Instrument allergies can sour the sound

 Musicians can present a unique group of skin rashes related to their profession or avocation. Some of these rashes are so common they have characteristic names such as fiddler’s neck, flautist’s chin, guitarist’s nipple and harpist’s finger.

In a recent survey, 21 percent of musicians reported some type of instrument-related rash. Some of these rashes are mechanical in nature, such as chaffing, erosions or blistering and callusing due to repeated trauma.

Many of the rashes are allergic in origin and the common causes are exotic woods, metals, resins, stains and varnishes. The most common allergic metals used in instruments are chromium, cobalt and nickel. Many wind instrument users develop skin or lip rashes from their instruments.

Woods that have a high allergic potential are ebony, cocobolo, African Blackwood, Brazilian and Indian rosewood. Also, cane reed used in mouthpieces can cause allergic problems.

Paraphenylendiamine is a black dye that causes allergy and is commonly found in stringed bows and chin rests. Propol is also known as bee glue and is used in violin varnish and is a strong allergen. Colophony – a solid form of resin obtained from pines and some other plants, mostly conifers – is also a significant allergen for violinists, violists and cellists.

The metals that cause allergy are not only found in wind instruments (brass), but also in string instruments – especially guitars, cellos, violins, sitars and harps.

The key (pun intended) to diagnosing the cause of these rashes is that they occur in the specific body parts that touch the instrument.

Kiwi fruit a mix of tasty, pesky and protective

 Kiwi fruit is a source of increasing allergic problems. The kiwi first became commercially available in the U.S. in 1970 and has led to a variety of allergic problems. The most common issue is oral allergy syndrome which consists of itching, burning and swelling of the lips, mouth, tongue and throat. Although not of life-threatening consequences, the symptoms are quite disturbing.

Much less frequent is anaphylactic allergy which is truly serious in nature. Of curious interest, most people with kiwi allergy are also allergic to birch pollen and in many cases to latex. Other allergens that commonly cross-react with kiwi are figs, avocado, banana, melon, hazelnut, rye, wheat and pollen from Timothy grass, mugwort and olive tree. Kiwi is native to southern China and is the Chinese national fruit. Seeds were introduced to New Zealand in 1940 and from there spread to Italy, Chile and the U.S.

Skin allergy is also seen from contact with the fruit or the vines, the main allergens in the kiwi are an enzyme called actinidin and a protein called kiwellin. The skin allergy is similar to poison ivy in that the rash appears one to three days after the contact.

Despite the mischief it can cause, kiwi has a lot of health value. It is a very rich source of antioxidant free radical scavengers, and thus, can reduce risks of cancer and cardiovascular disease. Kiwi extract has also been used in treating serious burns.

Vaccines after 65 — who and what for?

Dear Dr. K: I recently heard that there are certain vaccines that are recommended for adults. I thought I got all my necessary vaccines as a kid.

Not to pick on you, but I can tell by your question you didn’t read last month’s newsletter. In that issue I discussed influenzal vaccine (flu shot) which is recommended on a yearly basis. The vaccine is given yearly because it is a different shot each year, in order to address the new viral strains that emerge.

The tetanus/diphtheria (TD) vaccine is needed every 10 years throughout life. A new spin on this recommendation is that once during adulthood the TD should include pertussis (TDap).  The “ap” stands for acellular-pertussis, which is the new, improved whooping cough vaccine. This new recommendation reflects a resurgence of whooping cough illness in adults, due to waning immunity from our childhood vaccine.

Pneumococcal vaccine (pneumonia shot) can be taken by all adults, but is felt to be essential for persons with respiratory disease (COPD and asthma), heart disease, kidney disease, liver problems, diabetes, HIV and asplenic patients (persons who have lost their spleen). If the first vaccine is given before age 65, then a second vaccine is recommended after five years. If the initial vaccine is given after age 65, then no further shot is needed.

Herpes zoster (shingles) vaccine is recommended for all adults 60 years or older. Even if a person has already had shingles, the vaccine is still recommended.

Meningococcal vaccine (meningitis) is recommended for all young adults attending college. It is also recommended for mature adults with asplenia, HIV; and those who travel to endemic areas and for military personnel.

Hepatitis A vaccine is recommended for travel exposure, gay men, people with liver disease, and people with daycare exposure.

Hepatitis B vaccine is recommended for gay men and for heterosexual people who are not in a monogamous relationship. It is also recognized for all healthcare workers and for public safety personnel and for family members of patients who have chronic hepatitis B infection.

New asthma medicine: A hopeful mouthful

The September issue of the New England Journal of Medicine discussed research on the newest medicine for asthma, Lebrikizumab. This drug is an IgG4 humanized monoclonal antibody that binds to interleukin-13 (I-13).

I-13 is a cytokine (cell communicator) that plays a big role in causing the inflammation of asthma. It does this in part by causing airway cells to produce periostin, which causes narrowing and thickening of the airways.

Inhaled steroids are supposed to inhibit I-13, but they don’t always accomplish the task. In a study of 219 moderate and severe asthmatics there was dramatic improvement in lung function (measured by breathing tests). Of special note, this improvement was almost immediate with starting the medicine.

The people who improved the most were the ones with the highest periostin levels.

Lebrikizumab is still undergoing clinical trials but hopefully, will soon be approved by the FDA. If the FDA gives a thumbs up, let’s cross our finger they’ll mandate a simpler name for the drug!

Quick Tips – Dental work

•               In 2007, the widespread policy of antibiotic prophylaxis before dental procedures was challenged by an international group of academic cardiologists. The UK instituted this new approach in 2007 and just completed a four-year outcome study. They have found no increase in infective endocarditis despite cessation of pre-dental antibiotics. They do, however, still recommend antibiotics for people with congenital heart disease and artificial heart valves.

Quick Tips – flying with food allergies

     – Call the airline in advance to learn its policy on food allergy and what snacks are served, and about special seating arrangements.

     – Confirm your food allergy status with the gate agents and flight crew.

     – Pack safe snacks; most airlines allow fluid exceptions for formula and breast milk.

     – To head off hassles, bring a doctor’s letter regarding these fluids and also about carrying an epi-pen.

     – Label your carry-on bag clearly so in the event of emergent need for your epi-pen or medicine, you can locate it quickly.

Afrin addiction study offers hope

 For years allergists and ear, nose and throat docs have preached Afrin avoidance due to its addictive nature. In some people use of Afrin for as little as four or five days can lead to severe addiction with rebound congestion. Such patients often are trapped into escalating use of Afrin with poor outcomes.

That said, Afrin is very seductive as it is an extremely effective way to reduce nasal congestion. Hence, the University of South Carolina School of Medicine did a study to see if nasal steroids could prevent Afrin addiction.

In this study patients used both Afrin and a nasal steroid once nightly for six weeks.

The results were amazing.

The patients had excellent improvement in nasal congestion and no rebound effect. The researchers cautioned that this was a short-term study and plan to study such an approach over a longer time frame.