Some Thoughts About Skin

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Seven Steps to Stop Sweaty Feet

There are 250,000 sweat glands in each foot, producing half a pint of moisture per day. People with excess sweating, called hyperhidrosis, can sweat much more than that, leading to scaling, fungus infections, and overall sandal-unworthy feet.

If you have mild to moderate excess sweating:

• Wash your feet every day with antibacterial soap, such as an antibacterial hand soap. Then dry them completely, including between the toes (you know you don’t).
• Use a hairdryer on the cool setting to get your feet completely dry.
• Apply a foot powder (powder is better than corn starch, which tends to absorb the moisture, leaving a wet paste on your skin). Try Lamisil AT defense with tolfnaftate, an antifungal, if you have a tendency to get athlete’s foot, or try Dr. Scholl’s Deodorant Foot Powder with Zinoxol (zinc oxide and baking soda) if you have smelly, sweaty feet.
• Wear synthetic socks, instead of cotton (yes, you read it right. NOT cotton). Synthetic socks wick moisture away instead of trapping it like a sponge. Try Adidas’ Clima Cool socks.
• Use a spray antiperspirant such as Gold Bond Maximum Strength Foot Spray. Your regular underarm antiperspirant will work as well, but the aluminum chloride concentration is much lower, so it is less effective.

If you have seriously sweaty feet or hyperhidrosis:

• Call our office. We can prescribe a prescription-strength antiperspirant (Drysol ®). After one week of applying Drysol nightly, most patients have a significant reduction in foot sweating. It can, however, be irritating and some people cannot tolerate using it every day.
• Botox®. Yup, Botox. When injected into your feet, it blocks the signal from the nerves that turn on your sweat glands, stopping sweating. The downside: getting stuck with little needles about a hundred times on the bottom of your feet. The upside: a marked reduction in sweating that lasts many months.

Will Drinking Water Moisturize Your Skin?

This is a popular myth, perpetuated by fitness and fashion magazines.

Only one study ever linked drinking water with skin hydration. That study used expensive mineral water, not plain bottled or tap water, and the study didn’t have any impact on your skin and no controlled study has ever shown that any type of drinking water has an effect on your skin.

From a physiologic perspective, drinking water could only have a negligible impact on your skin’s hydration. In fact, patients who have too much water in their tissues (edema) do not have healthy skin. For example, patients with venus insufficiency who have swollen, fluid filled legs have skin that is often dry, itchy, and scaly.

The amount of water in your skin after a 5 minute shower is magnitudes higher than you could achieve by trying to hydrate it from the inside out. The key is to apply a cream or ointment when your skin is still wet to seal in the moisture.

Then drink as little or as much water as you like.

Lotion or Cream?

When cool, dry air hits it makes many patients’ skin dry. Many tell me that their skin remains scaly and itchy despite moisturizing daily. The best advice I can give is to teach them to moisturize properly.

The first question I ask is: Are you using a lotion or a cream?

The difference between the two comes down to the water content. Creams and lotions are mixtures of oil and water. It is the oil component that is most important for your dry skin.

Lotions are droplets of oil mixed in water. They have a high water and low oil content. As such they are easy to spread on dry skin. However, the water is not well absorbed and quickly evaporates, which actually dries your skin further.

In contrast, creams are droplets of water mixed in oil. They have a high oil and low water content. They are more difficult to smear on dry skin but apply easily to moist skin. Therefore, they are best used immediately after your shower or bath when your skin has soaked up the water like a sponge. Applying cream then creates a layer of oil that locks the moisture in your skin. The water does not evaporate, and your skin stays hydrated.

This is why in the wintertime I advise patients to use only creams. In the warm, humid summer, lotions are actually better.

Lip Licker's Eczema

With holiday and winter ski trips upon us, this common childhood aliment is likely to arise. When many kids have dry skin, they often also get red irritated skin around their mouths. As the skin gets irritated, many children will begin to lick the area to keep it wet. Unfortunately, the chronic licking establishes a pattern of accelerated evaporation and destruction of the epidermal barrier leading to the classic lip licker's dermatitis. Out of desperation, parents try topical steroid creams and antifungal products with little improvement. Fortunately, this type of rash usually responds well to water barrier moisturizers such as Vaseline, Aquaphor Healing Ointment, and Eucerin Original Moisturizing Cream, etc. The trick is that you have to put moisturizers around your child's lips several times an hour, to help break the cycle of irritation and lip licking.

Sunscreens, UVA and UVB

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I took this from a journal called The Prescriber's Letter. It discusses a few of the things to be considered when buying a sun screen.

A new sunscreen called Mexoryl SX will raise questions about optimal sunscreen protection.
SPF is often misunderstood. SPF applies only to UVB...not UVA. UVB causes the familiar sunburn. Explain that SPF is an estimate of how long a person can stay in the sun without obvious sunburn.
For example, if a person would burn in 10 minutes with NO protection, then an SPF 15 sunscreen will protect 15 times longer or 150 minutes...and an SPF 30 would protect 30 times longer or 300 minutes.
Tell patients there's no proof that an SPF over 50 gives any measurable added benefit.
UVB ratings get the most attention, but are only part of the story.
UVA ratings will appear on some sunscreens. You'll see 1, 2, 3, or 4 stars indicating low, medium, high, or highest protection.
UVA causes skin aging and skin cancer...not visual sunburn.
For now, recommend sunscreens labeled broad-spectrum. These contain UVA blockers such as avobenzone, zinc oxide, and/or titanium.
You'll now see Mexoryl SX (ecamsule) in some Anthelios sunscreens. Mexoryl SX covers some of the shorter UVA rays that are not covered by avobenzone...and it's more stable in sunlight.
But when avobenzone is combined with octocrylene, oxybenzone, or other ingredients it's more stable and has a broader spectrum.
Recommend zinc oxide or titanium dioxide for sensitive skin. They block UVA and UVB by sitting on top of the skin...not binding to it.
Water resistance ratings refer to how long the product is effective during swimming, heavy sweating, etc.
Explain that a product labeled "water-resistant" lasts about 40 mins in water...and a "very water-resistant" product lasts about 80 mins.
Proper application is key. Instruct people to apply sunscreen 20 minutes before sun exposure...and reapply at least every 2 hours.
Emphasize applying enough...about 1/2 to one teaspoon per body part (leg, arm, back, face, etc)...or about 1 ounce for the full body. Applying only half the amount will give only half the protection.
Advise avoiding sunscreen/insect repellent combos. Suggest using separate products because the sunscreen needs to be applied more often than the repellent. Advise patients to apply the sunscreen first, then the repellent.
Drug-induced photosensitivity is primarily due to UVA rays.
Advise patients taking photosensitizing drugs to use a broad-spectrum sunscreen.

H1N1 Flu vaccine recall for ages 6-35 months

Most of you have heard about the recall of H1N1 flu vaccines for ages 6-35 months. We recieved from the CDC the lot numbers that were affected by this recall and are happy to announce these are not the lots that our office has in stock. So if your child is in this age range and received their vaccine in our office this recall does not pertain to them. Also, if your child is still due for their second dose we still have vaccine available. If you have further questions or concerns please see the link from the CDC which gives you the full report on the recall. http://www.cdc.gov/h1n1flu/vaccination/syringes_qa.htm

Sears Treats Reservists Right

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This is another post that doesn't have much to do with children's health, but if you or a loved one is or has served in the military's reserves, you will be pleased to find that some large corporations are driven by more than just profit. This is taken from an e-mail that has been circulating through our in-boxes lately, and has been verified by Snopes.com. Read on.

Subject: Sears

I assume you have all seen the reports about how Sears is treating its reservist employees who are called up? By law, they are required to hold their jobs open and available, but nothing more. Usually, people take a big pay cut and lose benefits as a result of being called up...Sears is voluntarily paying the difference in salaries and maintaining all benefits, including medical insurance and bonus programs, for all called up reservist employees for up to two years. I submit that Sears is an exemplary corporate citizen and should be recognized for its contribution.

Suggest we all shop at Sears, and be sure to find a manager to tell them why we are there so the company gets the positive reinforcement it well deserves.

Pass it on.

So I decided to check it out before I sent it forward. I sent the following email to the Sears Customer Service Department:

I received this email and I would like to know if it is true. If it is, the Internet may have just become one very good source of advertisement for your store. I know I would go out of my way to buy products from Sears instead of another store for a like item even if it was cheaper at the other store.

Here is their answer to my email......................

Dear Customer:

Thank you for contacting Sears.

The information is factual. We appreciate your positive feedback. Sears regards service to our country as one of greatest sacrifices our young men and women can make. We are happy to do our part to lessen the burden they bear at this time.

Bill Thorn
Sears Customer Care
webcenter@sears.com
1-800-349-4358

Please pass this on to all your friends, Sears needs to be recognized for this outstanding contribution and we need to show them as Americans, we do appreciate what they are doing for our military!!!!!!!!!!!

Interesting Facts About Salt

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This has little or nothing to do with pediatrics and/or children's health. I just thought it is interesting, and you may, too.

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Mining salt in Bavaria
By Morgen Jahnke

Nowadays, we take salt for granted. Sold for a pittance, the most common of spices, we think of it as an everyday thing, when we think of it at all. It wasn’t always so. In fact, great empires and fortunes rose and fell according to its supply. It is hard to imagine a modern war being fought over salt. But consider these historical events, as recounted in Margaret Visser’s Much Depends on Dinner:
Morocco fought Mali in the sixteenth century for the mines of Taoudeni; the Venetians, whose salt interests are an historical study in themselves, destroyed Comacchio in the tenth century and the salt gardens of Cervia in the fourteenth; pirates throughout the centuries ambushed and raided the slow heavy convoys of salt ships.
There are plenty of other examples—all of which seem outlandish to us today, considering that the biggest battles fought over salt have to do with whether it should be spread over icy roads in winter. Salt has lost its nobility, its historical power—but from the salt-starved Vikings to the salt-greedy Romans, salt has played an important role in human history.

The Saltman Cometh

Nowhere does this seem more obvious than in the salt-rich environs of eastern Bavaria and western Austria. The de facto capital of the region, Salzburg (or “salt town”) was built by its first archbishop in the eighth century with profits from salt mining, but the practice of salt mining goes back even further, to the civilization of the early Celts. In his book Salt: A World History, Mark Kurlansky describes the discovery by local salt miners in the 1600s of a “perfectly preserved body, dried and salted ‘like codfish,’” believed now to date to 400 B.C. Dressed in colorful fabrics, this “saltman” and two others like him were found with the tools of their trade near them, proof of an ancient salt mining culture.

Salt of the Earth

This salt mining tradition continues in the modern salt works along the German/Austrian border, and it’s possible to experience some of what those ancient miners might have felt, deep in the mountains of salt. Founded in 1517, the Salzbergwerk Berchtesgaden (“Berchtesgaden salt mine”)—located near Salzburg but on the German side of the border—once entertained only aristocratic visitors, but now welcomes the public to its underground facilities and caves. Berchtesgaden, erroneously linked in the public imagination with Hitler’s southern headquarters (they were actually located at Obersalzberg, a small settlement further up in the mountains) is a town that developed in proximity to the Augustinian monastery that owned the Salzbergwerk. In the early 1800s the monastery was converted into a palace for the Wittelsbachs, rulers of Bavaria at the time, and the entire area became associated with this colorful family.

Mine Games

Still operational, the Salzbergwerk is a joy to visit. Donning the traditional leather vests and helmets of the miners, you start to feel as if you are a miner yourself. This sensation is heightened when, after a short train ride, you are asked to slide down a wooden chute into the mine itself. After overcoming my apprehension, I slid into the dark, feeling even more like a miner heading to work. Our guide, a local man, explained the workings of the mine to us—or so I gathered, since I couldn’t understand his thick “Bayrisch” accent. This only added to the feeling of being in a different world, a world where life goes on underground.
The most striking element of this topsy-turviness was the presence of a large underground lake in the mine. Gliding silently across its depths on a wooden platform boat, it was eerie to see the lights at its edges through the darkness, and to feel the oppressive nearness of the stone “ceiling.” I imagined myself gliding across the river Styx, and shivered in the damp air.

Worth Its Salt

Returning from the depths of the mine, it was hard to think of salt the same way again. It is, after all, the only rock that we eat, and with thousands of tons of it looming above your head, you don’t immediately think, “pass the salt.” Vital to the functioning of our vital organs, we would die without salt, yet we live in a salt-glutted world, so much so that we are told to reduce our intake, for the sake of our health.
In their song “NaCl (Sodium Chloride),” folk singers Kate and Anna McGarrigle make a case for the worthiness of salt. Describing the meeting, mating and melding of a sodium atom and a chlorine atom in the primordial sea, they ask us to “Think of the love that you eat, when you salt your meat.” Silly, meant to be taken with a “grain of salt,” yet it expresses the mystery of salt, the serendipitous compound that protects our cells, and fills the ocean. —Morgen Jahnke

Roller Shoes are Risky Business

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Protective Gear Recommended When Using Roller Shoes
By Jennifer Warner
WebMD Medical News
Reviewed by Louise Chang, MD
June 4, 2007 --

Gliding down the sidewalk in roller shoes may look like fun, but without protective gear the shoes may wind up sending kids straight to the emergency room.
A new study shows one hospital reported 67 cases of injuries caused by roller shoes last summer vacation. Wrist injuries were the most common. No protective gear was used during the time of these injuries.
"To reduce the rate of such injuries, parents buying roller shoes need to understand both the benefits and risks of this activity," write researcher Mihai Vioreanu, MRCSI, of Temple Street Children's University Hospital in Dublin, Ireland, and colleagues. "Full protective gear needs to be used at all times, including a helmet, wrist guards, knee pads, and elbow pads when using roller shoes."
Roller shoes are a popular type of sneaker that has a detachable or convertible wheel in the heel, which allows the wearer to lean back and glide on the wheel as well as walk. They're often sold under the brand names "Heely" or "Street Gliders."
The shoes were introduced in 2000 in the U.S., but researchers say little is known about their safety.

Roller Shoes Tied to Injury

In the study, published in Pediatrics, researchers tracked the number of roller shoe-related injuries at their Dublin hospital during the 2006 summer school holiday.
They found 67 children suffered orthopedic injuries while using Heelys or Street Gliders, such as broken bones or dislocated joints. Girls were much more likely to be injured than boys, and the average age of injured children was just under 10.
The study showed:
Broken wrists were by far the most common type of injury reported. Other injuries included other broken bones in the arm, elbow dislocation, foot and ankle injuries, and broken bones in the leg.
Injuries were most commonly caused by falling backward or forward as the child tried to transfer their body weight and find balance on the wheels. In a few cases, the injury was caused by jumping or a sudden change of direction.
Most of the injuries happened while gliding outdoors on a road, sidewalk, cycle lane, or playground.
Researchers also found that 20% of the injuries occurred on the first time the child tried to use the roller shoes and 36% occurred while they were learning to use them.
They say the results show that close adult supervision is needed during this learning curve and use of protective gear, including wrist guards, is recommended at all times.

What Are Probiotics and Why Do I Need Them?

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I am using more and more probiotics in my practice, for problems as wide-ranging as "tummy viruses" to ulcerative colitis and most everything in-between. Here's a little primer on what they are and what they do.


Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2006 by Therapeutic Research Center

What are probiotics?
Probiotics are live, “friendly” organisms that live in the intestine. They help decrease “unfriendly”
bacteria and viruses that cause diseases such as diarrhea. Examples of probiotics include Lactobacillus,
Bifidobacteria, and Saccharomyces boulardii.

For what conditions are probiotics effective?
Certain probiotics have been shown to be beneficial for preventing and treating some types of diarrhea, including diarrhea caused by antibiotics. Probiotics also seem to help some bowel diseases such as ulcerative colitis and irritable bowel syndrome.
Some yogurts that contain the probiotic Lactobacillus might also help women who get frequent vaginal yeast infections. However, eating yogurt doesn’t seem useful for preventing vaginal yeast infections caused by antibiotics.

What probiotic products are available, and how do I choose one?
Not all probiotic products are the same. Some do not contain what they say on the label. Others do not contain enough live organisms to be effective. And some probiotics work better for certain conditions than others. Clearly, product selection is important. To prevent diarrhea caused by antibiotics, choose Culturelle (Lactobacillus GG) or Florastor (Saccharomyces boulardii). You can also try these products for prevention of traveler’s diarrhea. Start taking them a few days before travel, and continue them for the duration of your trip. Yogurt is a source of probiotics, but not all yogurts contain the right kinds of organisms. Choose a
product with the National Yogurt Association’s “Live and Active Cultures” seal on the label (e.g., Dannon, Yoplait). You will need to eat about 8 oz twice daily to prevent antibiotic-associated diarrhea. To prevent frequent vaginal yeast infections, try 6 oz daily of a yogurt containing Lactobacillus acidophilus.
VSL#3 is a probiotic mixture used for certain bowel conditions such as ulcerative colitis and irritable bowel syndrome. It may help reduce stomach pain and bloating if you have irritable bowel syndrome. Studies published just this year (2009) have documented VSL #3 and Align as very effective for bloating and cramping.

What are the side effects of probiotics?
In some people, probiotics can cause stomach and intestinal upset, including gas and bloating. These usually improve with time.

Are there any drug interactions with probiotics?
Antibiotics are used to reduce harmful bacteria in the body. They can also reduce friendly bacteria like Lactobacillus and Bifidobacteria. If you are using these probiotics or yogurt, you should take them at least two hours before or after the antibiotic. The calcium in yogurt can also decrease the effectiveness of some antibiotics. You may need to allow more than two hours between eating your yogurt and taking your antibiotic. Check with your pharmacist for the best way to avoid this interaction. Saccharomyces boulardii is a fungus. Medications for fungal infections help reduce fungus in and on the body. Taking Saccharomyces boulardii with medications for fungal infections can reduce its effectiveness. Some medications for fungal infections include Diflucan, Lamisil, Sporanox, and others.

Who should not take probiotics?
For healthy people, routine use of probiotics to maintain bowel health is unnecessary. There is a small risk of infection with probiotics. If you have a weakened immune system you should not take probiotics unless you’ve checked with your healthcare professional. If you are pregnant or breastfeeding, you
should get approval from your healthcare professional before taking any probiotic other than yogurt.
Detail-Document #220704
−This Detail-Document accompanies the related article published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
July 2006 ~ Volume 22 ~ Number 220704
More. . .
Copyright © 2006 by Therapeutic Research Center

What Should I Eat to Get My . . .?

I'm often asked what foods are best for a variety of different nutritional entities. I just found this little list, and while it is not exhaustive, it's a good start.
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Vitamin B6: Beans, nuts, legumes, eggs, meats, fish, whole grains, and fortified breads and cereals

Folate: Beans and legumes, citrus fruits and juices, wheat bran and other whole grains, dark green leafy vegetables, poultry, pork, shellfish, liver

Vitamin D: Fish, fish oils, oysters, fortified foods such as cow milk, soy milk, rice milk, and some cereals

Calcium: Milk, yogurt, buttermilk, cheese, calcium-fortified orange juice, green leafy vegetables (broccoli, collards, kale, mustard greens, turnip greens, and bok choy or Chinese cabbage), canned salmon and sardines canned with their soft bones, shellfish, almonds, Brazil nuts, dried beans

Zinc: Beef, pork, lamb, oysters; dark meat of poultry, peanuts, peanut butter, nuts, and legumes (beans), fortified cereals

Essential fatty acids (omega-3 fatty acids such as linolenic acid)

Fish (tuna, salmon, and mackerel oil) fish oil, flax seeds, flax oil, canola oil, walnut oil, dark green leafy vegetables

Tryptophan: Turkey, chicken, fish, milk, cheese, eggs, soy, tofu, sesame seeds, pumpkin seeds, tree nuts, peanuts, peanut butter

Irritable Bowel Syndrome

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Irritable bowel syndrome (IBS) affects more than one in ten people. Little is known about the causes of IBS. It can be worsened by stress or emotional upsets. There may be differences in the symptoms of IBS between patients. This means that, of the many different treatment approaches available, you and your healthcare provider will need to select those that are most likely to help your individual symptoms.

What nondrug measures can I use?

Many people say that changing their diet is helpful. Some common culprits thought to make IBS worse are caffeine; alcohol; sorbitol (the artificial sweetener); fried or fatty foods; and gas-forming foods like cabbage, broccoli, or beans. Make sure that, if you do exclude something from your diet, you aren't risking any type of deficiency (calcium, for example, from eliminating dairy products).
Adding fiber might be helpful for reducing the symptoms of IBS. Soluble fiber is best (supplements like Metamucil and dietary sources like applesauce, oatmeal, potatoes, and rice). Insoluble fiber, like wheat bran, doesn't seem to work. The downside of fiber is that it can increase your chances of having gas and bloating. Add fiber gradually to reduce these effects.
You may also benefit from eating smaller, more frequent meals. Large meals can sometimes worsen IBS symptoms.
While stress does not appear to cause IBS, it may make the symptoms worse. Some patients have found that techniques to reduce stress or a good exercise program are helpful. There's no harm in trying, so do what works best for you.

Are there medications I can take?

Over the years a number of different medications have been tried for IBS. You should always consult with your healthcare provider before trying any medication, especially nonprescription ones. Listed below are the most commonly used medications for IBS. Some of these medications require a prescription.
Antidiarrheal agents. Loperamide (Imodium) can be used for diarrhea, but it doesn't help with stomach pain and bloating.
Antispasmodics. Hyoscyamine (Levsin [U.S.]), dicyclomine (Bentyl [U.S.], Bentylol [Canada]), and hyoscine butylbromide (Buscopan [Canada]) can reduce pain and cramping by decreasing muscle spasms in your intestinal tract. They're especially helpful if your IBS symptoms are worsened by meals. However, antispasmodics may have some unpleasant side effects such as dry mouth, sedation, and constipation.
Laxatives. Osmotic laxatives, like polyethylene glycol or PEG (Miralax [U.S.], Lax-A-Day [Canada]) and milk of magnesia (MOM), can be tried for constipation.
Antidepressants. Antidepressants can reduce IBS symptoms as well as relieve depression and anxiety.
Herbal products. Several products have been tried that are available without a prescription. For example, peppermint oil is an antispasmodic that may help. You should consult with your healthcare provider before trying any alternative medications as these are active compounds and may have other physical effects and drug interactions that need to be considered.
Probiotics. Some probiotics might help with the symptoms of IBS, like bloating and gas. Look for products that contain Bifidobacteria, as this probiotic seems to be the most beneficial. Some products that contain Bifidobacteria include Align (U.S.), Activia (U.S.), Bifidox (Canada), or VSL #3.
Other therapies. Lubiprostone (Amitiza [U.S.]) is a prescription drug that's helpful for women with IBS who have constipation. Alosetron (Lotronex [U.S.]) is another prescription drug that's sometimes used in women with severe IBS with diarrhea. These drugs are expensive and have some important side effects, so they are generally used when other treatments have failed.

Where can I go for information?

There are some very good places on the internet where patients with IBS can go to keep up with current information about this disorder. A listing of these sites is given for your reference. Remember to talk with your healthcare provider about any information you find so you can discuss which treatments are best for you.
International Foundation for Functional GI Disorders: www.iamibs.org
The UNC Center for Functional GI and Motility Disorders: www.med.unc.edu/medicine/fgidc
The IBS Page: www.panix.com/~ibs/
IBS Resource Center: www.healingwell.com/ibs/
Canadian Society of Intestinal Research: www.badgut.com/
May 2009




Treatments for Irritable Bowel Syndrome (IBS)  
Background
Irritable bowel syndrome (IBS) affects about 7% of individuals in North America. It's defined by abdominal pain and altered bowel habits for a period of at least three months. Patients can experience predominant constipation (IBS-C), predominant diarrhea (IBS-D), or mixed symptoms (IBS-M). Unlike organic bowel diseases (e.g., celiac sprue, colitis, inflammatory bowel disease, etc), there are no structural or biochemical abnormalities associated with IBS.1 A new systematic review of therapies for IBS was recently published. This document discusses the treatments for IBS and their evidence for effectiveness. Recommendations for managing IBS patients are also included.

Fiber and Laxatives

Increasing fiber is one of the most common recommendations made to IBS patients, with the intent of reducing pain and regulating bowel function. However, studies show that insoluble dietary fiber, like wheat bran, is unlikely to improve symptoms.1
Patients may get improvement in overall IBS symptoms with psyllium hydrophilic mucilloid (Metamucil, etc). This is a soluble fiber, which absorbs water and forms a gel that helps food move smoothly through the GI tract. One study also showed some benefit of using calcium polycarbophil (FiberCon [U.S.], Prodiem Bulk Fibre Therapy [Canada], etc) compared to placebo. Like psyllium, calcium polycarbophil is a hydrophilic bulk-forming laxative.1
The downside of adding fiber is the potential for an increase in bloating, abdominal distension, and flatulence. Gradually adding fiber might help avoid this.1
One small study suggests that the osmotic laxative polyethylene glycol (PEG) (Miralax [U.S.], Lax-A-Day [Canada]) can double the frequency of bowel movements in patients with IBS-C. However, pain intensity is not reduced by osmotic laxatives.

Antidepressants

Pooled data from studies of both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) (n=789) show that these drugs are likely to improve overall symptoms of IBS, regardless of IBS type. About one in four patients treated will have some benefit.
The largest individual trial with a TCA (n=216) looked at desipramine. The dose was started low, and then titrated up to a dose recommended for the treatment of depression. (However, most trials used low doses of TCAs, and using antidepressant doses don't appear to be necessary).2 The presence of depression did not predict a response to treatment for IBS symptoms. A high incidence of side effects resulted in a dropout rate of almost one-third of subjects.1
SSRIs have a better side effect profile than TCAs. Unlike TCAs, good evidence for efficacy in improving IBS symptoms from individual trials of SSRIs is lacking.1
The SSRIs have a prokinetic effect, so they might work better in patients with IBS-C. Since TCAs are more likely to cause anticholinergic side effects like constipation, they might be better for individuals with IBS-D.1 Experts say that TCAs might be best for improving pain.

Antispasmodics

Antispasmodics (e.g., dicyclomine [Bentyl-U.S., Bentylol-Canada], hyoscyamine [Levsin-U.S. only], hyoscine butylbromide [Buscopan-Canada only]) as a class can provide short-term relief of symptoms like abdominal pain and discomfort from IBS. The reason for this might be that pain with IBS is caused by colonic smooth muscle spasms.1
Systematic review (n=1,778) suggests that about one patient will have symptom relief for every five patients treated with an antispasmodic. However, most of the antispasmodics that have been studied for IBS are not available in the U.S. or Canada. In addition, studies typically have not specified the type of IBS treated.1
The most common side effects with antispasmodics are anticholinergic in nature. These include dry mouth, dizziness, and blurred vision. About one in 18 patients treated will experience a side effect, according to available data.
Limited data suggest that peppermint oil, thought to relax smooth muscle in the GI tract, might improve symptoms of IBS in about one out of three patients treated. Side effects reported in studies were rare.1
The usual dose of peppermint oil for adults with IBS is 0.2 to 0.4 mL given three times daily, in enteric-coated liquid-filled capsules.
Antispasmodics should be considered especially when IBS symptoms are exacerbated by meals. In this case, they can be taken about 30 minutes before a meal, on an as-needed basis.

Antidiarrheals

Since patients with IBS-D have a faster colonic transit than healthy patients, drugs that slow colonic transit might be beneficial. There is some data on loperamide. Loperamide (Imodium, etc) doesn't help for IBS symptoms like pain, but it does reduce frequency and improve stool consistency in almost all patients who are treated.1
Alosetron (Lotronex)
There's good evidence that alosetron (Lotronex, available in U.S. only), a serotonin 5HT-3 antagonist, is better than placebo at improving IBS symptoms in patients with IBS-D.1,5
The majority of the body's serotonin is found in the GI tract. Serotonin plays a major role in GI motor and secretory function and visceral sensation. Antagonism at the 5HT-3 receptor specifically delays GI transit, reduces colonic tone, decreases the gastrocolic reflex, and decreases visceral sensation.1
Data from eight placebo-controlled trials (n=5,000) show that about eight patients will need to be treated with alosetron for one patient to experience adequate relief from discomfort and urgency. However, alosetron has serious side effects that include constipation and colon ischemia. The number needed to harm (NNH) for one adverse event with alosetron is ten. About one patient for every 1,000 patient-years of alosetron treatment will have ischemic colitis.1
The benefit vs. risk is most favorable in women who have not responded to other therapies. Several years ago, alosetron was pulled from the market for a period of time. However, it was subsequently returned to the U.S. market, and has since been available through a special prescribing program for women with chronic, severe IBS-D who have failed other therapies.5
A 30-day supply of 1 mg twice daily of Lotronex costs over $1,000.
Tegaserod (Zelnorm)
Tegaserod (Zelnorm) is better than placebo at relieving IBS symptoms in women with IBS-C and IBS-M. However, cardiovascular events like stroke and heart attack are more common with tegaserod compared to placebo. It was withdrawn from the U.S. market in 2007.1
For a period of time, tegaserod was available through FDA under a treatment investigational new drug application (T-IND) protocol. However, it is no longer available under the T-IND, and is only available for emergency use in life-threatening situations.
Tegaserod is no longer available in Canada.
Lubiprostone (Amitiza)
Lubiprostone (Amitiza), available in the U.S. but not Canada, is more effective than placebo at relieving IBS symptoms in women with IBS-C. Its efficacy in men has not been conclusively demonstrated.6
Lubiprostone is derived from prostaglandin. It's a C-2 chloride channel activator. Lubiprostone works topically from the luminal surface of the GI tract to promote chloride secretion into the intestine. Sodium then enters the lumen as a result of the negative charge of the chloride ions, and water follows passively.6
The most common side effects with lubiprostone are nausea, diarrhea, and abdominal pain. Lubiprostone is contraindicated in patients with mechanical bowel obstruction.6
Lubiprostone was first approved for the treatment of chronic constipation. The recommended oral dose for constipation is 24 mcg twice daily. Note that the dose of lubiprostone for IBS is lower, at 8 mcg twice daily.6
A 30-day supply of lubiprostone will cost cash-paying patients around $220.

Antibiotics

Short courses of non-absorbable antibiotics are better than placebo for improving overall symptoms of IBS, and for reducing bloating specifically. There's data for rifaximin (Xifaxan, available in U.S. only), with three RCTs (n=545) supporting its superiority over placebo. Duration of effect is variable. Symptom improvement can last after the antibiotic is stopped, for ten weeks or more in some cases. Most of the patients studied had IBS-D.1
Studies of rifaximin for IBS used higher doses than the FDA-approved dose for treatment of traveler's diarrhea, which is 200 mg three times daily for three days. The dose of rifaximin studied for IBS was 1,100 to 1,200 mg divided two to three times daily for ten to 14 days.1
No severe adverse events were seen with these high doses of rifaximin. Two of the rifaximin studies reported individual side effects, and there was no significant difference between the rifaximin and placebo groups.

Probiotics

Nineteen trials evaluating the use of probiotics in IBS patients (n=1,668) were included in a systematic review. Eleven of these studies (n=936) looked at improvement in IBS symptoms as a dichotomous (benefit vs. no benefit) type of outcome. About one in four patients treated had symptom improvement. All of the different probiotics, including Lactobacillus, Bifidobacteria, Streptococcus, and combinations, showed a trend toward benefit.1
However, when the degree of improvement in IBS symptoms was considered as reported in fourteen trials (n=1,351), Lactobacillus did not have an effect on IBS symptoms. Probiotics with Bifidobacteria (e.g., Align, Activia, VSL #3 [all U.S. only]; Bifidox [Canada]) appear to be more effective.1 For more information about probiotics and their uses see our, "Comparison of Probiotic Products."

Nondrug Therapies

Pooled data (n=1,278) show that psychological therapies (e.g., cognitive behavioral therapy, interpersonal psychotherapy, hypnotherapy) can improve overall symptoms of IBS. However, relaxation therapy alone does not offer any benefit. The mechanism for improvement of IBS symptoms might be stress reduction, empathic attitude of the provider, etc.1
There isn't good evidence to support avoiding specific foods to help improve symptoms of IBS. However, the majority of patients relate symptoms to consumption of certain foods and as a result, avoid those foods. If this is the case, don't discourage the patient unless exclusion of the particular food could lead to dietary deficiencies.

Conclusion

There are a wide variety of treatments for IBS, with varying degrees of effectiveness. Treatment decisions are often based on the severity of disease, and on the predominant IBS symptom of either constipation or diarrhea.3
For all patients with IBS, insoluble fiber like psyllium can be tried for regulating bowel movements and reducing pain.1 Be aware of the potential for gas and bloating. Introduce fiber gradually to minimize these side effects.1
Recommend antispasmodics or peppermint oil to reduce abdominal discomfort.1,2 Consider this especially for patients whose symptoms are worsened by meals.3 Antidepressants might also help with abdominal pain.1
Probiotics containing Bifidobacteria might help improve bloating and flatulence associated with IBS.1 SSRIs or TCAs can be tried for overall symptom improvement as well.1 Consider SSRIs for IBS-C, and TCAs for IBS-D.
Recommend loperamide to reduce the frequency of bowel movements for patients with IBS-D, but don't expect it to help with abdominal cramping.1 Reserve alosetron (Lotronex) for women with severe IBS-D refractory to other therapies. It's available through a restricted prescribing program because of the increased risk for ischemic colitis.1
Try osmotic laxatives like PEG for increasing stool frequency in patients with IBS-C.1 Reserve lubiprostone (Amitiza) for women with IBS-C who haven't responded to other therapies. It's prescription only and quite expensive.1
Psychotherapy can help improve symptoms of IBS, possibly by reducing stress.1 But relaxation therapy alone doesn't offer any advantage over usual care.1
Project Leader in preparation of this Detail-Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor

References

1.Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based systematic review on the management of irritable bowel syndrome. Am J Gastroenterol 2009;104:S1-S35.
2.Jellin JM, Gregory PJ, et al. Pharmacist's Letter/Prescriber's Letter Natural Medicines Comprehensive Database. http://www.naturaldatabase.com (Accessed April 15, 2009).
3.American Gastroenterological Association. American Gastroenterological Association medical position statement: irritable bowel syndrome. Gastroenterology 2002;123:2105-7.
4.Mertz HR. Irritable bowel syndrome. N Engl J Med 2003;349:2136-46.
5.Product information for Lotronex. Prometheus. San Diego, CA 92121. April 2008.
6.Product information for Amitiza. Takeda. Deerfield, IL 60015. April 2008.

Holiday Hours/Closing

Meyer Pediatrics will be closed for Christmas & New Years Holiday as follows:

December 24th - Christmas Eve - Closed at noon.
December 25th - Christmas Day - Closed
December 26th - Saturday - Closed

December 31st - New Years Eve - Open
January 1st - New Years Day - Closed
January 2nd - Saturday - Open

We hope everyone enjoys celebrating the holiday with family and friends!