- Home
- About Us
- General Health
- Men’s Health
- Women’s Health
- STD
- Skin & Allergy
- Blog
- Contact us
Pruritus is a medical term for ‘itch’. Itch is an uncomfortable sensation that provokes a person to scratch. When the itching lasts more than six weeks, it is termed chronic pruritus [1].
Although itching is not a life-threatening symptom, it can have a profound negative effect on a person’s social life. It can cause difficulty sleeping and an inability to concentrate on work/studies or daily routine. Chronic pruritus can cause emotional distress and is associated with mental health conditions such as anxiety and depression [2]. To make things worse, frequent scratching or rubbing of the affected skin area can lead to injury or impairment of skin tissues, resulting in infections and other health complications.
In this article, we explore these itchy symptoms and explain the possible underlying causes in simple layman's terms. The article strives to educate and empower patients to better understand these common symptoms and seek medical attention when symptoms persist.
Chronic pruritus is a common symptom that can affect anyone at any age or in any walk of life. Approximately 22% of people may experience chronic pruritus throughout their lifetime [3]. The condition is commonly seen in elderly people who are above the age of 65 [4]. In Singapore, nearly half of the elderly may experience chronic pruritus [5].
Though the sensation of ‘itch’ is a nuisance, it functions as a body’s self-protective mechanism. It is supposed to warn us against harmful external agents and protect our bodies. The itch sensation is comparable to other skin sensations such as touch, pain, etc.
Itch occurs when the itch-sensing nerve endings known as ‘pruriceptors’ on the skin are stimulated by heat, chemical, mechanical causes, infection, or even inflammation. Once the pruriceptors are activated, the ‘nerve signals’ will be delivered via the C-fibres that are present on the skin to the spinal cord and the brain. When we scratch or rub the affected area, the pain and touch receptors on the skin can also be activated. The concurrent pain and touch sensation can interfere with the itch sensation, resulting in temporary relief. However, the skin can be irritated or injured via scratching, eventually leading to a never-ending vicious itch-scratch cycle [6].
You should consider seeing a doctor for further checkups and treatment if your itch:
There are a few key questions that you may want to consider preparing yourself before seeing your doctor to evaluate chronic pruritus further; these are:
Chronic pruritus is a medical condition that can be tricky for patients and physicians to diagnose and manage.
We can split the causes of a persistent itch into broad categories, such as:
In a real-world circumstance, a person may have multiple factors that contribute to experiencing a persistent itch. Unfortunately, sometimes, it may be impossible to pinpoint a single cause of chronic pruritus.
Prolonged, unattended itch can lead to a vicious itch-scratch cycle. Out of itch desperation, one may even resort to repeated rubbing and washing to achieve temporary relief of the symptoms. Nonetheless, all these actions can lead to injury of the normal skin barrier, resulting in skin infection or even scarring of the affected area.
Chronic pruritus can be uncomfortable, affecting the quality of social life. It is known that a person with chronic pruritus is predisposed towards mental health disorders such as anxiety and depression.
Furthermore, chronic pruritus can be more than a skin-deep issue. It may suggest underlying medical conditions that, if left unattended, may result in potential long-term systemic complications.
It is useful to discuss your symptoms with your healthcare providers. Depending on individual circumstances, your doctor may offer tests such as the ones below to identify the possible trigger of your persistent itch symptoms.
Tests offered may include:
If there is an underlying condition that causes the recurring of itch, the underlying medical condition needs to be addressed.
Chronic pruritus can be relieved with:
You can discuss with your doctor to understand more about the management of chronic itch symptoms.
Experiencing discomfort after sex? Is it truly an infection or an allergy from the condom used?
In this article, we delve into the medical part of condom allergy, the possible predisposition to other forms of allergies and alternative options to mitigate your concerns.
In latex allergy, a person’s immune system recognises the protein in latex and mistakes them as harmful foreign bodies, releasing exaggerated antibodies to fight the protein. In the cascade of inflammatory response, one manifests clinically with allergic symptoms.
As most parts of condoms are made up of latex, this can affect a person’s sexual well-being.
In allergy, a person can develop three mechanisms of response to rubber/latex.
Based on the allergic mechanisms discussed above, it becomes evident that condom latex allergy may develop gradually with prolonged use, as the body becomes increasingly sensitised to the latex protein upon repeated exposure.
In comparison between men and women, women tend to experience more severe symptoms of latex condom allergy given the thinner mucous membrane of the vaginal tract with a larger surface area of contact and absorption of the allergens from the condom.
Thankfully, most patients with condom latex allergy present with mild allergic symptoms over the contact surface (genital region) of the condom.
Common symptoms of latex allergy include:
In some cases, symptoms may involve systemic symptoms such as wheezing, watery eyes, runny nose, facial swelling or flushing, and rashes over the body.
Rarely can one develop anaphylactic symptoms within seconds to minutes upon exposure to latex.
However, it is still important to be aware of severe allergic symptoms.
Severe symptoms of latex allergy include:
In such a dire situation, please go to the emergency department immediately as anaphylaxis can be life-threatening, and it is a completely reversible condition if prompt treatment is given.
Interestingly, about 30-50% of people with latex allergies are predisposed to have allergies to certain fruits. This is in view of the cross-reactivity of the allergen from latex and fruits. The body, being sensitised to the protein in the latex, mistakenly recognises the protein in certain fruits, causing a similar allergic reactions in the case of latex allergy. This is known as latex fruit allergy.
One may be more allergic to fruits such as avocado, banana, kiwi, peach, tomato, potato, passion fruit, and bell pepper.
If you are concerned about latex or fruit allergies, you can reach out to your doctor, who you are comfortable with, for further evaluation. In certain cases, you may be offered an allergy blood test (RAST test) to confirm your latex and fruit allergy.
Yes, it is possible. One can be allergic to chemicals in the condom such as spermicide (nonoxynol-9), lubricants that have paraben, propylene glycol, glycerin etc. Symptoms associated with sensitivity to other chemicals in condoms are similar to latex condom allergy, such as redness, itch, burning, and swelling over the genital region.
Often, the symptoms can be challenging to differentiate from a latex allergy or even other differentials such as sexually transmitted diseases (STDs). It is worth speaking to your healthcare providers about your possible concern about allergy to the components of condoms and allow your physician to evaluate further.
You can consider latex-free condom alternatives such as:
If you are feeling uncomfortable down below following intercourse, with symptoms such as itching, discharge, pain, redness, swelling, rash, or fever that doesn’t resolve, you should reach out to your doctor for further checkup.
Your doctor will obtain your relevant medical and sexual history and then offer a relevant physical medical checkup. In the event of a concern of condom latex allergy, your doctor may offer you an allergy test, such as a RAST blood test, to detect any latex antibodies present in your body. Depending on individual risk of exposure, if there is concern of a concurrent infection, your doctor may discuss with you further STD screening tests.
In the case of latex condom allergy, avoidance of culprit allergen is key. Your doctor may counsel you on various alternative options of latex-free condoms or other effective modes of contraception.
Antihistamines and topical steroids may be offered for localised latex condom allergic symptoms. In life-threatening allergy reactions, urgent medical attention with an adrenaline injection may be required to reverse the allergy.
In Singapore, egg allergy is one of the most common food allergies seen in young infants and children, together with cow’s milk allergy. A person develops an allergic reaction to eggs when the body inadvertently recognises egg proteins as a foreign or dangerous substance and mounts an exaggerated immunological response.
The clinical manifestation of egg allergy can range from mild symptoms such as hives, rhinitis, and eczema to severe life-threatening allergic reactions such as anaphylaxis. Thankfully, most people with an egg allergy experience mild symptoms, and most children who experience an egg allergy tend to outgrow the symptoms over time.
The allergic response to eggs may vary from one person to another. Symptoms may occur within minutes or hours following consuming eggs or food which contains eggs.
Most allergic symptoms are mild, though occasionally, one can develop life-threatening symptoms following the consumption of eggs. Allergy symptoms can affect multiple organs of the body:
Dermatological symptoms
Respiratory symptoms
Gastrointestinal symptoms
Rarely, one may develop anaphylaxis. This is a very serious medical condition that warrants immediate medical attention as one can succumb to the allergy.
Symptoms are systemic; always remember the algorithm A-B-C:
If you or your loved ones develop any symptoms of A-B-C, please seek medical assistance immediately. Don’t delay; anaphylaxis is reversible if managed promptly.
The proteins found in an egg's white and yolk can cause an allergic reaction, though it is far more common for one to be allergic to the white of the egg.
Allergen proteins in the egg white, such as ovomucoid, ovalbumin, ovotransferrin, and lysozyme, are allergens commonly associated with egg allergies.
The egg yolk contains a protein known as alpha-livetin. This protein plays a role in an allergy condition known as bird-egg syndrome. This is a condition where a person is firstly exposed and sensitised to airborne related bird allergens, with a subsequent secondary exposure and sensitisation to egg yolk protein. Patients with this medical condition present with respiratory symptoms such as asthma or rhinitis following exposure to the bird and eating the eggs.
So why do we develop an allergic reaction from the egg proteins? Simply put, the ability to cause allergy to the protein can be correlated to their resistance against the gut's digestive enzymes and heat. The more robust the egg proteins are against heat and digestive enzymes, the more likely they can elicit an immune response. This is seen in people who are allergic to ovamucoid protein, which is more ‘heat-stable’ and ‘stable against digestive enzymes’, where they may have more persistent allergy symptoms than people who are allergic to other types of egg proteins.
If you develop the allergy symptoms discussed above and are concerned about egg allergy, you can visit your doctor to test for the possible allergy. Your doctor may work with you to review the potential allergies based on your symptoms and advise accordingly.
Diagnosis of egg allergy is based on a strong history and physical symptoms of allergy and the positive correlation with egg consumption. Depending on the individual case, your doctor may advise you for allergy tests in the form of skin prick or blood (RAST) tests to evaluate the possible allergy further.
There are available allergy tests for the whole egg, the egg white, the egg yolk, or even the individual egg proteins. You may be advised to temporarily eliminate eggs from your diet and reintroduce them back to your diet later under medical guidance.
The only treatment for food allergies is avoiding the food particles that cause the allergy- in the case of egg allergy – to avoid eggs.
For mild symptoms, your doctor may prescribe antihistamines and other symptomatic relievers to manage your allergy symptoms. In those who are at risk of anaphylaxis, your doctor may prescribe you an adrenaline injection pen to use in dire circumstances.
In the case of food allergy, it is important to read food labels before consuming food. While eating out, it is always important to remind the kitchen/chef of your food allergy. If you are breastfeeding and your child has an egg allergy, do avoid food that contains eggs, as the allergic protein can be passed on through breast milk to your child.
Medical literature reveals that patients with an egg allergy may be able to tolerate highly heated or baked/processed eggs (muffins/cookies). This is due to the possible denaturing of the allergenic protein by high heat, allowing patients to tolerate food with eggs. However, it is difficult to identify such a group of patients unless the patients are determined through an oral food challenge test.
This should be practised cautiously as severe allergy can occur during oral food challenge tests. You are advised to discuss with your doctor before trying processed or high-heated eggs if you have a history of egg allergy.
Real-life scenario: You may have had an amazing trip overseas, met terrific people, and explored new places, but you start noticing skin rashes [1] and itching upon returning home. Could this be due to bedbug bites, especially since there is a major global resurgence? Or could this be something else — like an STD instead?
In this article, we delve into bedbug bite symptoms, ways to manage these symptoms, and possible differentials besides diagnosing bedbug bites.
Bedbugs, also known as Cimex lectularius, are tiny, brown-reddish insects [2] that hide in the crevices of mattresses, bed frames, headboards, cupboards, or box springs. Although they can come out any time of the day, they tend to creep out at night to feed and suck on the victim’s skin and blood. Bedbug bites and saliva can trigger an immune response in the victim’s skin, leading to an inflammatory response.
Bedbug bites are more common [3] in people with poorer hygiene, lower socioeconomic status, and living in homeless shelters, hotels, and/or hospitals.
In recent months, we have noted a global resurgence of bedbug infestations affecting major cities, including Paris, London, and New York. The adventurous hitchhiker is also making progressive headlines of infestations in Asia countries, including Korea and our beloved home, Singapore.
In more severe cases, one may develop a secondary immune allergic reaction, known as an ‘id’ reaction, with presentation of the following:
If you are experiencing a skin rash and are uncertain of the cause of your condition, do reach out to your physician for evaluation and treatment. Bedbug bites are a treatable condition.
If you are experiencing any bedbug bite or allergic symptoms stated above or are concerned about other differentials such as STDs, please contact your doctor for further evaluation.
Your doctor will obtain a relevant history regarding your rash. Your social history, including recent travel history and sexual history, maybe enquired to aid the diagnosis. Your doctor will then examine the rash, which may involve examining your mouth, eyes, or even your genital region.
Depending on individual conditions, your doctor may offer skin tests in the form of a scrape or swab. If an infection is suspected, further tests in the form of blood and/or urine tests may be offered.
As their name suggests, bedbugs tend to thrive near our sleeping environment. You may be able to find bedbugs infesting [5] the bed, mattresses, headboards, box springs, clothing, cabinet, luggage, carpet, or boxes near your bed.
A recent travel history to bedbug-infested cities may increase the risk of contracting bedbug bites. Individuals who live in dormitories, sheltered homes, cruises, hotels, and/or trains may also be slightly predisposed to bedbug bites.
Bedbug bites are not STDs. As the name suggests, bedbug bites are due to insect bites leading to a skin inflammatory response. In STD, the infection is contracted [6] from sexual intercourse, such as in the form of oral, vaginal, or anal sex. Bedbug bites are not transmissible from one human to another. STDs can be passed on between people if they are not treated and there is sex involved.
Fact of the day: bedbugs do not carry and spread STDs. STDs are transmitted through sexual contact and passed between people. Having said that, rashes caused by STDs occasionally mimic rashes from a bedbug bite. Hence, it is important to consider screening for STDs if there is a risk of exposure.
| STD rash (by condition) | Bedbug bites rash | |
| Syphilis | Widespread red bumps, scaly and itchy. Can mimic any skin condition. | Widespread discrete red bumps, itchy, can be scaly due to repeated scratching |
| HIV | Faint red dots which blanche when touched | Red bumps which tend to be raised, palpable, and itchy but can mimic HIV rash |
| Scabies | Red itchy bumps, excoriated, with mite ‘burrows’ seen | Red, itchy bumps, excoriated, can be linear in appearance – like scabies |
| Herpes | Grouped or clustered blisters (fluid-filled lesions) | In severe bedbug bites, blisters can be seen as part of an allergic response or as a result of intense scratching |
| Chlamydia Gonorrhoea | Can occasionally present with pustules (white) bumps | Less commonly present with pustules- though this may occur as a result of secondary bacterial infection |
Bear in mind the appearance of the rash for both bedbug bites and STDs can be medically quite technical. Sometimes, even a trained pair of eyes can find it difficult to differentiate between them.
The suspected differential can be confirmed or ruled out through appropriate tests. Discuss with your doctor whether appropriate tests are required for your skin presentation.
Thankfully, most bedbug bites are not dangerous. Treatment includes antihistamines, topical steroids, and soothing moisturiser. In severe cases of bedbug bites, especially with an allergic reaction, your doctor may prescribe a short course of oral steroids to clear off the symptoms. Oral antibiotics may be considered for individuals with secondary bacterial infections.
Affected clothing or objects should be washed at a high temperature, around 60℃ and tumble dried at a high temperature. Placing affected items in an extremely cold environment, such as the freezer (-18℃), is another method to eradicate bedbugs.
You may consider contacting pest control services to eradicate bedbugs from your living space effectively.
The fun fact of the day: bedbugs tend to bite over exposed areas of the skin; they seldom burrow beneath clothing. Wearing covered/long-sleeved clothing or pyjamas may reduce the chances of getting bitten by bedbugs.
When you are living abroad or in a hotel, check for bedbugs! Inspect the crevices of the bed(s) or mattress(es) for possible bedbugs or bedbug particles. Place your bags and luggage on the dressers or luggage rack, keeping them away from the bed. If you suspect bedbugs are in your belongings after travelling, you can consider placing them in a plastic ziplock bag and sealing them up.
When you return home from abroad, unpack your luggage or bags on concrete/solid surfaces such as the bathroom floor, garage, or at the entrance.
It is reassuring to know that there are effective medical options for managing the symptoms secondary to both bedbug bites and other disguised diagnoses such as STDs. Being safe is key. Reach out to your medical physicians for further consultation and to confirm your skin diagnosis.
Pets are man’s best friend. What if you have allergies and have always wanted a cat or a dog? These days, we commonly hear the term ‘hypoallergenic pets’. Is this truly the solution for pet lovers with long-standing allergy symptoms?
This article explores the term 'hypoallergenic pets' and clinical and non-clinical treatment options for managing pet allergic symptoms.
An allergic reaction is an exaggerated body response towards an innocuous substance upon exposure to the substance through the respiratory system, skin or mucous membrane. In the case of pet allergies, it is often not the ‘dander or fur’ of the pet that causes the allergic reaction but rather the protein in the pet’s urine or saliva. These proteins can attach themselves to the pet dander. When the hair is shed periodically, the particles will be disseminated onto the surrounding environment, such as the carpet, linen, bed, sofa, furniture, etc. When a person is in contact with the particles through direct touch onto the skin or mucous membrane or breathing, the body mounts an inflammatory exaggerated immune response leading to allergic symptoms.
To make things worse, pet danders also create an environment to capture various airborne particles such as dust mite particles, mould spores, or pollen that may also potentiate allergic reactions.
Pets such as cats and dogs have been marketed as ‘hypoallergenic breeds'. Essentially, this means the hypoallergenic pets shed less than other ‘normal breeds’. Less dander shedding will lead to less or minimal protein allergens released in our living environment, hence reducing the risk of allergies.
However, it is worth noting that even hypoallergenic pets are not entirely ‘shed-free’; hence, they are not ‘allergen-free’ either, and one can still develop allergic symptoms. Also, the length and amount of the animal fur do not determine the allergic response. Allergic symptoms can still occur even if a person obtains a hypoallergenic pet.
Allergy can present a spectrum of symptoms affecting various organs of the affected person. The severity of individual allergic symptoms varies from person to person – some may present with mild symptoms. In contrast, others may develop symptoms that disrupt their daily function or require clinical intervention.
Allergic reactions from pet dander allergies include:
Pet dander allergic symptoms are usually exacerbated when a person is in contact with the animal. However, the allergic symptoms frequently persist even when the pet is no longer physically present. This is due to the remnants of the dander in the surrounding environment and the impracticality of removing or altogether avoiding the allergen (dander).
You are advised to see your doctor, who will obtain a medical and social history to understand the possible correlation between the triggering allergens and your symptoms. Depending on your condition, your doctor may offer you a skin prick test or IgE RAST blood test to rule in or rule out the concerning allergens.
When pet dander allergies are of concern, your doctor may offer an allergy test to test for pet dander, dust mites, mould and other common airborne allergens. Your doctor can advise you further on treatment and management of the allergies from the results.
Here are some tips to reduce pet allergens in your living environment:
Patients do commonly seek medical support for pet allergies for two reasons:
Thankfully, there are effective medical treatment options to manage pet allergy symptoms.
Your doctor must understand your history and the correlation of the allergy symptoms with the pet. Depending on individual risk of exposure, your doctor may offer an allergy test in the form of a skin prick test or blood RAST test to confirm the pet allergies or possible concurrent air-borne allergies such as dust mite or mould allergies.
Your doctor may offer symptomatic medications such as antihistamines, steroidal tablets, topical creams, nose sprays and inhalers to relieve your symptoms immediately. In patients with positive allergy tests for pet allergies or airborne allergies, your doctor may discuss the medical option of immunotherapy.
The idea of immunotherapy is re-educating and re-setting the immune system. As mentioned, in allergy, the body’s immune system develops an exaggerated inflammatory response towards a generally harmless substance. In immunotherapy, one strives to re-challenge the immune response with repeated small dose exposure of an allergen to the body and de-sensitize the immune response towards the allergen. Over time, this leads to a down-regulation of the immune response against the allergen, significantly reducing or resolving the clinical allergic symptoms.
When used under the proper supervision of a physician, immunotherapy is safe and is a clinically evidence-based long-term treatment for airborne allergies. It has been proven to alleviate and treat allergic rhinitis, allergic conjunctivitis, and asthma associated with air allergens. Immunotherapy reduces reliance on symptomatic or 'rescue' medications in allergy patients and minimises the patient's medication burden in the long run. With allergy symptoms under control, the affected person's quality of life can be improved.
If you struggle between your allergic health and your love for your pets, consider speaking to your physician to understand more about allergy testing and immunotherapy treatment.
‘Doctor, there are tiny bubbles on my palms, and they are extremely itchy. I cannot sleep! Am I allergic to something?’ This is a common encounter in the consultation room. This article explores hand eczema – a common skin inflammation and its correlation with our diet.
Pompholyx is a type of eczema, also known as dyshidrotic eczema. It is a type of skin condition that affects the hands and feet. Eczema is a chronic inflammatory skin condition that causes intermittent itchy red rashes (of various forms) that can occur on any part of the skin. In pompholyx, eczema mainly targets the palms of the hand and soles of the feet. It is commonly seen in women and those under the age of 40.
In dyshidrotic eczema, one presents with deep-seated tiny, multiple watery blisters that are immensely itchy and uncomfortable over the hands and feet. Over time, the blisters can become weepy, especially when broken, and one will be susceptible to bacterial infection. This further causes skin inflammation with swelling, discomfort, pain and itch. The weepy affected area will eventually dry out, leaving the skin dry and flaky with painful fissures and cracks. Patients with chronic symptoms of dyshidrotic eczema can have abnormal nail folds (skin surrounding the nails) and nail changes.
The exact reasons for developing pompholyx remain unknown. Patients who develop dyshidrotic eczema are generally more atopy (sensitised to the surroundings – be it environment or food). They can be associated with atopic eczema, allergic rhinitis, and asthma and may have a family history of atopy as well.
Potential triggers of dyshidrotic eczema include the following:
As individual patients may have different triggers and genetic predispositions, it is worth speaking to your trusted doctor regarding your symptoms, and your doctor can guide you further on the possible triggers in your case.
Although the clinical evidence between eczema and food allergies remains much to be elucidated, it is worth exploring the relationship between dietary intake of nickel and dyshidrotic eczema.
Nickel is one of the common elementary microminerals found in most of our staple diets. It is clinically observed that nickel in diet can predispose an atopic person to dermatitis (skin inflammation), with the hands being one of the common sites associated with nickel dermatitis. A diet low in nickel has shown improvement in eczema conditions. Regarding pathophysiology, exposure to nickel may lead to ‘sensitisation’ of the body against nickel. Over time, with repeated exposure to nickel from the diet, the body develops an allergic reaction that manifests as skin inflammation.
Most dietary nickel comes from plant-based food. Food that are high in nickel content includes chocolate, oatmeal, rye, buckwheat, tea, liquorice, chickpeas, soya, nuts, almonds, lentils and legumes, broccoli, onion, garlic, leafy green vegetables, canned and processed food. (This is pretty much everything we eat daily!)
As nickel can be found in nearly all food, completely eliminating nickel from our daily diet is not feasible. However, the risk of exposure and sensitising a person with nickel in the context of dermatitis can be reduced with prudent food selection and a diet with low nickel concentration.
The caveat is that a low nickel diet does not guarantee a complete clear-up of dermatitis. Instead, a mindful diet practised over time may be associated with lesser or milder eczema flare-ups.
You can speak to your doctor to understand further the association between food allergy and your skin condition. Depending on individual risks and skin conditions, your doctor may discuss further on allergy testing to evaluate further.
Your doctor will obtain a relevant history of your symptoms and examine the rash on your hands and feet. Depending on the presentation and index of suspicion, your doctor may offer you other tests such as bacteria or fungal swab/scrape test or even scabies/syphilis screen to rule out other differential. If there is an allergy concern, your doctor may even offer you a skin prick test or blood RAST test. Do visit your doctor if you have a rash that does not resolve.
Generally, dyshidrotic eczema is not a life-threatening condition. However, chronic severe eczema is known to be associated with significant reduction and impairment of quality of life. This is because the affected inflamed skin will become flaky and dry, and open wounds/bleeding may occur. The associated itch with dyshidrotic eczema can be intense and unbearable, which can impede the daily function of the affected body part.
As dyshidrotic eczema presents with blisters over the hands and feet, the condition also mimics various infective conditions such as herpes, syphilis, or even hand-foot-mouth disease. Other differentials that have a similar appearance to dyshidrotic eczema include allergy/irritant skin inflammatory conditions and autoimmune blistering skin conditions.
It is worth letting your doctor look at the rash that affects your hands and feet. The medical treatment differs depending on the individual medical condition. If you are experiencing severe pompholyx/dyshidrotic eczema, see a healthcare professional rather than self-medicating with various ointments, creams, and over-the-counter medication that may worsen the condition further.
Treatment for pompholyx/dyshidrotic eczema depends on various factors such as severity, underlying conditions, and the individual's overall health. In general, treatment involves the following:
In severe dyshidrotic eczema or recalcitrant cases, second-line treatment such as phototherapy or oral immunosuppressants may be required to control the symptoms. You are advised to speak to your doctor regarding the symptoms and treatment you have tried. While the above is a general guide to treating dyshidrotic eczema, your doctor may tweak the treatment regimen to suit your condition and needs.
If your pompholyx/dyshidrotic eczema is mild or you would like to try and manage your symptoms, consider the following:
Some people suffer only once in a lifetime episode of dyshidrotic eczema/pompholyx. Unfortunately, others may have a recurring and frustrating journey of skin inflammation. Good patient education on this common benign skin inflammatory condition is key for managing their skin with appropriate treatment and minimum exposure to possible triggers, including food triggers.
If you would like to learn more about eczema, dyshidrotic eczema, food allergy, or allergy in general, do feel free to reach out to your trusted clinician.
What prompted this article is an episode of distressing skin inflammation by one of the authors of this blog. For some background information, this writer is a creature of repetitive habits without a shadow of a doubt. After a recent change in one of the facial topical products, the skin over their face started to become red, inflamed, painful, and very itchy after just three days of use.
The skin is the largest organ in our body. While building a good skin barrier layer takes months to years, acute contact dermatitis can lead to an evident and sudden skin deterioration due to an acute skin barrier breakdown. This can happen to anybody.
In this article, we delve into the types of contact dermatitis, causes of the condition, ways to minimise developing contact dermatitis, and tips to rescue the affected skin.
As the name suggests, contact dermatitis is defined as a skin inflammatory condition due to direct contact with the application of substances onto the skin’s surface. Contact dermatitis can occur on any part of the body, though the hands, face, and feet are frequently affected.
There are two types of contact dermatitis: irritant contact dermatitis and allergic contact dermatitis.
Patients with contact dermatitis tend to present with:
The skin rash response during contact dermatitis is a negative inflammatory response from one or more external agents in touch or contact with the skin. This leads to a vicious cycle of weakening the skin barrier, inflammation over the skin, and further impairing the skin's protective layer.
In irritant contact dermatitis, the external agents present as irritants that corrode the normal skin barrier, leading to a skin inflammatory response. The most common irritants include water, strong chemicals (acid or alkalis), detergents, solvents, and abrasives (repeated friction). Strong irritants cause immediate breakdown of the skin barrier, leading to a skin reaction within hours after exposure. Generally, after repetitive and cumulative exposure to irritants over months and years, individuals may notice a more subtle skin reaction over time.
In allergic contact dermatitis, an interesting delayed allergic response takes place. This is known as a type 4 hypersensitivity allergic reaction. To begin with, patients with allergic contact dermatitis tend to have eczema with a weaker overall skin barrier. The introduction of external substances to the skin allows even easier access due to a weakened skin barrier. The substance is recognised by T-cells (immune cells) in the body, and upon repeated exposure to an external substance, the body’s immune system is reinforced and re-challenged with the external substances, leading to the development of an allergic skin response.
In allergic contact dermatitis, auto-sensitisation may even occur due to the awakening of the immune system, leading to a generalised spread of the rash. For example, a person may start with a facial rash due to direct contact with an allergen substance on the face; there may be a further spread of rash throughout the body and lower limbs due to auto-sensitisation.
Although irritant and allergic contact dermatitis is often discussed and explained separately, clinical practice commonly sees both causes occur simultaneously.
In irritant and allergic contact dermatitis, the skin barrier is compromised as the skin integrity is no longer at its best. This can be due to irritated skin or an allergic response. Subsequently, the skin will continue to deteriorate by a physical manifestation of increased damage.
Common irritants that cause contact dermatitis include:
Common allergens that cause contact dermatitis include:
If you are unsure of which of these are causing the above symptoms, a skin prick allergy test is a simple and accurate way to detect allergies. Allergy treatment will follow depending on the results.
There are few tell-tail signs to differentiate the presentation between irritation and allergic contact dermatitis, though often the presentation may not be as clear-cut and may co-exist simultaneously.
| Irritant contact dermatitis | Allergic contact dermatitis | |
| Common sites | Hands | Exposed areas of the skin |
| Borders of skin rash | Strictly confined to the exposure site | Demarcated borders, though, may spread to the peripherals and become generalised |
| Clinical symptoms (Acute) | Intense stinging, pain, then eventually itching | Itching, which can lead to pain |
| Clinical symptoms (Chronic) | Itching and pain | Itching and pain |
| Appearance (Acute) | Redness, blisters, broken skin, erosions crust, and scaling | Redness bumps, broken skin, crust, and scaling |
| Appearance (Chronic) | Bumps, crust, scales, fissures | Bumps, patches, scaling, crust |
| Timeline (Acute) | Rapid, within hours after exposure | 12 to 72 hours after exposure |
The key to managing contact dermatitis is to eliminate and stop the offending substance(s) that plays a role in contact dermatitis.
In the real world, sometimes, complete elimination of the offending substance(s) may not be feasible due to the nature of certain occupations, or common irritants such as water or dust may not be wholly avoided. However, understanding the possible culprit(s) is important, as unnecessary exposure to irritants or allergens can be minimised.
For example, in the case of water irritants, one should avoid repetitive unnecessary washing and use protective hand gloves when available and possible. If your workplace allows, consider protective gear or even a change of job roles to avoid exposure to offending substances.
Patients with contact dermatitis should be encouraged to repeatedly use moisturiser and barrier cream to maintain the skin barrier integrity. Avoid moisturisers with plant-based proteins, chemicals, or even fragrances. In active inflammation cases, topical steroids or even oral steroids may be required to manage the condition.
It is a knee-jerk reflex when the skin condition deteriorates, and we wish to troubleshoot it with various medications and creams on the affected area(s). Often, this may lead to further introduction of more irritants or allergens that potentially worsen inflamed skin. It is important to take a step back and remind ourselves that in contact dermatitis, less is more. Stop triggering substance(s) and avoid further aggravation!
The outcome of contact dermatitis depends on whether the triggering external substance(s) can be avoided. If this is achievable, one can prevent further episodes of dermatitis. This may be challenging, as there may be more than one offending factor involved in contact dermatitis, and complete avoidance of the offending factors may be impractical.
Speak to your doctor if you are dealing with contact dermatitis. Your doctor can guide you further in evaluating the root of your condition and ways to manage the symptoms.
Hay Fever is also medically termed as rhinitis. It can be divided into Allergic Rhinitis and Non-Allergic Rhinitis.
Allergic Rhinitis occurs when the immune system wrongly identifies a harmless substance as an allergen and responded exaggeratingly by releasing histamines and other chemical mediators causing symptoms in the nose, the roof of mouth, throat, eyes, ears and skin.
Allergic Rhinitis can occur together with allergic conjunctivitis. It can exacerbate lung disease such as asthma in people who suffers from both conditions.
Non-Allergic Rhinitis, as the name suggested, is a condition that does not involve the immune system. People with Non-Allergic Rhinitis has similar symptoms of runny nose and nasal congestion, without a trigger. This tends to occur in the adult.
Indoor allergens cause perennial allergic rhinitis, meaning the symptoms can occur all year round. Common allergens include:
Outdoor allergens cause seasonal allergic rhinitis as it occurs the different time of the year when the pollen level is high in the air. Typically, in countries with four seasons, the symptoms tend to flare during spring and fall.
Irritants such as smoke, open burning, strong odours, change of humidity and temperature of the air can trigger allergic rhinitis by causing inflammation of the nose linings, hence sensitizing the nose to irritants.
Typical symptoms include:
Your doctor will take a thorough medical history and allergy history, physically examine you. Your doctor will enquire on your lifestyle, home and work environment. An allergy diary may be useful. You may be offered allergy testing such as skin prick tests and allergy RAST blood tests to determine the triggers of your allergic rhinitis. Sometimes, your doctor may even refer you to an allergist or immunologist.
By identifying the culprit allergens, your doctor will work with you to develop a strategy to avoid the allergens as much as you can. In triggers that are inevitable such as in the case of seasonal allergic rhinitis, you may be recommended to start medications before you have contact with the allergens to prevent developing allergic rhinitis or reduce the severity of the symptoms.
Medical treatment options for hay fever include:
Consult your doctor if you have a sensitive snuffly nose! Take care.
The same medication may not cause any reaction to a person, yet may cause unforeseen allergic reactions to another person. An allergic reaction occurs when the body’s immune system mistaken a harmless substance as an allergen, in the case of a medication, triggering a cascade of allergic events.
Drug Allergy manifestations differ individually, with a wide spectrum of symptoms such as
In severe end spectrum of drug allergy, one can potentially develop anaphylaxis that if not being reversed and treated on time, can lead to death. You should seek immediate medical attention if you suspect of having anaphylaxis.
A drug history and a history of relevant symptoms are important. It would be useful to obtain the timeline relation between the start of the culprit of medication and the onset of the symptoms. Often, you may be taking multiple drugs concurrently. Your doctor will work with you to produce a drug chart to see the correlation between the drug and allergy symptoms.
You may develop various different adverse reactions to medications that can range from stomach upset from aspirin to diarrhoea caused by antibiotics. Some people who are taking certain blood pressure medication such as ACE-I (Angiotensin-Converting Enzyme Inhibitors), can develop cough, facial and tongue swelling.
Allergy testing such as skin prick tests, blood tests, or even an oral challenge test may be offered to certain suitable patients. Your doctor may work together with immunologist or allergist to further evaluate your Drug Allergy.
When drug allergic reactions occur, the offending drug should be stopped. Your doctor is likely to prescribe you antihistamine, corticosteroid or even epinephrine during serious allergic reactions.
In circumstances where there is no other alternative medication available, and the allergic medication is essential, you may be offered a desensitization procedure. Your doctor will gradually introduce the medication in small doses and monitor closely for any adverse reaction to achieve the maximum possible dose that you can tolerate and simultaneously aiming to achieve a therapeutic dose.
You may have come across the below, if not, it may be worth spending a minute of time reading.
DRESS syndrome, as the name suggests, is a serious Drug Allergy that causes skin rash and involves other body systems. One can present with fever, facial swelling, rash, kidney or liver injury and swollen lymph nodes. Patients with DRESS have abnormal blood cells counts with elevated levels of eosinophils. Eosinophils are blood cells that are associated with allergic conditions.
Almost any drug can cause DRESS syndrome. However, antibiotics, allopurinol (anti-gout medication) and anti-epileptic medications are commonly associated with DRESS syndrome. DRESS syndrome typically starts after 2 to 6 weeks of starting a person on the culprit drug.
DRESS syndrome is a condition that is usually managed in the tertiary hospital setting with the involvement of the Dermatology and Immunology/Allergist department. The key step is to stop the culprit medication. Oral or even injection steroid may be used to suppress the allergy reaction and prevent further damage to body organs. The treatment of steroid may be needed for weeks or even up to months, and DRESS patients will need long term to follow up with specialist care.
Steven-Johnson Syndrome (SJS) is a rare, yet potentially fatal skin emergency condition. SHS can progress into an even more severe form of a condition known as Toxic Epidermal Necrolysis (TEN). Both conditions occur with extensive skin and mucous membrane reaction to a particular medication, or a pre-existing bacterial infection or illness.
Although SJS and TEN can affect any age group, the elderly, people with HIV or Herpes are more at risk.
One can present with flu-like symptoms such as fever, cough, aching, headache, eye burning sensation. This is followed with red to a purplish painful skin rash that spreads quickly over the face and body. The rash subsequently progresses into skin blisters. Blisters can also involve the eyes, mouth and genitals. Skin layers may shed away, giving the appearance of skin being burned.
This is a very severe emergency condition, and one should seek hospital medical attention immediately.
Although Drug Allergies can be unforeseen, especially when a person is taking a new medication, it is important to keep your doctors, dentists and pharmacists updated on any known drug allergies. One should always be constantly vigilant on the symptoms and red flags of Drug Allergies. In doubt, speak to your doctors.
Take care.
The concept of early avoidance as prevention of future allergy has been challenged over recent years.
The presence of peanut allergy has increased over the past decade in countries that recommend peanuts avoidance during pregnancy, breastfeeding and during the infancy period of the baby. Peanut allergy affects approximately 1.5% of young children and tends to be diagnosed in those aged less than 2 years old.
LEAP (Learning Early About Peanut Allergy) is a randomized controlled clinical study performed by the Immune Tolerant Network (ITN) sponsored by the National Institute of Allergy and Infectious Diseases to find ways to prevent peanut allergy in young children.
The study investigated over 600 children between age 4 to 11 months of age who are high risk for allergy to peanut. The risk severity is based on the history of egg allergy and/or severe eczema. The children are randomly separated into two groups- children who consume peanut-containing snack food 3 times a week, and children who avoid peanuts.
LEAP study revealed 17% of children who avoided peanut developed peanut allergy by the age of 5 years. Interestingly, only 3% of children who consumed peanut snack food developed a peanut allergy by 5 years of age. It showed the effectiveness of preventing peanut allergy by 80% later in life in high-risk infants who continuously consumed peanut beginning of their first 11 months of age in comparison to non-peanut consumers.
LEAP ON study is a follow-up study from the original LEAP study to investigate whether the children who had consumed peanut for over 4 years had persistent protection against peanut allergy when they stopped eating peanut. The study followed up 556 children from the original children in LEAP for a one-year period of peanut avoidance. After a year of avoiding peanuts, children from original peanut consumers showed only 4.8% of peanut allergy while 18.6% of the children with original peanut avoidance showed peanut allergy.
The findings from LEAP and LEAP ON trials have challenged the old school of thoughts of avoiding allergenic food in early infancy in preventing the development of food allergy. Food guidelines over the world have been revamped, embracing and shifting food allergy concept to encouraging early repeated exposure of a child’s immune system to peanut at an early age, to allow the body to learn, adapt and tolerate peanut.
The Canadian Pediatric Society advises in their food guideline in early 2019 to offer babies with the risk of allergies, common allergenic food such as peanut butter and eggs, around the age of 6 months old, but not earlier than 4 months old.
In the United States, the food guidelines since 2017 have been recommending the introduction of peanuts in the early days of infancy to avoid peanut allergies.
In Singapore, common allergenic foods include eggs, peanuts and shellfish. It is advisable by most paediatricians for commencing common allergenic food between 4 to 6 months of age, and this should not be delayed beyond 6 months of age. Breastfeeding should be encouraged at least up to the first 6 months or even up to a year. Pregnant mothers are not advised to avoid allergenic food as the evidence remains inconclusive in reducing the risk of allergies in children.
Importantly, your children should receive a healthy balanced diet.
Speak to your doctor, or an allergist to find out more.
Allergy Immunotherapy modifies a person’s body immune response towards allergens, hence easing allergy symptoms. Allergy immunotherapy is effective against IgE-mediated allergy, and benefits in particular individuals with a limited type (1 or 2) of allergies.
Allergy Immunotherapy Shots
Immunotherapy shots are delivered via injections in high dosed standardized vaccines containing the allergen every month. Over time, the dose is gradually increased for the body’s immune system to adapt. As there is a risk of unforeseen severe allergic reactions such as anaphylaxis, immunotherapy shots should only be given by a trained doctor or immunologist in a controlled setting clinic with standby resuscitation facilities available. The duration of Immunotherapy shots is usually 3-5 years.
Sublingual immunotherapy (SLIT)
SLIT is emerging as an effective and safe alternative to Allergy Immunotherapy Shots. Furthermore, SLIT has the advantage of self-administration of medication by the patient himself at home. As the name suggests, sprays or tablets containing allergens are administered under the tongue daily.
The choice of whether considering immunotherapy shots vs sublingual immunotherapy can be determined by the patient’s preference with prudent guidance from the trained physician.
You can consider Allergy Immunotherapy if you are:
You should avoid Allergy Immunotherapy if:
Medical reviews have shown significant improvement in allergy symptoms with immunotherapy, with the reduction in requiring rescue medication, and general improvement of quality of life. Also, immunotherapy has shown long term benefits by modifying the underlying cause of allergy condition. There are several research studies that showed continue long-term benefit of reduction of allergy up to 7-8 years following discontinuation of immunotherapy.
Allergy Immunotherapy is a proven effective treatment for allergic conditions such as allergic rhinitis, asthma, insect sting allergy, and certain individuals with eczema in particularly allergic to airborne allergens such as house dust mite, and animal dander.
The limitation of immunotherapy shots lies on the risk of possible systemic allergic reactions, such as anaphylaxis that can be fatal. Risks factors for systemic reactions include a history of previous systemic reactions, the presence of asthma, a history of high sensitivity allergen exposure.
SLIT is a safer option. SLIT is associated with localized symptoms such as itching and tingling of the tongue or mouth, tongue and lip swelling in 50% of patients. The symptoms usually resolve within 1-2 weeks after commencement of treatment.
Afterword...
Allergy Immunotherapy remains a novel, exciting, highly effective and promising area for both trained physicians and patients with allergy, seeking for long term control and remission of allergy. Speak to your doctor to understand further.
Recognizing the signs and symptoms of anaphylaxis are important. This can be life-saving. Involvement in any of the 2 systems of the body should lead to prompt immediate treatment with epinephrine.
Epinephrine
Antihistamines
Steroids
Asthma Inhalers
Prevention is always better than cure
Prepare and Be Ready
Recognize and Act on Anaphylaxis Promptly
Remember, anaphylaxis is completely reversible if managed promptly. However, any delay in anaphylaxis can be lethal.
Take care, stay safe.
It is useful in allergic respiratory diseases such as allergic rhinitis and asthma. It is suitable for adults, and even children above the age of 2. The medication is administered beneath the tongue.
Oraltek® Spray is a type of sublingual Immunotherapy that can be administered via a spray underneath the tongue. It comes in a vial with a spray nozzle containing extracts from particular allergens.
You do not usually need to stop your other medications for allergy treatment. However, over time, you may need less of your medications as the sublingual immunotherapy has effectively reduced your allergy symptoms.
If you are concerned with any medications interacting with sublingual immunotherapy, you can speak to your doctor.
The effectiveness of the treatment correlates with the length of treatment. Good medication compliance promises a better long-run sustaining effect of reduced allergy symptoms or even an allergy cure.
You are expected to see some functional results within the first year of treatment.
You should:
If after one year of treatment, you do not achieve the above end results, you should speak to your doctor to revise the diagnosis and treatment plan.
You may experience temporary side effects such as mild itching, burning sensation or swelling over the administered site. However, as the spray covers a wide surface area of the mouth, the side effects are lesser in comparison on tablets or drops.
If you encounter such symptoms, you should still continue to treat through with the spray, as the symptoms resolve spontaneously with repeated use of the spray.
The recommended duration of treatment is 3-5 years. In the event of you stopping the treatment before 3 years, the effectivity of allergy improvement may not sustain over time.
You are advised to keep the spray in the refrigerator at a temperature of 2-8C. Having said that, the spay is safe and stable at a temperature below 25C.
It is relatively hassle-free. You are allowed to hand carry when travel by air, and stored it in a small bag with an ice cube.
You should avoid stopping the treatment for more than 1 week.
Yes, speak to your doctor, there are tablets form as well.
Furthermore, the fur of pets can act as a reservoir for pollen and mould spores. These proteins when coming into direct contact on a person’s skin or being inhaled can behave as allergens to a body’s immune system, triggering allergic reactions. Common allergic medical conditions associated with Pet Allergies include allergic rhinitis, asthma, eczema, and hives.
Contrary to many believe, there are no actual ‘hypoallergenic breeds’ of cats and dogs. The length of the animal’s hair or the amount of hair or fur shed do no determine the allergenic potential.
Pet Allergy symptoms can occur during, and shortly after contact with a pet. The symptoms tend to last long even when the animal is gone. This is because the dander can stay in the air, on the surrounding furniture or on your clothes for a long while.
Common symptoms include:
You may have chronic symptoms discussed above if you are exposed to your pet on a long term basis.
Your doctor will obtain the relevant allergy history. Allergy testing in the form of blood tests and skin prick test may be offered by your doctor/ allergist to confirm the allergy.
As of any type of allergies, avoidance of trigger is key. Often, staying away from your pet is not an option, you may consider symptomatic relievers such as antihistamines, decongestants, and corticosteroids.
Pet allergy can be a long term concern if you own the pet. Symptomatic relievers may not be an ideal solution. You may consider speaking to your doctor/ allergist for immunotherapy allergy shots as a long term solution.
This allergy is common among healthcare workers, people who have undergone multiple surgeries, rubber industry workers, laboratory workers, hairdressers, housekeeping workers, food handlers, and gardeners.
Latex is a watery milky sap that is derived and tapped from rubber trees. It is processed with other chemicals to enhance its elasticity. Rubber latex can be found in rubber gloves, rubber bands, erasers, balloons, and condoms.
In Latex Allergy, the body’s immune system perceives latex as an allergen and triggers a cascade of an allergic reaction. Half of the people with Latex Allergy have an allergy to other common allergies.
The reaction symptoms can range from mild to very severe, including life-threatening anaphylaxis reaction. The severity of Latex Allergy can worsen with repeated exposure of the latex substance as the body’s immune system is sensitized by latex during the past exposure, and recognizes the allergen during subsequent exposures.
Delayed reaction
In this reaction, the allergic symptoms tend to occur 12-36 hours after exposure to latex and manifest as contact dermatitis. One can present with red, itchy and scaly raw skin. The symptoms tend to be localized over the exposed skin area, and they are not life-threatening.
Immediate reaction
This type of allergic reaction occurs in people who have been exposed to latex and the body’s immune system is sensitized to latex and able to recognize the allergen on subsequent exposure, leading to more severe immune responses such as:
In severe life-threatening case, anaphylaxis can occur within minutes of exposure to latex. Anaphylaxis symptoms typically involve more than one body system, with manifestations of:
*Call 995 or seek medical assistance immediately if you suspect anaphylaxis.
Your doctor will enquire a thorough medical and allergy history. In certain clear cut cases, a history of latex exposure followed by a reaction may suffice to diagnose the allergy. In other cases, your doctor may offer you allergy testing such as skin prick test, patch tests and RAST blood tests to determine your allergy triggers.
Avoidance is key.
Consider Substitutes:
Mild skin reactions can be relieved with oral antihistamine and topical corticosteroids.
People with anaphylaxis secondary to Latex Allergy to carry auto-injectable epinephrine (Epipen) in case of a severe life-threatening emergency. They should be taught how to self-administer the injection. Those suspected of anaphylaxis should seek medical help as soon as possible to prevent a fatality.
Common insect stings in Singapore come from yellow jackets, hornets, wasps, and honey bees. After stinging human’s skin, the insects leave behind their stingers. The stingers are best removed by a scraping action, rather than a pulling motion to prevent further squeezing of more venom into the affected skin.
The body’s immune system reacts differently towards insect stings. Reactions can range from simple painful swelling and redness to severe life-threatening conditions such as anaphylaxis. A person who has experienced an allergic reaction to insect sting has a 40-60% chance of a similar or even more severe reaction for each subsequent sting.
Most people sustain localized pain, redness, and swelling over the affected area of an insect sting.
In the case of an Insect Sting Allergy, the immune system overreacts to the sting, leading to possible symptoms of anaphylaxis with symptoms involving more than one body system such as:
Insect stings can also cause a toxic reaction. This is not an allergic reaction, rather, the body perceives the insect venom as a poison. Having said that, both toxic reaction and allergy reaction from insect stings can cause similar symptoms in the affected person. In a severe toxic reaction, one can have fainting spells, shock, seizure, or even succumb to the reaction.
Your doctor will obtain a thorough history of your current and previous stings. It will be useful to inform your doctor about how many stings you have had, the reactions from the stings, and how long the reaction lasted in the past. In certain circumstances, your doctor may offer skin prick tests or blood tests to an insect venom panel.
It is important to avoid contact with insects in the first place. If you are allergic to insect stings, take precautionary measures against this.
Anaphylaxis and Immediate Treatment
If you have an anaphylactic reaction, please ask for help and call 995 as you will need immediate medical attention. This can be life-threatening. Immediate epinephrine injection can be life-saving. Aside from delivering epinephrine, other emergency medications include antihistamine, corticosteroids, intravenous fluids, and oxygen. Anaphylaxis patients usually need to be admitted to the hospital overnight for observation.
Long Term Treatment with Venom Immunotherapy
This is a form of long term management. It is a procedure done by trained doctors or allergists by the gradual introduction of incremental venom doses to a person. This is with the theory of repeated exposure to the venom will reduce a person’s immune system sensitivity towards the venom, hence reducing the risk of a future allergic reaction.
Immunotherapy in the form of allergy shots is introduced to build tolerance and 97% protection against the future sting. This therapy is particularly useful to those who are active outdoor individuals for both recreational activities or work-related activities.
Most insect stings in Singapore are from yellow jackets, hornets, honey bees, wasps.
Once stung, twice shy! Be careful, and avoid insect stings! Take care!