What Was Torturing
words by Maryann Brinley / photograph by Pete Byron
There is passion in Amy Pappert’s demeanor when she describes one of her most surprising cases of dermatological detective work. This was the kind of patient story that offered her the gratification of an “ah-ha!” moment.
A graduate of Rutgers School of Pharmacy before she pursued medicine at Robert Wood Johnson Medical School and a residency at Columbia-Presbyterian Medical Center in New York, Pappert is the director of the RWJMS
residency program in dermatology. She absolutely loves her work, especially when she can solve a mystery that has eluded the rest of the medical community for decades. This feature, designed to showcase stories from the files of UMDNJ physicians, illustrates how persistence, especially in asking the right questions, can make a huge difference.
ur patient, a 65-year-old woman, had so many letters in her last name that the team of physicians, residents, nurses and support staff in the clinical offices of the dermatology department on Worlds Fair Drive in Somerset would refer to her affectionately as Pooski*.
“Pooski’s here,” they’d say when she arrived for regular, monthly visits for nearly three years. She had come to us after suffering from redness, pimples, itching, burning, scaling on her face, hands and legs for several decades. Her skin had gone through so much turmoil that areas were disfigured. She traveled with a briefcase of the lotions, potions, creams, over-the-counter and prescribed medications she used — any evidence that might be helpful — as well as a long, convoluted medical history compiled over the years by many other physicians and specialists. No one could figure it out.
I first saw her in February 2005, having been asked by another doctor in the practice to weigh in and examine this frustrated, anxious patient.
Though good-natured, Pooski was clearly depressed and wearily distrustful about the ability of anyone in the medical community ever being able to solve her skin problems. This condition affected her entire life, making it nearly impossible to socialize, go outside or enjoy most normal activities. Once an avid gardener, she had given that up completely. I would have to say that solving this health mystery had become the main focus of her life. Her physical disorder had taken an emotional toll.
Her file indicated that she had been treated with topical and oral medications for acne as well as rosacea, which is characterized by red skin on the cheeks, nose, chin and forehead, small visible blood vessels, bumps and pimples as well as watery, irritated eyes. Pooski had been on several regimens of antibiotics, oral, topical, and intramuscular steroids, and over the years, she had undergone six skin biopsies. Her history of testing was long and varied, including checks and blood tests for allergies, lupus, hepatitis, HIV, porphyria (a type of sun sensitivity), Lyme disease, and mercury levels. She had even seen a psychiatrist for anxiety, which had been blamed for causing her skin condition.
In my last year of pharmacy school, I did an industry rotation at Ortho Pharmaceutical Corporation in pharmaceutical formulations and as I finished up, someone suggested that I explore a job as a clinical trials research assistant in dermatology there. I took the job and loved it, because it fit me like a glove. Even when I was later in medical school, every time I came across something in dermatology, I’d get excited. I still do. And I love these kinds of cases. Right away, my initial impression at our first appointment nearly three years ago led me to believe that she was not suffering from one thing; I suspected three. She definitely had rosacea, a condition that afflicts millions of Americans and really has no simple explanation or cure. But I could see steroid-induced skin changes making the rosacea even worse than it might have been. I also surmised that she had some kind of contact dermatitis.
While steroids aren’t always bad for your skin, they can be tricky to use, especially on the face. When you apply a topical steroid, your skin can clear up very quickly (even if it is not the right medication to use for the condition). But after a while (even as little as one to two weeks), your skin may get used to it and not feel comfortable without it. You can end up caught in a cycle where you can’t stop putting on this topical medication because without it, your skin burns, stings and looks really horrible. Not enough people realize this "addictive" aspect of topical steroid medications. Pooski’s skin was definitely caught in this dependent trap. However, and this was key: I also believed that she was allergic to something right there in her everyday life. We just needed to figure out what it was.
So I sat down with her and started asking questions. “What do you do when you get up in the morning? What do you put on your skin every day?” She resisted at first, answering in quick, matter-of-fact responses, having obviously been asked similar things before. It was the same old story for her and she was tired of telling it. But I kept pushing, “No, no, go back. Start at the very beginning of your day. What do you do when you get out of bed in the morning? What exactly happens? Start with the smallest of details. I want to know absolutely everything about you and your daily routines,” I said to her.
I had to drag information out of her. It took an hour to find out that in addition to the products in her suitcase, she had also been using baby shampoo. In fact, Pooski had been washing her face as well as her hair with baby shampoo. This revelation — and I do mean revelation — made me turn to the resident at my side, and say, “Ah-ha! That’s it.” We both nodded in instant agreement. “The baby shampoo!” Meanwhile, the idea that something as mild as a baby shampoo could be the cause of such a nightmare was so unthinkable to Pooski that she had never mentioned it before.
“Baby shampoo? It’s been around forever. I’ve used it for years,” she protested. “How could it be bad for me?”
The answer: cocamidopropyl betaine, an ingredient in baby shampoo, now being included frequently in all sorts of cosmetic products for sensitive skin, a lot of cleansers, and makeup removers. It all started with the original baby shampoo, which was popular because it didn't sting the eyes (no more tears!). This allergen has become much more prevalent in the marketplace and turns up in a wide variety of products. It’s even in my toothpaste! But for most of us, it’s a harmless amphoteric surfactant, which is just a mild cleansing agent.
So I told a perplexed Pooski to stop using the baby shampoo immediately. Of course, we still needed to make certain that cocamidopropyl betaine was the culprit. One of the most exciting things we do here in the Department of Dermatology is contact allergy testing. While there are thousands of things you can be allergic to, there is a smaller group of known, common, contact dermatitis allergens. Using little strips of 10, we put tiny amounts of 65 different chemical allergens onto separate little patches and tape them to the patient’s back for two days. On removal, you can see the allergic reaction right there on the skin and in Pooski’s case, it was definitely the cocamidopropyl betaine. This kind of testing is not the same as what allergists do for their patients. We are one of the few dermatology practices in central New Jersey that does such contact dermatological testing. But keep in mind that you also have to do the investigative work first. And, the problem isn’t always as clear cut as it was for me in Pooski’s case. Sometimes, even after you get the reaction you expect to a particular chemical, you can’t always be certain where the patient is being exposed to that allergen.
Some medical dermatology cases can be so hard to diagnose and treat that one Wednesday evening a month, a group of 10 to 15 professionals meet here for clinical consultations to discuss our most difficult cases. We deal not just with the medical histories on paper, but with the actual patients who come in to be seen by all of us. This is unique to dermatology. Residents present the cases and then one by one, we’ll each offer input and answers. Pooski didn’t end up at this roundtable, however.
Because the damage to Pooski’s skin had occurred over decades, it took more than a year to see real changes for the better. To treat her rosacea, I put her on topical metronidazole, as well as oral tetracycline, which she is still taking after two years. I hope to be able to taper her off that eventually. I also weaned her gradually off the topical steroids (after the “cold turkey” approach resulted in an unbearable flare-up). But at her last visit, the despair was gone. She’s back to her gardening. Over the months of care, she would have moments of despondency. Yet, because we had the answer this time and knew it would just be a matter of healing time, I could say to her with confidence, “You are getting better. You are going to be okay.”
Dermatology is just the most amazing and unique field in which to practice medicine. You have to love details, as I do, and revel in the tiniest of factors. As I instruct the residents I teach, we have to take care to listen to our patients! Here was a case in which a “soap-free, hypo-allergenic, dermatologist-tested” product carrying “the gentlest touch you can provide” and designed to “leave skin of any age feeling baby soft” was the cause of so much misery.
Amy S. Pappert, MD, RWJMS ’89, is an assistant professor of dermatology and director of the residency program, which attracts hundreds of applications for each class. Her Department of Dermatology, previously a division of the Department of Medicine, was established in 2005, and the acting chair is Babar K. Rao, MD, a clinical assistant professor of medicine at RWJMS. This office, located at 1 Worlds Fair Drive, Somerset, NJ, 08873, can be reached at 732-235-6519. Dr. Pappert’s email address is email@example.com.