Paradoxical Pathology

Every Thursday afternoon, I have been going to a diet program. It has helped me lose some weight, and that’s healthy for me. I feel good about it in general, despite my occasional lapses. The program involves weighing and testing every week, and I meet with the doctor. There’s also a nutrition class to help re-educate me, which is also a support group for the dieters. It’s been really, really, hard. I have often felt ravenously hungry and uncomfortable. I do the best I can. Apparently, however, I was the only one who was struggling. Everybody else in the support group would brag how this was the easiest diet they’ve ever tried, that they are never hungry, they love the protein shakes, they don’t miss eating, and they were losing weight like never before. I felt great about my weight loss, but felt like a complete failure after each support group. By the end of the second month of the program, I had lost about 20 pounds. After every Thursday support group meeting, I would drive directly to a local restaurant and have a huge plate of nachos, with guacamole and sour cream.

In my post Squirmy, some detective work and a lot of experience led me to the realization that the cream the parents were using to get rid of the baby’s rash was actually causing the rash it was supposed to treat. As the baby’s rash became more extensive, they put on more cream. As the baby’s skin became more inflamed, even more cream.

(By the way, that true story is a potent example of how valuable a house call can be. If I had not been there in person, to see the baby’s surroundings, to ask the parents to show me the actual container of every single thing that touched the baby’s skin, a different cascade of events would have happened. They would have taken the baby in to see me. I would have had to prescribe a very strong steroid medicine. It probably would not have worked, or not have worked well. Without progress, I would have done a bacterial skin culture and probably started the baby on antibiotics. I might have sent the baby to a dermatologist, who would have intervened even more. When would the parents have mentioned the ‘safe’ ‘natural’ ‘herbal’ skin cream?)

As I thought about the unsupportive support group, I realized that this was a phenomenon that occurs from time to time, and is often extremely difficult to diagnose if the problem is a medical one. I have coined the term Paradoxical Pathology because the resulting problem is contrary to what might be expected.

A couple of years ago, an adorable little girl came to the office with hives. She was itchy almost all over. Her mother said that this started last night, but it was very slight and didn’t bother her too much. Her mother gave her a Benadryl. She didn’t have any trouble sleeping. When she awoke early in the morning, she was covered in hives and was very uncomfortable, so the mother called me right away. I met them in the office about 7:30. By that time, the Benadryl had long worn off and I gave her another dose. Her mother and I reviewed absolutely everything that had gone in or on her body in the previous 48 hours. She hadn’t had new foods, been to new places, worn new clothes, or had any medications. I told both mother and child that I wasn’t sure what caused this, but told them to continue the antihistamine medication and stay as cool as possible.


By itself, this story wasn’t particularly concerning to me. The child was breathing comfortably, without wheezing or coughing, and could speak a whole sentence. She was itchy, but not in any danger. I sent them home.

Hives is the term we use for a medical condition called urticaria. Basically, when the body senses the right trigger—such as a protein from a certain food—it sends out messengers that cause certain cells to release a chemical called histamine. Histamine makes tiny capillary blood vessels leak, which causes swelling and redness. It also is extremely itchy. Naturally, the medicines we use to help with this are anti-histamines. Most of the available ones work pretty well, though some make you sleepy. Because urticaria causes swelling and redness, we can usually counter this directly, with a cool shower. When kids (or grown-ups) are itchy, warmth will worsen the itch and keeping cool will often help it. Nearly half the time, we never figure out what causes hives.

The girl’s mother was frantic when she called that afternoon. So a few hours later, they returned to my office and the child was much worse. She really looked miserable, but now her whole face was puffy, her eyes were red, and the serpentine red marks of the hives had joined into a giant red ocean on her skin. I gave her a shot of steroids in her behind, and made them wait in my office. In 5 minutes she started to feel better, and in 30 minutes most of the redness was gone. She felt great.

I sent them to the lab for allergy testing. In general, there are two types of allergy testing: skin tests and blood tests. In skin testing, each substance being tested is scratched into your skin. Then we see if you get red, itchy, and swollen. The problem with this in children is that in order to test a large number of things, the kid has to be scratched a large number of times. Each scratch can cover just one thing. With a blood test, the child’s blood is sent to a lab where it is exposed to as many possible culprits as I request. It’s still just the one poke. The downside here is that they usually need to draw quite a lot of blood. Sometimes one kind of test will show a reaction but the other kind won’t, which confuses things. The bottom line is that these are just tests. There’s only one lab that gets absolutely accurate results every time—the child herself. I have often had an allergy test say that a patient isn’t allergic to something. But when they eat it, their tongue tingles, their lips swell up and get itchy, and they say they don’t feel right in their throat. Whatever the lab said just doesn’t matter. The only thing that matters is what’s going on in my patient.

Even so, the lab test said (and her mom confirmed by experience) that she probably wasn’t allergic to wheat, corn, milk, eggs, nuts, peanuts, seafood, shellfish, chocolate, melon, strawberries, blueberries, kiwi, tomatoes, cocoanut, banana, soybeans, cheddar cheese, 3 different varieties of mold, 2 different species of dust mite, cats, dogs, 12 different local varieties of pollen, 4 different grasses, and chicken feathers. I sent her to an allergist. There, he repeated many of the blood tests with skin tests and got the same result, with a much less happy little girl.

They returned to my office, and her mother and I started over. This time, I read every ingredient on every label. I sent the poor girl back to the lab with a long list of exotic tests. I even tested for some of the ingredients in the diphenhydramine (Benadryl) that she had been taking. She wasn’t allergic to any of the ingredients of anything she had eaten.

She was, however, highly allergic to Red Dye #40, a food coloring used to make the coating of her pink pills pink. Every time she took one to help with her itching (sometimes at my instruction), she would get worse.


As I think about it more, I think there are many cases of paradoxical pathology. The support group story applies to a lot of social situations. For people with anxiety, for example, forcing them into anxiety-provoking situations often just makes them more anxious.

Do you have a story of being given a treatment for some problem that ended up causing that very problem? Please share it as a comment.

Epilogue: I stopped going to the support group. I felt better and ate better.

Repeated Lessons

A little hydrocortisone cream was all that was needed to clear up the rash caused by the calendula. The parents had noticed a little rash, and did what parents everywhere would do. They went to the ‘natural pharmacy’ and asked what would be good for a rash.

The rash caused by the calendula cream cleared up within a day or so of starting hydrocortisone. This seemed to control the baby’s mild eczema. So maybe it was natural for me to suppose that this aspect of the baby’s care was under control. when I was in the house, examining the baby on her changing table, I noticed a bottle of moisturizer next to the table. I said to the parents, “That’s for you, right?” The mother said that she used it on the baby. I asked her why she used it on the baby—she said that it made the baby’s skin soft. Was the baby’s skin soft before using the moisturizer? We had a talk about what the baby actually needed on her skin. This baby in particular, given our experience with her eczema and reaction to calendula cream, had sensitive skin at very least.

These were the parents for whom I had to spend a half hour explaining why the hydrocortisone cream wasn’t a dangerous steroid. Even as their baby cried with her rash. How long did the sales clerk have to explain the safety of calendula?

So when they called and said that they need to put their baby to sleep on her stomach, I suspected some detective work might be needed.

It seems to be true that some babies just prefer to sleep on their fronts, and not on their backs. Unfortunately for them, the epidemiology is fairly convincing. Babies placed on their tummies to sleep have about 6 times the risk of SIDS. The right thing to do would be to try and convince these parents that putting her on her back would be the safest thing for the baby.

They told me that the baby didn’t mind being on her back when she was on the changing table. Didn’t mind when on a blanket on the floor. In fact, the baby didn’t mind so much when first placed in the co-sleeper at the beginning of the night. But she would wake up with increasing frequency as the night went on, and was screaming when put down on her back in the early hours of the morning. Desperate at this point, they put her down on her tummy, and she quickly fell asleep.

Maybe it wasn’t the position that was bothering her. I asked them to describe the co-sleeper for me. I asked for and was told all the details. The padded sides were of undyed fair-trade cotton, and the frame was of sustainably-harvested wood, unpainted and unstained. The baby was placed on a very soft unbleached untreated natural Australian fleece.

I stopped them at the fleece.

Wool allergy is actually rare. Most of the people who get itchy with certain types of wool fabric are not truly allergic. They have sensitive skin and it’s irritated by the tough wool fibers. But people can be allergic to a class of natural chemicals called wool alcohols. These chemicals are a major component of lanolin. Lanolin is in a lot of the skin lotions and creams, including medicated creams, that we put on our skin. It’s the major component of creams used on breastfeeding moms.

I suggested they remove the fleece completely, and use a folded towel as padding. They weren’t happy with this plan, since the fleece was sent to them direct from a relative in Australia. I suggested they use a plastic trash bag over the fleece, then a baby blanket or two to keep the baby from getting too sweaty on the plastic. That night, the baby slept on her back.

What was happening was contact dermatitis, an itchy eczema-like rash that we get from something we come in contact with. At the beginning of the night, it wasn’t a problem. As time passed, the baby’s back got more and more irritated. When it was irritated, it became more and more sensitive. The more sensitive it got, the more irritated it became with continued contact with the fleece. By the end of the night, the baby was really uncomfortable and unhappy. When they put her down on her tummy—which was not irritated—she calmed right away and went back to sleep.

These caring parents had the best intentions for the comfort of their baby. My role was really being a seasoned detective, who might know 'usual suspects' when I meet them.

This is a baby with sensitive skin. We should learn, eventually, to be sensitive to that.

Squirmy

When I heard that the baby was 'thrashing around' and crying, I didn't know what to make of it. Her father said that she had a rash, and he wondered if this new behavior was related.

Here's a tip: don't ask the doctor, 'what could it be?' I have whole textbooks filled with awful diseases that your child doesn't have and won't get. Try to focus on what they do have. But an important part of my job is indeed to worry about what a problem could be. So during the phone conversation with the baby's father, I thought of the possibilities. These included everything from using the wrong detergent on her onesies to serious illnesses with seizures. Though I was reassured by some basic screening questions over the phone, I decided to see the baby in person that night. It was Saturday on a 3-day Memorial Day Weekend, and I didn't want to wait until Tuesday when the office was scheduled to open. The baby was only 2 months old.

When I got to the house, the baby's parents gave me more history. They said that this has been going on for about a week. She didn't have fever or any other symptoms of being sick. They noticed a couple of rough patches on her skin which they have been treating with a calendula cream. Over the week, despite more frequent treatment with the calendula cream, the rash has been getting much worse and more widespread over her body.

I felt the rash, which covered her forehead and cheeks, behind her ears, her elbows and lower legs, and had patches all over her body. She had eczema. In older kids, eczema typically affects different places on the body than it does on babies. Her places and the appearance and feel of the rash were characteristic of eczema for kids her age.

Eczema seems to travel genetically with allergies and asthma. Sometimes a parent will have one of these and the child will have another or some combination. In this case, the father said that he had eczema as a child and the mother had a little eczema now.

But I wondered what caused it to erupt so suddenly. Though eczema usually goes through times of improvement and worsening, these don't usually happen in just a few days. I had seen the baby in my office about 2 weeks earlier, and the parents didn't mention it and I didn't notice it. I asked them to tell me about absolutely everything they put on the baby's skin. It made my job a little easier when they showed me the product. It was very expensive, and from a very successful all-natural, organic, line of 'Natural Medicines.' (Except for removing the actual brand name, the following is an exact quote from the company's description of the product.)

"Brand Name® Calendula Cream is excellent for use on general diaper area, cradle cap, on cuts and scrapes, and may be used on face and body for extra-dry or sensitive skin. Botanically based, our light and fluffy Calendula Cream contains the active ingredient of Calendula, which has been used to heal the skin for centuries. Brand Name® Calendula Cream offers deep hydration, absorbs completely, and leaves skin feeling satiny smooth. Use daily for everyday protection and especially when the air is dry and baby's skin needs relief. Our customers have reported excellent results with Brand Name®'s Calendula Cream in their fight against eczema, perioral dermatitis, and other skin sensitivities. The entire family can benefit from this soothing, multipurpose cream. We suggest that you try Brand Name® Calendula Cream and/or Brand Name® Botanical Moisturizing Cream in combination with any of our Shampoos & Bodywashes. Also add Brand Name® Calming™ Soothing & Healing Spray, and any of our non-chemical sunscreens to your skin care regime.

• Contains organic and sustainably grown ingredients
• Active ingredient: Calendula officinalis is the common pot marigold and is well known for its skin healing properties
• Safe, gentle and effective for cuts, sores and general skin abrasions
• May be used around the diaper area for simple rashes
• Hypo-allergenic
• Works very well on cradle cap and chapped skin
• Light and fluffy consistency"

What, exactly, does 'hypo-allergenic' mean? I certainly don't know in the context of any calendula product. Calendula is from marigold flowers. Marigolds are in the same family as ragweed, which is probably the most common pollen that people are allergic to, maybe as much as 10-20% of all Americans. This has been studied. In about 2% of people, using calendula on the skin causes an eczema-like rash.

The poor baby was suffering and itchy. I sent a parent out immediately to get some medicated cream that I hoped would start helping her feel better right away. Within a couple of days of stopping the calendula and starting some very low-strength medicated cream, the rash was nearly gone and the thrashing had stopped.

Except to instruct the parents to stop using the calendula and stick to the regular medicated cream right now, I didn't say anything about the product they had been using. It wasn't their fault that the label does more than imply—it states quite clearly—that the product is hypoallergenic and safe to use. And I wondered why they let this rash spread and grow along with their baby's discomfort as they used something, though with the best of intentions, that was clearly not working. If I had prescribed a cream for the baby which was clearly not working, and the baby was getting worse and worse, would they have continued using it for a week? Would they have called me after a day or two, concerned? What were their expectations for this product? Why did they wait until the baby had such a severe, extensive and obvious rash? What was there about this product that allowed them to tolerate its ineffectiveness much longer than I suspect they would have tolerated a prescription product?

The rapid worsening and extension of the baby's rash, I believe, was the result of a reaction to the calendula. It's common enough (about 1 in every 50 people) that I think it should be a caution on the label. Especially because it's intended use is for the very rash that it causes. Because it's sold as a natural supplement, the manufacturer doesn't have to do this.

This may or may not be related to the Bollywood version.