Chicken Pox: How Does It Looks Like?

Chicken pox is a very common childhood virus infection. It is caused by varicella zoster virus and is extremely contagious. The virus spreads through droplets (exhaled air, coughing, sneezing) and contact with fluid from skin lesion (direct contact, sharing towel etc). The virus can survive outside human body in the environment for few hours.

Once you know that your child's schoolmate has chicken pox with skin rash, it is usually too late to avoid infection to your child unless there is no real close contact between them. This is because the infected child is able to spread the virus even 2 days before the rash appears.

If after contact with a chicken pox child for one week and your child still seems alright, it still does not mean that your child is not infected, as the incubation period for the virus is between 10-21 days. Usually the first symptoms to appear are rather non-specific such as mild fever, body ache, minor cough or flu symptoms. Most people only aware of the infection after the body rash appears.

Chicken pox rash is quite obvious and there are generally three stages. The first rash to appear is like a red dot, which will then progress to blisters that will eventually burst and become crusted (scabs). Typically the rash appears in crops, which means that at one time these three types of rash will appear together.

      Rash appears in crops

       Typical chicken pox rash

Chicken pox rash usually will last for 5 days. The infected child is considered non-contagious once all rashes have become scabs (dry). The infected child usually can return to school/nursery 1 week after the rash first appears.

There is no specific treatment for chicken pox other than symptomatic relief for fever/pain and itchiness. Antiviral is indicated only in some special circumstances such as in immuno-compromised child or when complication occurs.

Chicken pox can be prevented through vaccination. Young children can get the vaccine after 12 months old. For children more than 12 years old or adult, two doses given 6-10 weeks apart is recommended. 

Various Types of Hair Loss

Normal human hair grows in a cycle consists of 2 phases: growth phase and rest phase.

In growth phase (anagen) which lasts for 2-3 years, the hair grow about 1cm a month. After that, it enters rest phase (telogen) which lasts for 3-4 months. During rest phase, hairs stop to grow. At the end of rest phase, the hairs will fall and a new cycle of growth phase will begin. A person normally shed 50-100 hairs a day.

Causes of hair loss:

• aging
• 40% of men by 35 years old and 65% of men by 60 years old have noticeable hair loss
• 50% of women by 50 years old have noticeable hair loss

• genetic 
• more prone to develop hair loss if one of your immediate family has it

• poor nutrition
• iron, zinc or protein deficiency

• medication
• warfarin, fibrates, anti-acne, ACE-inhibitor, calcium-channels blockers, allopurinol, anti-thyroid drugs, epilepsy drugs, birth control pills etc

• male-pattern baldness (androgenic alopecia)
• hair loss at both temporal areas & the top
• treated with oral finasteride / topical minoxidil

• female-pattern baldness (androgenetic)
• hair thinning at the mid-line top
• treated with oral anti-androgen / topical minoxidil

• telogen effluvium 
• hair growth enters into telogen phase prematurely, triggered by body insult / stress such as: emotional/physical stress, surgery, starvation, high fever, serious illness, extreme diets, childbirth etc
• hair loss starts 3-4 months after the stress event
• reversible after the stress factors subside

• anagen effluvium
• caused by chemotherapy drugs where actively growing hairs at anagen phase are most affected

• tinea capitis (scalp fungal infection / ringworm)
• itchy red scaly scalp with patchy hair loss
• treated with topical anti-fungal 

• alopecia areata
• autoimmune disorder with exact cause unknown
• non-scarring patchy hair loss
• may regress (hair grow back), recur or progress to total baldness
• treated with topical steroids/minoxidil or monthly steroid injection

• cicatricial alopecia (scarring)
• caused by inflammation and damage to hair follicles
• patchy and permanent hair loss
• associated with SLE and lichen planus

• traction alopecia
• caused by regular use of hairstyles that tightly pulling the hair
• patchy hair loss and non-permanent hair loss

• hormonal changes
• hyper- or hypothyroid
• diabetes
• childbirth / menopause

• excessive hair styling
• chemicals used & over-styling

• trichotillomania
• a mental disorder with irresistible hair-pulling
• patchy bald areas

Urticaria: A Common Problem

Urticaria, hives or wheals are raised, pink or red skin lesion that are usually associated with allergy. The lesion can be generalized or localized at certain body parts. It is a fairly common problem that everyone will experience in their lifetime. Some are mild, but some can be serious.

When the mast cells are stimulated by allergens, they release certain chemical mediators such as histamine etc. These mediators result in the dilation of the small blood vessels in which fluid will leak out from the vessels into the tissues under the skin, causing the swelling in urticaria and the itchiness.

       Urticaria rash

Urticaria can be classified into a few types depends on its clinical manifestation

• acute (last<6 weeks)
• chronic (last>6 weeks)
• episodic (acute & intermittent)

Common causes of acute urticaria are allergy to certain foods or medication, insects bite and viral infection esp in children. The urticaria emerges within few minutes to few hours after the contact with allergens and typically goes away within a day.

If the urticaria does not really goes away and persist for more than 6 weeks, then it is called chronic urticaria. The causes for chronic urticaria are more complex and may overlap with causes of acute urticaria. 

Causes of chronic urticaria include:

• Physical
• dermatographism
• pressure
• cold
• heat, exercise, stress (cholinergic)
• sunlight
• water (aquagenic)
• vibration

• Food consumption (milk, nuts, eggs, seafood etc)

• Insects bite/sting (scabies, bedbugs, fleas etc)

• Contact urticaria (latex, animals, foods etc)

• Medication and drugs
• aspirin
• NSAIDs
• ACE-inhibitors
• opioids
• alcohol

• Autoimmune conditions 
• urticarial vasculitis
• systemic lupus erythematosus (SLE)
• autoimmune thyroid disorders
• rheumatoid arthritis

•  Infection
• hepatitis B
• mycoplasma
• streptococcus
• herpes simplex virus
• helicobacter pylori
• mycobacterium tuberculosis

• Chronic idiopathic urticaria (no cause can be found)

The actual cause for chronic urticaria is not easy to determine accurately. History from the patients is important and it can suggest physical, medication and food related urticaria. For example if the urticaria rash appears after a hot bath, then it is likely a cholinergic urticaria. Physical challenge can be done if physical cause is suspected.

       Papular urticaria

Laboratory tests are mainly done to rule out the presence of autoimmune disorders in chronic urticaria. Acute episode usually does not need any test. Tests that can be done include complete blood and differential count, ESR, CRP, IgE, ANA, RF, complement, thyroid function and its autoantibodies. Skin biopsy is beneficial only if urticarial vasculitis is suspected. 

The type of tests to be done depends on clinical evaluation by the doctor. If no cause can be found after thorough examination and investigation, the urticaria is referred to as chronic idiopathic urticaria.

Most common and useful treatment for urticaria is oral non-sedating anti-histamine (2nd or 3rd generation). If anti-histamines do not work well, other types of medication can be tried. If you know what is the most likely precipitating cause, then try your best to avoid it. Sometimes chronic urticaria may improve after a few years.

Blood Blister In The Mouth

Sometimes you wake up in the morning and notice a black dot inside your mouth. You look closely into the mirror and notice that it looks like a blood-filled blister. Is it a serious problem?

It may be the first time you notice it, or it may have come and go for a few times before. Most likely the blood blister is caused by break of small blood vessels (capillaries) on the inner side of the mouth. If the bleeding continue, the lesion may enlarge. When the bleeding stops, the lesion will usually disappear within few days time. There may be slight pain or no pain at all.

       blood blister at inner cheek

This condition is usually benign, and is said to caused by minor trauma or injury to the oral mucosa. The trauma can be from chewing hard food, hot food, dentistry, brushing teeth, oral treatment, accidental self-biting during sleep etc. This condition is also called "angina bullosa hemorrhagica".

Nevertheless, you need to rule out whether you bleed abnormally easily or not. You need to check whether you have blood blisters elsewhere in the body other than inside the mouth. If you have easy bruising, easy bleeding from gum or nose and your wound is slow to clot after injury, you might need to check your blood for platelet count and coagulation profile. Low platelet (thrombocytopenia) can cause easy bleeding, which is not very uncommon.

Sometimes the blood blister could be "pyogenic granuloma", which is actually a bunch of abnormal capillaries present as a red nodule and can bleed easily. Compare to angina bullosa hemorrhagica, pyogenic granuloma can occur on the skin all over the body. Its size can be large and may not heal even within weeks. Pyogenic granuloma is more common in children while angina bullosa hemorrhagica is more common in older adult. 

       pyogenic granuloma

If the blood blister in your mouth come and go within few days, and you don't have any other problems such as fever or easy bleeding elsewhere, then it is probably angina bullosa hemorrhagica and is completely benign. If you are still worry, you should see a doctor and perhaps check your platelet and coagulation profile.

Shingles: Can it spread?

Shingles and chickenpox share a similarity: they are both caused by varicella zoster virus. Shingles is also called Herpes Zoster. Can shingles spread to you? Well, it’s a bit complicated: shingles cannot spread shingles but can spread chickenpox; chickenpox can spread chickenpox but cannot spread shingles.

In other words, if you haven’t got chickenpox yet, you can get chickenpox from a person with chickenpox or shingles. If you already have chickenpox, of course you won’t get chickenpox anymore and you CAN’T get shingles from a person with shingles. If you already have both chickenpox and shingles before, then you can’t get both anymore.

Shingles only can occur in people who already have chickenpox before, where the virus remains “hiding” in the nerve. For some not so well-understood reason (usually related to poor immunity), shingles will pop up as a patch/patches or a band of blisters. It can be at any part of the body but not all over the body. It is more common in elderly >50 years old.

    Blisters in clusters

Shingles is extremely painful, and it usually last 2-4 weeks, sometimes it heals with scar. Anti-viral drugs if given early enough within 72 hours may reduce the severity and duration of shingles. Strong pain-killer is certainly required. Sometimes the pain may last for > 1 month even after the skin lesion has disappeared. This is a complication called post-herpetic neuralgia which can happen in about 10-15% of people with shingles. This troublesome condition may require more potent medicine to control the pain.

Not like chickenpox, shingles cannot spread through the air. It is transmitted through direct contact with the blister fluid. Thus, if you don’t want to get chickenpox, you not only need to avoid contact with chickenpox sufferers, but also shingles sufferers as well. Or you may consider getting a vaccine for chickenpox.

PUPPP -> PuPP-P -> PUPPY

If you are in the 3rd trimester of pregnancy and you feel very itchy all over the body and you see some rash, you may have PUPPP. PUPPP stands for Pruritic Urticarial Papules and Plaques of Pregnancy. What a long name! Luckily we can write or read as PUPPP. (Pruritus = itchy)

Though the name is long and sounds scary, PUPPP is completely a benign (not-serious) skin problem. It occurs in the third trimester (after 28 weeks) of pregnancy. It usually starts at the abdomen where there are striae (stretch marks) and spread to other areas. It seldom involves face, palms and soles.

The skin may have raised spots (papules) or patches (urticaria) of red rash. No one knows why it happens. However, what we know for sure is that it won’t affect the mother and the baby. It will resolve by itself 1-2 weeks after delivery.

    

 PUPPP: Dots and Patches of rash

The big problem is…. It’s very itchy and you can’t sleep well! For this, doctors will give you rather strong steroid cream to relieve the itchiness and redness. Use it sparingly when the itchiness is less serious. Anti-histamine and moisturizers may also be given though not as effective. Soaking in warm water may help some.

Nevertheless, not all itchy rashes in pregnancy are PUPPP. It can be allergy, eczema, infection etc.