiotic" ointment or cream. Topical antibiotics are used to aid healing of minor cuts, scrapes, and burns. Since many people are allergic to neomycin, it may be best to use a topical antibiotic that does not contain this ingredient.

Here are some guidelines for deciding when to use an ointment and when to use a cream:
  1. Creams are best when covering large areas of the skin or to avoid the greasiness associated with an ointment.

  2. Wet or "weeping" skin lesions, such as eczema or poison ivy, are best treated with a cream (or gel).

  3. Ointments are best when treating dry skin conditions, such as psoriasis.

  4. Ointments allow greater penetration of the active ingredient in the topical medication, whether it is an antibiotic, steroid, or anti-fungal medication.

  5. The best moisturizers are in ointment form.

  6. Ointments may be better to use on sensitive skin since many creams are manufactured with sensitizing preservatives.

Wednesday, November 21, 2012

Controlling Holiday "Hungeritis"

Of course being hungry is not a disease, but overeating and excessive weight is clearly a risk to health. Controlling one's appetite and managing food intake seems to be particularly difficult during the holiday season. According to the National Institutes of Health, Americans gain an average of one pound during this time. While this may not seem like much, the problem is that people typically do not lose that additional weight. Over time, the additional weight accumulates and can lead to becoming overweight or obese. Fortunately, there are ways of combating "hungeritis" and enjoying a healthier Thanksgiving.

Celebrate the season, not the food.
Rather than a time to give thanks for the blessing in our lives, it seems that Thanksgiving has become a holiday that is centered on eating. This year, focus more on friends, family, and making new acquaintances. See to it that the holiday meal remains secondary to enjoying each other's company.

Practice healthy meal management. There are a number of tried and true "tricks" used to decrease the chances of overeating. Taking small bites and eating slowly will help give the brain the 20 minutes or so to get the message from your stomach that you are getting full. Using a smaller plate will help with portion control, but be careful with seconds! Eat only until satisfied and when appropriate, leave the table to avoid habitual eating. Try drinking 8 to 12 ounces of water before the meal to increase the sensation of satiety.

Burn some additional calories. If you are currently exercising, consider increasing the duration of your workouts to compensate for the inevitable increase in calories during the holiday season. Following meal time, consider organizing an after-meal activity, such as a group walk. Exercise is also a great way to help relieve holiday stress.

Go easy on the alcohol. Not only can alcohol stimulate appetite, many alcoholic beverages consumed during the holidays are loaded with calories. A cup of eggnog, for example, has approximately 350 calories, even before the liquor of choice is added. While some "light" beers have as few as 100 calories per 12 ounces, "craft" beers with their higher alcohol content can reach 350 calories. Mulled cider or lowfat eggnog are good, lower-calorie alternatives.

Make healthy substitutions. When making stuffing, use less bread and add more onions, celery, or other vegetables. Substitute low fat broth for "drippings" traditionally used in making gravy. Set aside the skin from the turkey that is loaded with saturated fat and calories. Use skim milk, fat free sour cream or yogurt for making mashed potatoes.

Don't go to a holiday party on an empty stomach! Skipping a meal usually results in consuming far more calories than one would if they had eaten something beforehand.

It's OK to splurge a bit during holiday meals, but choose your extra calories wisely and try to burn a few of them afterwards with exercise. White turkey meat, vegetables without heavy sauces, mashed potatoes with defatted gravy, and pumpkin pie are usually the safest choices in order to avoid excess calories. This Thanksgiving, try to make sure that the turkey, rather than you, gets stuffed!

Friday, November 16, 2012

Uncommon Symptoms of Common Diseases

In medicine, there is a saying that "common things are common", meaning that most conditions seen by doctors are not obscure, nor is the manner in which they present themselves. On occasion, however, illnesses present in unusual ways and it is up to the doctor (with the help of informed patients) to be aware of some of these unusual presentations.

  1. Cough - Asthma. The most common symptoms of asthma are wheezing and shortness of breath, particularly during exertion. In some people, however, a dry cough is the predominant symptom. Cough-variant asthma can be suspected in someone who has a cough lasting for more than six to eight weeks and characteristically occurs during exertion or exercise. A second condition, gastroesophageal reflux (GERD) can also be suspected in someone with a chronic cough, particularly if it occurs while sleeping. GERD is caused by the regurgitation or reflux of gastric fluid into the esophagus which triggers the cough.

  2. Toothache - Sinusitis.
    Sinuses are spaces within the facial bones that connect to the nasal passages and are in close proximity to the upper, rear teeth. Fluid build-up that occurs during a sinus infection or from allergies can put pressure on the nerves that enter the roots of the teeth. This simulates the type of toothache caused by dental problems such as cavities or abscesses. If dental evaluation rules out the possibility of a dental cause for the toothache, sinusitis should be suspected.

  3. "Wrinkled Sock" - Nerve Entrapment. The sensation of a sock being wrinkled underfoot may be due to reasons other than the sock. Morton's neuroma, a condition in which the sensory nerves that supply the toes becomes compressed is a possible cause for this symptom. Although rarely reported in medical texts, I have also heard this complaint from two patients who eventually were discovered to have herniated discs in their lumbar spine. The herniation was apparently applying pressure to the nerve root that supplies sensation to the lower leg. In most cases, herniated discs will also be associated with lower back discomfort, shooting pain into the back of the leg (sciatica) and tingling ("pins-and-needles" sensation) in the leg.

  4. "Tutti-frutti" breath - Diabetes. A fruity odor to the breath can occur in Type 1 (insulin-requiring) diabetics as the body is getting rid of excess acetone. Acetone is generated when the body has inadequate amounts of insulin to use in the metabolism of sugar and is instead using fat as an energy source. "Tutti-frutti" breath could also be called "nail-polish" breath since acetone is found in some nail polish remover. A very serious form of acetone breath is seen in uncontrolled Type 1 diabetics when they enter a state called ketoacidosis. A similar odor to the breath can be seen in the much less serious state of ketosis that occurs with people on very low carbohydrate diets, such as the Atkins diet. Unless the person is diabetic, this form of "tutti-frutti" breath is not serious.

  5. Jaw pain - Angina. Temporomandibular joint syndrome (TMJ) and dental problems are some of the most common causes of jaw pain. One cause for jaw pain, however, is quite serious and should be considered in someone suspected of having heart disease. Angina is chest discomfort that is seen in people with coronary heart disease that occurs if an area of the heart does not get enough oxygen-rich blood. The most common description of angina is as a squeezing or heaviness of the chest that often spreads to the left arm. In some people, angina will be noted as a discomfort in the jaw. "Atypical" presentations of angina or heart attack, such as jaw pain, appear to be more common in women.

  6. "Brain fog", rashes, and hair loss - Celiac disease. - Some of the most common symptoms of celiac disease are diarrhea, abdominal pain, and bloating. But, depending on the individual, celiac disease can be responsible for many other symptoms, including some that don't seem to be related to the gastrointestinal tract. Less common symptoms of celiac disease include a rash known as dermatitis herpetiformis, unexplained hair loss, and neurological symptoms such as memory loss or confusion. In someone with unexplained or unusual symptoms, particularly if some of them are gastrointestinal in nature, celiac disease should be a consideration.

  7. Snoring - Obstructive Sleep Apnea. Up to 50% of the adult population of the U.S. snores, but in a certain percentage of these people, snoring is a symptom of a medical condition known as obstructive sleep apnea (OSA). In OSA, the airway collapses or becomes blocked during sleep. This impedes normal air flow, resulting in snoring. Other clues to the presence of OSA include pauses in breathing (apnea) when sleeping, excessive daytime drowsiness, restless sleep, and gasping or choking during sleep. OSA in most common in overweight adults, but children with enlarged tonsils or adenoids can be affected also.
These are just a few of the unusual presenting symptoms for common diseases seen by doctors. If you have questions or concerns about symptoms that could be due to an underlying disease, write to us at eDocAmerica and we'll be glad to help.

Friday, November 9, 2012

Joint Replacement

Hip and knee joint replacement is a procedure that has been performed on millions of Americans since it was introduced around 40 years ago. In most cases, joint replacement is performed because of arthritis. The common feature of the various types of arthritis is that cartilage on the joint surfaces becomes worn out. This results in joint surfaces that do not move smoothly along with pain. Injury, tumors, and loss of blood supply with bone death (osteonecrosis) can also damage joints and necessitate replacement.

Which joints can be replaced? While many people are aware that hips and knees can be replaced, it is less well known that other joints have artificial (prosthetic) substitutes also. Other joints that can be replaced are:
  • Finger joints (the joint at the end of the finger, called the PIP joint)
  • "Knuckle" joints (called MP joints, where the finger joins the hand)
  • Wrist joint
  • Ankle joint
  • Shoulder joint
  • Elbow joint
  • "Big toe" joint (the first MTP joint, where the big toe joins the foot)
What are artificial joints made of? The materials used in artificial joints vary, depending on the type of joint being replaced and its function. The components of artificial joints must be strong, with varying degrees of flexibility, and able to be placed within the body without causing a reaction from the immune system. Prosthetic substitutes for major joints, like the hip and knee, are mostly made of metal, such as stainless steel, titanium or alloys of chrome or cobalt. They also include elements of polyethylene plastic used on the joint surfaces. Smaller joints for fingers and toes may include a silicon component to provide flexibility. A ceramic material called zirconium is starting to be used in some of the newer prosthetic joints.

How do you know if it's time for a joint replacement? In general, joint replacement is considered to be the treatment of "last resort". Prior to the undergoing joint replacement, most people will have gone through less invasive treatments, such as oral medications, physical therapy, braces, joint injections, and minor surgical procedures. Should the above mentioned measures prove unsuccessful two major issues affecting the involved joint determine the necessity for replacement: 1) pain that cannot be controlled with reasonable measures, and 2) creation of a disability that diminishes one's quality of life.

How long will a prosthetic joint last? In most cases, hip and knee replacements will last 15 or more years. In general, the better that the joint is cared for, the longer it will serve its recipient. In the case of weight-bearing joints, it is important to keep one's weight under control to reduce the load on the prosthesis. While increased activity following hip or knee replacement is an expected lifestyle change, activities involving high impact or vigorous twisting may need to be given up. Low impact activities, such as swimming and cycling are particularly good for replaced hip and knee joints and the muscles that surround them.

What can I expect from the surgery? Joint replacement is considered to be major surgery and is not without risks. Blood clots, infection, and breakage of the prosthesis are well-known complications. Following surgery, a hospital stay and physical therapy are usually required. Should the prosthetic hip joint wear out or fail, a second joint replacement may be necessary. Despite the risks and rehabilitation required, however, joint replacement surgery has improved the quality of many patients' lives by easing pain, improving joint function, and restoring quality of life. For more information on joint replacement, go to the American Academy of Orthopaedic Surgeons website.

Unhealthy Heart Habits, the other "99%"

A while back, the Occupy Movement voiced its concern for the 99% of Americans who were not among the top 1% of income earners. There is another 99% (or 98.8% to be exact), however, who may be in a considerably worse position. This is the group of Americans who fail to adhere to the "7 Heart Healthy Habits" promoted by the American Heart Association.

The seven health factors that are associated with a lowered risk of dying from cardiovascular disease, such as heart failure and heart attack, are:
  • Not smoking
  • Being physically active
  • Having normal blood pressure
  • Maintaining normal blood glucose levels
  • Maintaining healthy blood cholesterol levels
  • Having a healthy body weight
  • Eating a healthy diet
A study recently published in the Journal of the American Medical Association was designed to compare the risk of dying from cardiovascular disease with the number of these heart healthy habits that Americans practiced. A nationally representative sample of nearly 45,000 adults in the U.S. was surveyed for the study and participants followed for an average of 14 years.

Perhaps not surprisingly, adhering to a greater number of heart healthy habits was associated with a lower risk of cardiovascular death. What was interesting, however, is that adhering to these seven practices was also associated with a reduced risk of death from any cause, including cancer. The study participants who met 6 or more vs. 1 or fewer of the heart healthy practices had a 51% lower risk of all-cause mortality and a 76% lower risk of dying from cardiovascular disease.

One of the most shocking statistics from this study was that only 1.2% of Americans in the group of participants drawn from 2005-2010 practiced all seven healthy habits. The other 98.8% of subjects from this study practiced six or fewer. While people can debate the benefits of being gluten-free, eating organic foods, or avoiding drinking sodas, these seven health habits have proven benefits that many fail to recognize. These are the factors that have the potential to make the biggest impact on the health of the U.S. population.

Learn more about the seven heart healthy habits at the American Heart Association's site My Life Check. Assess how well you are doing currently by completing the Life's Simple 7 Action Plan.