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Dr. Andrew Rynne

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Suggest treatment for itching throughout body

Answered by
Dr.
Dr. Prof. Kunal Saha

General & Family Physician

Practicing since :1954

Answered : 4360 Questions

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Posted on Tue, 7 Jun 2016 in General Health
Question: For kind review of Dr(Prof) XXXXXXX XXXX, Physician
Respected Sir,
I submit below case history of prolong illness of my wife. I do also enclose some reviews of the doctors, reports and present skin pictures. Her main difficulty is now whole body itching/itchiness.
Kindly find some time for me and give your valuable review, advice and guidance.

My wife had whole body itching/itchiness, swelling of face and limbs, mild swallowing difficulty from liquid, generalized weakness, joints/muscles pain, jaw movement restrictions etc developed gradually one by one and suddenly within 2-3 weeks in the month of July 2014( 1 year and 9 months ago).
She had history of joints pain of whole body from 10-12 years back. She is on menopause for last 8 years(2007) and age presently at 46 years. Married in 1995 and son is born in 1997. After clinical check-up by Physicians and Orthopedic Surgeons and on the basis of radiological imaging, it was seen she had early spondylosis, osteoporosis, osteophytes and degenerative changes in vertebra.
After the current episode, doctors had given her initially anti-histaminic tablets, vitamins, anti-inflammatory non-steroid tablets and skin ointments. Initially some routine pathology was carried out. Hb% was 10.4, Eosonophil and ESR were very high, Calcium deficiency, huge Vit-D deficiency, CPK 239, Absolute Eosonophilic Count 369 and TSH was 6.5 No improvement after treatment for one month rather conditions deteriorated gradually. After Chest X-ray, ECG, Whole abdomen USG, Blood Pressure check-up, nothing adverse was found. Skin became tight and shinny and muscle stiffness started. Doctors suspected MCTD or Systemic Sclerosis(Scleroderma) or Dermatomyositis. Then Rheumatoid Arthritis and Immune over-activity relating tests were carried out ( RF, Anti-CCP, ANA Profile, ASO-titre, CRP, CPK, Anti Scl-70, CK-MB, Anti U1-RNP, Anti dsDNA, Creatine, LFT, Na+,K+, Ca+, HCV, HbAG, Serological Culture) etc done several times in XXXXXXX and also in Apollo Hospitals XXXXXXX In Apollo Hospitals, XXXXXXX a complete health check-up was done and clinically checked up by Physician, Dermatologist, Endocrinologist, Gynocologist and she was there for 10 days. 2-D Echo Colour Doppler, PFT, LFT, Whole Abdomen USG, X-Ray Chest, HRCT Scan of Chest, whole Auto-immune screening by immunofluroscence method, Urine Re/Microbiology and Spot Urine Ration and many other tests and lastly Skin Biopsy were done. Initially after clinical check-up and systemic review, they had suspected most probably MCTD or Scleroderma or she would have early diffuse scleroderma. After all pathological/radiological tests and Skin Biopsy reports came, they had finally diagnosed as Subclinical Hypothyroidism, Anemia, Dyslipidemia, Vit-D deficiency and Eosonophilia. They did not found anything significant in the reports. They had explained the skin rashes and itching, swelling of limbs/puffy face all are due to hypothyroidism.
Her conditions were so painful that she was taken to XXXXXXX and returned by Air. Her conditions had worsened further. She was then helplessly taken to a renowned Endocrinologist MD, DM(Endocrinolgy) in local Multispecialty Hospital, The doctor on 23/09/2014 evening after clinical check-up had viewed that her conditions were not due to only Thyroid moreover TSH was very marginally high for which medicine was not required and noted some sclerodermatous changes of skin. She was admitted there on 26/09/2014 morning. Skin Biopsy, Muscle Biopsy, Routine Pathology and some autoimmune parameters tests were done. Before reports came, considering her painful conditions of whole body itching, swelling, pain, movement restriction, jaw stiffness, swallowing difficulty, weakness for about two months, they gave one Vit-D3 Inj and started treatment by Pulse Methyle Prednisolone I.V. 1 gm each for 5 days alongwith other medicines orally and blood /Urine tests, Clinical check-up were being done twice daily. A group of doctors were monitoring her case. After treatment by high dose steroid, she had got relief immediately after 3rd dose and was admitted there for 22 days for other complications, complete check-up and care due to tolerance of treatment and after Pulse steroid, she was given Prednisolone Oral 40 OD. She was discharged in a stable condition with lot of medicines including Prednisolone Tablet 40mg. Thereafter she was being checked-up by clinically and routine pathological tests fortnightly. After one month she was given Oral Azathioprine(Azoran Tab) 50 mg OD and after three months 100mg OD. Prednisolone Tablet was gradually reduced/tapered-off and stopped in almost after one year. Tablet Azoran 100mg continued upto October 2015(11 months) and then stopped as WBC count became low in repeated CBC test. During last more than one year after Pulse Steroid and during the course of Prednisolne Tablet and Azathioprine Tablets and other medicines like CCM(Calcium, Vit-D3, Folic Acid)Tab 1000 mg OD, Tablet Livothyroxine 50mcg OD, Pantoprazole 40mg BD, Cholecalciferol Powder(Vit-D3) once in a month, Tablet Livocetrizine( 2 weeks), Tablet Hetrazen(3 weeks), Primosa Tablet 1000mg OD(2 months)
Present problem : She was gradually feeling better but she had only shoulder joints pain and restrictions. After few months started whole body itching. She was given again Livocetrizine Tablets and Skin Lotion by the doctors in 2/3 spells. But itching is persisting continuously. Till now she has been checked-up and followed up by different other doctors(Rheumatolgist in SSKM Hospital Kolkata), XXXXXXX Physician(North Bengal Medical College) and XXXXXXX Dermatologists simultaneously with her primary doctors.
Every doctor still has doubt whether she is suffering at all from MCTD or Scleroderma or Dermatomyositis. However they have completely ruled-out Rheumatoid Arthritis. According to all of them till now by clinical check-up, she had some very weak and mild signs of MCTD or Scleroderma. As once in the onset of illness and in acute conditions which were relieved by high dose of steroid immediately, hence she requires immune-suppression. Steroid phase was well tolerated but for NSAID as DMARD treatment Oral Azathioprine has not been well tolerated, they are of the view to start Oral Salfasalazine 500mg BDPC and Oral HCQS (Hydroxychloroquine) 300mg ODHS and Oral Salfasalazine 500mg BDPC initially and gradually to increase dosages to some extent apart from Livothyroxine and Calcium + Vitamin D.
Her family history : Mother(Rheumatoid Arthritis Factor Strong Positive), suffering from spondylosis, osteoporosis( shoulder pain, joints pain and movement difficulty) for last more than 30 years. Eldest Sister(Rheumatoid Arthritis Factor Strong Positive), has confirmed chrone's disease and IBD, second sister (Rheumatoid Arthritis Factor Strong Positive), suffering from spondylosis, osteoporosis( shoulder pain, joints pain and movement difficulty, swelling of joints) and all under medications.
Her present only complication : Whole body itching/itchiness for last about one year(from May 2015). In between it was relieved significantly but recently for last 2-3 months, it has been aggravated.
Treatment summary : (i) Pulse Mythyle Prednisolone 1g each x 5 days from 30/9/2014 to 04/10/2014). (ii) Oral Prednisolone 40mg from 12/10/2014 and gradually tapered-off to 5mg and finally stopped on 30/09/2014. (iii) Oral Azathioprine 50mg OD from December to March 2015 and 100mg OD from May to November 2015. (iv) Oral HCQS 300mg ODHS from 07/03/2016 continued. (iv) Oral Salfasalazine 500mg BDPC will be started now after one Complete Blood Count again. (v) Livothyroxine 50mcg and Calcium, Vitamin D3 and Folic Acid Tablets continued are continuing from October 2014 to till date.

With regards and thanks,
XXXXXXX XXXX( Husband of Mrs XXXX, the Patient),
03/04/2016, XXXX(WB)
E-mail ID: YYYY@YYYY
Phone Nos. 0000 / 0000 / 0000
doctor
Answered by Dr. Prof. Kunal Saha 1 hour later
Brief Answer:
Treatment seems to be proceeding in right direction. Wait and watch.

Detailed Answer:
Thanks for asking once again on HealthcareMagic.

I have gone very carefully through the entire details that you have painfully and meticulously summarized. Sorry about the sufferings of your wife but even though the reports have not given definitive findings, I would mention that family history has a role to play. Her siblings have positive history for multiple autoimmune disorders like Reumatoid arthritis and Crohn's disease. Her doctor has done the right thing by starting DMARDs (disease modifying agents) like HCQS and Sulfasalazine. Even the pulse therapy of methyl prednisolone seems proper.

The other medicines are also proper and need to be continued. Also give her a fibre rich diet. Green leafy vegetables and fibre supplements like isabgol need to be taken regularly.

Let me know if you have anything specific to ask and I would definitely guide you further.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Prof. Kunal Saha 6 hours later
.
doctor
Answered by Dr. Prof. Kunal Saha 9 hours later
Brief Answer:
Diagnosis and treatment seem to be progressing in right direction.

Detailed Answer:
Thanks for providing the attachments. I have gone very carefully through them and they tell the same story that had come up from the details that you have already provided. The presence of anti-Ro52 antibodies should probably precede development of autoimmune disease and must induce sequential follow-up of positive patients. Be it scleroderma, polymyositis, rheumatoid arthritis, mixed connective tissue disorder, they are all part of the same autoimmune spectrum. The treatment and diagnosis seem to be progressing in the right direction and there is not much to be done thereafter. You would have to be patient and to wait for the gradual improvement.

Let me know if you wish to know anything specifc.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Prof. Kunal Saha 24 hours later
Respected Sir,
Once again I am giving you some pain for my another query in connection with my wife's sufferings. Before getting your review and advice, 3-4 days back we had visited one local Dermatologist for her continuous whole body itching/itchiness. Doctor's prescription is attached herewith. No matter of concern regrading skin ointment and ant-histaminic/anti-allergic tablet, but I have doubt whether the Inj TRICORT 40mg (Traimcinolone Acitonide) high dose synthetic corticosteroid is at all required. The doctor insisted to give her the injection instantly then, but I took time from him though her condition is very irritating. But she as of now due to god bless, has no other difficulty. You have already explained about her condition and medication very well. I understood that it will take some more time to get substantial relief from skin itching as HCQS and Salfasalazine will take time to work fully.
Kindly review her skin pictures once again and advice whether the steroid Inj I.M. is at all required and beneficial at this moment.

Sorry for giving you the pain repeatedly.

Thanking you Sir, with regards.
XXXXXXX XXXX, XXXXXXX 05/04/2016 , 4.38 P.M.
E-mail ID : YYYY@YYYY
Phone : 0000 / 0000 / 0000
doctor
Answered by Dr. Prof. Kunal Saha 9 hours later
Brief Answer:
Try using cetirizine and calamine lotion.

Detailed Answer:
Thanks again for writing back. Pardon me for not being able to respond faster.
I have checked the attachments.

Tricort (Triamcinolone) is a steroid as is Methyl prednisolone. I am not sure whether the dermatologist has noted the use of the latter. If he still suggests it as an add-on, it can be tried, but not otherwise since another similar agent is already in use. Try giving her some antiallergic like cetirizine and apply calamine lotion topically and see if it provides relief.

Do not hesitate to write back again. I would be there to help you.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Prof. Kunal Saha 2 days later
For kind review of the case by Dr(Prof) XXXXXXX XXXX

Respected Sir,

Good Morning. Once again I am at your door step. This time for my son, age 18+, Weight 61, Height 169cm. College student(1st Year).

He was feeling feverish in the night of last 04/04/2016(Monday) and next early morning had developed 2-3 eruptions. One eruption was like fluid filled vesicle and another two were scratched or punctured. After a couple of hours I had taken him to local hospital OPD and he was checked by General Physician and Dermatologist. Prescription is attached. Some skin images are also attached.

Recently his maternal aunt who is residing in the same area has suffered from chicken pox and her condition had become very serious. For her also I had sent you detail of her case and you had given your review and advices.

Medications :

1.     Acyclovir Tablet 800 mg 5 times daily( 25 dosages) . Today is 4th day and 16th dose complete( 4 + 5 + 5 + 2).- Continued

2.     Livocetrizine Tablet 0.5mg 1 x BDPC(Today is 4th day). - Continued

3.     Calkem Lotion(Calamine + Alovera) - Being applied locally on every spot either old or new. - Continued

4     Paracetamol Tablet 650mg given 2 times ( on 1st day and 2nd day when temperature was 1020 F.

5. # Clamoxy DS 625 mg Tablet (Amoxycillin 500mg + Potassium Clavulanate 125mg) BDPC x 5days - # I have not started this medicine.

He had/has no other problem except itchiness. Taking normal bath every day as usual. Food sufficient but easy digestible. Plenty of water and two times fruit juice. Confined in home but in normal life.

In my son's case now, you kindly see his skin pictures closely and note above medications and care.

My queries are :-

(a) Whether above medications are proper and sufficient ?

(b) Whether his condition is going to right and safe direction ?

(c) Whether Oral Clamoxy 625 is at all required ?

(d) Mostly reddish blister are growing and 3 or 4 are fluid filled vesicles getting scratched/punctured. Is it desired ?

(e) Should I clean the spots new or old, by antiseptic lotion(Suthol) before applying Calamine lotion.

I am awaiting your valuable advice and guidance.

Thanks and regards.
XXXXXXX XXXX, 08/04/2016, XXXX(WB)
Phone Nos : 0000 / 0000 / 0000
E-mail ID: YYYY@YYYY

Respected Sir,

Have you received and reviewed my another query regarding my son's sudden illness ? I have not yet received your response .

Please look into.

Thanking you with regards.

XXXXXXX XXXX, 08/04/2016, 11.05 P.M. XXXX(WB)
Phone : 0000 / 0000 / 0000

Sorry to disturb you once again. I forgot to mention that I have sent all the relevant medical papers via E-mail.
doctor
Answered by Dr. Prof. Kunal Saha 12 hours later
Brief Answer:
Questions answered sequentially

Detailed Answer:
Thanks for writing back. Sorry for not being able to respond faster. I have checked the attachments. I have gone through the details and let me try to address the questions one by one:

(a) Your son could be having chicken pox. Acyclovir usually reduces the intensity of symptoms but is optional and provide limited benefits when started after the eruptions have already occurred. So, it is upon you to decide whether you want to continue it. I do not see a role of giving antibiotics like Clamoxy. Other medicines are proper and sufficient.

(b) The condition will follow its natural course. In around 5-10 days the vescicles will crust off. The fluid contained is virus laden and hence infective. Isolation is advisable. The condition will become non-contagious after the crusts fall off.

(c) I do not see a role of giving Clamoxy 625.

(d) Do not puncture them. Let them arise on their own and then crust off.

(e) Calamine lotion has a soothing effect and can be used. No need to clean separately. That will increase the chance of spread.

Pardon me once again for the delay.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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