Search for tag: "treatments"

Interviewer: When depression or bipolar disorder isn't responding to standard treatments, they are referred to as treatment-resistant mood disorders.

Psychiatrist Dr. Brian Mickey from Huntsman Mental Health Institute's Treatment-Resistant Mood Disorders Clinic is an expert at treating these conditions, and today he's going to tell us how visiting a specialist can help people suffering from this condition live happier and more productive lives.

Dr. Mickey, first, when does a treatment-resistant mood disorder become classified as treatment-resistant?

Dr. Mickey: There's no kind of magic formula, but in most cases, we consider if you've had at least two adequate trials, meaning medication trials, psychotherapy trials, that are robust and that lasted long enough and you didn't respond, we would consider that treatment-resistant.

Interviewer: Either through medication or through psychotherapy, you would have to go through at least two of those. And if you weren't seeing an improvement of the symptoms, that would be classified as treatment-resistant.

Dr. Mickey: Right. Exactly.

Interviewer: Okay. When a patient comes to you after it being identified as potentially treatment-resistant, what are the interventions that you offer then initially?

Dr. Mickey: So some of the initial options that we would discuss would be changes to their current medication regimen. That would be a common one. Sometimes people haven't had an adequate treatment trial.

Another option that we would offer within our clinic would be transcranial magnetic stimulation. That's a non-invasive brain stimulation treatment.

We also can offer ketamine infusion therapy. That's an intravenous ketamine infusion that can be helpful for depression.

And so if these less invasive options aren't effective or cause too many side effects, then there are other surgical options that we sometimes will go to next.

Interviewer: Tell me more about the less invasive options. How long do you try those? How many of those do you go through before you kind of get to that point?

Dr. Mickey: That depends a lot on the particular patient, the kind of depression they're having, how severe it is, and, of course, insurance coverage. But typically for people who are functioning fairly well, they're going to work or doing their daily routines, then transcranial magnetic stimulation or ketamine infusion therapy can make the most sense.

Transcranial magnetic stimulation and ketamine infusion therapy are more compatible with maintaining your kind of regular daily routine and the side effects are relatively low for those as well.

For people who have had more severe depression that has been very debilitating or is preventing them from working, or let's say they're admitted to the hospital, then electroconvulsive therapy, or ECT, is what we would think of probably before those other treatments.

Interviewer: Are people intimidated by that name, the fact that you're using electrotherapy? I mean, that could sound kind of scary.

Dr. Mickey: Yeah, I think it can sound scary and if you don't know too much about it or if you only know what you've learned in the movies, then it's very scary.

Interviewer: And what happened like 100 years ago. It's not that anymore.

Dr. Mickey: Yeah, it's very different and it's a very safe treatment. It does have side effects and we counsel people about that, but it can really change the game for people with severe depression.

Interviewer: It sounds like you have a lot of options and tools at your fingertips to help somebody who has gone through some initial treatments and has not been able to handle the symptoms, take care of the symptoms in a way that they're able to go back to their life.

Tell me about a typical patient that walks into your office. Describe what that looks like and the conversation you have.

Dr. Mickey: So a typical patient that we see would come feeling pretty hopeless, I would say, because they've tried many different kinds of treatments and feeling like they've gotten to the end and they don't know what else there is to try.

Typically they've had years of illness, if not decades. And most people that we see also have had this illness since they were very young. So, most of the time, the onset of their illness is in their teenage years or young adulthood.

Typically, people are not able to enjoy life. They're not enjoying their work. They're not enjoying their social interactions. They become less interested in pursuing hobbies and being with other people. Most people have then become kind of socially disconnected, and that can even make things worse, because that's . . .

Interviewer: Yeah, and not finding satisfaction in work. Do these individuals realize that this is happening and are like, "I would love to find satisfaction in my work, but I just can't"?

Dr. Mickey: Right. Most people do, and the way they experience it is usually they're not sure why they're not enjoying it. And of course, we all have stress in our lives, but these are situations where the amount of sadness and mood dysregulation and loss of interest and pleasure is far beyond that. It doesn't make sense in the context. That's kind of what we're talking about here when talking about depression.

Those are the kinds of experiences and symptoms people are having before they're coming to our clinic. And what these treatments can do is they relatively quickly, within a few weeks, start to relieve people of those symptoms. And then the effects can last for months or sometimes even years before people will very often have a relapse.

And so that's something that we also educate people about. This is not a cure. It's a treatment that we can administer for this episode. But that can be a really meaningful difference for people.

Interviewer: And then if a relapse occurs, what then?

Dr. Mickey: For people who've had a recurrence, then we can oftentimes use these same treatments. And so we don't think of them as permanent fixes obviously. And so people will always have this kind of vulnerability. That would be the most typical pattern, that people have recurrences.

But if you understand the patterns, sometimes you can prevent them. That's the ultimate goal, is to prevent a recurrence. But if people do have a recurrence, then we can use these treatments again. And so those are the folks that we see and that I think we can help.

Interviewer: And for those individuals that have suffered for decades, what's the barrier to seeking out more treatment?

Dr. Mickey: There are a number of barriers. One is not knowing about what options there are beyond the things they've already tried. Another is oftentimes just insurance barriers.

Another barrier that people have I think is just fear of the unknown, kind of maybe not quite understanding what these treatment options are really like, which we can help educate people about that.

And then I think another is just that a lot of times people don't want to be a depressed person. It's not a great place to come from. And so you have to sort of admit that you have this condition before you're really going to come to the clinic. I think that can be a barrier as well.

Interviewer: Do you find it common that somebody that is suffering from a treatment-resistant mood disorder is not able to seek out help on their own and generally a family member is needed?

Dr. Mickey: It is pretty common. And I think part of it is that they may not want to think of themselves as a depressed person or they may not realize in some cases how severe things are.

And that's one thing that depression does, is it changes how you see yourself and how you think about the world. It makes you more kind of internally focused and less able to appreciate how far things have gotten in many cases. And I think sometimes people just don't remember how they were when they weren't depressed. So it has these effects on your own cognition and understanding of yourself, which kind of makes it unique.

Interviewer: You mentioned insurance can be a barrier for some people. Is there somebody at Huntsman Mental Health Institute that if somebody is concerned about "How am I going to pay for this?" that could help walk that individual through maybe some of the options if insurance isn't the option?

Dr. Mickey: Yeah, absolutely. In our clinic, we have referral specialists who will do all of those checks ahead of time and help you understand what the financial situation is. You don't want to go into a situation like this and not know what the cost will be. And there's nothing like an extra bill to accentuate your depression. So, yeah, that's an important aspect of the care that we pay a lot of attention to.

Interviewer: Well, it sounds like that you are offering hope to some people that have struggled with mood disorders for a long, long time. As we wrap this up, is there anything that you would say that you would like the listener to take away from our conversation today?

Dr. Mickey: Yeah, I would say that there is hope. And that's a very common reply or response that we get from patients at the end of a consultation. They're often saying, "I didn't even know there were all these options." It's pretty common actually for people to feel quite a bit better just after this single consultation visit before we've even administered any active treatments.

Interviewer: So maybe you or a loved one has a bony protrusion on your foot. It's maybe painful, maybe not. It's a bunion. How exactly does one treat a bunion and what kind of results can one expect from the treatment options?

We're here with Dr. Devon Nixon. He is an orthopedic surgeon at University of Utah Health, with an emphasis on lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, before we kind of go into treatments, let's just start real basic. What is a bunion exactly?

Dr. Nixon: A bunion is an interesting thing that we see really commonly in clinic. It's more than just a bump that's forming on the inside part of the big toe. What's actually happening is there's a complex three-dimensional change that's occurring where one portion of the toe is beginning to move towards the inside, which then drives the big toe part towards the second and third toe. And it may begin to even cross over under those second and third toes.

Interviewer: And is there any way to, say, prevent them?

Dr. Nixon: I wish there was a way to prevent them. They're very common, and certainly not everyone with a bunion needs surgery. And so there are plenty of things to do to try to make them more comfortable, like modifying your shoes or adding a toe spacer. But unfortunately, those options don't necessarily change the long-term progression, which is that the bunion may slowly increase over time.

Interviewer: So let's go back a little bit with that. When you're talking about treatments, you said it's not necessarily surgery. If we're not doing surgery, what are the other options available, and what are you actually treating with those?

Dr. Nixon: Like most things in my practice and in most orthopedic practices, there are nonsurgical and surgical treatments. And the nonsurgical things that many patients choose to do are to add some modifications to their shoes. So they get them in wider forms to help reduce some of the irritation on the inside part of the big toe, which, for many patients, is one of their biggest pain drivers.

Another thing is they can add over-the-counter gel inserts that slide between the big toe and the second toe to help push the toe a little bit out of the way to make it more comfortable.

And those are all driven based on symptoms. So the choice of whether or not to move forward with surgery is a patient-driven choice. It's certainly not one that I will make for them. My goal is to help them have the information they need to make the right choice.

But the options after modifying your shoes and adding an insert, there's not a lot of in-between. So, unfortunately, the conversation may then move towards, "What are my surgical options?" which are to help get the toes straighter and to help remove the bump.

Interviewer: So let's move on to those surgical options. As an orthopedic surgeon, any time a patient hears the word "surgery," there's a little bit of anxiety. There's a little bit of weighing the risks and benefits. Kind of walk us through the surgery. Not necessarily the nuts and bolts of everything, but as a patient, is this an outpatient procedure? How long can I expect to recover, etc.?

Dr. Nixon: Absolutely. I mean, I'm a surgeon, but I'm extremely sensitive to the fact that no one wants to go through surgery. And my job will never be to sell anyone on the surgery. It's the patient coming in to tell me that this is what they think is the best option for them. They feel like they've tried these other things.

And then the different technical options for surgery vary from patient to patient. So it's driven by a lot of factors, some of them clinical, some of them on the X-ray, some of them very patient-specific.

But largely, what we're doing is we're trying to correct the bunion by straining the big toe. And you can do that by either cutting the bone and shifting it. We call that an osteotomy.

You can fuse certain joints around the big toe. So one of them is fusing a joint closer to the middle of the foot, and we call that a Lapidus procedure.

And then another procedure is, depending on the patient, if they have some arthritis that's developed, you can fuse the actual big toe joint itself.

But a lot of these decisions of what to do from a surgical perspective are not uniform to everyone. So that's a conversation that we all have in clinic. If patients feel like they're at a surgical level, I look at the X-rays, I talk to them, get a good history, understand their activity level, what are their goals, and if there's any arthritis present, and then we talk about, "What are these varying treatment options?"

Interviewer: So a surgery like this, how long can someone expect to be undergoing treatment? How long does the procedure last and how long is recovery?

Dr. Nixon: Yeah. The surgery is an outpatient procedure. You go home the same day. The main goal is that . . . Depending on which type of surgery to do, it doesn't really change the fact that for the first four to six weeks, we're going to be keeping you off of your foot in terms of full weight out at the big toe.

If we're cutting the bone, doing what we described as an osteotomy, we need that bone to heal. And if we're trying to get joints to fuse, then we need those bones to heal together too. And so there is a form of protected weight-bearing, which can be challenging if it's your right foot because it's going to limit your driving.

But the first two weeks, you have sutures in. They get removed at two weeks. And then between Weeks 2 to 6, you're kind of protecting your foot, and then usually get X-rays around the six-week mark. Depending on the type of surgery you had, we may begin to advance your weight-bearing so that you're putting more full weight on the big toe.

Interviewer: Now, is there much physical therapy or anything involved with this particular procedure?

Dr. Nixon: Physical therapy is certainly a very reasonable thing to consider. And for some patients, they think that it's helped them considerably. Some of that depends on the type of surgery and the surgeon's specific decision-making. Not all bunions need physical therapy afterwards, but certainly plenty of patients that I operate on benefit greatly from physical therapy.

Interviewer: And what is the success rate for a procedure like this?

Dr. Nixon: It depends a little bit on the operation you do. So one of the things that we're trying to address if you have both a bunion and arthritis, if you have the big toe joint fused, and if that goes on to fusion, which can occur in about 90% or so of patients, then those are some of our happiest patients. They do quite well. They can remain very active.

The downsides to a fusion are that it does limit the motion in the big toe. So getting back into high heels is challenging. Getting back into certain types of activities, like certain yoga poses, the toe just won't let you do that. So that is one of the downsides, but it certainly is a very powerful and successful operation.

If we are preserving the joint and we are cutting the bones, then patient satisfaction is usually in the 80% to 90% range. Patients do quite well from those operations.

Whichever one you choose, they do require some level of recovery. And I would be lying to you if I said that it's a fast recovery. Some patients recover faster than others, but the first couple of weeks, there's going to be some swelling involved, so it's really important to keep it elevated. But as you begin to progress your recovery, you'll begin to get that swelling down and hopefully be able to quickly transition back into regular shoes, as we allow you to, once we get X-rays that confirm that everything has healed up well.

Interviewer: What is something that you as a surgeon would tell to give that last bit of kind of confidence to someone who's considering bunion surgery?

Dr. Nixon: I think what's really important is that the decision-making is all by the patient. My job or any of my partners' jobs is just to make sure that you have the right information to make the decision.

And at the end of the day, patients can get a lot of good pain relief and a lot of satisfaction and a lot of improvement from having their bunion corrected, whichever method you choose.

And like most things in life and in medicine, they all have some form of a pro and con weighing, a pro and con assessment, but whichever one you choose, patients do quite well from these operations. There is a recovery involved, but ultimately, patients do quite well.

Dr. Tarbox: Hello and welcome to Skincast, the podcast about skincare. I'm Michelle Tarbox and I'm a dermatologist. Dermatologists are medical doctors who take care of the skin, hair, and nails. And joining me is . . .

Dr. Johnson: This is Luke Johnson. I'm a dermatologist at the University of Utah in Salt Lake City.

Dr. Tarbox: I practice in beautiful sunny Lubbock, Texas, at Texas Tech University Health Sciences Center.

Dr. Johnson: We are going to be talking about various products on this episode because our goal is to keep your skin, hair, and nails as healthy as possible. And to do that, sometimes you need to use stuff. But we're not paid by any of the people who make these. We have no commercial conflicts of interest.

Dr. Tarbox: Exactly. So, speaking of hair, let's talk about hair loss. There are lots of different kinds of hair loss that can affect patients throughout their lifetime. The most common type that most people probably think of when you say ‘hair loss’ is going to be Androgenetic Alopecia, which is an inherited type of hair loss. It affects both men and women. It affects men a little bit more severely in most cases, but women can also be affected. And it's relatively common actually.

Dr. Johnson: Androgenetic alopecia is a fancy name for male-pattern hair loss, which some people call ‘female-pattern hair loss’ in women. But if you have an uncle who's balding, then that person has androgenetic alopecia in all likelihood.

Dr. Tarbox: Other people also have hair loss after stressful events. This can happen after a severe illness or a period of hospitalization or a surgery, but can also happen with severe stress. And this form of hair loss is called telogen effluvium, but you can think of it as just stress-related hair loss.

Dr. Johnson: And the classic example if you're a dermatologist is when a patient comes into you complaining that she's been losing her hair lately and she brings her 5-month-old baby in with her. Giving birth is a really stressful event on the body, and what basically happens . . . the way I explain it to my patients is that the body decides it has better things to do than put resources toward growing hair. So it stops growing hair.

Dr. Tarbox: Absolutely. There are other kinds of hair loss that are a little bit less common. Some of those include something called Alopecia Areata. That is a kind of autoimmune hair loss that causes usually small circles of hair loss to occur on the scalp. But occasionally, it can be very severe and involve the whole scalp.

Dr. Johnson: There are a few other kinds as well that dermatologists have to learn about. They have names like Trichotillomania, which is when people pull their hair out, and Anagen Effluvium, which is when people lose their hair because of chemotherapy. Those are fairly uncommon, but if you're worried you might have something like that, then obviously you should probably see a medical doctor. And then there are some potentially nutritional causes of hair loss.

Dr. Tarbox: Yeah, it actually takes a lot of nutrients to make hair. That's one of the reasons why if a person is having trouble with caloric intake, like a crash diet, your body doesn't really know the difference between that and you starving because there's a glacier and you're being chased by a tiger or something. And so it starts to shunt nutrients away from the hair.

Dr. Johnson: So you need enough protein and you need enough iron. Those are what I usually think of when I think of vitamins, for lack of a better word, or nutritional products that are related to growing hair.

Dr. Tarbox: Zinc is also helpful, as are some B vitamins. And we'll talk about that a little bit more later.

Dr. Johnson: So, if you have an autoimmune disease, something like lupus, and you feel like you've got areas of hair loss, please see somebody like us quickly so that we can help and hopefully stop it from getting any worse.

Dr. Tarbox: Fortunately, most kinds of hair loss are non-scarring, and that means the hair can be recovered through different treatments.

Dr. Johnson: And I want to spend most of this episode talking about the most common kind of hair loss that I think people will be wondering about, which is that male- or female-pattern hair loss. Again, the medical term is Androgenetic Alopecia.

Dr. Tarbox: It is very common and it causes a lot of problems for people both emotionally as well as sometimes socially. And so it's a good idea to treat it early if it's something that distresses you.

Dr. Johnson: I think most of us have a pretty good idea of what this looks like in men because it's more obvious in men. In women, it's more like kind of diffused thinning of the hair, especially along the central part. So, if you're a woman and you worry that that might be what's going on with you, probably you have this androgenetic alopecia thing, female-pattern hair loss.

Dr. Tarbox: So we always want to know "How bad is it going to get? What is the prognosis?" And that does vary somewhat based off of the individual and their unique genetics, but it is a progressive process. So, if you don't do anything to interfere with it, it will continue to get worse in most patients.

Dr. Johnson: But the good news is that we can do stuff to interfere with it.

Dr. Tarbox: We have the technology. We can repair it.

Dr. Johnson: Dermatologists are, again, medical doctors when it comes to the hair, so one of the things we treat is various types of hair loss. And our goal with this pattern hair loss, male or female, is mostly to slow it down or stop it. And if we can recover hair that's already been lost, that's kind of a bonus. So that's an argument in favor of getting to your dermatologist early to jump on this so that you don't lose more hair than you have to.

Dr. Tarbox: So the most common and easily accessible treatment for androgenetic alopecia and really useful in all types of alopecia is topical minoxidil. Minoxidil goes under the brand name of Rogaine, but there are a lot of generic producers of this medication as well. And it has sort of a fascinating origin story. Luke and I are both comic book nerds, so we love a good origin story, and minoxidil has a great one.

Dr. Johnson: Interestingly, my great uncle was involved in the team that developed this drug in the first place.

Dr. Tarbox: What? I never knew that.

Dr. Johnson: Yeah, Herschel Schnapper. We called him Uncle Hershey. The only other medical doctor in the family before my brother and I. But that's an aside.

Dr. Tarbox: Absolutely. Topical minoxidil works where it is applied. So it's been used in both liquid form as a solution, there are sprays, and there are foams. The strengths over the counter typically are 2% or 5%, but there are some manufacturers that will go up to about 8% over the counter. It's a very safe medication if it's used topically. We don't recommend it's used during pregnancy. However, if you are not pregnant, it is safe to use.

Dr. Tarbox: My adult teeth did not start to come out, yikes. I still have them all. Thank you.

Dr. Johnson: Oh, I'm sorry. What happened when your adult teeth started to emerge? You shed your baby teeth, right?

Dr. Tarbox: I did. I put them under the pillow and got money from the Tooth Fairy.

Dr. Johnson: Exactly. So, when minoxidil is used in a patient who has alopecia, sometimes that will trigger a new hair shaft to just start growing out of the hair follicle. And if there is an old hair shaft in that follicle, it can get pushed out by the newly growing hair shaft. And that means that you can end up having some shedding after starting minoxidil. Some people panic when this occurs and they stop the medication. But the thing is if you have that shed, it actually means you're responding really well to the minoxidil and a whole new bumper crop of baby hairs is trying to grow. And if you continue the medication, you can continue to get that benefit.

Dr. Johnson: Minoxidil works pretty well. There's an old "Simpsons" episode where Homer uses it and gets impressive hair. I think Harvey Fierstein is a guest voice in that one. Usually, it's not that impressive in real life. Give it a good six months before you decide whether or not it's really working for you.

Dr. Tarbox: And it's really safe in most people. If you have a severe cardiac problem, a heart disease that's very bad, the heart doctor that treats you should be asked if you should start that medication, as it is, when used orally, a blood pressure altering medication.

Dr. Johnson: There are some other over-the-counter products that can be helpful for hair loss regardless of the kind. But again, usually, it's this androgenetic type of hair loss. And one of them is a vitamin called biotin. So biotin has been shown to be good for hair and nails. Don't take too much of it because that can play around with some lab results that your doctors might want to get for some reason. Just follow the instructions on the bottle and it's shown to be good for hair and nails.

Dr. Tarbox: Yeah, I've seen some supplements that have crazy mega-doses of biotin and you really don't need that much of it. Now, biotin being a B vitamin, there is some good news about that. All our B vitamins tend to be fat . . . they tend to be liquid soluble, so they dissolve in water, which means that if you take too much of them, they are excreted in your urine. So taking too much doesn't really help so much.

Dr. Johnson: Yes, I remember a hair loss expert talking to us once how she knows a number of very fit, healthy young women who eat nothing but salads. And because they don't have enough protein intake, they can't grow their hair properly.

Dr. Tarbox: So Viviscal is a different kind of oral supplement for hair loss. It has a couple of ingredients in it that are a little bit novel. So it has some marine minerals. It has actually shark cartilage, but they're not murdering sharks to make this product. It's a cultured cell line of shark chondroblasts. So it's the cells that make cartilage.

Dr. Johnson: So they don't get it actually from sharks. They get it from cells that make cartilage that is the same type of cartilage that sharks have.

Dr. Tarbox: Exactly. And there's some apple enzyme in the Viviscal. They have some pretty decent studies to show that it has some benefit. In my personal experience using it for a lot of hair loss patients, I find that it slows down the rate of shedding if somebody has one of those stress-induced moments of hair loss we talked about earlier, that telogen effluvium. And in patients who have androgenetic alopecia, it tends to help thicken the hair back up.

Dr. Johnson: Do you like Viviscal or Viviscal Professional?

Dr. Tarbox: Well, I personally like Viviscal Professional. Viviscal Professional is a little bit more expensive than the regular version of Viviscal, but both are effective. Viviscal without the professional branding, that is available I think at Walgreens. The Viviscal Professional is often sold through doctor's offices. I don't sell any products in my practice because I'm at a university and it just doesn't work well to do that. But I do think that that's a good product and a lot of people use it and tolerate it well.

Dr. Johnson: So massage, this Viviscal, biotin supplements, and minoxidil that you put on your scalp, those are all over-the-counter things that can help. It's important to know that if you stop them, especially minoxidil, you will lose all the hair that it gave you. So one of my colleagues likes to talk about it like toothpaste for the scalp. You brush your teeth twice a day to keep your teeth healthy. You can put this stuff on your scalp twice a day to keep your hair healthy.

Dr. Tarbox: I think that's a great way to think about it. It's like any other cosmetic product. So I find that a lot of people's hang-ups about using it are, "Well, I'll have to keep using it." I'm like, "If it works for you, you do have to keep using it. You'll lose the benefit of it if you stop." But it's not that cumbersome of a thing to do and it's really quite effective. And if people do stop it, they would only lose what they gained from it. So you're not going to be worse off for having used it.

Dr. Johnson: There are a couple of other out-of-the-box ideas. So there are ways to disguise your hair loss rather than actually correcting it by getting hair back or slowing the hair loss. So I think there are . . . they look like markers or pens and you sort of just color in the scalp where you don't have the hair or where you have thinning hair, so it becomes less obvious.

Dr. Tarbox: That's one product to use. The ones I like better actually . . . they have these powders that are keratin fibers that are electrostatically charged, so they stick to the hair. Just like when you were a kid and you'd rub a balloon on your hair and then you could move the hair around with the balloon. So these particles of keratin are electrostatically charged and dyed to match different hair colors. You can actually spray them onto the area where the hair is thinner and they will adhere by electrostatic forces to those hairs and make them seem fuller and thicker and they help to camouflage in the areas where the scalp is showing. And then they just rinse out in the shower.

Dr. Johnson: Do you remember the name of that product?

Dr. Tarbox: There are a couple of different ones. One is called Toppik. Viviscal also makes one that are the hair fibers. There are a lot of different ones. There's another one that you can kind of buy at the salons, but most of them are well made. The ones that I've found that work the best . . . I like the Viviscal one because they actually have a little atomizer. It's kind of a squishy thing that blows little fibers out onto the areas where you have the areas of thinning. So it's very easy to use.

Dr. Johnson: So those are some over-the-counter things that can be helpful for the type of hair loss you have, mostly regardless of what kind you have, but there's lots of stuff that's not available over the counter, but that a dermatologist can help you with. So how can a dermatologist help if you have hair loss, Michelle?

Dr. Tarbox: So, if you are a person who is a gentleman, we really only have one . . . well, we have two prescription medicines that we can use kind of with some routine usage. So one of them is Finasteride. Finasteride is a medication whose first indication was actually to treat patients with prostate cancer or prostate hypertrophy. It is a medicine that inhibits an enzyme that is called 5-alpha reductase, and it basically turns testosterone into super testosterone.

Dr. Johnson: So, if you wanted to go see a dermatologist for your hair loss, dermatologists can help by getting the right diagnosis so we know what kind of hair loss you have, and they can do that through numerous ways. They can look at your scalp, they can sort of tug on your hair to see if it comes loose easily, they have special magnifiers that they can use to take a really close look at the hair follicles, or we can draw labs. So sometimes we'll check iron and vitamin levels and thyroid levels and things like that. Some patients get a skin biopsy of their scalp so that we can look at some of the scalp skin tissue under the microscope to figure out what's going on.

Dr. Tarbox: And so finasteride can be used for men. It is also able to be used for women, but women have to be very careful that they might not be pregnant, because if you were taking finasteride and you were pregnant, it could have effects on the fetus, especially if the fetus was a boy.

Dr. Johnson: But very good for some people, and a dermatologist can help you with it. So come to somebody like that and we'll help you out.

Interviewer: Wave therapy for erectile dysfunction. We're going to learn more about that today, including what is it and are all wave therapy machines created equal. Dr. John Smith is a urologist at University of Utah Health.

So I've heard of this thing called wave therapy for erectile dysfunction. Can you tell me a little bit how that works? What's going on?

Dr. Smith: Yeah. So the wave therapy machines, there's a few different types and we'll get more into that later. But the idea is, these machines put off a wave similar to like an ultrasound machine where there's a wave coming out of the machine and those waves are meant to help stimulate the tissue for regrowth of blood vessels is what you hear a lot of times on a lot of the advertisements.

And that's what a lot of the research has been shown to do is as these machines are used, that it causes the body to have an increase in the factors that cause regrowth of blood vessels and that's how they work.

Interviewer: All right. And how does that help somebody who is suffering from erectile dysfunction?

Dr. Smith: So a lot of times with erectile dysfunction, you know, it can be as simple as, you know, the blood flow issues. It can be not enough going in, too much going out, those types of things. But a lot of times these wave machines will help to regrow or regrow blood vessels to help more blood go into the penis. Because the erection is pretty much the two chambers on the top of the corporate cavernosa get filled with blood. They become very erect, they become stiff and rigid and that's what gives a good quality erection. And so the more blood flow you have and the more quality blood flow you have, the better quality erections you have.

Interviewer: So individuals that have erectile dysfunction, some of them, it might be because they're not getting enough blood flow. So the sound waves, if I'm correct on this wave machine, actually it helps stimulate more blood vessels. You get more blood in there and then it's just hydraulics. You fill that up and you get a better, more sustainable erection.

Dr. Smith: There's couple of different types of machines and you mentioned sound waves. The most of the literature has been done on the mechanical wave, more of the ESWL machines, a similar type wave that they use to break up kidney stones.

However, there's multiple types of machines. Some of the machines do use acoustic waves or sound waves versus these mechanical waves to do it. And the research has been done with the mechanical wave machines, which have been shown to do a lot more. And the acoustic wave machines haven't really shown to be super beneficial in the research.

Interviewer: So an acoustic wave-like when you get super close to a speaker and you can feel the vibrations, is that what we're talking about with those machines?

Dr. Smith: Similar, yeah. It's an acoustic style wave machine, whereas a mechanical type wave machine uses more of a mechanical pulse wave similar to like I said, breaking up a kidney stone with the shock wave. So they'll call that a shockwave treatment versus the acoustic treatment. And the shockwave treatment has been the one with a lot of the research done over in Europe and other parts of the world to show improvement in regrowth of blood vessels.

Interviewer: So not all wave machines for treating erectile dysfunction are created equal. Now, how do you know the difference? How would a consumer know which machine they're getting when they show up?

Dr. Smith: You would want to be very, you know, you'd want to ask the right questions. What type of machine do you have? There's quite a few different types of machines. And, you know, you'll hear a lot of different things from different people, but the acoustic machines, if you look at the research and actually looked up the studies, the studies have been done with the shock wave machines.

And the shock wave is not new, it's been around for quite a bit of time. It started with kidney stones, where they used to put people in a big bathtub to break up kidney stones. And now they have handheld units with this shockwave therapy and it's actually used quite a bit and is FDA approved in the sports medicine arena for things like plantar fasciitis and other issues that way.

And it's still experimental and not FDA approved for erectile dysfunction, but it is being used for erectile dysfunction as kind of an off-label use because there has been good data that shows increased growth, increased rejuvenation, or neovascularization where there's new blood flow in the area.

Interviewer: And what kind of wave machine does University of Utah Health have?

Dr. Smith: We just actually got a new wave machine and it is the shockwave machine. We made sure we did as much research as we could, knowing that this is kind of a hot topic. A lot of people are very interested. And I get asked about it quite a bit.

And so, in the men's health department, we had a lot of patients who came in and asked quite a bit about it so we did the best research that we could to find a machine that could possibly give us the best benefit.

Now we're very selective with our patients at the University of Utah, for who we would recommend this to because it's not covered by insurance, it's relatively expensive. And again, you have to pick the right folks in order to get a good result. For someone who has a mild erectile dysfunction, someone who's taking pills and doing rather well with them, they may be able to come off the pills completely or need a lower dosage of the pills.

This isn't for someone who has a severe erectile issue after they've had a surgical procedure like a prostatectomy or something like that. It's not going to give them their erectile function back in those instances. This is for a very mild to mild-moderate erectile dysfunction. Those are the people who've really seen a benefit from this machine.

Now, if someone really wanted to say, hey, can you do it? We could do it, but I would very much caveat that to this likely is not going to help you.

And that's really the biggest thing for me is making sure that patients understand the expectations because this is not an FDA-approved treatment for erectile dysfunction yet. However, in the future, it may be as long as the research continues to look promising.

Interviewer: And after those treatments, you said you continue to monitor the patient to see how things go. Generally, are there a lot of follow-ups after that or once the treatments are done and those new blood vessels have grown, generally they survive pretty well and things work out?

Dr. Smith: So depending on the patient's medical history, but a lot of times, right now, we're still working out our protocols because this is relatively new that we have this machine. But again, you know, a lot of these folks, if they're rather healthy individuals who may have just had a blood flow issue, you know, they should be good and it should continue to be beneficial for them for a duration of time.

For folks who may have other medical problems, like people who are diabetics, who are going to have vascular issues, people with cardiovascular disease who are going to continue to have progression of those things over time, those would be people who are going to continue to follow up with us and make sure that, you know, things continue to stay well.

Interviewer: If somebody is having success with the pills, why would they choose the wave machine? Why are people choosing to come off the pills?

Dr. Smith: That's a long discussion that I have with patients, because the big thing is, is people are always looking for the easy, quick fix. And a lot of times the advertisements that they've heard make the wave therapy seem like a quick fix. And, you know, with the shockwave therapy, it can be beneficial, but again, a lot of these people don't understand that, you know, sometimes they may not be a good candidate or it may not be beneficial for them.

So after that discussion, a lot of them will continue with the pills, knowing, you know, the cost of the procedure is relatively, it's not covered by insurance so it costs a little bit more than everything else.

But the main people who will come in and just say, I want to get off of pills, I don't like taking pills, and if there's any possible way I can not have to take pills or not have to do that because erectile dysfunction pills can be somewhat cumbersome. If you have to take them an hour before sex on an empty stomach that can be kind of less spontaneous or, you know, other things, if you've had side effects to the medication, those would be the people who would generally look for another alternative.

I would talk with a professional. Talk with them, ask the right questions. What kind of machine is this? What can I expect? And look at the literature, you don't have to be a scientist to be able to look at it and see, but look at what's been done. And there is some good information out there about it but the shockwave machine has been the one that's shown the most promise of being able to improve erectile dysfunction. I would just say, make sure you're getting what you think you're getting.

Interviewer: For men who have been diagnosed with an enlarged prostate, there are a lot of treatment options, but it can be a little overwhelming. And some men fear about the side effects of those treatment options. We're going to sort through that today.

Dr. Stephen Summers is a urologist at University of Utah Health, and he's going to help us better understand the treatment options available for an enlarged prostate and, more importantly, understand what you would want to weigh as a patient when you're having a discussion with your physician or urologist about those different treatment options. So you were telling me that sometimes men put off treating an enlarged prostate because of the fear of side effects. So let's start there. Treatment options have side effects. Do they all have side effects?

Dr. Summers: Unfortunately, any treatment option will have side effects. So the first one, I guess, that has the fewest side effects is lifestyle modification. So if you can lose weight and improve your diet, cut out caffeine, you may have some benefit. But once we start talking about medications and surgical treatment, it's a matter of weighing the side effect with the benefit that you expect to see.

Interviewer: Okay. So can you talk us through that a little bit? So, if I understand, the hierarchy is lifestyle changes first. And you've given us a great reason to want to do that to avoid the side effects of medication. But then it would be medication next. So talk us through, what are some of the options there?

Dr. Summers: Yeah. There are three categories of medications. But primarily, we start with alpha blockers. And the most common medication used is a medication called Flomax or tamsulosin. It works to open up the prostate and the bladder neck to allow the urine to flow through a little bit easier. For the most part, it's well tolerated, but the side effects that bother men with taking that medication can be dizziness. And so you get up all of a sudden, you may have some lightheadedness or a possibility of fainting. And the other one is something called retrograde ejaculation or a sexual side effect. And that is when a man orgasms, instead of having the semen come forward out the end of the penis, it goes backwards into the bladder. And that certainly can be concerning to a lot of men and is one of the main side effects of a lot of different treatments for prostate enlargement.

Interviewer: Is that something I should be concerned about?

Dr. Summers: No. It is a concern if you're planning to father more kids. Obviously, that is an important part of reproduction. But in terms of your overall health, it doesn't make a big difference. It doesn't impact the sensation of orgasm too much, but it's highly individual. In some men, that can be a real bother.

Interviewer: Yeah. Sure. Like I would imagine a lot of these side effects are going to be very individual.

Dr. Summers: Sure. Yeah. The other medications that we use, there is a medication that falls into a class called 5α-reductase inhibitors. There's a medication called finasteride or Proscar or Avodart or dutasteride,. These medications get at the effect of testosterone on the prostate. So they block the effect of testosterone on the prostate growth and over time can cause some shrinkage of the prostate. They are very slow medications to work, and you have to continue on those medications for life once you start them if you're going to experience the benefit of the treatment for them. The main side effects with those can be erectile dysfunction, problems with mood, energy level. It can cause occasional breast enlargement in men. And it does have the side effect of causing hair regrowth. So the medication that was commonly prescribed called Propecia is in this class of drugs. But there are more substantial sexual side effects, I will say.

Interviewer: Why would a man choose this particular treatment then over maybe the first one?

Dr. Summers: No. That's a good question. So, oftentimes, they're combined. So we will use both medications. There's pretty good data out there to suggest that both of them work almost synergistically together than using either one alone. The other advantage with the finasteride, that we were just talking about, is it does reduce the progression of symptoms and severity of the disease, and so you can reduce the risk of progression to the point where one might need surgery by about half. And so there are clear benefit with that.

Interviewer: And you said the one that you have to take for life, say I started, at six months later, I'm like, "Ah, these side effects, I can't live with these." Am I able to then take a different treatment option?

Dr. Summers: Sure. You can always change the treatment option. There is some controversy though, and I think it's important for men to know that there have been some men that have had persistent side effects even after stopping that medication.

Interviewer: Okay.

Dr. Summers: So some of those sexual side effects have lasted even once they've come off of it. Now, that's a very small percentage of men, but certainly, if you're one of those patients, that's going to be a concern for you.

Interviewer: Yeah. And then there's a third category of drugs as well?

Dr. Summers: Yeah. The other category of drugs works primarily on the bladder. It relaxes the bladder, so it treats the symptoms of the disease, but does nothing really to the prostate. And so you're really putting a Band-Aid on treating the symptom, the frequency, the urgency, the getting up at night, but you're not really addressing the problem. So a lot of times we'll use those medications in combination with these other drugs to help lessen or minimize the symptoms as we're focusing on the problem of the prostate itself.

Interviewer: All right. So it sounds like that, you know, you need to have a conversation with your physician about the risks and benefits of the medication. At that point, if that doesn't work or is it possible that a man just might not choose to do the medications because of the side effects that they would move on to surgery. Let's talk about that as a treatment option.

Dr. Summers: You bring up a great point. Sometimes we consider surgery even before medications when you're trying to minimize some of those side effects. So there are a couple of new or recently developed treatments that I think are important to highlight here. And I highlight them specifically because they do not have those sexual side effects that are so common with the medications. And we call them minimally invasive surgical treatments. They're done in the office with a local anesthetic. So it's a very quick recovery with little downtime or little missed work.

The first of those treatments is something called a UroLift. That is a device that is implanted in the prostate that holds back that prostate obstructing tissue and opens up the channel to allow the urine to flow through easier. The advantage with it is it's done relatively quickly in the office. A lot of men do not even have to have a catheter following that procedure, and it doesn't have any of the sexual side effects. So there's no risk of erectile dysfunction, there's no risk of retrograde ejaculation, and there's no risk of urinary incontinence following that procedure. Unfortunately, not all men are candidates for that procedure. It depends a little bit on prostate size and anatomy. But it can be a great option for a lot of men.

Interviewer: And are there other surgical options that you discuss with your patients?

Dr. Summers: Sure. I think it's important to really know all of the options, and so I like to review everything with my patients prior to entertaining any one of them. Another office-based procedure that we do is something called Rezūm. Rezūm uses steam or water vapor therapy in an effort to shrink or ablate and remove prostate tissue. And so, similarly, it's done in the office under a local anesthetic and with some mild sedation. We go in and I inject the prostate with the steam. And depending on the size of the prostate, you may get anywhere from 4 to 10 or even higher injections. And that steam destroys the prostate tissue, shrinks it down and opens up the urinary channel. Men following that procedure do have to have a catheter for a few days. The recovery can be a little bit longer, but there are no restrictions. You're able to go back to work as soon as you're able to tolerate things. It similarly does not have any risk of sexual side effects, including erectile dysfunction or retrograde ejaculation, and no risk of incontinence.

Interviewer: Is this one a little bit more of an option for men than the previous one? Because you said the previous one, you know, some men would not necessarily be a good candidate for it.

Dr. Summers: Yeah. So it has the ability to tailor the treatment a little bit more to a broader range of prostate anatomy, so different prostate sizes and three-dimensional constructs of the prostate. But both of them are, you know, often used interchangeably, and both are good options for a lot of men that are hopeful to avoid some of the bigger surgeries.

Interviewer: Is there a reason why a man might pick one surgery over the other if they were eligible for either one?

Dr. Summers: A lot of times it comes down to the recovery. It comes down to experience, provider preference too, and duration, you know, how long we've been doing those treatments and what's the long-term data and retreatment rates for each of those. So, you know, it gets into a little bit more in-depth discussion that I try to tailor to the individual. When they come seeking one of those treatments, we kind of look at the data and say, you know, "This is what I have that's published based on this treatment. And how does that fit with kind of your expectations and the symptoms that we're looking to treat?"

Interviewer: Getting close to wrapping this up, are there other options that we haven't covered yet that we should?

Dr. Summers: You know, I think one of the common questions I get in surgical treatments that a lot of men that talk about it is the TURP, and that stands for transurethral resection of the prostate. For some reason, men affectionately call it the rotor-rooter. It's an older treatment -- it's better around, you know, almost 100 years -- where urologists go in and using a resection knife in the operating room, with the patient asleep, we hollow out the prostate. It's still a commonly practiced procedure. Most urologists do a lot of them. It still has its place. And technology, of course, has improved as have the side effects. So we've, you know, gotten better at that procedure. But I think a lot of men come thinking that is their only option. And, unfortunately, they have, you know, all had a friend that has had this done and has had maybe a complication, and they fear and procrastinate putting off treatment because of some of the side effects of this older treatment option.

Interviewer: So did I miss something there? I guess I assumed that the surgeries would remove the prostate. And I don't know that I heard any of the things you talked about actually explicitly say removing the prostate.

Dr. Summers: Yeah. That's a common question we get too, and it's a bit confusing when you look at pictures of the prostate. So most of the treatment for benign prostate disease does not remove the entire prostate. We're removing the inside glandular portion of the prostate that's obstructing the urine flow. That is contrasted and much different than an operation that we do for prostate cancer. So if a man has prostate cancer, most of the time that cancer is on the outside of the prostate, and we have to remove the entire prostate. Whereas with benign prostate disease or BPH, that growth or enlargement is on the inner part of the prostate that's obstructing and pushing on the urethra.

Interviewer: And then does that affect the function of the prostate? Is it no longer functional at that point?

Dr. Summers: Once you remove the whole prostate, yeah. Certainly, it's no longer functional. In terms of removing a portion of it, you do lose some function. The function of the prostate is to secrete supporting fluid in your semen for sperm. And so, for most men that were treating prostate enlargement, that is less of an issue. But certainly, if you're a younger patient still planning on fertility or have fertility concerns, then we need to weigh that in with what treatment options we're considering.

Interviewer: Final question. How can a man go into this meeting with their urologist, armed and ready to have this conversation, other than listening to this great interview, of course?

Dr. Summers: Yeah. I think just being open and honest about what your symptoms are, kind of what your priority is, knowing that there are side effects and risks with any of these treatments, what's important for you. Is it that we're treating your nighttime symptoms? Are we improving your flow or your frequency? If you can identify what really bothers you the most, then I can tailor the treatment to fix or improve that symptom. It's really hard to certainly change things and reverse things to make it a 100% better, but if you can tell me what bothers you most, then I can highlight that and incorporate that into our treatment.

Interviewer: There is no cure for allergies. Really the best you can do is manage the symptoms, and the first step to doing that is to avoid the things that give you allergy symptoms, but that can be hard. A lot of times you can't do that. So then the next step are sprays, pills, and eye drops.

Dr. Gretchen Mae Oakley is a nose and sinus expert at U of U Health. She's also an allergy expert, and she's going to take us through the process of trying to figure out how to manage those symptoms and then maybe help us understand when you might need to get professional help. So Dr. Oakley, let's first start with allergy sprays.

Dr. Oakley: There are a couple main nasal sprays that work really well and have great evidence behind them for the treatment of allergies. Our first-line treatment based on the literature and just how well it works in patients is nasal steroid sprays, and fortunately they're all over the counter. Some of those sprays would be, if I were to name some, Fluticasone nasal spray, Mometasone, Budesonide. Those are probably some of the three most common. There're a couple others in that, you know, similar family and those work really well.

You can use them up to twice a day, more than that is not going to help anymore, but once or twice a day use. They're very reliant on regular consistent use, and they have a bit of a slower ramping up effect, so you really want to use them for at least, you know, a few weeks on a daily basis just very regularly to get their full effect rather than, you know, here and there when your symptoms bother you.

Interviewer: If the over-the-counter stuff doesn't work, are their prescription ones that are very different from that, or is most of them over the counter nowadays?

Dr. Oakley: There's an antihistamine spray that is a prescription that can actually work great for a lot of patients too, either as their primary treatment or as a, you know, secondary, an additional treatment if the corticosteroids sprays alone don't work enough for them. That antihistamine spray is called Azelastine, and it works particularly well for those let's call them the wet allergy symptoms, which is, you know, more of those like sneezing, runny nose, itchy, watery eyes, that kind of tickle sensation that we can get with allergies. They work okay for the nasal congestion symptoms, but the steroid sprays work better for that.

Interviewer: What is it that makes it so different from person to person that perhaps maybe a steroidal spray would work for one person but not another, they'd have to use, you know, an antihistamine spray? Is it just the difference in us as humans?

Dr. Oakley: We don't always know exactly why some patients respond better to some sprays, you know, versus others. It may just be a severity of their symptoms. You know, they may get 75% better with the steroid sprays, but it may just not quite be enough. Whereas somebody else where their symptoms are maybe moderate rather than severe, they may do great, and that's all they need.

Some patients may be a little more bothered by like the runny nose and the sneeze, whereas, you know, in those cases antihistamine sprays would work better for them. So sometimes we just get different presentation of our allergies, different symptoms and different severities. But you're right that the other factor is we're all just a little bit different and we respond just a little bit different to certain treatments.

Interviewer: It can be a little frustrating as an allergy sufferer sometimes because I think sometimes as patients we think, "Well, I'm going to go in and the doctor's going to give me the cure," right? But with allergies it sounds like, you know, sometimes you have to do some experimenting on what's going to work best for that individual person.

Dr. Oakley: Exactly. There's definitely some trial and error there to try to get it just right for that patient. The third thing in terms of nasal treatments I didn't mention, that I'd be remiss if I didn't mention, is very straightforward, and it's just some saline in the nose, saline irrigations specifically. Those can work really well as an adjunct treatment. It's not going to in and of itself fix your allergies, but it can help with some of the symptoms along with some of these other treatments by mechanically washing, you know, those allergens, those irritants, those pollens out of the nose so they're not just sitting, you know, on the lining of the nose inflaming it. So it can help, you know, in some of those ways as well.

Interviewer: So do you normally go nasal spray first and then oral medication? Is that how that usually goes?

Dr. Oakley: I would say, in general, yes. I like to give people topical treatments over oral treatments if possible, just because your side effects tend to be lower. The other thought in that however, that I'll talk to patients about, is that certain oral treatments, like oral antihistamines specifically, those tend to work similarly to a nasal steroid spray, have similar effectiveness, but sometimes patients will have symptoms that are not just in the nose. They'll have, you know, maybe some dermatitis that they get with their allergies that bother them or, you know, symptoms like that that are elsewhere, and sometimes the systemic therapy, an oral therapy in that case can be a little bit more helpful than a localized therapy.

Interviewer: So oral medications, let's talk about over the counter first. What are kind of the choices there?

Dr. Oakley: I would say the main one, the front runner are those oral antihistamines. So the newer versions that tend to work better for patients with fewer side effects are those medications like Loratadine and Cetirizine and Fexofenadine. Those are the main kind of newer generation oral antihistamines. The older generation antihistamines would be, you know, what we know as Benadryl, which can work too but has, tends to have higher side effects and be more sedating for patients. So we generally recommend those newer generation, non-sedating medications. And they have great evidence behind them, they work well, and those are over the counter.

Interviewer: And then itchy eyes is another symptom that a lot of people have with allergies. I used to suffer terribly, and then I was prescribed some eye drops, which now I think I can just get over the counter because I've bought them. I think they're the same thing, which makes all the difference in the world. Can you talk about some of the eye drops you might want to look for if itchy eyes are part of your allergy symptoms?

Dr. Oakley: Yeah, eye drops can actually help a lot, and it is generally an antihistamine eye drop. There are a couple different ones. One that's popping into my mind is Olopatadine. That can actually help patients significantly because a constant itchy eye will drive you crazy.

Interviewer: And just like all the other things, the nasal sprays, the oral medications, I had to try a couple of different antihistamine eye drops before I found the one that really kind of worked for me. So you know what, I started out thinking, well, let's see if we can give people, you know, some things they can try on their own, but then you start talking about how, you know, this combination isn't proven to work as well as that combination, and it can get really complicated really fast. So I'm starting to think maybe if like the first nasal spray doesn't work, maybe go see a doctor to try to figure out what combinations of stuff because that does get complicated pretty fast, doesn't it?

Dr. Oakley: It does get complicated pretty fast. It is certainly reasonable to try a couple over-the-counter meds on your own. I personally, you know, if I were in the patient's shoes, I would start a nasal spray and give that a few weeks personally. If that didn't work, you know, I'd maybe try an oral antihistamine for a couple weeks and see how I do. But after that, I don't see a lot of sense in just suffering. I think it's worth going in and talking to your doctor about some alternative options that may help quite a bit rather than just being miserable.

Interviewer: They're ugly, and, for some, nail fungus can be painful and also very tough to get rid of. Dermatologist, Dr. Christopher Hull, what's the first thing you do when a patient comes in with nail fungus?

Dr. Hull: Well, first, I like to make sure that it actually is nail fungus, because there are other nail conditions that can look very similar to and mimic nail fungus. So first that usually involves assessment of the nails. Sometimes we'll do some confirmatory testing with clippings and cultures and scrapings. And then, once we're comfortable that it's a fungal infection and not another condition of the nail that looks like nail fungus, then we talk about how it's affecting them and what they're hoping to achieve as far as treatment.

Interviewer: Got it. So if it's something else, the treatment options would be different. That's why you really want to find out, what . . . it is fungus, right?

Dr. Hull: Right. And treating nail fungus is notoriously very challenging, often with failures along the way. And so it's important to be sure that before you start going down the path of treatment, that you've actually got a correct diagnosis.

Interviewer: And it can take a long time to treat. So you wouldn't want to go down this path of treatment and then . . . yeah.

Dr. Hull: Right. And some of the treatments require monitoring and have some risks associated with them.

Interviewer: Got it. So you find out it's a nail fungus. At that point, what are the treatment options?

Dr. Hull: There are a number of treatments. There are many things that are you know, available over the counter. You go to the internet and Google "nail fungus treatment," you'll come up with 10,000 hits, I bet.

Interviewer: Yeah, pills, polishes, creams?

Dr. Hull: Right.

Interviewer: Yeah, all sorts of things. What do you tend to like to use?

Dr. Hull: Most of those have not been investigated with really good clinical trials. But I think there's things that people have used and have found to be helpful. One common thing that comes up are products that contain menthol. So Vicks VapoRub is a common nail remedy for nail fungus. It probably won't help. But it won't hurt anything either.

Most of my conversation is usually discussing medical therapy, so things that are available by prescription only. And those come in two main forms, which are topical antifungal medications, and then oral antifungal medications. There are other surgical or procedural options, so you can remove nails as well. And then there's starting to be more interest in technologies like lasers for nail fungus.

Interviewer: So you would said at one point that you have a conversation with the patient, what is it you're trying to accomplish. I understand for some people it can be very painful. So it might be to alleviate the thickness of the nail and the pain.

Dr. Hull: Right. And it gets difficult to clip, trim, and groom nails when they get very thick. It can be associated with pain because of ingrown nails. And in some cases, it can also predispose people to infection, so cellulitis and so forth. So there are medically important reasons to treat them. Some people just don't like the appearance of the nails.

Interviewer: Yeah. Because doesn't look good in your flip-flops, does it?

Dr. Hull: Right. Wearing sandals in the summer time with thick, yellow nails is something that a lot of people would like to not have to do.

Interviewer: So if it isn't necessarily painful, do you recommend treatment? Do you really leave that up to the patient at the point?

Dr. Hull: Yeah. My personal philosophy is to leave it up to the patient. So I give them the different options, talk about the length of treatments, the monitoring, the likelihood of success, and then have a conversation with them about whether they want to move forward with those treatments. And a lot of people like not to do anything and many people are very motivated to treat their nails.

Interviewer: Sure. What about the oral drugs? I understand that some people are concerned about the side effects those can cause. So are the oral drugs, generally, better than the topical or . . .

Dr. Hull: Yeah. The oral medications are more effective than topical treatments.

Interviewer: Sure.

Dr. Hull: The good news though is that the safety of most of these oral medications is very good. And the treatments are also much less expensive. So there's quite a bit of cost benefit from using the oral medications.

Interviewer: What are some of the concerns with the oral medication side effects?

Dr. Hull: The primary concern is liver toxicity, because these medications are metabolized by the liver. Looking at cost effectiveness of oral versus a topical medication, I'm really sort of arguing for the oral medication because it's so much less expensive. But then, also, looking at a lot of the safety information about the medication and the risk of serious liver adverse event is very low in that medication. That said, I still will recommend appropriate monitoring. And that's laboratory testing, usually a baseline and then midway through the treatment.

Interviewer: Are they antibiotic based?

Dr. Hull: They're antifungal, so they're specific towards fungus. So they have no effect on bacterial like an antibiotic would.

Interviewer: So people that are afraid of antibiotics for whatever stomach reasons they might have.

Dr. Hull: Yeah. It won't have any effect on the flora of the gut. And actually, interesting, they don't . . . this particular one, terbinafine, doesn't have an effect on the natural yeast that we see in the intestine called candida. So it shouldn't have any effect on that. Some people can get rashes, and there's, you know, other less common side effects. But for the most part, I find them to be well tolerated.

Interviewer: Some of the home remedies that I saw, you mentioned Vicks VapoRub, snake root extract, tea tree oil . . .

Dr. Hull: I haven't come across snake root extract yet. But it sounds like it might eat away a nail pretty well.

Interviewer: Sure.

Dr. Hull: Yeah. There's a lot of those things out there. A lot of people use vinegar, tea tree oil. The hard part with any of these topical medicines is they don't penetrate the nail unit very well. So getting them, actually, to the fungus in the nail unit is very difficult. And that's why a lot of the prescription topical medicines have such limited effects.

Interviewer: What about do-it-yourself at home trying to thin that nail out like, you know, by coating it with . . . what do people coat it with?

Dr. Hull: Well, I think doing debridement at home is, actually, helpful. So a lot of times, I'll have people file their nails down, clip the nails back, because that helps to kind of trim away some of the infected nail as well.

Interviewer: Would your recommendation, generally, be for somebody to use the oral pills if possible just because it's such a shorter treatment time?

Dr. Hull: Well, I think it just depends on the person. There are some people who have other risk factors, who have a history of liver disease or something where I wouldn't be comfortable putting them on that medication. So I use both medications, and sometimes I use them in combination. So I'll have them do a first course with an oral antifungal and then follow up with a topical. And that may help prevent reinfection, too, down the road.

Interviewer: Which is pretty common from what I understood.

Dr. Hull: Yeah. So it's common. You can get the nail clear, and then people are just exposed to the fungus in their environment, in their shoes and so forth, and they can get reinfected easily.

Interviewer: So it sounds like that if somebody does have nail fungus, for the most part, does it bother you because it's ugly? If there's pain involved, then for sure, you would recommend some treatment. For some people, there could be other medical reasons to treat it.

Dr. Hull: Right, yeah. Somebody with, you know, for example, diabetes who's at risk of ulcerations on the feet, cellulitis infections, they are people that may be . . . they may be more proactive about treating to help reduce their risk of infections.

Interviewer: But for the most part, it sounds like if you don't really have many symptoms, it's just kind of a personal choice?

Dr. Hull: That's true.

updated: August 26, 2020
originally published: July 19, 2017

Interviewer: It wasn't too long ago that HIV treatments were a nightmare and the diagnosis was a death sentence. What's treatment like today for HIV positive patients?

We're here with Dr. Adam Spivak. He's an assistant professor in the School of Medicine and he specializes in HIV. And today we're talking about some of the HIV treatments available these days. How is the treatment today different than say what we did 10 years ago, 20 years ago? How has treatment changed?

HIV Treatment and Care Has Changed in Recent Years

Dr. Spivak: I think one of the things we've come to recognize is that the real revolution in HIV care began roughly in the mid '90s, by 1995, '96, with the introduction of combination antiretroviral therapy and you go back to the medical journals and recognize from the scientific studies how miraculous that was. Taking a disease that for the previous 15 years, from its first descriptions of AIDS in 1981 through, again, the mid '90s, this was a death sentence for patients. This was a disease that we really could slow down but not stop and that was killing more and more people every year. And we got these amazing combinations of drugs and people started to do fabulously well.

However, that didn't seem to apply to everybody and even though the drugs were so great, it was really under the rubric of a controlled medical study that we were seeing the benefits. And so, when you bring those into the real world and you're asking people to take at least in those days, difficult combinations of medicines that had lots of side effects, had to be taken every day, some with food, some without, some refrigerated, some not, it was extremely difficult to do. Even the most compliant patients, any of us trying to take medicine three times a day, it's difficult. And to ask people to do that up to 20 pills, it was really, really hard.

So I think what happened in the late '90s, early 2000s, was the recognition that we needed to do more than just sort of have the medicines available. And a physician just writing a prescription is not enough, which is perhaps an obvious thing in retrospect. But a clinic like ours is trying to really maximize the benefits of these medicines by providing enough of the resources to actually make it happen.

Interviewer: So specifically with medicines, what has changed? Are we still dealing with those 20 pills a day, 3, 4 times a day or what are they dealing with now?

Dr. Spivak: Yeah, luckily that has also changed and so that's really perhaps what we would call version 1.0 and that's way actually, luckily in our distant past. What has happened in the last certainly 10 years or so, is that we've gotten some new medicines and what the drug companies have also provided, are combination pills. So we have some new classes but also a recognition that those early days, medicines are only good if you can take them, you can tolerate them. And we are now to the point where we have four or five first-line regimens that are one pill, once a day.

Within that pill are three different medicines. They're co-formulated, minimal side effects. Again, very easy to take. Take on an empty stomach, take them with food, really not a huge deal. And this has really freed people to live their lives and take these medicines on a regular basis, without missing them, and basically live long healthy lives.

What to Expect at an HIV/AIDS Clinic

Interviewer: Besides the medications, just the straight up treatment. Take me through. An individual has tested positive for HIV and they come into your clinic. What do they expect when they come to the clinic there?

Dr. Spivak: HIV, even though the picture I was just painting, had been a life-threatening, devastating illness, and is now essentially a chronic medical condition that can be well controlled with medications, it's a disease with a lot of stigma. And so it's a devastating diagnosis to have, it is an extremely difficult thing for patients who are newly diagnosed.

So my first visits, and I know this is the same with my colleagues in the clinic, when I sit down with a patient who is new to the clinic and new to the diagnosis of HIV, we essentially spend the first visit or sometimes first several visits, just talking it through. Just talking about what it means. A lot of reassurance. A lot of education trying to get the patient up to speed with modern treatments, with life expectancy, with how they acquired HIV.

There's often a lot of discussion, a lot of reflection about what happened, what risks were taken, what can be changed going forward. I think I'm an optimistic person at baseline, but there's a lot to be optimistic about in this illness. And I think one of the messages I try to get across is that, "You're going to be okay. You're going to be fine. This is a partnership. We have phenomenal treatment. You're going to live a long healthy life."

And again, perhaps on the on the bright side or the silver lining, any number of patients that will come back after six, nine months, a year, obviously we have been seeing each other in clinic in the interim but they'll come back and reflect upon those first visits and they'll tell me how much they've changed.

A lot of the changes that they identify in their life after a diagnosis of HIV are positive changes. Some of the behaviors that may have put them at risk in the first place leading to their diagnosis have changed. Their lifestyles have changed and so I think certainly if people could go back and reduce those risks and minimize their chances of HIV diagnosis, they would.

But I see this a lot where people come in and realize that this in some ways was a wake-up call and they're leading a healthier, happier life than they were, believe it or not. So it's not necessarily something we tried out right away, but there can be some positive benefits. So it's a lot of talking. We take it slow at first.

Interviewer: So if there was one thing with the new treatments, with the clinic care and everything, that you would tell to someone who had just found out that they were HIV positive, what would it be?

Dr. Spivak: I would say what I tell my new patients, which is, "You're going to be okay. We're going to take care of you. You're going to live a long, healthy, productive life and you're entering a new phase of that life with a new set of partners who's going to help you through."

updated: December 1, 2022
originally published: February 22, 2017

Interviewer: Killing malaria with light? We'll talk about that next on The Scope.

Announcer: Examining the latest research, and telling you about the latest breakthroughs. The science and research show is on The Scope.

Interviewer: I'm talking with Dr. Paul Sigala, Assistant Professor of biochemistry and the University of Utah. So Dr. Sagala, malaria isn't something that we think of a lot in the U.S. but it's actually quite a problem in other parts of the world. Can you talk about that a little?

Dr. Sigala: Malaria is really one of the most urgent health problems facing the world. It has been for many decades. Even now with all of our great public health advances, hundreds of millions of people every year around the globe get infected by the malaria parasite, leading to nearly a million deaths. Tragically, most of those deaths are among children under the age of five in Africa.

Interviewer: There are treatments for malaria. How effective are those?

Dr. Sigala: We currently have good treatments. So artemisinin in combination therapy is the frontline therapy and has really been an amazing drug that's saved millions of lives so the importance of was recognized. The discoverer in China was awarded, or shared the Nobel Prize last year. But like most of the drugs that have come before it, eventually parasites come up with ways to develop resistance. And so much attention right now is trying to devise either new drugs that can be combined with artemisinin to overcome that resistance or other ways to combat or reverse multi-drug resistant.

Interviewer: Part of what you're trying to do is understand how malaria works so that you can come up with ways to block it. One of the ways you're doing that is looking at how it interacts with heme, which is part of our red blood cells.

Dr. Sigala: Right, so parasites infect red blood cells, which are the most heme rich cell in the human body. And parasites also utilize heme as a cofactor in its own heme proteins. So it needs a way of getting heme and so we've been looking at how the parasite is able to either make its own heme or scavenge our heme within the red blood cell.

Our red blood cells, during their early development stages, had their own heme biosynthesis enzymes that were massively productive in generating lots and lots of heme. And those stick around in the mature red blood cell. They're not ordinarily active. But what we found with the parasites living inside, that we came up with a way to hyperstimulate the activities these enzymes in a way that allows us to kill the parasite.

Interviewer: Help me understand this. So you can take advantage of some of the heme synthesis tools that happen to be floating around in our blood that we make.

Dr. Sigala: That's right. So these are enzymes that are inside the red blood cell but are no longer active because our red cell heme synthesis petered out at the end of development of those cells. But the enzymes are still there, so when the parasite is inside it now has the enhanced ability to take up nutrients and other compounds from the serum. And so one of the compounds that we found that we could put in actually stimulates the activity of these remnant human enzymes that are there. And some of the intermediates that accumulate as a consequence of that activity actually sensitize the parasite such that when we hit the parasite with light it kills it.

Interviewer: What is the light doing?

Dr. Sigala: So there are classes of compounds that are phototoxic. Meaning that when they absorb light they lead to generation of what are called reactive oxygen species, or really reactive molecules that kind of rapidly react with all sorts of biomolecules and just kill the cell in which they're generated. This is utilized for a form of cancer therapy, which is called photodynamic therapy and we think there are possibilities for adapting this approach for potentially treating malaria.

Interviewer: So how can you do that? I mean, first of all, how are you even getting light in there? This is inside your body.

Dr. Sigala: That's right. So that was part of the creative challenge here. It's not very practical to imagine inserting a fiber optic cable in someone's blood stream and trying to illuminate every infected cell. It's additionally challenging because falciparum malaria sticks to the walls of our blood vessels, so called sequesters, which means a lot of the really mature forms are not in active circulation which makes it difficult to target them.

So we wanted to devise a strategy that overcame the reliance on an external light source and what we figured out is that we could use a compound called luminal, that's a very well characterized chemi-luminescent compound. Meaning it's a small molecule that gives off light. And when we combined luminal with other compounds to simulate heme biosynthesis that those would converge within the parasite infected red blood cell and would generate light within that cell and selectively kill the parasite.

Interviewer: I think you had told me once before that the luminal is actually what's in glow sticks. Right?

Dr. Sigala: That's right. So it's commonly used in glow sticks and also in police departments for forensic reasons for trying to identify blood at blood scenes because one of the curiosities of luminal is that it needs to be activated. And it gets activated by interactions with iron so heme has iron in it. So blood that's a blood spot at a crime scene is exposed to the air and so when you spray luminal in it, it activates it.

But chemistry is also what contributes to the specificity of luminal targeting the malaria parasite. Because it requires this iron activation mechanism, most human cells tightly sequester iron and it's not readily available. But the parasite during its normal 48-hour cycle degrades up to 80% of all hemoglobin within a human red blood cell, breaks the protein part up into amino acids. The heme though, it basically sequesters into a vacuole so all of the iron within that heme is now much more exposed than it would be in a healthy red blood cell. Which then provides ready access to then activate luminal when it is delivered.

Interviewer: That's very convenient.

Dr. Sigala: It is.

Interviewer: So how are you investigating this in the lab? Kind of what stages are you at?

Dr. Sigala: Right, so what we have so far have done is explored in principle whether in an x-vivo culture system can actually potently kill the parasite with this type of combinatorial treatment. And the answer is yes, we certainly can. What we discovered along the way is that not only is the ALA, amino linoleic acid, plus luminal effective, but it synergizes very well with the current antimalarial compound, artemisinin in what is really a new twist. And so the combination of all three of those compounds is extremely potent in vitro at killing the malaria parasite.

So the next challenge is really to ask whether this will be effective in vivo. That's challenging to do directly in humans but one can turn to studies with plasmodium species that infect rodents. There are mouse malaria and those provide a ready means to ask, can we cure a mouse from malaria using a combinatorial treatment with these compounds?

Interviewer: Something else I wanted to bring up is that the parasite that produces malaria is actually somewhat mysterious. There's actually a lot we don't know about it.

Dr. Sigala: That's right. For a bug that we've been battling for thousands of years and especially in the current age of understanding so much about genes and genomes, it's unusual. It's an opportunity to deepen our understanding about how a highly effective parasite carries out its mission and devises clever new strategies to survive within our cells. So it teaches us something about general mechanisms in biology, but more importantly it means there are opportunities because those genes and potentially the proteins themselves are so different from our own proteins that we can selectively target them if we're able to understand their functions in a way that really avoids toxicity to our bodies.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Interviewer: Inflammatory Bowel Disease treatment options. We'll talk about those next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. John Valentine is an expert in treating inflammatory diseases of the intestinal tract including inflammatory bowel disease. Dr. Valentine, after you've been diagnosed or you've diagnosed someone, I should say, with IBD, is there a standard treatment order that you follow or what can the person expect at that point?

Dr. Valentine: Well, there used to be a misconception that you'd start with the milder medications and work your way up, but people were failing. I think the better concept is to treat to the disease severity. If somebody has mild disease, see if you can get by with some of the milder medications. If somebody has obviously severe disease, you're wasting your time starting slow and the patient's going to get into other kinds of problems. It also makes a difference if you're talking about ulcerative colitis or Crohn's disease.

Let's start with ulcerative colitis. I would like to see everybody fail a class of drugs called mesalamine back in the '50s, '60s, and '70s, a drug was called sulfasalazine. That still exists, but they all deliver the same medication to the colon. Most patients will respond well to that. There is a proportion, 30-40% of those, that that class of drugs isn't enough. Then they need to get into medications to suppress their immune system.

We may use steroids such as prednisone in patients just to get them better quicker while you want to see if the mesalamine drugs will be effective for them. But if they're not effective, then steroids can give some prompt relief, but they're not good for your long run. They are full of complications.

Then we get into what we call steroid sparing therapies, which could include azathioprine, methotrexate, or anti-TNF medications, infliximab. Vedolizumab is a newer so-called biologic, but that blocks the signal that sends the inflammatory cells to the intestine.

Interviewer: Are there any drawbacks to those medications?

Dr. Valentine: Well, with the mesalamine medications, they are very safe. Every drug has potential side effects to it, including aspirin, but these drugs, like I've said, have been around since the '50s in one form or the other. So they have a long track record and they're very well tolerated for the most part. When you start getting into the medications that suppress the immune system or blocking a key component that we have for a reason, given what we're doing to the immune system, I think there are also surprisingly well-tolerated. But you do need to be aware of potential complications.

So we avoid chronic steroids because of effects on mood. You can get depressed, trouble sleeping, get irritable. It can push you over to be diabetic if you're prone to that already, weight gain, acne, other cosmetic changes can occur, as well as osteoporosis from long-term use. So we need to avoid long-term use of steroids.

The other medications, methotrexate, azathioprine is a therapy and we'll start with those. They can reduce your white counts so you need blood monitoring. Abnormal liver tests can occur with both of those so you need to monitor the liver enzyme. Look for irritation of the liver. There's also an increased risk of skin cancers and lymphoma with patients on azathioprine. Now, it's not dramatic, but there is an increased rate and patients need to be aware of that.

So then, you get into the anti-TNF medications. These are monoclonal antibody or biologic drugs that bind the protein in your immune system called tumor necrosis factor, which is very stimulating to the immune system. While there appears to be less of a risk of malignancy with those medications, it's not zero. You need to screen patients for exposure to tuberculosis because putting somebody who has been exposed but not been treated can let the TB run wild. Screening for TB and for Hepatitis B is very important for that class of drugs.

Interviewer: Sounds like some of these cures are just about as not fun as inflammatory bowel disease is.

Dr. Valentine: Well, if you don't need to be on those medications, you shouldn't be. But I think if you need them, the benefits outweigh the risks.

Interviewer: Got you.

Dr. Valentine: While these complications can occur, they're not very common.

Interviewer: That's good. When it comes to the treatments, it's all about just managing the symptoms or is it about actually suppressing the disease?

Dr. Valentine: It's suppressing the disease. You might be able to manage the symptoms with pain medications, antidiarrheal medications, but the inflammation is still there and problems will occur.

Interviewer: Yeah, all right. So let's talk about if you're diagnosed with Crohn's Disease, then. How do the treatments differ?

Dr. Valentine: So since Crohn's Disease likes to, or commonly affects, the small intestine, the mesalamine drugs don't work very well because they're designed to deliver to the colon. In addition, with Chon's Disease, rather than being just the lining of the bowel that's inflamed, the whole thickness of the bowel wall is inflamed so you need more potent medication. Mesalamine medications don't work very well for Crohn's Disease. Very mild, colonic Crohn's, I've seen it'd be effective. But if you have more severe disease, you need to move on.

The only thing to move on now is to immunosuppressant medications. The same ones I mentioned before. The azathioprine, methotrexate, the anti-TNF drugs, infliximab, adalimumab, certolizumab, and then the vedolizumab, the one that blocks the lymphocyte traffic, has also been approved. There have not been head-to-head comparisons, but it doesn't appear to work as well as the anti-TNF medications. So because you need to get into more aggressive medication, and because of the complications with Crohn's, you don't want to let that drag out too long.

Interviewer: What's somebody's eating or their lifestyle, or are there any changes they could make there that will help inflammatory bowel disease, or is that not even related?

Dr. Valentine: There are some things you could do to help the symptoms. So when you're bowel's inflamed, especially the colon, the job of the colon is to absorb water and to hold your stool until it's a convenient time to get rid of it. When it's inflamed, it's having a hard time doing that so certain foods that pull more water into your colon are going to give you more symptoms. So we advise people with the inflammation of their colon to avoid raw fruits and vegetables, high fiber foods until we get the inflammation under control.

Once it's under control, you can add that stuff back to your diet and tolerate just like before your diagnosis. In Crohn's disease involving the small intestine, but when the whole thickness of the bowel wall is inflamed, the lumen, the center part of the intestine, actually gets narrowed. So again, bulkier, fibrous foods may have a harder time getting through the narrowing, which give symptoms of abdominal pain, distention, and if bad enough, nausea and vomiting. So again, avoiding those until we get the inflammation under control is often recommended.

Interviewer: But it doesn't actually treat the problem, which as you indicated, if untreated, could cause bigger problems?

Dr. Valentine: Correct. I firmly believe we need better dietary studies in inflammatory bowel disease, but the studies that have been done to date haven't really identified any particular diet or lack of things in your diet that causes inflammatory bowel disease.

Interviewer: Are there any other common things that patients say to you that they wonder if it will help as opposed to taking some of the medications that you recommend? And what do we know about those?

Dr. Valentine: Diet comes up a lot and I think patients are frustrated and disappointed when I can't tell them how to change their diet. Probiotic supplements also come up frequently and in the test tube, they do have anti-inflammatory activity. But there are thousands of different species and strains of bacteria within the gut.

Most of the probiotic supplements have between one to 10 species of bacteria and we don't know which ones and how many and which ones you need for which disease processes. So they won't be harmful, but I really would have difficulty going to the medical journals and finding clinical trials of probiotic supplements showing they're of great benefit.

Interviewer: What can a patient expect for the rest of their life, then, since this is something that you manage and treat throughout the rest of your life as far as dealing with inflammatory bowel disease?

Dr. Valentine: Well, the need to stay on chronic medication and keep regular follow-ups with the gastroenterologist is important. Because we can't cure this, chronic treatment is needed. Then, if you have inflammation in your colon, after you've had the disease for about 10 years, you need to get into colon cancer screening surveillance programs because of the higher rate of colon cancer that's found in these patients.

So typically, it's a colonoscopy every two to three years after 10 years, and then current guidelines recommend a yearly colonoscopy after 20 years of inflammation in the colon. So if you have Crohn's disease only in the small intestine, the rate of colon cancer is not increased. That's another reason why to determine where in the bowel the inflammation is occurring.

Interviewer: As far as my lifestyle, if I'm on the medications that are managing the symptoms, it's taking care of the inflammation, which is the root cause, life relative is normal beyond that point?

Dr. Valentine: Except for having to remember to take your medication.

Interviewer: Yes.

Dr. Valentine: That is easy to do when you feel bad, but then when you're feeling well, you have to remember to take it.

Interviewer: Take that medication and you'll be fine.

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