Immunotherapy: a history of histamines

"Winter" here in the San Francisco Bay Area may not be severe by anyone's standards, but there's a definite change in the air that has flipped some sort of switch for me and Voov. It's always been this way, mysterious: changing weather makes eczema worse. Toward winter, it's probably reduced humidity in the air; in spring, there's probably pollen. Can't do much about either! Slather on more moisturizer after November, maybe, but it's not a 100% remedy. And as far as antihistamines go for pollen: completely useless, in my experience.

So here we are, skin suddenly tighter and drier, the red excoriations on our hands and wrists. But neither of us is going through an extreme flare.

I ran out of Eucerin on the weekend, and picked up a jar of generic moisturizer at CVS. You know the kind. It's the store brand stuff stacked next to the Eucerin, and the price tags read "Eucerin: $15.99" "CVS Moisturizing Creme: $9.99." You get what you pay for. The problem is, the cheap stuff may LOOK the same as Eucerin, but it sucks. It's thinner and slippery and wears off fast. I have to relearn this the hard way every six months or so.

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I want to share this review with you. It covers the history of our understanding of how immunotherapy works. The senior author is Mitchell Grayson, the scientist from the Medical College of Wisconsin who gave a presentation on eosinophils at the recent annual meeting of the American College of Allergy, Asthma, and Immunology.

The review is only eight pages including two of references, but it's encyclopedic. It follows immunotherapy all the way from its inception in 1911 (Leonard Noon's paper in the Lancet on injecting hay fever patients with grass pollen extract) to the current day. The authors explain how the therapy has remained essentially the same, but our understanding of how it works has evolved to become ever more complex as scientists have laid bare the secrets of the immune system.

In short: in the 1930s, scientists realized that patients given immunotherapy develop "blocking antibodies" that hinder the overeager allergic response. In the late 1960s, they learned that immunotherapy stabilizes mast cells and basophils and reduces the quantity of histamine released when patients encounter allergenic triggers. In the 1990s, after the discovery that there are at least two subtypes of helper T cells, scientists realized that immunotherapy partially shifts the T cell population in allergic patients from the allergy-related type 2 to the infection-related type 1. And in the mid-2000s, regulatory T cells were discovered; immunotherapy apparently increases the number of regulatory T cells that inhibit type 2 helper T cells.

Over time,  immunotherapy has been refined. With greater understanding of how the mucosal membranes process allergens, scientists developed sublingual immunotherapy, in which the allergens are placed under the tongue and absorbed into the tissue, where they are taken up by dendritic cells. (Straight-up oral immunotherapy, where the patient swallows the substances, is a bust.)

And, for asthma patients at risk of severe allergic reactions, doctors now administer immunotherapy along with the monoclonal anti-IgE antibody "omalizumab." Which is produced by Genentech, naturally, and costs $10,000 to $30,000 a year. I wonder, within the US, which insurance plans cover this, and whether the product is available outside the US. It's relevant to eczema because it appears to be quite effective-- it might become cheaper over time (e.g. after the patent expires) or other companies might develop alternatives to take excess IgE out of our systems.

Badge of honor

At the bottom of the right-hand column you'll notice a snazzy new badge. End Eczema has been recognized! By that fine institution, www.medicalassistantdegree.com. If you click on it, as I did, you'll end up on a page listing nineteen blogs. "Score!" I thought to myself. "A whole host of eczema blogs-- the vibrant blogger community I always knew was out there!"

Unfortunately, on closer inspection, all of the other blogs, if not dead, either have been quiet for months or clearly have no scientific merit. Or any kind of merit. Sigh. Eczema Mom and Cindy: L'eczema blogging community, c'est nous.

But I'll wear the badge with pride, at least until a better one shows up. It's like having a degree in blogging from the University of Phoenix.

Speaking of academic institutions, today I found a syndicated newspaper column in the LA Times online, written by Henry Bernstein, senior lecturer in pediatrics at Harvard Medical School. A reader asks him "what can I put on my 3-year-old grandson to treat his eczema?" According to Bernstein, those of us with eczema can expect to have

• Dry, scaly skin
• Plugged hair follicles that make bumps (usually on the face, upper arm and thighs)
• Swelling around the lips
• Darkening of the skin around the eye

Dry, scaly skin: check. Plugged hair follicles? Swollen lips? Dark circles around the eyes? Is this how they teach dermatologists at Harvard to diagnose eczema? I'd rather my dermatologist had a diploma from the University of Phoenix. Oh yes, Bernstein does get around to answering the question in the end: you should be putting moisturizer on your grandson. Duh!

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As you can see, I have been inspired by the holiday spirit.

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I learned that the company 23andMe in Mountain View, CA has a special deal out on personal genetic sequencing. For $99 you can send in your spit and find out your risk of developing 175 different conditions. Atopic dermatitis is one of them. If you're reading this, I suspect you already know what your risk is-- but FYI, they appear to be testing whether you possess one of the two common mutations of the filaggrin gene.

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In my last post, I mentioned that another Bay Area company, Anacor, has an interesting anti-inflammatory drug in the pipeline, a boron-based compound. I should have mentioned that I find it interesting because it is most likely not a steroid, and won't have the side effects of steroids-- though it will inevitably have other side effects. I'd like to know how it works and what strength it might be (compared to the US steroid scale).

And something else I'd like to know: is anyone making an anti-ITCH cream instead of an anti-inflammatory? Is anyone addressing itch neural fibers rather than just reducing the blood flow to the skin?

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Here's a story about another experimental drug: this lady, in England, suffered from hand eczema that became debilitating-- affected her right hand so that she could hardly use it for anything, and looked so nasty she had to wear a Michael Jackson-style single black glove. She was put on steroids, of course, and given UV treatment, which did nothing. What appears to have put her eczema in remission is a drug called alitretinoin, which is sometimes prescribed for Kaposi's sarcoma.

What is alitretinoin doing to relieve eczema? I'm not sure. At least it's not a complete shot in the dark for a dermatologist to prescribe: here's a story describing how a clinical trial of alitretinoin in Europe and North America cleared up hand eczema in ~50% of treated patients. I believe hand eczema (on the palms, not the backs) can often be triggered by rubber gloves or exposure to certain metals. A few years ago, I had eczema on the soles of my feet-- I think it was the hot, humid climate of Washington, DC, that was to blame-- and it was intolerably itchy. Denise Hyland has my full sympathy.

The holiday challenge begins

Tomorrow in America, the first wave of the great tide of holiday craziness will wash over us-- beginning with the inevitable turkey dinner. I'm not a native-born American, so although I have come to love Thanksgiving, I'm still not used to the idea of the entire month of December being given over to overeating and indulgence. At work, the holiday parties start the Monday after next. It's almost impossible to avoid eating or drinking all kinds of things that trigger eczema: chocolates, booze, spices. More booze. And eggnog. I used to like eggnog--in fact, I still do--but a few years ago, after having had a skin prick test that showed I reacted to raw egg white, I suddenly realized that eggnog has RAW EGGS in it, and that's why I was always scratching like a monkey after a glass or three. (Sometimes the eggnog has booze in it, too.)

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I'm always interested when there's a story in the news about someone with eczema. Here's a recent one from Scotland, about a five-year-old girl in Linlithgow (outside Edinburgh).

Despite being so young, Gaelle, a primary one pupil, has used her experiences of atopic dermatitis to educate her classmates and teachers, who have to help her apply her skin cream and bandages every day at school.

She even used her birthday party to fundraise for the cause.

At five years old, she can't have come up with these ideas on her own. She's got some parents who are taking the offensive. It's a good idea. When the kids in Gaelle's class are older and start to cast about for others to tease, they'll at least have had some hands-on experience with eczema and some understanding of what it means to someone who lives with it, and they may not be so quick to treat her as an alien.

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Another news item: UAS Labs, a probiotics company in Minnesota has won an award for "Probiotic Customer Value Enhancement." Thrilling stuff, you will agree. What caught my attention was that UAS makes five "formulations" of live bacteria for specific conditions, and one of them is atopic dermatitis. What's in the AD formulation? A mix of Lactobacillus acidophilus (the yogurt bacterium) and Bifidobacterium lactis. Both are common gut bacteria, but also common probiotics. UAS worked with a scientist in Ukraine on a study to explore how their formulation might improve AD in kids aged one to three. It's not clear whether UAS funded the study; I expect they did, because otherwise there'd be no need for someone in Ukraine to obtain UAS's formulation. Still, the results of the study--presented at a symposium, not published in a journal--showed that eczema symptoms were reduced by 34% on a standard scale for kids taking the probiotics, versus being reduced 19% for kids taking placebo.

If these results are real, which is not at all certain, then it's interesting to think how intestinal bacteria could help reduce eczema. Are they helping the body digest milk proteins or sugars that would otherwise cause an inflammatory response that, in susceptible people, manifests in the skin? Lactose intolerance is widespread. Perhaps it's linked to milk reactions in eczema. I don't know at this point.

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And a novel topical anti-inflammatory cream/ointment is entering phase 2 trials in eczema patients. Anacor is a San Francisco Bay Area company that makes drugs based on its trade secret, a "boron chemistry" platform. Phase 2 is VERY early in drug discovery, but it's interesting to watch this sort of thing emerge. They seem to have a good idea of what their drug is doing to reduce inflammation.

I'll be off tomorrow. We may be lucky and hear from Dr. Sib. She's Canadian and had her Thanksgiving about a month and a half ago. Unless she's working the midnight-to-8 am ER shift, what possible excuse could she have for not writing?

Sunflower seeds and coconuts-- good for more than eating?

In the email Peter Lio sent me the other day, he mentioned that he is getting excited about the potential of two natural products: sunflower oil and coconut oil. He sent me references to two research papers on the topics.

Since sunflower and coconut oils are both edible, I imagine the risk of adverse effects (unless you're allergic to them) is pretty small. And they're oils, so that means they can work as emollients, and soften the skin and reduce transepidermal water loss. I'd like to know how they work in this dimension compared to commercial moisturizers-- does a lot rub off? (I have a problem with my clothes getting greasy) and how often do you have to apply them?

The most interesting thing is that these oils may have special properties; apparently coconut oil contains a fraction with antimicrobial activity, and in one study with a small number of patients, was shown to reduce Staph. aureus colonization.

Sunflower seed oil may be slightly more complex; or perhaps it's just that in the review paper I read, the authors covered a lot of research considering different aspects of sunflower seed oil. Let's call it SSO for short. The point of review's authors is that SSO is actually good for eczema treatment, but allow me to digress for a paragraph.

/Start digression The main component of SSO is the "essential" fatty acid linoleic acid. The authors point out that linoleic acid can be converted to arachidonic acid, a precursor of prostaglandin E2, which they say is a "known modulator of cutaneous inflammation." Indeed it IS a modulator-- PGE2 is a vasodilator and used clinically to induce erections and hasten birth. The review paper considers pediatric use, though, so let's assume those aren't going to be issues. (I'm just pointing out that you can't vaguely say "oh, this lipid turns into something that is INVOLVED in modulating inflammation," and expect me to rub it all over my skin when the compound concerned CAUSES inflammation.) /End digression

The lead author of the study works at Rady Children's Hospital at UCSD, home to a famous pediatric eczema center, so he's probably not a kook. Let's look at some positive aspects of SSO the authors highlight: a number of studies show that in a 2% formulation, SSO has anti-inflammatory properties equivalent to a "mid-potency topical steroid" and, when used in tandem with an actual steroid, can enable the same effective strength for 25% of the original steroid dosage.

This former grad student has some questions for the speaker.

• Steroids are related to cholesterol-- is anyone sure that SSO doesn't contain a certain percentage of "natural" steroid that is causing these effects? (And could have the same side effects as an "artificial" steroid?)
• Is there more than one active component? One or more of the major lipids, or some drug-like compound present at a small percentage?
• I'd like to see a breakdown of what's in that "2% sunflower oil distillate." The scientists seem to be mixing SSO with a bunch of lipids that are essentially the same thing as SSO, but also adding some nameless "phytosterols" and vitamin E.
• Who decided that 2% formulation was the ideal composition? And, most importantly, where's the dose dependence data? In drug trials, it's key to show that the magnitude of therapeutic effect increases as you increase the dosage of drug-- that indicates that it's the drug that's making it happen, and not something else you hadn't considered. I don't see any mention of dose dependence in this review.

OK, I've evidently developed a skeptical reaction, which I honestly didn't have to begin with. Sunflower seed oil-- I'm going to need some more evidence that there's anything behind the claims. It's not going to be anyone's miracle cure, but there's always the possibility that a natural product is hiding some magical ingredient.

Aveeno stonewalls; and introducing eosinophils, the "riflemen" in your skin

So I wrote to Aveeno the other day, asking them two very simple questions:

1. What makes the Eczema Therapy line different from any of their umpteen other moisturizers?
2. What data can they show to prove that it works?

I found out that Aveeno is owned by Johnson and Johnson, and that, despite Aveeno's friendly Facebook video, J&J is as terrible at customer relations as any giant corporation.
Answer #1:

...the Aveeno® Advanced Care™ Moisturizing  Cream is different in these ways:

Essential ACTIVE NATURALS®:
-Pure oat essence and natural colloidal oatmeal to soothe skin
-Ceramides to help enhance skin's ability to retain moisture
-Plus moisture-rich oat oil

However,  this product has since been discontinued.

Not particularly helpful, since that wasn't the product I asked about. I wrote them again, repeating my original question. We'll see what they say. The active ingredient in the Eczema Therapy lotion is 1% colloidal oatmeal. Hardly revolutionary. Is it any different from anything else Aveeno puts out? Probably not.

Answer #2:

We are very sorry, but our company policy prohibits disclosing this type of information. Most of our research, marketing and sales information is proprietary, as is information regarding our ingredient percentages and formulations of individual products.

So: none of your business.

I did call the FDA to see if there were any instances on record of an official FDA warning letter being sent to Aveeno (recall, Peter Lio told me Aveeno had come out with this line a few years ago, and got their hand slapped because they were making an unsubstantiated therapeutic claim).  I was shuttled from the cosmetics division to the drug division-- colloidal oatmeal is classed as a drug, I found out, with the magical property of "skin protectant." There are no warning letters on record. I'm guessing that perhaps there was some low-level communication from the FDA to Aveeno that resulted in them listing colloidal oatmeal as the active ingredient.

The ridiculous thing is that someone at some point had to register oatmeal as a drug, which must have involved all kinds of safety trials.

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Last week, you may recall, saw the end of the annual conference of the American College of Allergy, Asthma, and Immunology. On the Saturday before last, there was this session in the afternoon called the "Great Atopic Dermatitis Raft Debate." I have now found out what this was about, or more specifically, what "raft" is doing in the title. From the conference brochure:

Premise: Experts involved in atopic dermatitis management are adrift in a life raft. There's enough food and water in the raft for only one to survive, and the surrounding waters are teeming with sharks. Each expert has exactly 15 minutes to make his case. Come and see who gets tossed to the sharks!

This explains why sharks feature so prominently in the Powerpoint of Mitchell Grayson, MD, one of the presenters. I wrote to all four professors in the debate, asking if they could send me their presentations and save me paying $350 to the ACAAI (now there's a posse of sharks) for the conference DVD. Only Grayson obliged. So I declare him, by default, the winner-- we toss Mark Boguniewicz, Donald Leung, and Lawrence Schwartz off the raft.

Grayson represented "eosinophils" in this epic tussle. Eosinophils are a type of white blood cell. My PhD topic had an immunological focus (helper T cells) but I really never heard diddly about eosinophils, so I was excited to go through his presentation. Let me share the gist:

On the battleground of eczema, eosinophils are the "riflemen," according to Grayson.

Eosinophils are, he argues, the cells most responsible for eczema. (Keep in mind that he was trying to win a 15-minute debate.)

Eosinophils, triggered through a signaling chain that begins with mast cells and goes through T cells, are the ones who "shoot" pathogens, destroying them with reactive oxygen species (e.g. peroxides) and "cytotoxic granules," aka poison. We'll ignore the fact that history usually holds the generals responsible for what the army does in war, although recent events at Gitmo show that we may not have enough perspective on that conflict yet.

Activated eosinophils are found in the middle layer of skin in patients with eczema. In normal skin, eosinophils have no business being there. Some scientists think that eosinophils contribute to skin irritation by releasing their toxic payloads. Here's a microscopic view of an eosinophil, from Grayson's Powerpoint:

You can see a cytotoxic granule highlighted. Some evidence that skin eosinophils may play an important role in eczema: urinary levels of eosinophil products are proportional to the severity of eczema; treatment of eczema with tacrolimus and pimecrolimus reduces the number of skin (but not blood) eosinophils; reduction of blood eosinophils has no effect on eczema. One experimental mouse model develops eczema only if eosinophils are present.

So there's a lot of circumstantial evidence against eosinophils. Our real question: OK, say you prove eosinophils are the key-- how can we target them to prevent eczema?

On that, Grayson has no answer. We can forgive him, though. It seems that dendritic cells and adhesion molecules are really what he specializes in.

The secret powers of oatmeal

I'd like to ask you a favor. Since the purpose of this blog is to raise $1 million for eczema research-- through a cunning plan the details of which will be revealed, and if you find out, please tell me-- I'd appreciate it if you could link to this site and share it with your friends. This will raise the blog's Google profile. At the moment if you go to blogsearch.google.com and type in "eczema blog," Google returns a lot of pretty useless sites. (Mind you, Priya Mulji's blog ranks highly--she sometimes has a good personal take on eczema, although not from a scientific angle.) To attract the attention of potential donors, I want to get this site ranked higher. I'm not asking YOU for money, unless you can write a check for $100,000. I just want to reach blue-blood philanthropists affected by eczema who may not realize they could make a difference.

About Aveeno's new "Eczema Therapy" product line, now touted on their Facebook page-- writing about it yesterday, I wondered what it was about colloidal oatmeal that makes it such a fantastic ingredient in these various powders, bars, lotions, etc. that Aveeno manufactures. I wrote to Peter Lio, MD, an associate professor of dermatology and pediatrics at Northwestern University. Lio gave a presentation at this summer's NEA Patient Conference in Chicago, and covered skin pH, cleansers, and moisturizing, so I figured he'd have an answer. And he did. Let me quote his email, since it is so readable and packed with information:

About the Eczema Therapy line:

They've actually been out for a few years, initially as Aveeno Eczema Care, then the FDA slapped their wrists for putting a disease name on a product without evidence to back it up... so they had to pull it and it was then called Aveeno Advanced Care... and now they've finally got it back up with some data, calling it Eczema Therapy.

On oatmeal:

Oatmeal is pretty interesting and does seem to have some specific anti-itch and anti-inflammatory properties of its own. "Avenanthramides" are thought to be the "active ingredient" in them (but it is probably a whole lot more complex, as with many plant products).

Aventhramides, he says, act to reduce cellular levels of NF-KB, a molecule that triggers protein production in the immune response-- so they could reduce inflammation in this way. From what I know, NF-KB seems to be involved in a lot of processes, so there must be more going on, and Lio elaborates:

Cells treated with avenanthramides showed a significant inhibition of tumor necrosis factor-alpha, a powerful inflammatory cytokine. They have also found direct anti-itch effect with these substances as well. (Reference)

He thinks Aveeno may be going too far, chasing novelty for marketing purposes: 

[The] Aveeno line...is such a complex lineup of products and they keep moving things around and changing things!  If I tell a patient about an Aveeno product, they go to CVS or Walgreens and find 2 shelves of different types of moisturizers... Active Naturals, Positively Radiant, Clear Complexion, Positively Ageless, Nourishing Refresher...I just wish they'd put their best foot forward and make the best one they can make. That's why I love CeraVe so much.

I agree. Less is more. Aveeno confuses me with their offerings. At least their shaving gel is back on the market, after a hiatus of frickin' MONTHS in which I had to shave using an Aveeno bar or whatever fragrance-free shave gel I could find at CVS. (Walgreens: still in the Stone Age, carries no fragrance free shave gel.)

Lio also has some interesting ideas about other natural emollients, which I'll share in a future post.

Remember the ACAAI meeting in Denver? (Peanuts in schools; anaphylactic shock via sex.) I did get in touch with Mitchell Grayson, one of the four pugilists in the Great Atopic Dermatitis Raft Debate. He was in the "eosinophil" corner, and he sent me his Powerpoint presentation. Now I know a lot more about eosinophils. And so will you, if you read my next post.

Aveeno rolls out new line of eczema moisturizers

In my newsfeed today I got a press release from Aveeno-- apparently they have just rolled out a new line of moisturizers especially for kids and adults with eczema. In fact, you can find a promo video on Facebook. In the video, Suzy Deprizio, a brand manager for Aveeno, talks about how she's been involved in developing the moisturizers (or developing the marketing strategy? Not entirely clear to me) for five years, and how she found out that her young daughter had eczema. She also offers a few tips, none of which will surprise you if you live with eczema: clip fingernails, etc. It is interesting to know that there are people at Aveeno who have a personal stake in the products. Aveeno's definitely an example of a company whose products benefit society. Looking forward to trying out the new creams!

On the topic of moisturizers & skin barrier, there is a good article in The Advocate, basically a transcript of a presentation by Peter Lio, MD, at the 2010 NEA Patient Conference in Chicago. Lio makes a few interesting points. One is that traditional soaps-- say, Ivory, or something that you might make yourself from lye and rendered fat if you're under the impression that "pure" or "simple" equals better--are harsh on the skin. Quite apart from their surfactant properties, when mixed with water, they increase the pH, making a strong alkaline solution. Why is alkalinity bad? Because the skin's natural pH is slightly acidic.

When the skin becomes more alkaline, the conditions favor the action of natural enzymes called serine proteases, which break down the bonds between skin cells and chew up other enzymes that produce fatty molecules called ceramides. Ceramides, in the right balance, are essential in creating a good skin barrier. So traditional soap not only removes these lipids from the skin, but reduces the skin's ability to replenish itself. You can find a good review of the skin barrier in eczema here.

Lio also discusses commercial moisturizers. He says (and I've found) that pure petroleum barriers such as Vaseline aren't very useful. They do indeed keep water in the skin, but as soon as they rub off, they don't. When I put Vaseline on eczematous skin, the benefit seems to wear off within minutes. "Right now I would say it's nice to look for something that contains ceramides," Lio says.* We're using CeraVe on Voov--it contains ceramides--and it seems to be working very well. The stuff is hella expensive though. It makes Eucerin look cheap. But I am going to start trying it out on my hands to see if it makes any difference. (I know, I know, Eczema Mom, you advised me to try it a while ago. But we all get attached to our daily routine and it's hard to change.)

*So do these Aveeno products have ceramides? If not, why is colloidal oatmeal so good for skin? Will investigate.

MRSA-- like a sourdough starter

An item to emerge from the American College of Allergy, Asthma, and Immunology meeting in Phoenix this week: if someone has an extreme food allergy, you can give them a reaction just by kissing them.

Bizarre, but makes sense, and highlights how sensitive our immune systems can be. If tiny amounts of allergen can cause such severe trouble, it seems more plausible to me that the broken skin of eczema can expose young children to allergens that might sensitize the body for life.

I've read through The Advocate once now (get this-- that picture of the torn-up foot on page 5-- I read that page while I was eating dinner, that's how DEsensitized I am to eczema) and, once again, I appreciated it on several levels.

1. I feel better by comparison, because some people out there evidently have it much worse than me and my daughter
2. I feel like I belong to a wider community facing the same challenges we do
3. I'm interested to hear advice from leading scientists in the field on day-to-day therapy and some of the more advanced/extreme options

My god, the poor kid, Joanna Hamilton's son Jonah, with MRSA. I can relate to him about the food (my mom says at one point she was only feeding me carrots and bananas, and my nose turned orange) and the scratching (my own feet and Voov's have at times looked like that photo) but not the MRSA. That is some bad shit. From what I've heard, the more you can stay out of the hospital, the better chance you have of avoiding it. But what about the doctor's office? When you have a young child, you are in the doctor's office virtually every week getting some rash or cough or weird eye tic checked out. Is MRSA in the doctor's office too? I'd appreciate knowing.

Earlier this year, Voov had some terrible staph all over her hands. She was crying all the time and her hands were all blistered and bloody and crusty and you couldn't even see a spot of decent skin. Naturally, we were on vacation. We got back home and Voov went on some antibiotics and her skin cleared up all over her body. Then, bingo, I suddenly developed a staph infection, a lovely one on the back of my head. It cleared up by itself, fortunately. In these six-kid families that have multiple members with eczema, they must pass an infection around for months, keeping it alive like a sourdough starter.

An ill-advised comment on peanuts

Upon arriving home this evening I was not only welcomed by Hidden B (torrid spousal kiss), Voov (loud acclamation from high chair), and Shmoop (whiny complaint from the floor, where he was lounging, practising to be a teenager) but also, on the kitchen table, this quarter's issue of The Advocate, the NEA's house publication.

The Advocate is best savored at leisure, like a fine malt whisky, so I'll save my review for future posts. Today I want to mention that the annual meeting of the American College of Allergy, Asthma, and Immunology is still ongoing in Phoenix. It was at this meeting that, on Saturday afternoon, Donald Leung and three other immunology heavyweights engaged in the knock down, drag out brawl known as the Great Atopic Dermatitis Raft Debate. The four presenters each argued that their pet cell types (keratinocytes, T cells, etc.) play the most important role in eczema. Man, I'd like to know what they said, but the event wasn't webcast. I did find out, however, that the proceedings of the entire conference were videorecorded and are available on DVD-ROM-- for me, at the low low price of $340.

Maybe there's some way to get just the session I'm interested in, but it'd probably take more effort than I can spare. (I was also informed that audio recordings might be cheaper... but who's going to pay a hundred dollars for a podcast when these scientists are probably leaning heavily on Powerpoint diagrams?)

* * *

The ACAAI meeting has been in the news, because the president of the whole shebang has gone on the record saying that people take peanut allergies too seriously. I'm sorry, but this immediately discredits his expertise. I know that latex and peanut allergies can be life-threatening; and their incidence is increasing. It doesn't matter if the incidence is low (~0.5%)-- in a school of, say, 1000, that means you have five kids who could potentially die if one of their classmates (it is clinically proven that 100% of kids are capable of being idiots) thought it might be funny to see what happens if Johnny takes a bite out of the wrong sandwich.

I know someone who died of an asthma attack; I also know someone whose wife nearly died from a latex allergy. I'm no expert, but I think peanuts probably pose the same caliber of problem.

This is one area in which America's "sue first, ask questions later" culture will work for the good of society. I can't imagine a school principal revoking a peanut ban because Dr. Bahna said so. Fewer peanut bans may get enacted, though.

For the record, I loves me some Snickers, and I eat PB&J every single day. But I'd quit on the spot if someone's life was endangered.

* * *

A blog post worth checking out: in which a UK citizen of east Indian descent talks about her teenage experience with eczema. For me, too, eczema came on with a vengeance not long after I got interested in the opposite sex. I didn't develop big boobs to compensate, as she did-- but, on reflection, that's probably a good thing.

Teenage years are hard

Not the happiest news today, I'm afraid: some poor kid in Manchester, England apparently committed suicide after being taunted at school about his eczema.

It's hard to be a teenager. Many kids are insecure--they think that others think they're not tough enough, or not cool enough, or whatever-- so they bully and torment kids who don't fit in. And it's easy to single out the boy with the funny rash.

Of course there could be more to this story. The boy may have been suffering from clinical depression, which is distinct from general teenage angst. But who among us adults doesn't still keenly recall every casual remark that wounded us during those years?

I'm lucky. Although I definitely had eczema all the way through high school, nobody made a habit of jeering at me for it. (Instead, they jeered at my accent, haircut, trouser cuffs, and Bryan Adams cassettes, among other things.)

We should tell kids with eczema that life does get better. Your eczema may not improve, if you're one of the unlucky 2% or so. But past high school, you're not trapped in the zoo any more; the cliques aren't as intense, because people have little to gain by making you feel bad. The more life experience people have, the less they care about how your skin looks. And if you can feel confident in yourself, it shows on the outside.

* * *

An important conference opened yesterday in Phoenix: the annual meeting of the American College of Allergy, Asthma, and Immunology. There's a particularly interesting session on Saturday from 1:30 to 3:00 pm. It's titled "The Great Atopic Dermatitis Raft Debate: The Greatest Role in the Pathophysiology of AD." (I don't know what "raft" means here.) It's basically a four-way mano-a-mano between presenting scientists, each of whom is claiming that the cells THEY study play the most important role in eczema. Our good friend Donald Leung (head of the Atopic Dermatitis Research Network) is in the T cell corner. He evidently wrote the abstract, because it says "Upon completion of this session, participants should be able to... describe the scientific evidence that supports T cells as playing the key role in causing AD."

Which is amusing, because the more I read about eczema, even in articles written by Leung, the more it emerges that eczema arises from a barrier defect in the outermost layer of the skin-- a defect in keratinocytes. (He does nod in their direction, saying keratinocytes have a "critical" role, but not the KEY role.

I've snoozed through many an academic conference presentation, but I'd sure like to be at that session! It'd be like Iron Chef, only immunology.

Eczema under the guns

Today, depending where you are in the non-German Western world, is Remembrance Day (British Commonwealth), Veteran's Day (US), or Armistice Day (France & Belgium).

My father's father, Titus, served in the 48th Nova Scotia Highlanders in WWI. I've seen a map of his regimental movements and although there were a number of famous place names on the path, I remember only one: Passchendaele. I think Ypres might have been there too. Old Titie, as my dad calls him, apparently used to freak out whenever someone burned the toast at home, because the smell reminded him of poison gas.

Titus was the one grandparent of mine who had eczema. His itch was legendary. "Old Titie was always scratching," my dad says. (I don't remember Titus; he died when I was five.) I don't know whether the stress of being under bombardment would exacerbate eczema, or distract the mind from itch, and with any luck I'll never find out. Eczema must have made life in the trenches even worse. Titus, we can't imagine what you went through. Thank you.

These days, eczema is a condition that disqualifies you from service in the US military. The reason: in 2007, a soldier vaccinated against smallpox gave his two-year-old son the often lethal condition eczema vaccinatum. An all-out medical effort saved the kid. Now, one can understand why eczema disqualifies you from active service: it would make sense that all service members have to be vaccinated against smallpox, a major biological weapon; and the military would face a major problem if soldiers, etc., refused to be vaccinated because they or their families might die from eczema vaccinatum.

The military therefore is only ruling out about 3-5% of recruits, is my guess. The crucial question is whether you've been diagnosed with eczema after the age of 9. I'm not sure what the precise number is, but about 20% of infants get eczema, and only 2% of adults continue to suffer from it.

I do think that we can look at the bright side of the smallpox/eczema question. It's a point of leverage for us. The US government spends a lot of money on the military, and probably wouldn't mind spending a few hundred million more. The Atopic Dermatitis Research Network was given $31 million to study MRSA and other infections in patients with eczema-- but the initial request-for-proposals was actually aimed at studying eczema vaccinatum. It wouldn't hurt to make our concerns about smallpox vaccination widely known; we could attract major funding. Eczema infection researchers might discover powerful new antibiotics, or other ways for us to protect ourselves from infections such as MRSA.

Eczema Haul!!!

An End Eczema first today: let's look at a video. As I've said before, this blog is going to be light on photos and such because eczema doesn't make the most attractive visuals. And video? Well, this one is an exception. It's kind of fun. The girl has decided to show us all the panoply or arsenal or whatever of the products that she uses daily to treat her eczema. She's titled her video "Eczema Haul!!!" --must be some new slang term I haven't heard of.

Easy to tell that she's American: well, first, her accent, but if you hadn't registered that, "I don't have insurance" is a dead giveaway. Let me be perfectly clear. I live in the U.S., but I think it's barbaric that this is the only first-world country without universal health insurance. Imagine having eczema and getting a staph infection and wondering whether you ought to go see a doctor because it might cost too much. For one thing, every infection that unnecessarily goes too far puts other people at risk of being infected.

Here's the video (she's disabled embedding).

A couple interesting points. She's obviously very keen on Aveeno. So am I. It's a great company with great products, and the Daily Moisturizing Lotion with dimethicone (a rubbery sealant) is almost the best I've found. The shaving gel is awesome, although a while back they were having manufacturing problems and you couldn't find it in stores, so I've been using some fragrance-free Edge. But you can't go completely Aveeno. I tried Aveeno shampoo and found it little better than ordinary shampoo,  leaving my scalp drier than the Mojave. Here's my secret: tar shampoo, rinse, and then, rubbed into the scalp, some jojoba oil.

Ironically, jojoba grows in the Mojave.

Toward the end she pulls out a bottle of vitamin E capsules and touts its benefits to people with skin diseases. "Vitamins are good for you, period, people." I am not so sure. I confess to taking a daily multivitamin (mostly for the potassium-- I get muscle cramps sometimes), but all that I read about eczema tells me that the way to a happier you is to avoid problem foods rather than take any miracle nostrums.

To quote an impeccable authority, Wikipedia:

The consensus in the medical community is that there is no good evidence to support health benefits from vitamin E supplementation, yet there is strong evidence that taking more than 400 IU of vitamin E per day for extended periods increases the risk of death.

I like to avoid death, myself. It's something that, according to the prophet Mohammed, even black cumin can't cure.

Something I forgot to relate after my trip east to the science writers' conference this past weekend: there is a new book just out on MRSA. Superbug: The Fatal Menace of MRSA. (The author, Maryn McKenna, was on a panel discussing how to publish a popular science book.) I'm not saying you should read it--even the website gives me the willies--but it sure looks like the comprehensive resource on the emergence of this medical hazard that is of concern to everyone with eczema. Perhaps Dr. Sib can give us her perspective on MRSA, what it's like to deal with it in the hospital.

Many are never diagnosed with eczema

Dr. Sib mentions something interesting in her first post. Although she is now a doctor, when she first developed eczema around the age of 19 she waited a long time to consult a doctor. (Who then confirmed her doubts about the medical profession by prescribing an antifungal cream.)

She isn't alone in this. Many people suffer from eczema without ever having it diagnosed by a doctor. In Jon Hanifin and colleagues' 2007 survey of eczema prevalence in the U.S., the authors estimate that there are 31.6 million people in the United States with some form of eczema. How did they know these people had eczema? They surveyed 116,202 people and extrapolated to the entire population; they asked, first, whether each subject had experienced symptoms that would add up to eczema; and then, whether the subject had been diagnosed with eczema by a doctor. Of the group designated as "symptomatic," i.e. suffering from eczema, only 37.1% had been officially diagnosed.

So there could be as many as 20 million people in the U.S. who have eczema and don't even know they could try to relieve it with steroids, emollients, restricted diet, or whatever therapy you might choose. Instead, they're doing nothing, or treating it as ringworm.

Let me take this opportunity to applaud, first, the NIH's PubMed catalog of medical papers, and second, open-access scientific publishing. In the U.S., the vast majority of science research is paid for by taxpayers via the NIH. And yet, the best papers end up in Science or Nature or Cell, or other journals that you have to pay to read. (Actually, Science makes papers open-access after one year.) In my day job, I have access to a lot of journals, but as soon as I come home, I'm locked out of almost the entire scientific literature. At least PubMed is free, so I can search for papers and see what has been published (you can often write to authors and they'll send you copies, as Jon Hanifin did for me); and there is a family of quite highly ranked open-access journals called Public Library of Science (PLoS). Check 'em out. It's all free! The problem is that I haven't yet found any interesting eczema research in PLoS Medicine. We should ask prominent researchers to publish their work in the PLoS family of journals. If we funded them, they're morally obliged to try!

Maybe your kid CAN eat more foods

I'm back from my weekend trip to New Haven for the science writers' conference. A smashing idea, getting about 500 of us in the same place and giving us drink tickets. The hubbub of eager networking (freelance writers have to network nonstop if they want to eat) at times almost drowned out the science-themed standup comedians and a cappella groups.

My trip was a success not only professionally, but because twice in the space of two days I got up at 4:30 am, endured the stress of making a flight, sat for 7 hours in the dry, recirculated, funky air of a Boeing 737, ate at McDonald's (Hartford airport is no food paradise), and downed my share of beer and wine-- and here I am at the end of it with dry skin, yes, but no eczema to speak of. Score!

I'm going to continue the food allergy thread today. There's a recent study out of National Jewish Health Center in Denver that found that many children with eczema are unnecessarily leaving foods out of their diets, for fear of food allergies that don't exist. The main issue the authors are making is that the proof of most food allergies is in the eating. Blood test results for IgE allergies are not believable unless they show you are positive for cow's milk, hen egg, fish, peanut, or tree nuts.

If a test shows your kid IS allergic to one of those five things, you definitely shouldn't eat it. But David Fleischer and colleagues (including Donald Leung, leader of the Atopic Dermatitis Research Network, who appears to be the heavyweight author) took 125 children who had been on restrictive diets based on IgE tests, and, in a controlled fashion, let the kids eat food that they had previously avoided. The result: "Depending on the reason for food avoidance, 84 to 93 percent of foods being avoided were restored to their diets."

This matters because your young child needs a balanced diet to develop properly, and also because substitute foods (goat milk, almond butter) are expensive.

I find the study personally interesting because Voov (18 month daughter) has been on an extremely restricted diet for many months. Skin prick tests showed allergies to a number of things and the allergist recommended, at first, some ridiculous diet--seriously, like "she can only eat sweet potato, broccoli, and chicken." Completely unreasonable, and after Hidden B protested, and we got advice from a nutritionist, the allergist relented a bit and permitted these items:

• zucchini
• broccoli
• asparagus
• sweet potato
• pears
• bananas
• chicken
• turkey
• rice
• soy

That is what Voov has been eating for at least six months, over and over. (She's also breastfed.) We're allowed to pour canola oil over her food so that she gets some omega-3 oils for her brain. She's a happy enough kid, but still has eczema flares, and she has to be getting pretty tired of this food by now. I know that I'm getting bored of making it, when it's my turn to boil the zucchini.

Fleischer et al. don't say whether skin prick tests are as useless as most IgE blood tests. But I sure would like to expand Voov's diet, so she can experience some new tastes. Wouldn't it be great if she could just eat the same things we do!

A tale of two itches

As SK is cavorting across the continent, I will take the opportunity to introduce myself as a guest blogger on End Eczema. You can call me Dr Sib.

As mentioned in previous posts, I share in approximately half of SK's genetic pool, being his sister. Unfortunately for me, our genetic overlap appears to include a faulty filaggrin gene that has been the root cause of much unhappy scratching by us both. And, while I've certainly spent my fair share of time shredding my own skin with my 10 digits, I have to confess that this particular organ is fairly intact at the moment, my atopy manifesting itself more at the asthma end of the allergy spectrum.

I attribute this happy state of affairs, based on a sample size of 1 (myself), in part to my geographic locale. My eczema has never been as flared as it was for the 12 months I spent on Vancouver Island on Canada's western coast. There, I spent the entire time bleeding into my sheets at night, tossing and turning with the torment, and avoiding showers because the chlorine in the water burned too much to bear on a daily basis. No dietary measure had any effect. Nor did the usual routine of steroids and emollients that I had come to rely on in the past.

Musing back, I realize (quite ironically for reasons that will become clear in a moment) that I never consulted a physician during this time, nor did it even occur to me to do so. Essentially, anything I had learned about managing my eczema up to this point had been from personal experience and the advice of fellow sufferers. It was well known amongst this same cohort, that our family doctors had proven to be pretty useless when it came to treating our dysfunctional skin. At the same time, I had never been referred to a dermatologist, so I assumed I was stuck with things as they were, bad as they were.

Now, as a first year resident in family medicine, what do I do with this memory? I admit I do feel it reveals a certain incompetence on the part of the family doctors I've had in the past in managing atopic dermatitis. The time I've spent with dermatologists thus far in my training has suggested that family doctors have a tendency to be far too cautious when it comes to the use of topical steroids, particularly in children and adolescents. I seek to rectify the problem in myself by taking a special interest in the dermatological complaints of my patients. And, I hope I have a well-developed capacity to empathize fully with the impact a symptom as 'harmless' as ITCH can have on an individual's life. Finally, I feel the drive to be competent in diagnosing, counseling, and managing this problem in my own patients. For me, this will mean an extra rotation in dermatology during my residency training.

My story brightened when I moved back east, first to central Canada (Ontario), and then to the Maritimes. My skin healed of its own accord. While I used to attribute my temporary misery to some quality of the water to which I was exposed, I've come around to assuming there must have been an environmental allergen triggering me, be it mould in the basement apartment I was inhabiting, or some type of noxious pollen circulating in the botanical breezes of the west coast. Either way, I'm left a number of habits/superstitions that I use to ward off a recurrence: I never miss a full-body moisturizing after a shower/bath. I don't expose my skin to long, hot soaks. And, I'm aware that every coffee, every alcoholic beverage, and every spicy meal exacts a toll that may tip me over the edge into a flare.

A shared resource for immunotherapy

I'm off tomorrow to New Haven for the annual meeting of the National Association of Science Writers. A junket that will see me absent at the kids' bedtime not once, but twice, as Hidden B pointed out, using this as a cudgel to get me to change a particularly stinky diaper. So the blog will resume on Monday.

I'm pressed for time tonight, too. Have to go get some cash, pick up an organics CSA box that is contending for the status of all-time most inconvenient birthday present, make dinner, and pack. Flying into the fair city of Hartford, departing Oakland at 07:35. You may recall an earlier post in which I awarded a Mark Twain Steel Trap Award to the gentlemen responsible for the FAA's no-moisturizer-in-carryons law. Messrs. Ali, Sarwar, et al. were on my mind the other day as I purchased a small, but filthy expensive, tube of Eucerin that will see me through the next two-and-a-half days.

The eczema news of the day is a little tangential. A few posts ago, I wrote about sublingual immunotherapy. The idea in this technique is that if your eczema arises predominantly from an allergy to one thing, you try to induce your immune system to become tolerant to that thing, thereby reducing your eczema symptoms. In the past, immunotherapy doctors have injected allergens. Now, for the wimpy, there is the (slightly less effective) droplet-under-the-tongue, or "sublingual," technique. The doctor gives you a small bottle of drops and you take one or a few a day; the allergens get taken up by dendritic cells in your mucosal linings, and presented to T cells, and thus (the hope is), your body learns that the allergen is no big deal and shouldn't induce an eczema reaction.

For scientists in the realm of immunotherapy research--the study of techniques to induce tolerance in autoimmune and allergic diseases--there is now a new resource at the University of California, San Francisco. UCSF's BioShare, a bank of over 100,000 specimens from a ten-year federal project to catalog biomarkers of various diseases, is now offering its samples openly to qualified researchers. The samples were taken from patients with thoroughly diagnosed conditions, at well-defined points in the progression of the diseases. So now you can analyze the samples to see how much of this or that protein or hormone or whatever the body is producing at each point-- and how the body alters its output when immunotherapy is given. It's a way to measure whether the immunotherapy is working or not.

Have a good weekend.

Boring yourself to sleep may be the best tactic

Yesterday I wrote about discovering by happy luck an editorial by Jon Hanifin on the topic of sleep and itch. Hanifin's an eminent dermatologist at Oregon Health Sciences University in Portland and the author of, among gazillions of papers I'm sure, "A Population-Based Survey of Eczema Prevalence in the United States." This is one of very few major surveys to explore how many people have eczema in this country.

The problem: the study appears in Dermatitis, a journal that my institution doesn't subscribe to. I wrote to Hanifin to ask whether he could send me a copy of the paper, and he very graciously agreed; so now I have that valuable source of data to explore.

Eczema is no rare disease. It affects a lot of people in the U.S., and by extension, worldwide. I'm interested in the U.S. because I live here and because I have some understanding of how science funding works. We might be able to increase funding for eczema research--and, in particular, "translational medicine" leading to a cure--by applying pressure on Congress. Although there's not much evidence that Congress makes decisions based on facts, it won't hurt us to quote some facts when we write our representatives.

Hanifin's editorial led an issue of the journal Sleep Medicine Reviews, and introduced two papers in the issue devoted to the topic of sleep and itch. I read the first of the two papers. According to the authors, eczema is one of several skin diseases for which itch and sleep disturbance is a problem. But there's not much research out there on how to manage sleep problems for patients with eczema. I didn't get too much out of the paper, to be honest. Here's what I learned:

• The itch of eczema causes sleep disturbance that has effects similar to insomnia; but the eczema is the cause, and if you can manage your eczema, the itch will recede, and your sleep will improve, which will improve your skin in a positive feedback cycle.
• Doctors prescribe antihistamines for eczema patients almost solely based on the drowsiness they induce. But the authors say there is no study that uses sleep as an objective measure and shows that antihistamines improve sleep.
• The only sedative that patients reported to improve sleep was nitrazepam (not an antihistamine). However, nitrazepam also induces amnesia, so it's possible the patients just forgot they had a terrible night's sleep.

Not particularly encouraging, hey? In theory, the authors say, doctors should prescribe "hypnotic" drugs like Ambien for short periods only, so that patients can get a few good nights' sleep and break the itch/wake cycle. I've tried Ambien myself, during a period of insomnia a few years back. It didn't knock me out, it just turned me into a zombie the next day. I'd recommend reading something boring-- for me, John McPhee's recent New Yorker article about golf would do the trick.

Good night, sweet prince

You may have noticed there's some sort of election going on. I am doing my best to ignore it-- having, though, voted this morning-- because it'll only increase my stress level. I don't know exactly why, but politics is one of those things that triggers instant stress. Whichever side you're on. I'm on one side, and the things that get said by the extreme members of the other side seem so ridiculous you'd laugh them off, if these people hadn't shown themselves capable in the past of doing what they propose.

So, please, let me not look at the electoral results until tomorrow morning. Then the night won't be so bad.

If you're like me-- that is, you have eczema-- you wake up some morning wondering what the hell happened while you were asleep. The skin on your hands, or your scalp, will be torn, and your sheets will be speckled with blood. Because of what you ate the day before, or because you're stressed about exams, or a relationship, or modern life, your body decided to have a scratching fit while on autopilot.

This behavior is well-documented in sleep and itch research. By chance today I came across an editorial written on the topic by Robert Sack and Jon Hanifin at Oregon Health and Sciences University. I think the piece might become open-access at some point. The neat thing-- two review papers in the journal issue cover the topic of skin disorders and sleep problems. I can't wait to read them. It's twisted, but I get off on learning that researchers are out there studying stuff that has happened to me personally.

For one: the itch of eczema--rather, the scratching--has, at times, severely affected my sleep. There have been periods when I have to have a good scratch before I can get to sleep, and then once I'm asleep, I partially wake up some time later, scratching the hell out of some body part, dreaming that by doing so I'm solving a vital problem. I used to do this a lot in college and grad school while I was taking physics or math courses. At the end of the night, you may have spent eight hours in bed, but only five of them in anything resembling restful sleep.

One of the reviews in this journal discusses how night-time scratching might, in kids, lead to ADHD.

The editorial also drops two nuggets of information. One: that it's well-known that at night, the blood vessels in your skin dilate (get bigger) in order to radiate more heat away, so you can lower your core body temperature. As I mentioned in my previous post, I find that alcohol, hot peppers, and exercise, all of which dilate your blood vessels, cause me to itch. So, every night, my body may be doing the same thing to itself.

Two: that although doctors regularly prescribe antihistamines for kids and adults with eczema, possibly in the hope that they'll reduce histamine levels and inflammation, there's no evidence that antihistamines reduce itch. They do, however, make you feel a bit drowsy, so they might help you go to sleep. I've found antihistamines to be of no use for anything, myself.

I'll read those reviews and see what I can learn. I'll be interested particularly in what Gil Yosipovitch at Wake Forest University is doing-- I read something in the NY Times a couple years ago about his International Forum for the Study of Itch, and they had some videos showing sleeping people scratching themselves silly. The reader was supposed to be aghast, but I just thought: "That could be me on camera!"

Mr. Peanut need not apply

Eczema Mom recently posted about her experience being on a plane with her kid, who's been diagnosed with severe peanut allergy-- some guy opened a bag of peanuts in the row ahead of them, and the smell drifted back, and she could do nothing but wait and see whether her kid would have a reaction. (On a plane! What are you going to do if he DOES have a reaction?)

Peanuts-- I love to eat peanut butter, and Snickers, but I'm learning that a lot of people have severe allergies to them. In fact, Voov was diagnosed with a peanut reaction on her skin prick test-- Hidden B will know all the details. Hidden B is breastfeeding Voov (who's been on solid food for a while now, being 18 months old) and has had to avoid peanut butter herself. I get in trouble for eating the sunflower and almond butter-- which somehow seem more exotic and tasty than my peanut butter.

Peanuts are in the news at the moment. There's a study out in the Journal of Allergy and Clinical Immunology by a group at the Mount Sinai School of Medicine in NYC, indicating that pregnant women ought not to eat peanuts if they can help it. The specifics-- seems only to apply to kids who are suspected of being allergic to milk or eggs, or have eczema and allergies to milk or eggs. (An odd study group, that-- but I can't see the details because my institution doesn't have access to the paper itself.)

Kids with eczema really have it tough-- the itch, the rash, the food reactions, and then they're at higher risk of developing a life-threatening peanut allergy. Life's a bitch.

I had a short email today from a reader, Jon, letting me know that his partner, who's had eczema for a long time, had recently seen a dramatic improvement after cutting out dairy products. That's awesome and I encourage anyone who has eczema and who has never tried an elimination diet to do the same thing. Cut out, one at a time and for two weeks or more, milk, soy, peanuts, wheat, and eggs. (And fish, if you eat it regularly-- Hidden B hates fish, so I never cook it.)

Here's my personal take: I draw a distinction between food ALLERGIES and food (or drink) that causes REACTIONS. I might have a food allergy; I don't know for sure. But I do know I have reactions to alcohol and hot peppers, which both dilate the blood vessels in the skin. I get itchy after drinking booze or eating a hot curry in the same way I do after I exercise. I'm guessing the heat or blood flow somehow stimulates itch nerve fibers. And then, I also have reactions (oh, so vicious) to aged cheese like real Parmesan, and to preserved foods that are high in histamine. These just have to be triggering inflammation systemically.

Does this mean I never have a drink, or enjoy a fine double Gloucester? Hell no. You have to live. But I often regret it the day afterward.