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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP 5. - Common Problems
RADIO 4
THURSDAY 30/12/04 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
ANN ROBINSON
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello today it's your questions on the everyday problems that take you to the doctor again and again and sometimes again. Coughs and colds, skin rashes and muscular aches and pains are among the common reasons for making an appointment to see your GP. But today you don't need to book - the doctor on call today is Dr Ann Robinson and as well as answering your medical questions she will, I hope, give us all some advice about getting the best out of our doctor, whatever our health problem.
Ann, I'm wondering if it is reasonable for a patient with a common problem to keep coming back and back and back again if necessary to get treatment, to get advice?
ROBINSON
Well I think if you're having to go back and back and back you shouldn't be the one who's apologising - your doctor should be apologising to you. After all you have a right to be heard and although the doctor can't necessarily cure all your ills, you should leave the room - preferably after the first consultation - feeling that you've been heard and you've got a clear sensible management plan which you find helpful.
MYERS
Thank you very much, let's see if we can help the callers on the line today. John Bryant is the first to get through and John has a problem with a very common condition - a skin rash. Where and for how long John?
BRYANT
Hello, yes my skin rash developed in March and it's under the arm, I believe it's called seborrhoea eczema. I've had it now for some time, it does vary in intensity but I can't seem to clear it. At the moment I'm using a cream which is a nystan and hydrocortisone based and it seems to keep it soothing. I have seen a consultant dermatologist, his diagnosis was the effect due to perhaps a washing powder but he suggested changing that, I've done that and that hasn't had any effect. I have tried various things, for example I'm on hypertension tablets, which I think might cause a rash, so I've decreased those but at the moment nothing seems to happen. It seems to vary in intensity from time to time.
MYERS
Let me put your question over to our expert - Dr Ann Robinson.
ROBINSON
Oh hello John, I'm sorry to hear that you're having all this trouble because I know although it doesn't sound - it's obviously not life threatening, having itchy armpits day after day can be really stressful. It sounds like you're doing all the sensible things by avoiding washing powders if possible, perhaps by washing your clothes through on a wash without any soap powder in at all. I mean obviously other chemicals like shower gel and soap should also be avoided, in other words contact with all chemicals. One thing you mentioned about the blood pressure pills, although drugs can very commonly cause rashes, if it's just under your armpits it's really unlikely to be your pills and if I were you I wouldn't necessarily decrease the medication, because obviously that will have an impact on your blood pressure and you know you don't want to have a stroke or anything like that just because of the armpits. So I wouldn't advise you to do that. The nystan and hydrocortisone mix of creams is a typical example of how all of us doctors hedge our bets - it's part antifungal and part steroid, which is sort of anti-eczema. As a GP I always find it really reassuring when people go off to a specialist and come back with this same sort of concoction that we tend to dole out when we're not really sure what something is. I mean the truth is you're covering both bases there but very often an itchy rash under the arms is actually more to do with thrush than with eczema and you might find it useful to use just an antifungal like Canesten cream. This is something you can discuss with your doctor.
BRYANT
Sorry what cream was that doctor?
ROBINSON
Either Nystan cream, which is similar to the stuff you're on, or Canesten cream - these are the common antifungal ones. You certainly shouldn't keep on using steroid creams for ages and ages - they start to thin the skin and actually become less useful the longer you use them. So short sharp courses of the steroid cream, just a pure steroid cream, perhaps a bit stronger than the one that is in your mixture, when it's very bad and perhaps a separate antifungal cream. And these are things that your GP could advise you on very well. The other thing I'd say is if you've been using a cream for ages and it hasn't worked at all stop using everything for two or three weeks and just see, because sometimes you're actually developing a bit of an allergy to the cream itself and just come off everything for a bit. But don't give up the blood pressure pills.
MYERS
John I hope that's been helpful. We will move along because we have a couple more calls on skin rashes.
BRYANT
Thank you very much indeed.
MYERS
Thank you very much for your call. Just before we go to our next caller, just to ask Ann about rashes, can you as a doctor then more or less tell what kind of rash it is when you see it, is it important for you to put an eye to it?
ROBINSON
Oh yes, I mean you definitely - you have to be able to see it, we quite often have people who phone up and try and describe their rash down the phone and I really have to say no please, come and show me, there's no substitute for seeing it. Most rashes are eczema, which is irritation of the skin, quite a lot are fungal and everything else can be grouped together as much, much rarer.
MYERS
We'll go to Clare Dawson who's waiting to describe her rash - what's your rash and where is it?
DAWSON
Well I've got this rather unusual sort of swollen rash on my left palm, only on my left palm and not on my right.
MYERS
Ah - and are you left or right handed?
DAWSON
I'm right handed. I've tried to work out what it could be from, what I do with one hand and not the other and I've come up with a few ideas. But I've tried altering the way I do things and it doesn't seem to affect the rash - it sort of goes away and then it comes back again.
MYERS
And is it itchy or painful?
DAWSON
Very, very itchy, incredibly itchy.
MYERS
Right over to the doctor.
ROBINSON
Clare, do you have any ideas of things that you do which are then followed by the rash coming up?
DAWSON
Well unfortunately I can't link it to anything but I have thought of a few things like grooming the dog, where I take the hairs into the left hand, so I put a little glove on for that. Doing the potatoes, although I do put them into the pan with two hands but I do hold them in the left hand. And shampoo as well - I've changed my shampoo. But all of a sudden it just flares up for no reason and it's so itchy it wakes me up in the night so I put that E45 cream on it and then it goes away and then it just comes back again for no reason that I can pin it down to.
ROBINSON
And about how long does it last for?
DAWSON
About a week.
ROBINSON
And do you get any blisters associated with it?
DAWSON
No but I looked at it through a magnifying glass and I can see little tiny pinpricks of red, just tiny weeny little - you can only see them really through the magnifying glass.
ROBINSON
Well an itchy area that comes up like that is one of two things. By far the most likely is that it's something called urticaria which is an allergic reaction really to - if you get widespread urticaria it can be to something you've eaten, sometimes people get it after eating strawberries or kiwi fruit or things like that. Or you can get a localised urticaria, especially if you've been in contact with something.
DAWSON
I do have a food allergy to wheat.
ROBINSON
Right well I mean if you are a slightly more allergic person then you will be much more prone to urticaria and I think that's probably what you've got. Now the urticarial reaction, once it comes up, often recurs and most people just learn to live with it and very often can't find - as you've said - can't find a specific trigger. All the things you're doing sound really sensible, like wearing gloves to protect your hands against things that could be potential triggers. It's always a good idea to keep the hands at a fairly steady temperature - some people get urticaria at extremes of temperature, particularly cold. I mean it is a bit unusual that you can get urticaria on kind of one part of the body and not the other but that is the way it works sometimes. And apart from avoiding potential triggers and protecting the hands as you're doing, really taking an antihistamine by mouth is the only way you can help it to go down quicker.
MYERS
And is there any more you can say generally about urticaria, as to what we understand by it, I mean is it something you see very frequently and would these be the symptoms and what really is the cause?
ROBINSON
Yeah, well we do see it fairly frequently and nobody knows exactly what the cause is but it's definitely the immune system overreacting to a specific trigger. And people who are allergic, whether it's food allergies or allergic sort of conditions like eczema and hay fever and asthma are more prone to it. We don't really understand why some people are more prone to it than others but there's often a genetic link.
MYERS
Thank you very much for the call Clare.
DAWSON
Thank you.
MYERS
And on we go. Our next caller is on the line now and we're going to be talking to John Barter. John, hello, what's your question please for Dr Ann Robinson?
BARTER
My problem is that about four years ago I became allergic to a shampoo who changed their formula. I've been to see a doctor, they prescribed several ointments, all of which contain hydrocortisones. What they do is they either do nothing or they strip the skin from my hands and fingers. But my symptoms are literally hundreds of blisters that periodically, that's to say over about two months, come up and go down. It's like a cyclic thing. It means I'm unable to use my hands for days at a time. I was wondering if there's any suggestion as to what I can do to alleviate this.
MYERS
Well it sounds very painful and very inconvenient if you can't use your hands, that's not good for business is it.
BARTER
No it's not. I take to wearing cotton surgical type gloves inside lightweight do-it-yourself gloves with the little rubber beads on the yellow fabric, this gives me the ability to move my hands fairly well but I keep applying the ointments and aqueous cream throughout the day.
ROBINSON
Hi John. Can I just ask what you do?
BARTER
Yes I deliver things.
ROBINSON
And do you drive a lorry or ...
BARTER
I'm afraid I do, yes.
ROBINSON
And is the steering wheel rubber?
BARTER
No, but the steering wheel of my car definitely triggers this.
ROBINSON
Right.
BARTER
The lorry I don't think does - my car definitely does.
ROBINSON
So you notice after you've been driving your car for a long time that the blisters tend to come up?
BARTER
Well no I always drive wearing gloves.
ROBINSON
Right.
BARTER
I know it's in the car because I went on holiday earlier this year without gloves and the result was a mess.
ROBINSON
Right. Well the small itchy blisters that you're describing on the palms of the hands sounds very much like a form of eczema or irritated skin which has got the great name of Pompholyx, it's just a sort of Greek name they give to it. But anyway it's got a name, which people often find reassuring, even if that doesn't cure anything. And it does tend to come up exactly as you describe - sort of time after time - and drive people crazy with the itchiness of it. It's very often triggered by contact - now it might be that the first trigger was the change of formulation of shampoo or that might be a coincidence. It's very possible that your hands are allergic to rubber or to whichever substance is on your steering wheel for example and also the symptoms will tend to get worse - the itching will tend to get worse when your hands are hot. So although it's excellent to wear the cotton gloves inside other gloves, from the point of view of preventing contact, you might find it slightly exacerbating it.
MYERS
We've lost the line but never mind keep going.
ROBINSON
Sorry John I hope you can hear out there. But you might find that the heat is certainly exacerbating it. Anyway what I would suggest you do is definitely try and avoid contact with rubber, get your GP to refer you to an allergy specialist or skin specialist for specific allergy testing for rubber and other products that might be making it worse. And this is important when it's a work related allergy because you need to be able to avoid it. Try not to let your hands get too hot, so possibly just wear the white surgical cotton gloves without hotter gloves on top. And put your steroid cream or preferably ointment, on only at night, it just gets rubbed off during the day and gets mucky and isn't really doing much, but put it on at night with the cotton gloves on top. And don't use it for weeks and weeks at a time, just use it for 10 days and then stop using it for a bit and see if that helps.
MYERS
Alright. Let's go to Emma Arnold who's on the line. Emma, what would you like to ask?
ARNOLD
Oh hello. My daughter is 10 and when she has a cold it will last for nine or more weeks. She seems to have a cold most of the winter really. Could there be an underlying cause or are there any supplements that you could recommend because it leaves her quite below par for the time she has it?
MYERS
Oh it sounds miserable.
ROBINSON
Yeah poor little thing. Hello Emma. Well the average school age child gets four to five bad coughs and colds a year, that includes ear infections. And as we all know gets most of them in the winter time. That's not because of anything other than the fact that children are herded together in rather poorly ventilated classrooms often and so of course just pick up one bug after the other from their classmates. So it might well be that your daughter is getting her four to five coughs colds a year seemingly all in one go from her classmates and hopefully because of Christmas holidays will get a bit of a break from her friends and her bugs - and their bugs. That's probably all there is to it and really the way to prevent coughs and colds is to make sure that children don't get crowded together too much and that the teachers keep the windows open and allow them in the playground, even when it's drizzling a bit. But I know in my own children's school that I'm always fighting a losing battle when I say that to the head teacher and surreptitiously go round opening the windows when no-one's looking. It's difficult, I mean it sounds - I'm not being frivolous really because we know that the crowding together is what causes these coughs and colds and that there has been work on supplements like Echinacea and zinc and vitamin C but frankly the evidence is poor and I'm always really nervous about giving any medicine really to any child because these medicines, although they almost certainly are safe, haven't been tested in randomised controlled trials on 10 year olds.
MYERS
So if there are no supplements that might help and this is, as it were, par for the course four or five colds a year, would there be any point actually in someone with a cold or a family member with a cold coming to see the doctor - perhaps they're just likely to spread it to your other patients?
ROBINSON
Yes or get something even worse in the waiting room. But no there isn't a tremendous amount of point but the only thing to say is that if a child is coughing for nine weeks they could very well have a touch of asthma and it is worth diagnosing that and getting a salbutamol inhaler and putting the child out of their misery by letting them have a few puffs, especially in the evening, so they can sleep through the night without - without coughing and they can wake up without that horrible dry cough. So I think it's certainly worth going to see the doctor if you're concerned about a long term cough. And the other thing to say is that if your child has a runny nose for 9-10 weeks continuously she might very well be allergic to something. I don't know - do you think that might be the case Emma?
ARNOLD
It's not something we've explored but it's a good idea to look into it.
MYERS
Alright thank you very much for the call Emma. We'll go to our - another caller with a cough, I don't know if it's a cold, but Mrs Price is waiting to speak to us. Hello Mrs Price.
PRICE
I had a quadruple heart by-pass four years ago which was really very successful and soon afterwards I seemed to develop a cough, mostly sort of in the mornings for about two to three hours after I got up and I put up with that for a while and then I went to see the doctor eventually who referred me to a consultant and I've been seeing a consultant on and off during those four weeks and it just seems as though nothing can be done about it. I've been tested and I've been on antibiotics and inhalers and just nothing seems to make any difference to it whatsoever.
MYERS
Oh that's very unfortunate isn't it, so you spend - what - an hour or two coughing everyday?
PRICE
Well I do yes.
MYERS
Alright well let's see what Dr Ann Robinson has to suggest.
ROBINSON
Hello Mrs Price, I'm very pleased to hear that the heart by-pass is so successful, that's great. Just a few thoughts. Do you take any medication after your by-pass, such as drugs called an ACE inhibitor do you know?
PRICE
...I'm on, yes.
ROBINSON
You are taking an ACE inhibitor?
PRICE
Yes, yes. I had those changed actually when I first saw the consultant, thinking that probably could be it, but again it has made no difference at all.
ROBINSON
Well the drug's called ACE inhibitors which are really excellent drugs for treating high blood pressure and also for protecting the heart after heart disease, they're an excellent group of drugs but they almost all can cause a long term cough as a side effect. And a lot of consultants just sort of thing well you know people should put up with it. But there are a few things you can do. One is sometimes changing to a different ACE inhibitor helps ...
PRICE
Well as I say they did do that very early on.
ROBINSON
But sometimes really most often people who are sensitive to one ACE inhibitor will be sensitive to all of them. So the cardiologist may recommend one of a few things - and your GP can just write to the cardiologist asking for advice - one thing you could do is change to a different group of drugs entirely like beta blockers - which also protect the heart.
PRICE
I'm on beta blockers as well actually.
ROBINSON
Well it might be that the cardiologist feels that having done so well you could just be on the beta blockers and any additional benefit you're getting from the ACE inhibitor is pretty minimal, so you could probably come off them. And the other thing I would ask to do is be referred possibly to a speech and language therapist becomes sometimes they're incredibly helpful in helping people to talk and breathe and operate without coughing. And now that you've been told there's nothing really serious going on in the lungs that might be an excellent way to go ahead.
MYERS
Mrs Price we'll I think have to leave it there, it sounds as though you're very well up with the game and have certainly pursued it and you need to go back to your doctor, I guess, for a referral to that specialist.
PRICE
Thank you very much.
MYERS
Thank you and thanks for the call. We'll go to an e-mail next and we have one from Gillian Ryan and she says briefly that she wakes up with headaches and pains and doesn't know what to do. She does add that she has scoliosis of the spine - twisted spine. Now aches and pains are very common I know - something you see day in and day out - what would you suggest to Gillian Ryan though - waking up with headache and pain everyday?
ROBINSON
It sounds like Gillian has got a tendency possibly to getting strain on the neck and the little nerves that come out of the spine at the level of the neck very easily get trapped if the spine is a bit arthritic and especially if she's got scoliosis, that means that the spine is bent in a slightly unusual way and that can obviously put more strain on the rest of the spine. So if you wake up with an aching head or a feeling of tension or pins and needles down your arms, in the shoulders or shooting up the back of your head and right across to the temples it almost always means that the way you've been sleeping has put traction on the little nerves that come out of the spinal cord. And the trick is really to try and protect your neck while you're sleeping. I'm a great advocate of the kind of C shaped pillows or the V shape that you can buy in big department stores that do protect the neck while you sleep. Sometimes you need to get a better slightly firmer mattress as well to support your spine.
MYERS
Would that be a general rule for anyone who wakes up with muscular pain, that perhaps sleeping in an uncomfortable bed has been part of the problem - whether it's the mattress or the pillows?
ROBINSON
Yes, I mean we spend about eight hours a night in bed and we probably pay less attention to our bed and pillows than we do to maybe a couch or something that we sit on for 20 minutes a day. So it does pay if you're waking up with pain to pay a bit of attention to the mattress and the way you're sleeping. Sometimes people are helped by taking a couple of paracetamols, just before they go to sleep and that gives them a bit of cover, so they don't wake up. The problem with the sort of pain that you wake up with is that if it's been generating during the night and then you wake up in pain it obviously makes you feel very tense and uncomfortable and then you tend to tense up your shoulder muscles and that just obviously compounds the problem. So if you can ease yourself into the morning a bit more gently by taking a couple of paracetamol at night that's a good idea.
MYERS
Ann, we're dealing generally in this programme with these common conditions, sort of self-limiting, certainly not life threatening, and skin, colds, coughs, general headaches, pains, but actually how do you know that these are not the start of something more serious or a symptom that really is indicative that there is something that should be taken more seriously and is a very good reason to make sure you do go to the doctor and don't just try to handle it yourself?
ROBINSON
Yeah I think that's a really good point because we all want to know how do I separate out the headache from the brain tumour, how do I know that the cough isn't the start of lung cancer? That's what is at the back of our mind when we're kind of concerned about these conditions. But there are a few, what we might call, red flags which should generally speaking send you along to a GP with a symptom. One is pain that wakes you up at night, most pain doesn't wake you up in the middle of the night, sometimes it stops you getting off to sleep but it doesn't usually wake you up at 3 in the morning, so night pain. Symptoms that have gone on for longer than six weeks - a hoarse voice that has lasted more than six weeks could be laryngeal cancer, a hoarse voice that just came on yesterday is probably just because you were shouting. Weight loss - abnormal weight loss - most of us are always fighting the inevitable weight gain but sudden unexplained weight loss is worrying. Sudden unexplained high fevers and certainly the sudden onset of an unexplained lump. These are all things that should drive us to the GP fairly promptly and demand to be heard. And the other thing is that it is still quite legitimate to go along with any symptom that is really worrying you, especially if you have a deep rooted feeling that this is a bit different from anything you've had before.
MYERS
Do you think that patients do know themselves quite well and that when they say they are worried and continue to be worried you would want to check and double check?
ROBINSON
Yes, I think parents know their children and I think adults know themselves and if somebody is really concerned no doctor worth their salt should ignore that.
MYERS
Ann, what are your rights to asking to be referred for a specialist opinion?
ROBINSON
Well you have every right to ask forcibly to be referred for a specialist opinion and GPs who refuse to refer people are on a very sticky wicket and you can make that the subject of a complaint. But you know hopefully you'll never need to. No, ultimately you just need to say I'm afraid I do understand where you're coming from but I do want to be referred.
MYERS
All very good advice in this special edition of Check Up. Thank you very much indeed Dr Ann Robinson. And that's where we leave it for today. But not for this week because I will back again on Saturday with a special New Year's edition of Check Up when we're dealing with your calls on the problems that you don't take to the doctor, though perhaps you should. It could be that you don't like to bother the doctor or maybe you're embarrassed to say what's wrong with you. Till then bye bye.
ENDS
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