Tick Bites

Five answers to common questions

With the changing of the weather to more spring like temperatures, we are also moving into the season, late spring and summer, where ticks are most likely to transmit diseases.  In this blog post, we will try to answer four of the most common questions that we are asked concerning ticks and the diseases they transmit.

 How does a tick transmit disease?

Ticks transmit disease when they are feeding on their host.  Ticks secrete an anesthesia like substance onto the skin, which prevents the person from knowing they are being bitten.  The tick then inserts a feeding tube into the skin and also secretes cement like substance that allows it to remain attached to the person while it is feeding. The tick will feed on the blood of a person for several days and eventually fall off.  During the feeding process, ticks which are carrying disease transmit disease via its saliva and though the feeding tube.  One good thing about ticks is that they are not very efficient at transmitting disease compared to mosquitoes.  Most ticks need to be attached for at least 24 hours to transmit disease.

How do I remove a tick if I am bitten?

According to the CDC , these are the steps to remove a tick.

  1. Use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible.
  2. Pull upward with steady, even pressure. Don’t twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with tweezers. If you are unable to remove the mouth easily with clean tweezers, leave it alone and let the skin heal.
  3. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.
  4. Dispose of a live tick by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet. Never crush a tick with your fingers.

Avoid folklore remedies such as “painting” the tick with nail polish or petroleum jelly, or using heat to make the tick detach from the skin. Your goal is to remove the tick as quickly as possible–not waiting for it to detach.  (http://www.cdc.gov/ticks/removing_a_tick.html) 

 

How do I know what ticks cause what sickness?  

There are a myriad of tick borne diseases.  We are going to highlight the most common in the United States.   This link includes a great reference for maps showing where certain ticks are found as well as a picture of the ticks.

 

Lyme Disease –Black Legged Tick aka Deer Tick

Black Legged Tick aka Deer Tick www.cdc.gov

Black Legged Tick aka Deer Tick
www.cdc.gov

 

Southern tick associated rash illness (STARI) – Lone Star Tick

Lone Star Tick www.cdc.gov

Lone Star Tick www.cdc.gov

 

Rocky Mountain Spotted Fever  – Brown dog tick,  American dog tick, and Rocky Mountain wood tick

 

Tick causing RMSF www.cdc.gov

Tick causing RMSF
www.cdc.gov

What are the symptoms that I should be concerned about if I am bitten by a tick?

  • Fever/chills: With all tickborne diseases, patients can experience fever at varying degrees and time of onset.
  • Aches and pains: Tickborne disease symptoms include headache, fatigue, and muscle aches. With Lyme disease you may also experience joint pain. The severity and time of onset of these symptoms can depend on the disease and the patient’s personal tolerance level.
  • Rash:  The rash can vary according to what disease process is causing it.

What does the rash look like?

Erythema Migrans www.webmd.com

Erythema Migrans www.webmd.com

In lyme disease the rash may appear within 3-30 days, typically before the onset of fever. The rash of Lyme Disease is the first sign of infection and is usually a circular rash called erythema migrans, which initially occurs at the site of the tick bite in 70-80% of those infected.  This rash can develop in other areas of the body several days after being bitten. Characteristically, it is warm, but is not usually painful.

The rash of southern tick associated rash illness is very similar to that of Lyme disease, with a red, expanding “bulls eye” lesion that develops around the site of a lone star tick bite. Unlike Lyme disease, STARI has not been linked to any arthritic or neurologic symptoms.

The rash seen with Rocky Mountain spotted fever (RMSF) is not consistent from person to person. It can vary from person to person in appearance, location, and time of onset.  There are also people who will not develop a rash at all. The CDC explains that the most common presentation of the rash begins 2-5 days after the onset of fever as small, flat, pink, non-itchy spots (macules) on the wrists, forearms, and ankles and spreads to the trunk. The red to purple rash that is most commonly associated with RMSF, is usually not seen until the sixth day or later after onset of symptoms and is found in only 35-60% of patients with the infection.

To learn more, please visit the following references online.

http://www.cdc.gov/ticks/

www.tickinfo.com

For information on tick borne illness in West Virginia.

http://www.dhhr.wv.gov/oeps/disease/zoonosis/tick/pages/default.aspx

FUTURE BLOG POSTS…. We will discuss mosquito borne illness and insect repellents.

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This post was written by Aaron Santmyire, APRN-BC, DNP

Sebaceous Gland Hyperplasia

www.crutchfielddermatology.com

Courtesy of   www.crutchfielddermatology.com

Sebaceous Gland Hyperplasia are common yellowish flesh colored papules or bumps usually seen on the face.  They generally have a central indentation in them.  To the naked eye, these look a lot like a basal cell carcinoma, the most common type of skin cancer.  However, on further examination you can see a difference.   To complicate matters, there is a malignant growth of the oil glands called sebaceous carcinoma.

Most patients over 40 have at least a few of these.  Many patients have hundreds.  They are often a cosmetic concern.

I like to describe them by using a head of broccoli.  Normally, if you look at the oil or sebaceous glands under the microscope they look like an upside down head of broccoli, where the florets are the oil glands and the stalk is the pore.  The oil glands are held in the skin by collagen and elastin that give the skin structure.  As we age, with sun damage and with rosacea, the oil glands will often flower up above the level of the skin.  So, in sebaceous gland the broccoli head is correct side up and the florets overgrow.

ww.uky.edu

Normal Sebaceous Gland. Courtesy of  www.uky.edu

Courtesy of www.pathologyoutlines.com

Sebaceous Gland Hyperplasia.  Courtesy of www.pathologyoutlines.com

 

 

 

 

 

 

 

 

How are they treated?  For patients that these are a cosmetic concern, we usually treat with electrodessication ( burning with a hot needle).  In this procedure, the objective is to melt the oil glands down and make a microscopic scar to prevent the oil glands from growing.  Insurance usually doesn’t cover this treatment, so it is an out of pocket cost.

Can they be prevented? Not really completely, but use of tretinoin or RetinA can help reduce the number that are developing by building up collagen and elastin in the skin.

If you have one of these that is growing out of proportion to the others, please have it checked by a dermatologist to be safe.

Parkinson’s Disease and Metastatic Melanoma

Yearly screening needed for those with Parkinson's Disease

During the month of May the blog posts have focused on melanoma. In the office we have been educating and emphasizing the need for regular skin exams and specifically focusing on melanoma.  Understandably so, the word “melanoma” is a word that can provoke a sense of panic, fear, and concern because of its propensity to metastasize (or travel to other parts of the body).  When melanoma does metastasize, its growth in other organs of the body can affect the life span of the individual. The key to preventing the metastasis is early detection and treatment of melanoma before it has the opportunity to metastasize and have significant impact on life span.

 

By doing regular skin exams, we are able to detect abnormally growing spots, discuss possible risk factors that might put someone at greater risk for developing melanoma, and treat those who have developed melanoma. Some of the more commonly known risk factors that increase the likelihood of developing melanoma include things we can control like our UV light exposure which would include tanning bed use. Others risk factors like family history of melanoma, Caucasian race, age, and weakened immunity are risk factors we have no control over.

 

One of the less discussed risk factors for melanoma is the association between Parkinson’s Disease (PD) and melanoma.  The link between the two diseases is an interesting one because Parkinson’s Disease is characterized by a decreased production of dopamine in the brain and melanoma is caused by increased production of abnormal melanin producing cells.  Another interestingly fact is that those with PD are more likely to develop melanoma and those with melanoma are more likely to develop PD. So you may ask, “What is the connection?” And that was the same question I asked myself.

After searching the literature for an explanation of this positive association between PD and melanoma, I concluded that there does not seem to be clarity in the scientific community. Researchers have investigated and are continuing to investigate the reason for the link between the two diseases, and have developed several hypotheses. However, none of these hypotheses have been able to adequately explain the association.

Although the positive association has not yet been clearly explained, the link between the two diseases is undeniable.  Until it can be identified, it is recommended that those who have PD should have a regular yearly skin exams.  This returns us to one of the first points we discussed that prevention, early detection, and treatment are the keys into taking some of the fear and concern out of the word “melanoma “, so those with PD should have a skin exam regularly.

If you have a family member who has Parkinson’s Disease, please make an appointment for them with a dermatologist today!

This article was written by Aaron Santmyire, APRN-BC, DNP. 20150714-0006

New Genetic Testing for Melanoma

 

Melanoma PicThere are two new types of genetic testing that we are beginning to utilize in the office for our patients.  These tests should help aid in more accurate diagnosis of melanoma as well as more accurate prediction of metastatic risk for early melanomas.

A little background in my simple terms… Along the base of the epidermis, the outer layer of the skin, we have cells called melanocytes that produce pigment in the skin.  When these pigment cells multiply and grow in clumps they make a nevus, aka benign mole.  When these same pigment cell multiply and grow cancerous they make a melanoma, a deadly form of cancer.  The problem is that sometimes, when the pathologist ( the doctor who evaluates the specimen under the microscope) evaluates the specimen it often looks abnormal but not abnormal enough to call it cancer.  These abnormal moles are scientifically called dysplastic or atypical.

The prognosis of an abnormal, dysplastic mole can vary depending on the degree of abnormality.  Generally, the pathologist grades the level of abnormality as mild, moderate or severe.  The degree of abnormality is graded based on the arrangement of the cells, the size of the cells, and the overall appearance of the cells and their nuclei.  Mild is not so bad, and many people have hundreds that are mildly abnormal.  Moderate is in between.  Severe is looking closer to the features that we see in melanoma.  This grading system is very subjective. The problem is with the severely dysplastic ones.  We want to make sure those very abnormal ones are indeed benign.  Unfortunately, a biopsy is a snapshot in time.  We sometimes cannot say from standard methods, which of these severely dysplastic nevi would progress to become a melanoma and which would stay benign forever. Because the follow up and treatment of dysplastic nevi can vary greatly depending on the degree of abnormality, accurate grading of these lesions is essential.  Let me digress and say that nerdy dermatologists have spent thousands of hours and thousands of pages trying to sort this out clearly, but there is still a lot of disagreement about the malignant potential of abnormal or dysplastic lesions. 

This is where our first genetic test comes into play… We send out all of our pathology specimens to a company called Dermpath Diagnostics.  We utilize their services because they are highly trained experts that specialize in skin pathology.  Their level of expertise greatly exceeds that which can be found in most hospitals or general laboratories at no additional cost to our patients. They have a team that works together on difficult cases, and they use the most current scientific techniques to provide the most accurate diagnosis possible.   One test that they are utilizing on more difficult cases of dysplastic nevi is called MyPath by Myriad Diagnostics.  MyPath is a genetic test done on the skin biopsy specimen that is sent to the dermatopathology laboratory.  In difficult cases, where the dermatopathologist is unsure if the lesion is likely to remain benign or become malignant, this additional test can give a more accurate diagnosis.

The result provided by this test is an objective, not subjective, numerical score that classifies a specimen as “likely benign, likely malignant, or indeterminant” with a great amount of certainty compared to traditional methods of analysis.  This is NOT a test that is done on every specimen, just those with more severe suspicious features.  It is up to the dermatopathologist to decide when this test is necessary to provide a more accurate diagnosis.  Those that are “likely benign” can be treated more conservatively, and those that are “indeterminant or likely malignant” are treated with more aggressive excision of the lesion and closer follow up evaluation.   Our pathologists are now using this additional test to help provide the most accurate diagnosis possible.

Melanoma Staging The second test is also done on the skin specimen that is sent to the lab, but the purpose is a little different.  This test is for lesions that already have been definitively diagnosed as melanoma.  Traditionally, staging of melanoma is directly related to how deep the melanoma grows into the skin (Breslow’s depth) as illustrated in this simplified diagram (Courtesy of www.yervoy.com) or the more complex detailed table.

 

But when I tell someone that they have a melanoma, there is only one question in everyone’s mind.  “How long do I have to live?” quickly followed by “What do we have to do to help me live longer?”.  Luckily, most melanomas we diagnose in the office are the earliest stage, Stage 0, which has a great prognosis of 95% 10 year survival rate.  For more detail on outcome based on staging look here.

The next genetic test is for Stage 1 and 2 melanomas.  In these stages, there is no evidence that the melanoma has spread to the internal organs.  This new test determines the likelihood that early (Stage 1 and 2) melanomas will progress to be metastatic and deadly.  The goal is to monitor and treat more aggressively those with higher metastatic potential.  Melanoma DecisionDx  is a new test offered by Castle Biosciences .

In the past we have used a test called Sentinel Node Biopsy where we test the lymph node to see if there is any melanoma in the lymph nodes.  This was the best method of predicting which melanomas were more likely to become deadly.  Those with lymph node involvement traditionally receive more aggressive follow up and treatment than those without lymph node involvement.  It is well known however, that 2 out of 3 patients who develop fast progressing deadly metastatic disease had normal lymph nodes at the time of diagnosis.  So, it would seem there is some room for improvement in accurately predicting which patients will need more aggressive therapy.

Melanoma DecisionDx analyzes the genetic expression of 31 genes known to be involved in melanoma.  This test provides a value which predicts disease free survival.

Class 1  -Low Risk provides a 3% likelihood that the melanoma will spread to the internal organs in 5 years.  In more simple terms, these melanomas are very unlikely to impact a patient’s life span.  These patients will receive traditional monitoring.

Class 2 – High Risk provides a 69% likelihood of having metastatic disease to the internal organs within 5 years.   In more simple terms, these patients are more likely to have a shortened life span, which may be lengthened by more aggressive treatment and monitoring.

To learn more, you can watch the following video or download an informational handout about Melanoma DecisionDx.

 

Of course, the best course of action for melanoma is prevention and early detection.  However, it is wonderful to now be able to utilize these new tests with hopes to improve long term outcome and survival.  If you have had a melanoma recently and you would like more information about utilizing these tests, please schedule an appointment to discuss this in more detail.  If you have a friend or relative who has been recently diagnosed with melanoma, please share this vital information with them.