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Although rosacea is common, we don't really know what causes it. One theory is that it's a disorder of the immune system - creating an abnormal response to mites or bacteria found normally in the skin, or even to sunlight. It could also be a combination of factors and tends to occur in middle age, affecting mainly the face.
There are four patterns of rosacea, one of which may merge into another, with overlap. It may start with persistent redness or flushing, progressing to a type with papules (red bumps almost like insect bites) and then pustules (which are like acne).
A third type is characterised by a thickening and distortion of the skin (which can lead to rhinophyma, a bulbous swelling and distortion of the skin of the nose), and finally ocular rosacea, which causes eye redness and irritation.
I am sorry to say there is no certain cure, so the emphasis has to be on suppressing the symptoms and improving the appearance.
Other clues are if the flushing worsens with temperature changes (such as from hot drinks, spicy food, alcohol and physical exercise) or even with changes of mood (such as anger or frustration).
A number of medicines have been tried to combat this flushing, including beta-blockers and clonidine (these blood-pressure drugs help dilate the blood vessels), gabapentin (an epilepsy drug) and antidepressants.
The last two are used not for their effect on the brain but because they dampen down the activity of the nerve endings which control the blood vessels in the skin.
However, their effect isn't predictable or consistent, and as treatment inevitably has to be long term, their use must be weighed up against the risk of side-effects.
There are other medications that work more reliably, but topical metronidazole (e.g., Metrogel, Rozex) and azelaic acid (such as Finacea) are prescription-only. They tackle the bacteria and mites in and on the skin that may have triggered the reaction.
They are used as first-line therapies for mild to moderate rosacea, with improvement usually visible between four and eight weeks.
Should this fail, the next stage is to treat it with oral antibiotics - tetracyclines have been used safely for many years and are best for sufferers with inflamed papules or pustules. The response can be rapid and dramatic (this fits in with the bacteria/mites theory).
Adding an antibiotic such as this to established topical therapy may improve the results, but the adverse effects may include gastro-intestinal upset (a risk that must be considered carefully if the patient also has irritable bowel syndrome, which your son's girlfriend has, as you reveal in the longer version of your letter).
Patients should also avoid products that inflame the skin, such as toners or astringents. Over-enthusiastic scrubbing will worsen the appearance, so cleansing must be gentle, using soap-free products.
Finally, I should mention isotretinoin, which can be prescribed only by a dermatologist. This is a potent drug which works on skin secretions. There are many potential side-effects, which include teratogenicity - harm to an unborn child - so it's very much reserved for the worst cases, and careful supervision and follow-up is essential.
Studies have shown remissions of at least a year after three to six months of treatment, and for those who fail to improve on either topical therapy or oral antibiotics, this may be an option.
I am an 80-year-old man and have always had an active life. I was diagnosed with peripheral neuropathy three years ago and now wear calipers on both legs and can walk only short distances. Is there anything I can do to prevent future deterioration?
Name and address withheld.
The term peripheral neuropathy describes any disorder of the peripheral nervous system, and includes nerve damage through injury as well as through disease (as a result of type 2 diabetes, for instance).
Given your description, we must conclude that in your mid to late-70s a disease process caused damage to the nerves supplying the muscles of your legs. These nerves originate in the spinal cord, and the major causes of injury are compression. For example, as a result of prolapsed discs in the lower part of the spine, ischaemia (a lack of blood supply), inflammation, or degeneration of the nerves themselves.
As your legs became progressively affected, I assume you were referred for investigations. However, in up to 50 per cent of cases the cause of a peripheral neuropathy is not pinned down.
As both your legs were affected, it's likely that the problem originated in the spine, or as the result of a more general problem.
CONTACT DR SCURR
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details.
Dr Scurr cannot enter into personal correspondence.
His replies cannot apply to individual cases and should be taken in a general context.
Dr Scurr cannot enter into personal correspondence.
His replies cannot apply to individual cases and should be taken in a general context.
Almost invariably there will have been a history of lower back pain, although you have not mentioned this symptom.
You say you are having physiotherapy, and regular injections of vitamin B12. This may be because you have been found to have pernicious anaemia, where you are no longer able to absorb this vitamin from food (a common problem which can creep up unrecognised over years).
Vitamin B12 deficiency is one cause of nerve damage - and the nerves may not recover fully even when this is recognised and the injections commenced.
I suspect you are doing all you can. The most important thing is to keep going, continuing the physiotherapy sessions to ensure your leg muscles are stretched through a full range, and to retain such active strength and movement as is possible.
Maybe you could write to me again with any details of the investigations that were carried out, or any conclusions reached by your doctors; further clues about the origins will help with more exact advice to prevent further decline in function.
By the way... Why you never see the same GP
The policy no longer requiring a patient to be allocated to one particular GP means doctors can no longer get to know their patients cumulatively
The Health Secretary, Jeremy Hunt, tells us that GPs are to be compelled to appoint 'a clinical care co-ordinator' for those aged over 65 - essentially a single clinician who will be accountable for their care at all times.
I imagine this is something to do with the dawning realisation of the importance of seeing the familiar face of a GP who knows you. All that was lost in 2004, when a new policy was introduced in which patients joining a GP practice would no longer be allocated to one particular doctor.
When I trained as a GP and was first exposed to the stress and difficulty of six-minute and eight-minute consultations on the NHS, I was taught that this style of working was justified on the grounds that continuity was all - the doctor got to know his patient cumulatively over a series of brief meetings across the months and years.
Indeed, all the research has confirmed the value of continuity (not least in keeping people out of hospital). So why, how, and on what grounds was this all thrown away? I think we should be told who was responsible. If it was a politician in Tony Blair's government, then they are long gone.
But if it was one of our venerable senior GP leaders, in consultation with government, then I would ask them to record this in their annual appraisal document, and hopefully their 'responsible officer' - he who must be impressed - will either not recommend them to the General Medical Council for re‑licensing, or maybe order the next punishment down the list, 're-mediation' (sending them for re-training at their own cost).
It's no less than would be expected of the rank-and-file GP.
But it's not only the elderly who need continuity of care. Younger patients, too, can suffer because they see a string of different GPs and no one joins the dots and sees the bigger picture of what's wrong.
Let's hope our leaders also know how to join the dots . .
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