skin conditions

Vicks, Feet, and a whole load of nonsense.

Vicks Vaporub. It's a staple of our medicine cabinet, and we all reach for it at the first sign of sniffles. You may have seen (usually on a poorly made image posted on Facebook) or heard (from a friend who heard from their friend who heard from their aunt's sister's niece's dogsitter) that actually we've all be using it all wrong. 

It's logical to use Vaporub on your chest, pillow, in a steam inhalation. It makes sense, because the vapours will end up in or around your nostrils, which is where it acts. But no- according to this particular internet fraud, it is only by smearing our tootsies with it that we will get the full benefit. 

I'm going to pick apart the standard Facebook post, piece by piece, so you can see my thought processes and logical reasons why I don't believe a word. Even if you do think this works, stick with me and see whether or not you agree with any of my individual points, or if you can come up with a more robust argument for using it on your feet. 

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between."

 Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.

But I’ve never heard of this. And don’t laugh, it works 100% of the time

100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happened. If a medicine had been truly found to be 100% effective for anything, it would have been ground-breaking, world-changing news- probably not something that's just shared by your cousin on FB. 

 In the interests of research, I actually tried this when I had a troublesome post-infective cough. Needless to say, it did nothing to the frequency of my cough, so we've already disproved that number straight away. Whether or not it works, it most certainly does not work 100% of the time, and if that number isn't true, then why on earth should we believe anything else in this post?

...although the scientists who discovered it aren’t sure why.

 What scientists? What were their names? Where were they working? Where did they receive their funding from? Why aren't their details given? If they aren't sure, do they have any working theories? 

The lack of detail here is really telling. It really suggests that this is a whole load of hokum, especially given that a search (see below) shows no formal records of any "scientists" or research.

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks.

Ahh, feet. Feet really are a favourite for peddlers of quackery. I'm not sure why, but from reflexology to detox foot patches, the alt med world seems to be obsessed with them. Any time feet are suggested as therapy for anything going on elsewhere in the body, loud alarm bells start going off. 

The ironic thing is that feet are probably the worst place to apply any medicine. The skin on your feet is miles thicker that elsewhere. Absorption through the skin tends to be low and erratic at the best of times, but if you apply something onto your feet, the chances of absorbing anything useful from it are very low indeed. 

Additionally, your feet, when lying down, are very far away from your airways. The post requests that you put socks on over it. Therefore there is certainly no way that vapour could get to your airways in any clinically relevant amounts.

Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. 

Coughing fits are just that- fits. They're acute- you cough a lot for a little while, then stop, then it all starts again. A more chronic cough will still follow this pattern or stopping and starting. So yes, persistent, heavy deep coughing will usually stop- albeit temporarily- in probably much less than 5 minutes. If you're coughing for longer than that, it's likely you're going to be having severe problems breathing, and you'll need urgent medical care- you wouldn't really be thinking about smearing goo on your feet. You may find that you put Vicks on your feet and your coughing stops shortly after, but the likelihood is that the coughing would have stopped even if you hadn't. This is called regression to the mean, and its one reason why we can't rely on anecdotes for deciding whether a medicine works. We need to scale up and look at robust clinical trials instead.

Works 100% of the time and is more effective in children than even very strong prescription cough medicines. 

That 100% claim raises its improbable head again. To claim that something is more effective than other medicines would suggest the existence of comparative trials, which-spoiler alert- don't actually exist. This is rather a strawman anyway, as there are very few prescription cough medicines on the whole. Even conventional cough medicines don't really work to any great degree, and are based on very shakey evidence. It would be a very, very rare occasion indeed that a doctor would prescribe a cough medicine on prescription for a child. 

 In addition it is extremely soothing and comforting and they will sleep soundly.

I can see how that tingly, cold sort of feeling you get from menthol could be pleasant, though I don't think I'd go as far as to call it soothing. To be honest, you'd have to have perfectly soft skin on your feet to feel anything at all- when I tried it I didn't even feel a tiny tingle, especially since it was covered over with socks. 

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened.

What guy, and on which radio station? What qualifications does this guy have for making medical recommendations?  Who is even meant to be narrating this post? The only medicines now available for coughs in children in the UK are glycerol and simple linctus paediatric. Both of these essentially work on the basis of being sugary, slightly gloopy water. There's no "strong drugs" here, just some soothing "demulcents" that taste nice and are supposed to leave a soothing lining on the throat, making a cough feel less raw. They're mainly placebos. 

It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly.

 Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, all of this is irrelevant really, as no studies exist. These statements come from the head of an internet fraudster, rather than actually being grounded in reality. 

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it.

 We don't even know who is narrating this thing in the first place, let alone their wife. As I've explained above, this is an anecdote, and we can't derive anything from it. A person, who may or may not be mythical, had a cough, and it went away after they did a thing. It might have gone away anyway, we just can't tell. 

A warm blanket?  far from it. It actually just feels like you have some oily gunk on your feet. At best it might feel a little cold, but for most of us, it'll feel no different at all thanks to our thick skin. 

If you have grandchildren, pass this on. If you end up sick, try it yourself and you will be absolutely amazed at how it works!

Well that's just bizarre. Presumably you don't need to bother if you're simply a parent, only if you're a grandparent? What a load of nonsense. I wasn't left amazed, I was just left feeling a little silly. And I had minty-smelling feet.

So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working. 

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is: Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course ;)

Hxxx
 

In which the title of pharmacist makes a real difference.

Here is a little story of something that made me proud to be a pharmacist. It works as a sort of counterpoint to all the talk of pharmacy as a quack profession, the sort of bad experiences I have recently had as a customer in a pharmacy, and the Which? Report. 

It happened now behind a pharmacy counter, or in my office, but instead at one of my last phototherapy sessions. Because they were three times a week for 10 weeks, you sort of start to get to know the other folk who go there, and of course I got chatting with a few. I had mentioned offhand to one of them during a bout of small talk that I was a pharmacist.

The next time I saw her, she was eager to talk to me "I've been thinking, and I have a question for you, although I hope you don't mind me asking." She had had very severe psoriasis for many years, and it was having a real, tangible impact on her life. It had been suggested to her that she could try methotrexate, but she had been resistant to this treatment strategy "Because I'm just so terrified of all the side effects"

Her question to me was simple: Would I, as a pharmacist myself, take methotrexate if I was in her position? What a great question. And how amazing that someone I don't know at all thinks enough about my opinion, simply because of my job description, to ask me it.  And so, shivering slightly in our hospital gowns in the clinical white of the dermatology changing rooms, we had a really good chat about the benefits and risks of all drug treatments, about how methotrexate works ("someone told me its like chemotherapy!"), about her fears of the medicine ("I've had a look on the internet and the side effects are terrifying") and her fears of the psoriasis ("I sometimes think other people think psoriasis is something that isn't serious enough to warrant a drug like methotrexate, when it's also used to treat cancer and things. But it really is ruining my life."), about the sort of monitoring she could expect. and some of the things to look out for if she did decide to take it. 

My bottom line answer was that yes, I would take it if my psoriasis was as severe as hers, and having the impacts on her life that she was experiencing. I explained that I too would be scared of the side effects, but not everyone gets them, and because you're quite closely monitored whilst you're on it, the most serious side effects should be pretty easily picked up and with some careful dosing, along with folic acid, could hopefully be minimized. 

"Eeee, well thank you. You've really put my mind at rest." she said, and off she padded to receive her few minutes on the NHS sunbed whilst I attempted to put my clothes on the right way round for the second time that day- no mean feat when you're me and you haven't yet had your first cup of tea or coffee yet. I don't know whether or not she was definitely going to start taking the methotrexate, but I get the feeling that I had given her a few things to consider that she hadn't thought about, and that I had provided some reassurance that the horror stories on the internet are not the full story. 

This just goes to show the sort of esteem we pharmacists have the privilege of in the eyes of some. Its a privilege we should honour by doing all we can to ensure our advice is good quality and evidence-based. Being a Good Pharmacist doesn't stop the moment we extract ourselves from behind the counter, or out of our office or wards. Our words are more trusted, more weighted than many of us probably realise, because to some (but not enough) people "Pharmacist" really does mean "expert in medicine", and we need to ensure that we don't take advantage of that to sell products that don't have a good evidence-base just for profit. Our integrity as medicines experts can and should shine through, even when you're standing in a cubicle failing to rock the hospital chic look, bleary eyed and in need of caffeine.

Hxxx

Skin deep: a lesson on empathy

For the past few weeks, I have been suffering from guttate psoriasis. My poor dear friends and twitter followers will be very aware of this by now, as it has led to much wailing and complaining. 

Guttate psoriasis appears a few weeks after a strep throat infection in most cases, as it did with me. It appeared pretty suddenly on my face and chest, then got worse and worse until I basically now resemble a small pox victim with Ebola in the midst of turning into a zombie, with some added bubonic plague thrown in.

The treatment? Well it tends to go away of its own accord after a few week or months. It's not helped by stress, so it's good to chill out. Usually treatment with topical steroids, emollients, and reassurance are all that's required. 

A few weeks ago I would have read that sentence with ease, accepting that reassurance and time would be enough for a patient. Slap on a bit of cream, and away you go.

A small section of my thigh at the moment. Imagine this rash, all over. And this is at its best,  after vigorous application of topical steroids. I feel like a mutant monster :S

A small section of my thigh at the moment. Imagine this rash, all over. And this is at its best,  after vigorous application of topical steroids. I feel like a mutant monster :S

You learn in university and in various courses that dermatological conditions can have a huge impact on a patient's life. You learn about all the creams an emollients, and how we should advise they're used. You know in the back of your mind that its probably horrible for the sufferer but you don't really give it a second thought. I know I've even been felt vague consternation at having to dispense and check huge, bulky prescriptions for various and many unguents, with my main thought being "how am I going to fit this damn prescription on that shelf?!"

Well, what a lesson in empathy these past few weeks have been. Nothing could have prepared me for the impact a rash would have on my life. Aside from the panic about what it was, the constant feeling that everyone was looking at me and feeling disgusted is utterly wearing. And of course you know deep down that they're not looking at you, but it makes no difference at all. I know I need to be calm about the whole situation because stress makes it worse, and that makes me even more stressed because I'm not destressed enough. I feel like all I want to do is hide in a darkened room, so I don't have to inflict my grotesque features on anyone else. 

And my goodness, the treatment. I get in the bath, which is already suffused with an oily emollient bath additive. I then apply some gunk, and wash it off with the oily water. I then get out the bath (which is made more interesting due to the added element of slippery danger) and proceed to apply more oily gunk, in various combinations of layers, then have to wait for it to dry sufficiently to be able to put on my most high-necked, low hemmed, least transparent clothing I can find. I haven't felt clean for weeks. You know on holiday, that awful sticky feeling you get from the sun lotion? That, all the time. In February.

All I've been able to think about is my rash. I'm struggling with conversations because my head is consumed only by thoughts of what bits of skin are visible and to whom. It's crossed my mind that converting to Islam might be an idea because then I could feasibly wear a burkha. Honestly, I have thought this. I've been turned into a hysterical drama queen all because of some spots.

In short, I have a whole newfound empathy for anyone who suffers from a skin condition. I can just about imagine the sort of impacts a longer term condition might have on your life. I can see how desperation can creep in, and how you could be tempted to try anything. 

It's no co-incidence that so many quacks target people with skin conditions, nor that so many preparations are so expensive. 

Hxxx

P.S. I'd very much like to thank everyone who has been supportive. You're all total darlings.