A bit of behavioral therapy

Mr. X was presented with a very unique problem. He was a patient of psoriasis and we prescribed usual medicines that most of the skin specialist start with.

Once he came to know that he has to take a tablet in weekly pattern he started feeling nausea.

Methotrexate is the drug that elicits nausea and vomiting in many patients because of its minor side effect of gastritis in normal or above normal doses.

Then we enquired about his past history of treatments and why he never responded to any of them.

Everytime he went to a skin specialist they give him this medicine which is in weekly doses and Everytime it causes vomiting. He was unable to take this important medicine so there was no improvement in his skin lesions.

This was an example of conditioning response of vomiting to the stimulus of dosing pattern .

Patient was unaware of the medicine name. Just the weekly dose was conditioned with nausea and vomiting. His spouse told us that even a sight of this tablet makes him vomiting. So we made this unique attempt of systematic desensitization of stimulus.

We adviced same thing initially as half tablet and daily doses just to stop conditioned reflex.

Later on we suggested him to reduce days one by one until it comes to two days a week.

The dose was reduced so there was no gastritis and dosing pattern was different than usual methotrexate so conditioned response of vomiting was not elicited.

Mr. X was happy after 4 weeks of treatment and he tolerated well this medicine and almost forgot how he felt initially with weekly doses.

Dotted white Lips : Vitiligo phobia

"Doctor , look at my lips , are they turning white?" This young lady was worried about white spot disease developing on her lips.

"No,its not , what you are thinking about.These are abnormal glands which are giving a pinpoint white appearance. Its not Vitiligo" we assured after examining her lips.

"So what doctor ? They are looking white and even if its not white spot disease but everyone would think so.Please do something" she was not happy with my assurance.

"But these are glands,its the structure of your skin,how can they just go away with medicines?" We always try to satisfy people with less or no medicine no surgery principle.

"All doctors say so, every one says its nothing.But i cant live with these spots doctor .Please do something." She was desperate.

And then we did CO2 Laser Ablation With local anaesthesia. It took an hour of very fine touching of each and every gland with magnification. Lips were turned a little red .

After one week she happily came with all normal lips . Execpt one or two dots still left and she wanted to undergo same procedure again .

"No doctor, its not possible"

"Look at this doctor, she is having these itchy rashes all over her body " while her mother was very  tense and explaining her problems with little exacerbation,  that cute small child was playful with the paperweight on the doctors table.
                     "Nothing to worry about ,this is Lichen Urticatus a sort of mosquito bite allergy " i was observing the child, she was still interested in my paperweight.
                     "No doctor this is not possible,we dnt have any mosquito in our house" her mother was not happy with my diagnosis.
                     "These rashes never appear on covered areas like back or belly, it occurs only on exposed ,open parts" i tried to convince her.
                     "No doctor there are rashes on back "she tried to find out but cdnt find any.
                     "So whatever it is, if not mosquitoes,its coming from outside,thats why only open parts are effected"i tried my best to educate her .
                      "No doctor there is no mosquito,no dust she is always indoors,how can this happen to my child"
                    She was in complete denial mode. Was she  taking my diagnosis as  blame on her parenting ? If there are a few insects its not her fault.
                    

Hope i wdnt die soon

Everytime this old man asks the same question "doctor,i hope i wdnt die soon".
                         And almost Everytime i reply in reflex "off course not, you are going to live atleast 100 years of age".
                          This man was under treatment for air borne contact dermatitis and was taking steroids on and off since several years.
                           Was it a normal joke ? A mere ice breaking attempt with serious looking doctors? Or some hidden fear of death ?             
                            Always i think about same questions and try to find out answer looking directly in his eyes .
                            Without steroids he cant live a normal life and with steroids he is not going to live long.

Scabies

"Ohh doctor this insect has made home in my skin" that old village man was humorously worried.  And i cdnt stop myself smiling.
                    Scabies is caused by a mite who makes home in your skin and a dermatologist is the  man who collects the rent.

Skin resurfacing

Her face was full of open pores and acne scars. She had tried various medicines with no results. Adding further to her disappointment we denied any medicines.
                        "But doctor i want to get rid of these pores and pits, please do something"  She was desperate.
                        " Open pores are openings of normal skin glands , how can any cream make them disappear" We were reluctant.
                          Then we started fraxional co2 laser to resurface the face and to improve the appearence of her face however we ourselves were not sure about results.
                           And after almost 10 months of regular sessions, here she is today......smiling with confidence.
                            We are surprised to see the magic of fraxional laser.

Innovations with available resources.

"En coup de sabre" literally means "a mark  by an axe". Technically it is localised scleroderma where all the layers of skin including fat and sometimes bone too gets atrophied.
                  Until recently there was no medical option available other than a few creams to lighten the mark
                  We started platlet rich plasma injections in affected area and found good results. It stimulates local tissue formation and gives a wonderful fullness effect. Now we are planning to do it for all such problems with loss of skin tissue or fat to produce a natural fullness from within.

Projection of the guilt

"Look doctor i never had any leukoderma....its when i started homeopathic medicines i got these white spots within few days. I stopped the medicines but the effect of medicine was so strong that new lesions are still appearing even after 5 years of that incident" she was very hopeless when she first came to us.
                 Is it true? Is it possible? We tried to explain her that its an autoimmune disease and it has nothing to do with what you had 5 years ago for a few days.
                 It was a case of projection of gereral guilt in form of false accusations. No doubt Vitiligo have such a strong impact on ones psyche.
                  We started the treatment along with some relaxing medications, knowing the fact that if it would increase again we would be her next target .

Oh man, God bless you!

"Doctor i have got melasma ! And now see i am developing acne too ! And my eyelashes are getting gray !" She was explaining the things endlessly and i was searching the things i can treat actually.
               There was no pigmentation. There were hardly any pimples. And if there is just one gray hair all over your body is it necessary to bother your doctor for that ?
This was a case of dismorphophobia.
               And then i saw her husband ! Oh man , you got a lady who has habit of complaining about the things which are not there ! God bless you .

Just common sense

"Doctor you are genius, your diagnosis was absolutely correct, see i am all improved". He came with a wonderful smile on his face this time . I remember last time on his first visit he was quite apprehensive regarding our diagnosis and treatment.
                          He had very thick skin lesions of lichen simplex over his legs and he had shown to many renowned dermatologists .
                          I wanted to tell him that neither our diagnosis nor our treatment was unique . Skin was so thick that the same medicine in creams or tablet forms was not penetrating in. So all we did was that we injected the same medicine inside his skin lesions. Just common sense no rocket science.

Cleaning away some trauma?

She had macerated,wet ,scaling , sore palms. She knew how it happened. And everyone else in her home as well. We explained her to stop washing her hands so frequently because its leading to fungal infections. She smilingly admitted the fact, but was unable to stop. It was obsessive compulsive disorder leading to skin infections.
                 Does this reflects some suppressd psychological truma in her subconcious? Was it an effort to clean the soul ?

Can't stop herself

She had many lesions over her face , repeatedly scrached and nonhealing wounds. We diagnosed it as Acne excorie. We tried to reassure her that spots are not disaapearing just because you have habit of touching and scratching it. She denied. We gave "Relaxing tablets" to ease her stress and it worked.
           Its amazing fact that our face is so much important factor. It can dominate our whole thought process and philosophy of life.

Cultural pains.

Afternoon 2:15, 17.3.2015 , today we did a punch grafting of white spots over foot.This type of lesions typically develop because of plastic slippers commonly used in rural India.

                                Reason for surgery?The young girl was unable to get married because of white spots over her legs and white spot disease is a big social stigma in India.

                                And why so? Because in India it is parents responsibility to get their children married "somehow". Funny culture. No matter if she has to go under the knife to cut away all her white spots to get married.