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Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey. This is Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about ways to take care of the meaningful sensation of itch. It is such a troublesome problem for patients and people really can suffer with it. So we've previously discussed what can cause itching and why it's so uncomfortable. Now let's talk about what we can do about it.

Dr. Johnson: And we discussed that just discussing itch makes me itchy, so hopefully discussing how to treat it will make me not so itchy.

So there are lots of different ways to treat itch, and as we discussed in our last episode, there are lots of different reasons why people can be itchy. So to start out, we start with the safest things that are effective for at least a lot of different types of itch, and we start off with just being gentle with your skin. I think we've talked about gentle skin care before.

What exactly dermatologists mean by gentle skin care is perhaps a little bit up in the air, but in general you want to avoid things like harsh soaps and harsh cleansers and irritating cosmetics, and just use gentle things on your skin instead.

Dr. Tarbox: I like to tell people to kind of think about how they would take care of a baby's skin. When we think about our skin, it's actually kind of like a living, breathing fabric. Its job is to protect us from the outside world, and it's designed to be able to do that by itself. We interfere with that function a lot by what we put on the skin. So we use a lot of things that can be potentially irritating, like harsh detergents. We also add things that might cause irritation, such as fragrance and other topical products with harsh preservatives.

So when you have itchy skin, really babying that skin is key. Very gentle cleansers that don't remove too many of the essential oils from the skin, that don't strip that natural oil that's there to protect it, and then things that aren't heavily fragranced to be irritating, using good gentle moisturizers that replenish the moisturization of the skin.

Dr. Johnson: We've talked about some specific products in other episodes, but white Dove bar soap tends to be a good choice if you're just looking for a soap to use in the shower, for example. By the way, we're not getting paid by any manufacturers of these products.

Dr. Tarbox: Not sponsored.

Dr. Johnson: Then for your face, just a gentle facial cleanser. There are lots of brand out there that make good ones, like CeraVe and Cetaphil and Aveeno and a bunch of others. So those are good choices for the face.

And then beyond that stuff, moisturize your skin. Dry skin can be super itchy, so if you want to go after your itch, you can moisturize your skin. I've had a number of patients, and not to stereotype them, but many of them were adolescents. They're kind of itchy, but they just don't want to be bothered to put moisturizer on their skin. So if you rather would be a little bit itchy than put moisturizer on your skin, that's your choice. But if you would like to moisturize your skin, and I think we've talked about this before as well, the thicker and greasier they are, the more effective they are at moisturizing your skin.

So I didn't realize this until I became a dermatologist, but moisturizers do not work by adding moisture to your skin. They work by preventing your own moisture from evaporating away from your skin. That's why the thick, greasy ones that prevent your own moisture from evaporating away tend to be the most effective.

I like plain old Vaseline or petroleum jelly. It's cheap, does a good job, but it's messy, so it's not for everybody. I also like shea butter and coconut oil. And then anything that's got to be scooped out of a jar or squeezed out of a tube is going to be more effective than things that pump out of bottles. Though if you're just a little dry or a little itchy, then the things that pump out of bottles might be fine and are more convenient.

Dr. Tarbox: If you've gotten past the moisturization stage, you're doing your gentle skin care, and you're still itchy, there are some things that are available over the counter that can help with itch. One of my favorite ones is an ingredient called pramoxine, which is actually a topical anesthetic that's very good at treating itch and it's very gentle to the skin. So you can get topical products with pramoxine over-the-counter such as Sarna Sensitive, which is a cream that's made for treating itch, as well as the CeraVe anti-itch cream or lotion, which also contains pramoxine, which is very helpful for itching.

What else can you use topically?

Dr. Johnson: Some people will use topical Benadryl, but Benadryl is not great topically. No offense, Benadryl. The generic name for Benadryl is diphenhydramine, and if it's in a cream, it doesn't really do anything. But you can take antihistamines like Benadryl or others by mouth and that can help with itch if your itch is related to histamine. They are antihistamines after all. The main itch that's related to histamine are hives. So if you get hives, then think about an antihistamine. There are a lot of them out. There are generic names. There are brand names. You want to use a non-sedating when you don't want to be sleepy. Xyzal or levocetirizine, that's two names for the same thing, is one of the least sedating ones. And then Benadryl or diphenhydramine is one of the more sedating ones that you might want to use in the evening.

Dr. Tarbox: And do remember that antihistamines can make you sleepy. They may also interact with other medications, so if you take a lot of other medications, you may want to discuss with your doctor which antihistamines would be safe for you to use.

Dr. Johnson: Dermatologists love topical steroids, and there's a reason we love topical steroids. They are effective and safe. So the over-the-counter topical steroid that is available is hydrocortisone 1%. It's totally safe to use. You could use it on your face every day forever and you would probably be fine. You can put it on babies. It's pretty wimpy. It's so wimpy the dermatologists sometimes look at it and say, "Is that doing anything beyond just being a moisturizer?" It probably is. There's a little bit of hydrocortisone in there. We have access to much stronger ones if you want to use prescriptions, but you might not need it.

So if you're a little bit itchy, especially if the skin looks a little bit pink plus is itchy, that could mean there's some inflammation there, and steroids are really good at calming down inflammation. So you can start with a hydrocortisone product. The ointment tends to work better than the cream. So if you can find hydrocortisone 1% ointment, that's the strongest topical steroid you can get over the counter and is still very, very safe.

Dr. Tarbox: If the itch is still uncontrollable past those different control mechanisms, sometimes dermatologists will turn to something called light therapy where we actually use some of the properties of natural light to help control itching. How do you use it, Luke?

Dr. Johnson: Light therapy is also called phototherapy, so if you've seen that or heard us talk about it, that's the idea. And the way I like to explain it is that there is a particular wavelength of light that helps calm down the immune system in the skin. The immune system is often involved in itch, so this tends to be effective for lots of different kinds of itch.

It's very safe, can be quite effective depending on the person. The main problem is that it is inconvenient. Not all dermatologists, but a lot of dermatologists have machines that produce this wavelength of light, and the machines often look like little closets, little rooms, or sarcophagi. You go stand in one and then this special light shines all over your skin.

The problem is you have to do it three times a week for at least three months to really see if it's helpful, which is not convenient because you have to drive to the dermatologist's office three times a week for three months probably during normal work hours or school hours. You're not really in the machine for very long, usually just one to three minutes, but it's the commute and everything that's really a hamper. But if you can make it work for your schedule, it can be a good idea.

Dr. Tarbox: And we sometimes also use outdoor sunlight for patients who are itchy when they can't get into the doctor's office. That does have to be done with some thought because, of course, sunlight can also cause sunburns, and in high doses over long periods of time can cause skin cancer.

So if you do have a chronic itching problem that's not under control, you may need some guidance on how to use some of these mediators to help improve the itching.

What about other medications, Luke? Is there anything else available to treat itch?

Dr. Johnson: Oh, yes. Itch fortunately, over the past five years or so, has been the subject of more research than in the rest of human history. We're finally believing Dante, that it is miserable to be itchy.

So if you've tried a bunch of this stuff and you're still itchy, then a dermatologist or another doctor might prescribe you various types of medicines to help you out. The first part of our job is to figure out if we can identify what exactly is making you itch. So dermatologists or other doctors might do some lab work, for example, to see if there's a problem with your thyroid, for example. Or we might do a skin biopsy where we take a little piece of your skin so we can look at it under the microscope to see if that might shed some light on why you might be itchy.

So depending on what's going on will help us decide what kind of medicine that we should use. For example, if you have thyroid disease, then you can take thyroid medicine. That should help your itch.

Otherwise, sometimes we're stuck using other therapies that are useful for various types of itch. So for example, we can use the type of medicine we call systemic immunosuppressants. They have several different names like Methotrexate and Azathioprine, and they're pills that you take by mouth that just calm down your immune system overall. So as you might guess, they have some potential significant side effects. That said, most people who take them do fine and they can lead to a lot of relief.

Dr. Tarbox: When we face chronic itch, sometimes patients will also have distress in the form of sleep loss. Some patients experience anxiety. Others experience depression. And of course, these are very important things to treat.

We've also found that addressing the patient's internal environment through means such as cognitive behavioral therapy can improve the sensation of itch as well as the suffering that comes from it.

So some patients improve from understanding and having a sort of presence mindset when they're dealing with itching, sort of an acceptance, "Yes, I'm itching right now. It doesn't mean anything bad is going on. This is what I can do to help make this feel better." A little bit of a wellness approach to dealing with chronic itch when there's not a whole lot else we can do, but that can also be beneficial. And treating that internal environment can sometimes lead to some resolution of the skin symptoms.

Dr. Johnson: On a personal note, when the pandemic started, I began a meditation practice, mindfulness meditation, and I think it has helped me out. Not that I was necessarily having a problem with itch, but this business of mindfulness and just being present and feeling the body's sensation and not getting wrapped up in the sensation but just noticing it and acknowledging it, I can understand why that would help somebody who is itchy get over it. Not the way the mindfulness people would describe it, but . . .

Dr. Tarbox: Cope with it. They can cope with it.

Dr. Johnson: Adjust your perspective on it.

Dr. Tarbox: Yeah. I think that's great. And even for some patients, hypnosis has been helpful for treating itch. So there are lots of different ways to go after chronic itching. It is one of those final frontiers in dermatology that we've got a lot of interest in, and there are new medications coming out to help treat it. But now that we understand how we can help prevent the itching, how we can treat our skin when we do itch, and ways we can cope with it when we can't get rid of the sensation, hopefully we can make everybody just a little bit more comfortable.

Dr. Johnson: Before we say goodbye today, I just want to talk about a couple more prescription medicines that are available just because I think they're cool and maybe you'll think they're cool too.

So if your doctor thinks that there's something going on with your nerves, your nerves are extra twitchy or firing and that's what's making you itchy, then they might prescribe a medicine called Gabapentin, or there's a similar medicine called Pregabalin. Those can help as well. They're quite safe, though again they can make you a little bit drowsy, kind of like antihistamines, if they're given in high enough doses. But they can be pretty effective.

Cells in your body talk to each other with little tiny chemicals and some of those chemicals have a special name. They're called interleukins, and I'm not just saying that because my name is Luke…

Dr. Tarbox: They're not “interMICHELLEns”? Come on, man.

Dr. Johnson: No “interMICHELLEns” out there. There's a whole bunch of them and they all have numbers, and in medicine we abbreviate interleukin as IL. So there's IL-4 and IL-13 and all kinds of ILs. But it's been discovered that IL-31 is strongly associated with itch, and so there's a new medicine that's in development nemolizumab. It has shown to be very effective for people who are itchy if they have particular itchy dermatologic conditions like eczema or even just itch and we're not really sure why. So if you are really itchy and you've tried a bunch of stuff and nothing has helped, there is hope on the horizon.

Dr. Tarbox: Well, thank you guys so much for joining us today. We've really enjoyed having you here to learn how to take better care of the skin you're in. Luke, you and I have another podcast.

Dr. Johnson: We sure do sure do. It's called "Dermasphere." It's intended for dermatologists and for the dermatologically curious. So if you're like us and kind of nerd out on a lot of the science aspects of dermatology, then you might want to check it out.

Thanks, of course, to our institutions. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. And thanks, of course, to you, listeners, for hanging out with us today. We will see you next time.

Dr. Tarbox: Hello and welcome to "Skincast," another episode of the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, hello. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah. This is Part 3 out of three to four episodes in our series on cosmetics. We had Dr. Adam Tinklepaugh, one of our faculty at the University of Utah, here a few episodes ago. We've got Michelle back here, and we're going to spend today talking about procedures.

So, in a couple of our last episodes, we talked about sort of things you could buy over the counter, maybe stuff that you can have your doctor prescribe. And here is stuff that you can basically pay to have people do to you. And since 70% of my patients are kids, I'm going to lean on Michelle's expertise to talk about a lot of these things.

Dr. Tarbox: Well, there are a lot of different kinds of things that can be done in the office or in a procedural specialty to help improve skin health and appearance. And it starts off relatively straightforwardly and simple with an office procedure called a chemical peel.

Now, chemical peels have been around for a very long time. In fact, the idea of a chemical peel has been around for a very, very long time. There are some writings about how Cleopatra used to bathe in soured milk because it would make her skin softer and more clear-appearing. And what we know now was happening is that some of the acid degradation products of the milk were helping exfoliate the skin, some of the lactic acid and things like that that were in that preparation.

They were used medically for the first time in the 1800s by an Austrian dermatologist named Ferdinand Ritter von Hebra, who actually helped us understand the virus herpes and a lot of things about it.

But chemical peels are one of the first ways that we start to improve cosmesis in the office. A chemical peel involves the application of some kind of chemical substance, usually an acid that's a weak to mild acid that's placed on the skin, and then utilizes what we call the skin's “wound healing response”. And that plays a role in a lot of our regenerative therapies that we can do in the office.

Any time we engage the skin's wound healing response, we can improve cell turnover, we can improve collagen building, we can improve the appearance of fine lines and wrinkles, and also just pigmentation.

But it has to be done carefully because all of us have had wounding to the skin and have had it turn out in not as cosmetically-elegant a way probably as we'd like if we scraped our knee or we fell down and ground our elbow into the concrete. Many of us wear scars to remind us of that. So this kind of procedure does have to be done with care.

But when we do a chemical peel, we evenly apply typically a chemical substance over the surface of the skin we're trying to treat. That causes some level of damage or wounding to the epidermis, and then the skin's natural self-healing mechanisms are triggered, and you get replacement of some of the damaged tissue as well as new collagen synthesis and improved appearance.

Dr. Johnson: Isn't the human body amazing? And especially the skin, of course. It's always pretty awesome when we can use the body's natural procedures in order to achieve results that we're hoping for.

There are a lot of different kinds of chemical peels out there. Some of them are available over the counter, the mild ones, as you might expect. And they can be used for different things. So some of them are used for dark spots, some of them are used for fine lines and wrinkles, and then some of the more intense ones can be used for deeper lines and wrinkles.

Dr. Tarbox: And they're very useful. They have to be used by somebody who knows what they're doing, and the person has to be literate with many different skin types so that they know how oily versus dry or sensitive skin might respond to the peel, as well as different skin tones.

So certain darker skin tones might have a greater risk for hyperpigmentation, where the skin becomes darkened, or hypopigmentation, where the skin looks lighter after the chemical peel if it's done inappropriately in a patient of different skin color. So you have to be careful about selection of therapy for each patient, and each patient should be treated as an individual.

After our chemical peels, we can do something called a Photofacial. You might have heard of Photofacial. That's usually referring to an intense pulsed light treatment. Intense pulsed light is a laser-like device that creates different wavelengths of light for therapeutic targets that can range from pigment, so dark spots on the skin, to vascular, so red areas of the skin, to hair. It can actually help remove unwanted hair with the intense pulsed light.

So those are things that can be done relatively quickly in the office and don't require a huge amount of downtime for light peels. Medium peels will take a little more downtime.

Dr. Johnson: And some of these are fairly inexpensive. I know for some of these cosmetic procedures the price tag can shoot up pretty quickly. But in my experience, the chemical peels and the intense pulsed light aren't too bad.

Dr. Tarbox: And really, when it comes to medical procedures, there are a few things that play into the cost of those procedures. One of those things is the equipment it takes to do that procedure, whether that be an expensive laser, whether that be a consumable product that can only be used once per patient. That has to get factored into the cost.

So, with a peel, the cost is the peeling agent and then the supplies you use to apply the peel. And then we also have price modulation for different services based off of the complexity of the service and the requirement for aftercare.

So things that are what we call the lunchtime facial, the intense pulsed light, or something where the risk is pretty low and the follow-up care is pretty gentle, that tends not to be as expensive as something that takes more product cost, or is more complex to do in the office, or creates greater risk.

As we get to the higher percentages of chemical peels, the more aggressive chemical peels, those might go up a little bit in price. You also have to have more downtime for those more aggressive chemical peels.

Dr. Johnson: You talked about the intense pulsed light devices, a laser-like device. Let's talk about actual lasers. There's a number of them out there, and they tend to be used for different purposes.

A lot of them remove color on the skin, and there are different lasers that target different colors. So, if you've got dark brown spots, there's a laser for that. If you've got pink or red spots, there's a laser for that. And then there are also lasers that just sort of destroy the skin. But again, we can do that in a controlled way to take advantage of the skin's own rejuvenating powers in order to rejuvenate the skin.

Dr. Tarbox: And there are all kinds of lasers. There are what we call ablative lasers and non-ablative lasers. An ablative laser, if you see a picture where somebody's skin is red and it has maybe little white dots on it or it looks very irritated after a laser procedure, that's probably an ablative laser. We call them ablative because they in some way or the other go through the epidermis. So those are laser procedures that are going to require some downtime.

Our ablative lasers can include a CO2 laser. You may have heard of CO2 lasering, like Fraxel. You may have heard of Erbium YAG or Nd:YAG. Those can be ablative as well.

So these are different laser treatments that can wound through the epidermis, which can help engender that wound healing response and improve texture and appearance, but that does require some downtime. And it's a little bit more of a moment, as I like to say, as the patient experiences that laser. So it's a little more intense, but those are really good lasers that can be used to improve skin texture and appearance. The resurfacing lasers, or the ablative lasers, can be helpful in improving skin appearance in a relatively aggressive manner.

Then those ablative lasers can be used either fractionated or fully ablative where they're completely taking out every bit of the surface that they're treating on, or they can be using it in a fractionated way where it's little individual dots across the treatment area, which is going to give quicker healing time and less severe change after the laser. So that's another option.

Dr. Johnson: Poking a bunch of little holes in the skin is how I like to describe it to patients. And it's good for wrinkles. It's good for acne scars. And there's another type of device called a microneedling device that is sort of similar in concept in that it also pokes a bunch of little holes in the skin. But instead of using lasers, it uses little needles.

Dr. Tarbox: So a lot of what we do is controlled wounding of the skin where we're actually using a tool of some kind of, be that a laser, be that a microneedling device, to in a controlled way use the wound healing capacity of the skin to improve its health and appearance. So those are other ways you can handle that.

Microneedling can be used to improve acne scars. It's very good for that. It's also used to improve texture of skin on the face with fine lines and wrinkles. It improves discoloration. It also improves some of the scarring that can be left behind after an inflammatory process.

And microneedling can be used to introduce different medications to the skin. It can also be used with platelet-rich plasma or used to help improve hair growth at home. So there are lots of options with microneedling.

It can also be used with radiofrequency, where the microneedles themselves actually have radiofrequency energy that goes through them and bulk heat the tissue in another way to wound it to help improve the appearance, and texture, and turgor of the skin, meaning it gets tighter.

Dr. Johnson: Some of these microneedling devices are available over the counter. If you were to want to purchase one of those and use it, just make sure you follow the instructions, because if you don't know what you're doing, you could perhaps end up in trouble.

I think it's useful to know that in a lot of these procedures, microneedling and laser and stuff, you often need multiple treatments before you get the full results that you're hoping for. So, for example, in microneedling, it probably takes four to six total treatments to get the results that you're hoping for. So, if you're planning to do something like this, go into it with that in mind. The procedures are usually something like four to six weeks apart.

So what if it's not my face that's the problem? What if I've got spider veins or varicose veins in my legs? Can dermatology help?

Dr. Tarbox: So, for spider veins in the legs, there are lots of different ways that dermatologists can be beneficial. One of the ways that's more straightforward is our sclerotherapy treatment. So sclerotherapy actually involves the use of a medicine that is injected into the tiny vein that is broken. So we're actually injecting into the lumen of the vessel.

It's kind of like a fun skill game for dermatologists. I don't know about you, Luke, but when I'm doing sclerotherapy, I think that I understand people who play video games compulsively because of the sense of reward I feel when I actually get one of those little blood vessels cannulated. And then I see that whole mat of those broken blood vessels just blanch out as the medicine goes through them.

And what the medicine does inside the vessels is it makes the walls of those teeny tiny blood vessels that we don't use for anything . . . They're just there because we have usually a broken valve in a vein or something. Those little tiny vessel walls get sticky to themselves, so they kind of close down on themselves. And they don't have blood circulating through them anymore, so you don't see them on the surface of the skin.

And because these are basically dead-end, useless tributaries that we don't need for anything else, there's no damage to the patient by treating these. It just improves the appearance, and sometimes if there's pain associated, it improves the pain.

Dr. Johnson: Dermatologists could treat some of the little to medium type veins, I would say. If you've got a big old varicose vein, then it might need a vein specialist.

Dr. Tarbox: Yeah, vascular surgeons might be the right place for those big veins. Some dermatologists do the endovenous laser ablation. Some don't.

Dr. Johnson: What about body contouring?

Dr. Tarbox: So liposuction was actually developed by dermatologists. The person who invented liposuction was trying to find a way to treat lipomas, which are those little fatty tumors that some patients get. And so he sort of conceived of a device that was like a suction needle you could put into the lipoma and remove it that way.

We don't really use liposuction to remove lipomas, but it is used for a lot of body contouring and shaping. And it does fall within the purview of dermatology. A lot of dermatologists do liposuction. I was trained to do it when I was a resident, and it can be very useful.

Dermatologists can also use liposuction to obtain fat for fat grafting, which is a procedure that can be done to help improve areas of volume loss on the face or help improve a scar cosmesis following reconstruction.

Dr. Johnson: In recent years, there have been other devices that have been developed that have taken advantage of other technologies and other aspects of physics in order to perform this body contouring. They have names like CoolSculpting, and then there are also radiation ultrasound-type devices that can potentially perform some of these actions.

I'm not super familiar with them since I don't do a lot of cosmetics. How do you feel about these, Michelle?

Dr. Tarbox: So they don't not work. The gold standard is liposuction, where a cannula of some variety is inserted under the skin and is passed through the fat layer either mechanically through the arm motion of the operator, or ultrasonically through a sonic oscillation of the cannula itself that can withdraw the fat cells from the patient's body.

There are other things that are also using the fat's vulnerability areas. So our fat is more vulnerable to cold than other parts of our body. There's a kind of condition that often will happen with toddlers, where they get a popsicle and they just sort of let it sit on the face while they're enjoying it, called popsicle panniculitis where the fat actually dies because of the exposure to sustained cold.

And that's the premise for CoolSculpting, which I have tried to see what it was like. It is a doable procedure. It's not completely uncomfortable, but it is not pain-free. So you need to be aware going in that it's going to require a little bit of mental toughness to go through.

But CoolSculpting is based off of that popsicle panniculitis or that cold panniculitis property of fat where fat does not tolerate very low temperatures for prolonged periods of time.

When they do CoolSculpting, they apply a little gel matrix pad to the skin that is to protect the epidermis from the freezing so you don't also get frostbite of the skin. And then they use a sort of suction probe to suction part of the area of adiposity they want to treat into the treatment handle, which can then cool down and basically freeze that part of the fat that is being subjected.

And then once they remove the suction device, the fat is still frozen. When they do it on the abdomen, it makes something called a butter stick. So it's about that size. It's just frozen solid fat. Then the esthetician or the person doing the therapy for you has to massage all of that out to kind of break it apart, which does two things. It sort of mechanically agitates some of the fat cells that are already frozen, and that can break them up, which kills them. It also helps prevent there being any kind of focuses of increased damage because of temperature irregularity. So that's CoolSculpting.

Dr. Johnson: There are a number of other products out there that exist for specific purposes that have reasonable medical data to support them. So, for example, what dermatologists call submental fullness, or sort of a fatty under-chin or double chin, there's a product that you can inject that'll dissolve the fat and help it tighten up. The brand name is Kybella.

Dr. Tarbox: It's bile acid. It's just bile acid going into the skin. That also hurts. That also is a painful procedure.

Dr. Johnson: But it seems to work all right.

Dr. Tarbox: But it works. It does work.

Dr. Johnson: If you have cellulite, especially on the butt, there's a new product out there that has collagenase, which is a protein that will dissolve collagen, that has some efficacy behind it. I believe the brand name is QWO.

And then plastic surgery is, of course, its own surgical specialty and they can do all kinds of stuff to your face. Some dermatologists do some plastic surgery.

And then we didn't really talk about Botox, or more generically botulinum toxin injections, or fillers. I think we've hit those in some of our previous podcasts. I think the short answer is that Botox . . . both Michelle and I are big fans of these botulinum toxin injections, and I think you'd heard Adam Tinklepaugh talk about them too. I like them. They tend to over-perform. They're good for wrinkles, especially rather small, rather shallow ones.

And then fillers add bulk to areas where you don't have bulk. So some people prefer to have more luscious-looking lips, for example. And then other people, perhaps because of the normal aging process, have just lost some of the subcutaneous fat in certain areas of their face, and filler can replace those.

That's my quick and dirty thoughts about those, Michelle. Do you have any thoughts that are slower and cleaner?

Dr. Tarbox: I really think Botox is a great treatment for facial wrinkles. Dysport and Xeomin are other types of neurotoxins that are similar to Botox. And they also help improve the appearance of the skin as well as decreasing unwanted facial movements.

There are studies that show us that we've reviewed on our other podcast, the more scientifically-based longer podcast that we do called "Dermasphere" . . . We've discussed the fact that long-term use of Botox actually improves brow position. So it helps improve the way the face ages over time. And it helps improve also some aspects of skin texture, so you have finer poor appearance often in areas that have been treated with Botox.

The fillers, there are a lot of different fillers. There's the Restylane product line. There's the Juvederm in product line. There are HA fillers. All of these definitely are usable in a different way to fill volume deficits, to improve tissue building, and to deal with lines and expression changes that happen over the face.

They should be used by somebody who knows what they're doing, because they are not without risk if they're done incorrectly or if there is just a day of really bad luck. People can have the filler get into a blood vessel accidentally, and that can either cause some part of the tissue that's supplied by that blood vessel to die. That's called necrosis, not something that you would want to have happen to you. Or in extreme cases, it can cause blindness. So they do need to be used by somebody who knows what they're doing and has been trained to select the right location and the right filler to use. And of course, they should only be done by medical professionals in a safe and clean environment.

Dr. Johnson: And that wraps up this three- to four-part series of cosmetics, but we might talk about cosmetics more later. Who knows? There seems to be a lot to talk about.

Thanks for hanging out with us today. Thanks also to the University of Utah for supporting the podcast and to Texas Tech for lending us Michelle.

And as Michelle alluded to, we have another podcast that's scientifically nerdy. It's called "Dermasphere." It's intended for other dermatologists and the dermatologically curious. And if you consider yourself dermatologically curious, come check that out. Otherwise, stay healthy, beautiful, and handsome, and we will see you next time.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: It's "Who Cares About Men's Health, the Sideshow." My name is Scot Singpiel. I'm here with Dr. Troy Madsen.

Troy: Hey, Scot.

Scot: He is the MD, I bring the BS. And we also have producer Mitch.

Mitch: Hey.

Scot: All right. Today, pig worms is the show or subtitled "Swallow Your Pride, Not the Undercooked Pork."

Troy: I'm so intrigued already, Scot.

Scot: Are you intrigued?

Troy: I am intrigued. I'm a little grossed out already too, but I'm intrigued.

Scot: Mitch, how are you doing so far with this?

Mitch: I just got a mystery invite to this recording that just said pig worms.

Scot: Pig worms.

Mitch: I'm excited to hear whatever's about to come out this conversation.

Scot: I know that Troy probably knows the answer to this question so I'll throw this at you, Mitch. Do you know why you're not supposed to eat raw or undercooked pork?

Mitch: I always assumed there was some disease connected to it, because I know like you got salmonella when you have undercooked chicken and I assumed that there was something with pork. I don't know what exactly it is.

Scot: Troy, what's the difference between like salmonella and what happens when you eat undercooked pork?

Troy: Well, there are two different diseases for sure. So pork, I'm thinking of trichinosis. Is that what you're getting at?

Scot: One is a bacteria, right?

Troy: Right. One is a bacteria, one is a parasite.

Scot: Which is just a nice way of saying . . .

Troy: Worms. You've got worms.

Scot: All right. So here's the story. And then where this is eventually going to go is just how to have a conversation with your doctor, because this was a very frustrating journey for me on a lot of different levels. And I think maybe we can pull a lesson out of this for other conditions other than if you ingest undercooked pork and have pig worms.

Troy: I think there's going to be a lot the lessons from this, Scot, but why don't you go on. We need to hear what happened first.

Scot: All right. So when it comes to trichinosis, which is caused by eating raw or undercooked pork, not so much here in the industrialized world anymore because the FDA and there are regulations in place to prevent this from happening, but you know, it can happen.

And it also can happen from eating wild game. So if you're a hunter and eat wild game and it's undercooked or raw, then you can also possibly get trichinosis, which is a parasite, which is a worm called trichinella.

And the internet is equal parts unconcerned about this disease and also terrifying and inconsistent. The other thing the internet is heavy on prevention. So right up front, if you get a piece of pork that looks undercooked, it should be white inside or raw, don't eat it. Send it back, don't mess around with it.

Troy: That's the first rule of thumb, yeah.

Scot: My wife and I were on vacation. We went to a restaurant. I hardly ever get the pork. I decided to get the pork and it comes out and I cut into it and it looks kind of pink, like pinker than I think pork should be. So I'm like, "Eh, does this look okay?" My wife's a vegetarian so she's like, it looks maybe a little . . .

Troy: She's like it looks it's disgusting.

Scot: Yeah. Looks a little raw but I don't know. So I have two kind of fatal flaws. Well, I've got a lot of fatal character flaws, but two that apply to this story. Number one is I don't like to look stupid. Number two is that I don't like to be a bother. So I'm in the restaurant.

Troy: You didn't want to make a scene. You didn't want to call the waiter and be like, "My pork's undercooked. Please take it back." You didn't want to be that guy.

Scot: Every time I've ever had an interaction with a waiter about the quality or the condition of the food, it's just never turned out me feeling good about it.

Troy: So this is your background coming into this. Like, you know, they're not going to, you know, or they're going to spit on your food or something.

Scot: Yeah. Or the other thing is I'm afraid I'm going to call them over and just be like, "Oh, I'm sorry, sir. That's how good pork is cooked."

Troy: That's how we do it here.

Scot: Right. Like, you rube.

Troy: That's how we cook it in South Dakota.

Scot: We were in Washington but actually we were in Idaho. You, rube, don't, you know, you're supposed to cook pork this way now. You know, in Boise, Idaho, that's what I'm afraid of. That's how little confidence I have in myself. Like the fine culinary practices of Boise, Idaho, I don't want to be insulted by those.

So I go on the internet and I look up and apparently the FDA has said that you could actually cook pork now at a lower temperature and medium rare is okay. Now I found this on a few different websites. So I take a couple bites of the, what I assume to be the medium-rare part. And then as I'm cutting into this a little bit more, it's starting to look more like how I would expect pork to look cooked. It didn't look overcooked, but it did not look like what I had just eaten.

So I waved the waiter over and I say, "Yeah, I'm sorry to bother you. I think that maybe this might be undercooked," and I turned my plate and he looks at, and he goes, "Oh my gosh."

Troy: Oh no. That was the response from the waiter. Oh, wow. And how many bites had you had at that point?

Scot: I'm not sure. Maybe a couple of that section. Possibly three. I mean, not a ton.

Troy: Okay. This is of the section where he's looking. As you're chewing on it, was it pretty squishy?

Scot: Yeah, it was.

Troy: But you just kept eating it.

Scot: Let me take another side.

Troy: This is how it's cooked in Boise.

Scot: So he says, of course, you won't be paying for that. Take the potatoes off your plate. I'm going to take this back to the kitchen. So he scoots it back to the kitchen. He comes back a few minutes later and he's like, "I've showed it to our sous chef, I've showed it to our manager, you will not be paying for that meal. We'll go ahead and going to cover your flight of your beer tasters there. You get 10% of our brewpub. Just don't sue us, please." No, he didn't say that.

Troy: Don't sue us.

Scot: But this reaction led me to believe that this was the deal.

Troy: That you would pay the price.

Scot: Yeah. So anyway, go ahead and open up the picture that I sent you.

Mitch: What am I looking at here?

Scot: Is that medium-rare or is that uncooked?

Mitch: Scot. Scot, what did you do? Why did you eat this?

Troy: Was it a dark restaurant? Could you not see what you were eating?

Scot: That's pretty raw, isn't it?

Troy: That looks like pan-seared tuna. Essentially. Seriously. It looks like pan-seared tuna, where they take the tuna, they throw it in the pan, and heats it up on the outside. The center of it is raw. I mean, that's like, that's definitely not cooked.

Scot: So I think the picture, I don't know, maybe. Our perceptions are such weird things. But anyway that's pretty raw is what I've come to the conclusion.

Troy: That's raw.

Scot: So anyway, so I start looking up trichinosis and this is where I run into the equal parts, unconcerned, terrifying, and inconsistent. So CDC says one to two days abdominal symptoms. Oh, by the way, hey Troy, do you know how the life cycle of a trichinosis, trichinella or do you want me to explain that?

Troy: You are the expert now, Scot. I'll say I know that it will reproduce in your liver and it works away in your muscles.

Scot: I didn't know that. Okay. Well, I knew the muscles part. I didn't know that it was via the liver. You eat this piece of raw meat that has these little, basically worm eggs in them that have this very hard coating on them. When you digest that, your stomach acids dissolves away the coating so then the worm can come out and be born.

Then the worms, I think they eat through your muscle, or somehow they get into your lower, they get into your intestinal system. So they get out of the stomach and into the intestinal system. Trigger warning, the worms then have sex, and then they have these little larva that go out into your muscle and then they embed themselves in your muscle. And then they do the same thing, they form this little thing around them, and then they wait there until they get their next opportunity to be digested and be born again.

Troy: I love Scot that you had to say, you can't say the worms reproduce, you have to give people this image of worms having sex in your intestines and making their worm babies that are then making their home in your muscles.

Scot: In your muscles.

Mitch: Gross.

Troy: Regardless.

Scot: So anyway.

Troy: Yeah. It's yeah. It's not good.

Scot: There's a couple of places here where you can start having symptoms from what I've understood. Place number one is when the little worms are freed in your stomach and they move into your intestines. You can have abdominal symptoms, that sort of thing. CDC says that can take one to two days.

I went to the Mayo Clinic's website. They said that that could take . . . well, they really didn't say when the initial symptoms happen. They say later signs could be a week after infection. Minnesota Department of Health, they say a few days after eating, you can have nausea, vomiting, diarrhea, fever, fatigue, abdominal pain. And I'm assuming that that's when they're actually coming out of the little worm protective coating into your stomach. I'm assuming that's when the nausea and stuff happens.

And then later on, when they move into your bloodstream and in your muscle, that's when your fever chills, weakness, muscle, and joint pain can start happening. At least that's how I've interpreted it from what the Minnesota Department of Health said.

All right. So I ate this Thursday night. Six days later, Wednesday at 3:30, I break out into a terrible sweat out of nowhere. I get incredibly nauseous out of nowhere. I go into the bathroom. I'm hovering. You know this one, I'm hovering above the toilet seat just waiting for something to happen for about 10 minutes. I am.

Troy: Which part of your body is hovering?

Scot: My mouth, my mouth.

Troy: I was like, what are we doing here? Yeah. Okay. So you're getting ready to throw up.

Scot: I'm sweating terribly.

Troy: So the diarrhea has not hit yet, but you feel like you're going to throw up.

Scot: Ten minutes later, instead of throwing up, it was diarrhea. We transitioned to that. Then the cold sweat goes away, and I'm cool for about 15 to 20 minutes. And then the chills come and it's 100 degrees outside and I am shivering and have goosebumps. Muscle pain, joint pain start developing, headaches starts developing. It is almost impossible for me to move around. I'm so weak at this point.

Troy: That sounds miserable.

Scot: It was miserable. And so I've done a lot of research on this. I'm kind of like, eh. And the part about being, when should you be concerned is a little tricky on the internet too, because some places say most cases are going to be mild. You're not even going to have any symptoms. If you've got more of a kind of mild to heavier infestation, then you might have started having symptoms, but a lot of these sites just kind of tell you, well, either call your doctor. They don't really tell you what to talk to your doctor about, or, you know, it's just going to run its course, which isn't very satisfying to me.

Troy: Especially when you think about them then burrowing into your muscles.

Scot: And these long-term. So they're saying, the Minnesota Department of Health website says after they move into your bloodstream and embedded in the muscle, you can have headaches, fever, chills, weakness, joint pain that can last for months.

So I call a virtual urgent care, talk to the physician, tell them exactly what happened. And their solution was, well, just, you know, kind of wait it out. Over the next four or five days, you should get better. If you start having severe abdominal pain, which I was not having, I just had nausea, then you should, you know, go to the ER.

So that was that solution, which I wasn't really cool with because I don't want to have worms continuingly to have sex in my stomach till my immune system takes care of it if there's actually something else that can be done.

The other tricky thing, Mitch, about trichinosis is there no . . .

Troy: I don't know if worms have sex though, Scot. I think they reproduce, but this image you've got I think that's very disturbing.

Mitch: That is what you had been focusing on is whether or not they reproduced sexually or asexually. All the disgusting, like upsetting, churning things that have been happening over the last five minutes, you're like, "Hmm. Scot, I think you actually got that point wrong about like the reproductive systems."

Troy: Yeah. I think there might be a different process. Anyway, go on. Go on.

Scot: And this might be the disconnect between regular people and MDs, Troy. I don't know.

Troy: There you go. We will dispute the details of their reproductive process.

Scot: At a later date.

Troy: At a later date, exactly.

Scot: But I just want it to be known for the record.

Troy: For the record.

Scot: No, so, I mean, I don't want this to continue to happen. Okay, so I think I was saying there's not really a good diagnostic. And it's even a little unclear on that. The diagnostic is kind of a secondary diagnostic. Meaning if you have these worms in your stomach. And from a couple of the websites I read, it's not even effective until the two to four weeks after you've eaten the pork. So here I am six days in, I need to wait two weeks to find out if this is what I've got?

So, you know, just to let my immune system take care of it, I wasn't digging especially if there's pills out there that you can take. So there are. So not being happy with that answer, I contact a second physician who after hearing my symptoms, I have a little cough while I'm talking to the second physician because I'm drinking ginger ale, which this particular ginger ale, for whatever reason, when you breathe it in before you take a drink would make you cough.

So now I'm getting a COVID test because they think it's COVID. So now I'm getting a COVID test because I mean, I get it, cases of trichinosis are so rare in industrialized countries.

Troy: Yeah. Common are common.

Scot: This particular physician saying, well, the Delta variant does have some gastrointestinal type of symptoms. You've got the fever, you got this. Their contention was it was six days since I ate whatever it was I ate and food poisoning takes, you know, it happens faster than that, which was frustrating to me because I . . .

Troy: Standard food poisoning.

Scot: Yes, exactly. Because I had a fever, I just felt like they weren't understanding, you know, what trichinella do. What was going on in my stomach, how long it takes for this process to happen. That was the delayed part of this process. So now I'm getting a COVID test, which, you know, disrupts my life.

Now my wife can't go into work for two days until I get the results. Comes back negative. So finally I contact a third physician and I finally had the conversation I wish I would have had initially, which was from what I understand, these symptoms are right on time for developing trichinosis. What's the downside to taking this medication I've read about?

And the side effects and the symptoms that might potentially come on for me taking it was pretty low. So for me, just having peace of mind that I've done something to at least try to get rid of this infestation in my stomach, I don't know if it was. Like, that's the other thing too. It could have been all of those things. Those symptoms are so just kind of generic. It could have been COVID, it could have been food poisoning, it could have been something I ate that day and didn't realize it.

Troy: It could have been a virus you picked up, but you're right. That's the hard thing. It makes sense that this could be the cause of it. It's certainly possible. There are a lot of other things it could be, but the downside of not doing something about this is that potentially, you know, it could be that it resolves on its own and it's not an issue, but it also could cause some longer-term problems as well. So yeah, your concerns are definitely well-founded.

Scot: So I think that kind of leads into this conversation about how to have a conversation with your doctor. Because my first doctor, I was very focused on telling them the symptoms, trying to be very specific about the time frames, that sort of thing. I left that conversation feeling like I wasn't heard.

The second one, I felt that left that conversation feeling like I was kind of steered off in another direction, which delayed doing what I wanted to do in the first place but didn't either have the words or hadn't gotten to the point in my journey where I was able to communicate that until I got to the third physician, which was, you know, a few days after that.

So Troy, how should we be having conversations with our doctors? And like the other thing too, is I'd done a lot of research within that first physician. I just felt like they weren't really interested in hearing about what I had learned. And I think part of it is because trichinosis is so rare. I don't know if there's a tremendously good understanding of it. And maybe that's a really egotistical assumption on my part. I don't know.

Troy: It's not egotistical. And that's the challenge, something like this, you know, and this kind of thing happens all the time. Where you have a specific concern, but you don't want to come out and say, this is my concern and say, well, this happened and this happened.

And, you know, as a physician, I may come to my own assumptions and certainly, common things being common. The first thing he says, well, it's probably just a viral thing or maybe it's COVID or something like that.

But with something like this, you at that moment may know more about this disease than your physician does because you've done tons of reading. And obviously, you used very reputable sites so you had great resources you were looking up and it may just be who you're talking to isn't really familiar with it. This is a rare thing, but again, as you really look into it, is something that definitely could be a possibility with what happened.

So I think it's really important when you talk to your doctor about these kinds of things, if that's your specific concern, just say it upfront. Just say, hey, I had raw meat. I'm concerned about trichinosis, and just be honest about what your concerns are. And I think that's very helpful.

And then as a physician, I then like to approach it, again, like kind of the shared decision-making, where I think physicians are receiving more training on this, where it's kind of like, hey yeah, you know, these are my thoughts. I think that it's less likely, but this is how we treat it. I don't see a lot of downside to treatment. I'm okay with doing this if this is what you want to do. And then I'll say the alternative would be to give it a week and just see if your symptoms resolve. What would you like to do?

And I do that a lot in the ER, I do it when I'm concerned about abdominal pain sometimes with CT scans. And while there's the risk of radiation, these are my concerns. We could do a CT, we could give it 12 to 24 hours, but I think, you know, some people come in and say, hey, I am just really concerned. I have appendicitis. And I say, well, these are my thoughts. I think your risk is about, you know, 2% based on your symptoms. If you want to CT, we can do it. And I say, you know, we could wait.

But again, I think the point here is just be upfront about what your concerns are. And, you know, you'd hate to have to do that where it's sometimes referred to as doctor shopping, where you're jumping from one doctor to the other until you find the answer you want, but sometimes you kind of have to get a second opinion. And there's no problem with that. With trying to talk to someone else or finding a different resource, whether it's going to the emergency department or your primary care doctor or whatever it may be to really try and put you at either peace of mind or to get the testing you feel like you need to have done.

Scot: I think peace of mind, that was an important part for me. It was just this peace of mind. And I actually did find an article that said one of the things about getting this type of thing is just that thought, that visual image that I had of what's happening inside your body, like that, just gave me chills, you know, thinking about those sorts of things. Not only, you know, the potential long-term downsides, which again, I realize are pretty rare in a already pretty rare sort of occurrence of something here, you know, in the United States and trichinosis.

Troy: But they're rare in part because people know to cook the meat. Like, that was rare. That meat was rare. So that's part of it too. They know to cook the meat and that was raw meat. I mean, that's something.

Scot: I think it's also rare because a lot of times people don't even get symptoms. Although I did have another friend of mine say, you know, it can be rare because they actually go to point of, you know, processing for pork meat and they test to see if this is a problem and that's where they're seeing whether or not it's an issue.

Mitch: One of the things I just, Troy, when I was hearing that, is that one of the things that I think I fall into a lot is whenever I go and I've done my research and I think I know what's going on when I get in front of the doctor, I have a hard time finding that, like that line between, oh, hey, I'm trying to advocate for myself and oh no, I'm crazy. Like I'm a hypochondriac, I've self-diagnosed, I'm not the professional, I need to trust them.

And so I guess for me, it's very good I guess, to hear that, you know, there is occasionally an appreciation for someone who's done their research and can kind of come forward and say, here's what I'm concerned about.

Troy: And I really appreciate it when people do that, because then it's kind of like and I'll ask them. Sometimes when I'm just I'm kind of sensing that from them, they're leading towards something, I'll just ask them like, "What's your concern?"

And even if they don't tell me that, I will say, well, these are my concerns. This is what I want to test for. Did you have any other concerns? Like what other things were on your mind? What brought you in today?

And I think it's helpful, but, and you can frame it exactly like you said, Mitch. You can say, "Hey, I'm not the expert. I recognize that everything on the internet is not accurate, but this is what happened. This is what I read. What do you think?" And just lay it out there.

And you have to realize as well, that certainly, yeah, as physicians, we have a lot of training, but you know, we may not consider everything. And I always appreciate when people bring those things up. And I may say, "Wow, I didn't think about that. That's a great point. Thanks for bringing that to my attention. Yeah, let's test for that."

Scot: I think another thing that I'd like you to talk about here, and I might be using the wrong word, but physicians use a differential diagnosis, right?

Troy: Yes.

Scot: So if you take a look at what are the chances that this person in of me, and maybe I'm mixing my things here, you know, it has this particular thing.

So sometimes that can be blinding to physicians, and I think understanding how physicians think can be useful for people like Mitch and myself to maybe understand, you know, why recommendations might be made that, you know, that we don't quite want or that don't address our direct concerns.

Like, for example, with my trichinosis, it's a pretty rare thing that's going to happen, and it's pretty rare that it's ever going to be a problem. So then they start looking for other potential things.

Troy: And you can take a couple of approaches with this whole differential diagnosis. And all that means is I come up in my mind with the things I think this could possibly be. And I'll move things up and down that list based on their likelihood. But the big thing I try and do as well is weigh the seriousness of each of those things.

So, Scot, if you come to the ER with chest pain, you know, I'll say, well, you know, here's a guy who's otherwise healthy. Is he having a heart attack? Probably not. But then say in my mind, "Am I comfortable saying that his likelihood of having a heart attack is less than 1%?" And if I can't say yes to that, then I say, "I need to do some testing."

So even though the heart attack is probably way down there on that list of likelihood or list a probability, maybe I think your odds are 5%. And I think the odds that you have, you know, like some inflammation in your chest wall is more like 30%. Still the more serious things you got to focus on those things and make sure you can rule those out.

So the differential diagnosis is interesting because yeah, there are a lot of things you could say you had, that are probably not as serious, but the trichinosis piece of it is definitely a concern and it's a serious thing and it could lead to long-term issues.

And so that's where I think, you know, it's important to make sure you highlight those things as you talk to your doctor and say, yeah, I know this is less likely, but I read a lot about it. I'm really concerned about what the long-term implications of this could be.

And so I think that then can help them in terms of raising that and not just saying, yeah, it's less likely. Yeah, it is less likely, but it's also a serious thing and it should probably be addressed.

Mitch: So Scot, like after I guess going from doctor to doctor and eventually really advocating for yourself, do you feel better now? Did you get the treatment that you wanted, that kind of peace of mind that you were looking for?

Scot: Yes, I did. Finally, the last physician I talked to, I just like I said, basically said, what are the downsides to taking to the pills is going to stop the worm sex? And the doctor said . . .

Mitch: You got it treated. Like you have treatment because even if there's like Troy said there is less than 1% of a chance that that is happening, that grosses me out so bad.

Troy: So you get the prescription, you took the pills, you're feeling all right.

Scot: Yeah. Yeah. I feel all right. It said that you could have some symptoms from taking the pills, then that's probably, you know, the death and destruction happening. It could pause that. So I was actually looking forward to those symptoms, which I never really got, but yeah, I feel a lot better. I have a much more of a peace of mind.

My body is back to functioning normally on all accounts, so, yeah, I feel much better about the whole thing. And who knows, it still might be happening, but all right. Well, I think this was a good conversation. I know I learned a lot from the experience. Everything from trying to find a reliable information on the internet is a little frustrating, then trying to communicate with a physician based on that unreliable information you find on the internet.

Like I was going to reliable sources, but it was just kind of pieces and bits and no consistency, and some places would leave some stuff out.

I liked a couple of things that you said, Troy, and I think this speaks to you to your concern too, Mitch, and I'd love to hear your thoughts. It's kind of like tell them what your real concern is, why it's your real concern, what you would like to do. Acknowledge that you did do some research and that, you know, you don't know what you don't know, and you might be missing some stuff. So help me as a physician fill in the blanks of what I might not be catching on to.

One of the things you said that I love Troy was I know that this is a small chance that this might be what it is, but I would just really feel better if there was something we could do about it. Can we discuss what those are, the upsides and downsides? I think that's huge upsides and downsides.

And then this shared decision-making, you know, hopefully, you can find a physician that's open to that. If they're not, I don't quite know how you negotiate that on a communication standpoint, other than just continue to advocate for yourself, acknowledge what the physician is saying and contrast that with what you feel and think. I don't know. Mitch, any other thoughts?

Mitch: Well, I really appreciate just having some of the language to kind of approach that kind of shared decision-making because the last thing I want to do, and I think my real hesitancy is like, I show up, I did my research on the internet. Like, let me tell you what I think is going on. And I'm really afraid of that. I'm really afraid of being disrespectful, especially to someone who is the one that is going to help me get better.

So by having this kind of terminology of like, hi, this is what I'm concerned about. That's really, I mean, that gives me a strategy that I can apply moving forward.

Troy: And it's that simple. Just say, this is what I'm concerned about. I recognize I'm not the expert. I know the internet isn't always reliable, but I've done some reading, and help me understand if I should be concerned about this, or if you feel differently. I think if you frame it that way, people will be very open to having that discussion with you and really helping address your concern. Either really helping to explain it to you a little bit differently where you feel comfortable or pursuing whatever diagnosis or treatment is necessary there.

Scot: Hopefully, this conversation has helped somebody that might be suffering from hopefully something other than eating undercooked or raw pork. Hopefully, you make a better decision than I do.

Troy: I was going to say let's hope so. So two lessons from this. Number one, talk to your doctor. Number two, cook your food. Number three, refrigerate your food. Three lessons from this.

Mitch: Send it back. If it's gross, send it back.

Troy: If it's gross, send it back. Don't be ashamed. Do not eat the worm larvae, send it back. And Scot, we can have a conversation another time about how I faced a similar situation and paid the price, but we'll save that for later.

Scot: All right, there you go. We'll hear Troy's story some other day. Thanks for listening. Do us a favor, if you enjoyed this or think, you know, somebody else that might enjoy it, let them know, tell them about the podcast, help us get one more listener. In real life would be the best, whenever you're talking about podcasts, what your favorite ones are, or on social media would be great too.

Just a reminder, we have three different kinds of shows here. First of all, we have shows about the "Core Four." Those are the four things everybody should concentrate on to be healthy now and in the future. That is your diet, your exercise, your sleep, your emotional health, and the plus one more is you should know your genetics.

So we have episodes that talk just about that help you get better at that, help you understand that. We have men's health essentials, which are those things that affect and impact us men in particular that you should know about so you can remain healthy.

And then we've got the sideshow where like today there could be some valuable information in it. It's just a little bit more loose, not quite as focused.

Thank you for listening. If you ever want to get ahold of us, you can do so. So easy. Go to hello@thescoperadio.com. You can call us at 601-55-SCOPE and leave a message. You can go to facebook.com/whocaresmenshealth, always to get ahold of us and let us know what you're thinking, what you want to talk about, what you want to hear about. And thanks for listening and thanks for caring about men's health. Scot and worms out.

Dr. Miller: You've injured your knee, what's the next step? Should you have it scoped? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here in the Department of Orthopedic Surgery at the University of Utah. He also has a practice at our Farmington facility. And Bruce, what's the story? There's been a lot of changes. I think folks who have injured their knees and have some swelling or clicking or pain, it used to be that a number of people would obtain or go to the orthopedic surgeon and they would have an arthroscopic procedure. That is, they would put a little scope inside the knee and look around. And more recently, there's been some changes in that thinking.

Dr. Thomas: That's true. There's more of a collaborative effort. In the old days, a doctor told the patient what the treatment was, and these days the doctor will share information with them and make recommendations. Not every meniscus tear requires surgery. Many people can do their regular life activities and the pain will subside, and it's not clear, in those patients, that knee arthroscopy will help them.

Dr. Miller: It's interesting to me because, I mean, do they know that they have a meniscal tear before we do the arthroscopy, or do we do the arthroscopy to find out that they have a meniscal tear? Or there might be a misunderstanding among patients about the purpose of the arthroscopy.

Dr. Thomas: For many meniscus tears, you can tell if it's present by the patient's history and by the physical exam. If there's questions, an MRI is 96% accurate at predicting a meniscus tear.

Dr. Miller: So now we have way, radiologically, to look at the joint, find out if you have a tear, without doing a surgical procedure?

Dr. Thomas: That's correct.

Dr. Miller: So, if you have a meniscal tear and you either figure that out based on the examination or the MRI, what role would arthroscopy play nowadays?

Dr. Thomas: If the patient has significant symptoms that aren't resolving with conservative measures and it prevents them from doing their regular activities, arthroscopy can assist the restoration of function and decrease in pain. It's a small out-patient surgery with, usually, two or three very small incisions, and the meniscus is either repaired or the damaged portion trimmed out, depending on the findings at surgery.

Dr. Miller: So, what you said I think is important, is that you don't do the arthroscopy immediately, you try some conservative measures first.

Dr. Thomas: That's true.

Dr. Miller: Is that the standard now?

Dr. Thomas: I believe that's the standard, because many people can function with a meniscus tear. The older literature suggested that an untreated meniscus tear will lead to earlier arthritis. Subsequent studies are less clear on that, and it depends much on the size, location, geometry of the tear, as well as the patient's activity level.

Dr. Miller: You know, many years ago they used to go in, when you had a meniscal tear, and they just took out a lot of the meniscus, a large percentage of it, and I think that was the standard back in the day. Is that right?

Dr. Thomas: That's true. Before the invention of arthroscopy, an open procedure would be made and the entire meniscus would be removed. And there are some papers that suggest that those patients would have end-stage arthritis within seven years of that procedure.

Dr. Miller: So they don't do that anymore?

Dr. Thomas: We don't do that anymore.

Dr. Miller: So the concept was, if you used an arthroscope, you could go in and take smaller pieces of the meniscus near where it was damaged, and that that might result in improved function, less pain.

Dr. Thomas: True. That's true. It will decrease their pain, improve their function, and if we can save even a rim of 3mm or 4mm, that's been shown to still function in preventing arthritis for the patient.

Dr. Miller: What were some of the things that patients received arthroscopy for in the not-too-distant past that are no longer done? For instance, I know that some patients have had an arthroscope to wash out the knee joint. Do they still do that, and does that have any therapeutic value?

Dr. Thomas: That really, probably, has no therapeutic value. Arthroscopy is not a treatment for arthritis. You use arthroscopy to treat mechanical symptoms associated with meniscus tears or, infrequently, loose fragments of cartilage. Symptoms like catching, locking, giving out, those kind of symptoms.

Dr. Miller: After you do an arthroscopy, how soon can the patient get back to normal activity?

Dr. Thomas: If there are no surprises and the articular cartilage is in good shape, we usually encourage them to start walking the day of surgery. Swelling takes longer to go away. Maybe four to eight weeks, depending on the setting. Many patients can get back to most of their life activities within eight weeks.

Dr. Miller: Now, are there any risks with arthroscopy? Obviously, there are risks with any surgical or invasive procedure. I would assume that those risks are less than they would be if you had an open procedure, an open, standard surgical procedure.

Dr. Thomas: That's true. The risk of infection, for example, is going to be far less than 2% with arthroscopy. There is some evidence that once you've had a meniscus tear on one side, you're a little more likely to have it on your opposite knee. And with removal of meniscal tissue, the loads on your joint surface are higher, and so you do wear your cartilage quicker and may be a little more likely to get arthritis down the road.

Dr. Miller: So, bottom-line, basically, is if you have knee pain and potentially a meniscal tear, you're going to probably want to go through conservative treatment first, before proceeding onto an arthroscopic procedure, and that you're working with your orthopedic surgeon you can define the best time for that, if that needs to occur.

Dr. Thomas: That's true.

Dr. Miller: Thank you very much, Bruce.

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Dr. Gellner: You look at your child's hand and see a bump and you know it is a wart. Do you rush to the doctor or can you treat it at home?

Announcer: Keep your kids healthy and happy. You are now entering The Healthy Kids Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: So warts are raised, round, rough surface growths on the skin. They occur most often on the hands and they're not painful unless they're on the bottom of the foot and that's called a plantar wart. They can also hurt if you child keeps picking at them and they get infected. Unlike a callus, a wart has brown dots in it and has a clear boundary with normal skin around it.

Warts are caused by papillomavirus and are harmless actually. Most warts disappear without treatment in two or three years and with treatment they're gone in two to three months. So how can you take care of these unsightly warts?

First it sounds strange but cover the wart with duct tape. I know, doesn't it just seem like duct tape fixes everything? You should:

• Cover the wart with a small piece of duct tape just like you would use a band-aid. Warts deprived of air and sun exposure sometimes die without the need for topical treatments.
• Remove the tape once a week, wash the skin, and rub off any dead wart tissue. After it has dried thoroughly overnight, re-apply the duct tape.

The tape treatment may be needed for eight weeks. So find some cool duct tape that your child will like wearing.

To get faster results with duct tape, use an over-the-counter wart medicine. The best ones contain 17% salicylic acid.

• Put the medicine on the wart once a day enough to cover the entire wart. Be aware, do this in a well ventilated area, because the acid stinks.
• Cover the wart with duct tape after you put the medicine on the wart and the medicine has dried.
• Make sure you don't get any of this medicine near the eyes or the mouth. The medicine will turn the top of the wart into dead skin and it will all turn white.
• Once or twice a week, remove the dead wart material by rubbing the dead skin off with a pumice stone or washcloth. The dead wart will be softer and easier to remove if you soak the area first in warm water for 10 minutes.

Warts are contagious but mainly to the child that has the warts. They aren't very contagious to other people.

If your child chews or sucks on the wart, cover the area with duct tape and change it as often as necessary. Encourage your child to give up this habit, because chewing on the warts can cause warts on the lips and or the face. If that happens, your child needs a trip to a dermatologist.

Warts can look ugly but we pretty much all have them at some point in our lives. By knowing how to treat them fast and right away, you can make these ugly bumps go away quickly.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: September 14, 2018
originally published: May 13, 2016

Announcer: We're your daily dose of health, science, conversation. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: Dr. Higgins, so when it comes to opioid pain pills, I'm getting the point personally, and I want to see how you would react to this with the physician perspective, that opioid pain medications, they're just really bad news and we really shouldn't have them in our medicine cabinets anymore. We really should look for other ways to treat pain because you continue to hear about deaths and overdoses and addictions. Am I being a little overstated on that?

Dr. Higgins: Yes and no.

Interviewer: Okay.
Dr. Higgins: There are certainly indications and uses for opioid pain medicines, where appropriate. And the presence of them in your medicine cabinet, by themselves, is not harmful. It is the chronicity of use, using them over a longer period of time, and ramping up the doses, which is, and this is proven in the literature, this is where people get in trouble.

Interview: What should we do about what seems to be going on? It seems almost like a national health epidemic. And there again, I may be overstating this.

Dr. Higgins: It's absolutely not overstating it. It is a national health epidemic. If you set aside cancer and heart disease, the thing that was most likely to kill an American under 65 was their car with some sort of motor vehicle accident. It was that way for some time. In 2003, it was the first year in the state of Utah where a prescription opiate was more than likely to lead your demise than a motor vehicle wreck. That was kind of revolutionary at the time. Now, it's that way in greater than half the states.

Interviewer: Okay. So we were kind of ahead of the curve.

Dr. Higgins: Yeah, it's nothing to be proud of.

Interviewer: Yeah, in a bad way, yeah. So it is something that we need to address. As a patient, if my doctor says, "I'm going to prescribe you some pain medication that's opioid-based," should I say, "I'd rather look for a different solution?"

Dr. Higgins: If you want to do that, your doctor should definitely respond. The old teaching was that as long as you had discomfort, the opioids [Audio skips 00:02:12] likely to be taking someone else's medicines. The people in the 40 to 60 age group are more likely to be taking their own medicine and they were on it chronically and they were on higher doses. And there are people here doing some pretty fascinating research on what the susceptibilities are. We may all have genetic susceptibilities to flip that switch. So even if you don't think you have "an addictive personality," then you can certainly develop one rapidly even if you don't think it's in you.
The other thing is to not necessarily judge those people that have had problems. Plenty of very prominent people and people who we wouldn't necessarily expect have certainly run into problems and, in some cases, have been fatal.

Interviewer: So at the end of the day, a physician perspective, what do we do to solve the problem?

Dr. Higgins: I think it's critically important of late that the public becomes aware and this happens through the lay press. And then, from a physician standpoint, we have to educate the patient at the beginning, the initiation of treatment. Secondly, have an exit strategy. Thirdly, entertain other modalities we can be using besides these medicines to treat the pain.

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