Aesthetic medicine blog

Picaduras de medusa, ¿se tratan con amoniaco, vinagre o pipí? ¿Cómo se tratan las picaduras en el mar? En este artículo, repaso la literatura y mi experiencia para conocer el tratamiento de las picaduras de medusa..

En los últimos años el aumento del crecimiento de las medusas está causando una mayor relevancia de su picadura. Este aumento puede deberse al cambio climático, la sobrepesca y la alteración de los hábitats marinos. Hay más de 10,000 especies de medusas de las cuales el 1% generan daño a los humanos.

Especies de medusas más reconocidas

Las especies más reconocidas son: Escifozoos o “medusa verdadera”, Cubozoa (“Medusa de caja”) y Hidrozoos (hidropólipos e hidromedusas o falsas medusas).

El cuidado de las picaduras de medusas es la actividad sanitaria más usual en las playas del Mediterráneo, y se estima que cada verano se producen unas 25.000 picaduras solo en la costa catalana (1).

the carabela portuguesa o fragata (Physalia physalis) nos suena familiar a todos, es un Hydrozoo o una falsa medusa. Está en el mar abierto de todas las aguas templadas del mundo, es un organismo colonial que forma un auténtico velero. Es capaz de producir reacciones severas pero su presencia en nuestras cosas es rara. Como veremos más adelante, el tratamiento de su picadura difiere significativamente del tratamiento de la picadura de sus “primas” las medusas.

Tratamiento de picadura de medusa: ¿Qué dicen los estudios científicos?

Hay mucha información en la literatura acerca de cómo tratar las picaduras de medusa y, a veces, es contradictoria, injustificada y poco clara. Hay poca evidencia basada en la evidencia y se aceptan recomendaciones anecdóticas, que en ocasiones pueden inclusive agravar los síntomas de la picadura.

Si revisamos la literatura, podemos resumir varias ideas clave con respecto al tratamiento:

• Hay un amplia variabilidad en la picadura según la especie que lo provoca: la picadura depende de la especie, la zona geográfica, la composición del veneno de la medusa, el lugar de contacto, etc. Hay especies no venenosas, cuya toxina no es capaz de penetrar en la dermis. Y además se sabe que no todos los tentáculos son capaces de provocar una reacción (2).

• Existe variabilidad según cada personaNadie es resistente a la picadura de una medusa, pero se sabe que afecta a cada persona de manera distinto. La mayoría de las reacciones se limitan a la piel de la zona de contacto, en forma de urticaria y eritema en la piel (enrojecimiento) que producen picor y dolor de distinta intensidad y duración. A pesar de todo, se han descrito reacciones sistémicas más graves y muy raras con angioedema y anafilaxia.

• La reacción que producen se debe a acción irritante directa de la toxina de las medusas en la piel o por estimulación del respuesta inmune de linfocitos. Esta respuesta inmune es celular de linfocitos T y humoral de linfocitos B. Para que se produzcan reacciones alérgicas, con agioedema o anafilaxia, hace falta haber tenido una exposición previa al veneno, dicho de otra forma, haber sido picado antes (1).

Primeros auxilios y tratamiento de picaduras de medusas

¿Qué debemos hacer ante una picadura de medusa?

Un interesante post resume el protocolo de actuación ante una picadura de medusa en Europa según la evidencia publicada en estudios científicos, es el siguiente (2,3):

1 Rescate al paciente y asegúrese de que esté seguro y estable.

two Asegúrese de que la víctima permanezca relajada y sin moverse para evitar la circulación del veneno.

3 Administra un analgésico oral.

4 Limpiar los tentáculos con agua de mar, NO con agua del grifo.

5 SOLO para medusas verdaderas y medusas de caja: remoje o empape la piel afectada con vinagre (4-6% de ácido acético) durante al menos 30 segundos. Parece que esta medida puede ser controvertida en las picaduras del buque de guerra portugués que recordamos es una hidromedusa o falsa medusa (4).

6 Si quedan tentáculos adheridos a la piel, quítelos con las manos enguantadas.

7 Para ortigas de mar: aplicar una solución de bicarbonato de sodio (50% de bicarbonato de sodio y 50% de agua de mar durante varios minutos y enjuagar con agua de mar. O rociar bicarbonato de forma directa sobre los tentáculos).

8 Si ninguno de los anteriores se encuentra disponible, el área afectada se puede sumergir en agua caliente al 42-45% continuamente hasta que se elimine el dolor o el área se pueda enjuagar con agua de mar.

9 NO use agua dulce, licor o alcohol para desactivar los tentáculos de la piel, dado que todos pueden causar una descarga masiva de nematocistos in some cases.

10 Hace falta acudir a urgencias si el paciente comienza con síntomas sistémicos (dolor abdominal, hipotensión, mareos, náuseas, vómitos, enrojecimiento generalizado de la piel) o el dolor no cede.

once El tratamiento posterior de los síntomas se realiza con antihistamínicos para la picazón, corticosteroides tópicos para disminuir la inflamación. En casos más graves, se pueden prescribir corticosteroides orales o intramusculares.

12 Además encontramos referencias menores en la literatura a la oportunidad de usar agua fría o compresas frías (4).

13 NO existe evidencia en la literatura del uso de coca-cola, alcohol o pipí en picaduras de medusas (4).

¿Cómo podemos prevenir las picaduras de medusas?

1 Nadar en playas controladas y con primeros auxilios o centros de atención adecuados.

two Evite nadar en aguas con medusas, sobre todo posteriormente de una tormenta, dado que las picaduras pueden ser causadas por los restos de tentáculos dañados que flotan en el agua.

3 Cuidado con las medusas aparentemente muertas o que se encuentran en la arena de la playa.

4 Use ropa protectora si practica esnórquel, bucea o nada en aguas abiertas.

5 Use protector solar con repelentes para medusas.

Limitaciones de los estudios sobre el tratamiento de las picaduras de medusas

Estas recomendaciones son generales y pueden variar en eficacia según el tipo de medusa y la reacción de cada paciente.

Cabe destacar que, aunque estas medidas recomendadas son las que más evidencia disponen en la literatura no hay grandes estudios o ensayos clínicos eso aumentaría la calidad de la evidencia para los tratamientos para las picaduras de medusas.

La base de datos Cochrane de revisiones sistemáticas (Revisiones sistemáticas de la base de datos Cochrane), que es la principal revista y base de datos de revisiones sistemáticas en salud, dicho de otra forma, un culto para los médicos, afirma. Parece lógico que no los haya en otros lugares. Y orinar no funciona.

References

1 Nogué S, Velasco V, Marambio M, Lopez L. Picaduras de medusas y otros animales marinos venenosos: su impacto en la actividad de los socorristas en la playa. Emergencias 2017; 29: 426-434-

two Montgomery L, Seys J, Mees J. Para orinar o no orinar: una revisión sobre el envenenamiento y el tratamiento en especies de medusas europeas. Drogas marinas 2016; 14: 127.

3 Li L, Mc Gee RG, Isbister G, Webster AC. Las intervenciones o los síntomas y signos dan lugar a picaduras de medusa. Syst Rev de la base de datos Cochrane 2013; 9 de diciembre.

4 Haddad V. Dermatología ambiental: manifestaciones cutáneas de lesiones provocadas por animales acuáticos invertebrados. Un sujetador Dermatol 2013; 88: 496-506.

Te invito a compartir este post para que otras personas tengan un conocimiento adecuado sobre el tratamiento de las picaduras de medusa y aprendan algunas estrategias para evitarlas.

Si deseas conocer el tratamiento de las mordeduras de otros animales marinos (como Anémonas, Corales, Esponjas, Erizos, Pepinos y Estrellas de Mar): Click here.

It is common for patients or parents of children to ask us what is the best clothing for atopic dermatitis.

Classically, dermatologists recommend cotton clothing and, on the other hand, patients often report intolerance to wool. The scientific literature can to surprise regarding this recommendation.

A usual question in the consultation

Patients with moderate-severe atopic dermatitis often consult us about factors that can aggravate or improve their dermatitis.

A common question in everyday dermatology is whether there are more suitable garments. In a traditional way we suggest cotton or natural fiber clothing, which is breathable and does not increase itching or cause skin irritation.

I also recommend cotton pajamas to go to bed after bathing and moisturizing the skin, with or without corticosteroid cream, I find them very practical to make a slight occlusion of the applied cream and facilitate its penetration.

But if we review the quality scientific literature, what studies do we find of clothing in atopic dermatitis?

What the science says about the best clothes for atopic dermatitis

I find the Study DESSINE published in the magazine of the British Association of Dermatology in 2017 (1), one of the most impressive in dermatology.

In this work, they study two groups of pediatric patients with moderate-severe atopic dermatitis. One group of patients wears cotton clothes and another group is dressed in superfine sheep's wool clothes.

They study the two groups and measure in them the severity of atopic dermatitis with normalized indices, the SCORE, the atopic dermatitis severity index (ADSI) and the quality of life index in children with dermatitis.

Surprisingly, they find that patients using wool clothing his dermatitis improves throughout follow-up.

Despite limited evidence, dermatologists have considered wool an irritating fabric that should be avoided in patients with atopic dermatitis.

At the same time, in Hanifin and Rajkapara criteria the diagnosis of atopic dermatitis, one of which is included is wool intolerance.

Wool fibers are composed of keratin, have insulating capacity, have a greater composition of water than cotton fibers, are thermoregulatory and transport moisture.

These qualities of wool can be beneficial in patients with atopic dermatitis and have been shown in children and adults (2). This study makes us reflect on the traditional recommendation to wear cotton clothing.

Other studies

In addition there are other interesting studies on textiles in atopic dermatitis in the literature:

• Textiles with an antimicrobial effect, coated with antiseptic substances (3), have shown to be beneficial, despite everything there are still studies to recommend their use on a regular basis and they are not included in the Management Guidelines (4).
• The CLOTHES study evaluates therapeutic silk garments, without showing improvement with them in children with atopic dermatitis (5).
• Another recent study finds benefits in clothing made from cellulose fibers enriched with silver-containing algae (6).

Conclusions on what is the best clothing for atopic dermatitis

We can conclude that the classic recommendation to use cotton fabrics in atopic dermatitis is mainly based on the sensation subjective of the patient, who feels more comfortable, but fine wool clothing may be beneficial in these patients.

Other tissues and components are being studied without there being any specific recommendation in the management guidelines at the moment. studies are missing to establish the best clothing for atopic dermatitis on a solid foundation.

References

1 His JC, Dailey R, Zallmann, et al. Determination of the effects of superfine sheep's wool on childhood eczema (DESSINE): a randomized pediatric crossover study. Br J Dermatol 2017; 177: 125-133.

two Griplas L. Changing perceptions of wool. Sydney: Woolmark, 2012. Available at:. [8 May 2014].

3 Lopes C, Soares J, Tavaria F, et al. Chitosan-coated textiles may improve the severity of atopic dermatitis by modulating the staphylococcal profile of the skin: a randomized controlled trial. Pls One 2015; 30: 1-14.

4 Lopes C, Silva D, Delgado L, Correia O, Moreira A. Functional textiles for atopic dermatitis: a systemic review and meta-analysis. Pediatr Allergy Immunol. 2013; 24(6):603-13.

5 Thomas K, Bradshaw L, Sach T, et al. Randomized controlled trial of therapeutic silk garments for the treatment of atopic eczema in children: the CLOTHES trial. Health Technology Assessment 2017; 9:16 p.m.

6 Portela Araujo C, Gomes J, Paula Vieira F, Fernandes JC, Brito C. An initiative for the use of novel silver algae cotton fibers in the treatment of atopic dermatitis. Cutan Ocul Toxicol, 2013; 32: 268-274.

Knowledge of Photodynamic Therapy helps to understand how light damages people with porphyrias and the importance of protecting themselves from it.

One afternoon, while I was in consultation, a young patient came to see me with his father. The patient had a porphyria, a strange disease, but after chatting with them, I realized that my years of dedication to photodynamic therapy could help these patients. And this is the reason why I write this text on my blog. I hope you find it useful.

Porphyrias are rare diseases and are characterized by a exaggerated photosensitivity (sun damage).

Dermatologists have “copied” this mechanism in Photodynamic therapy (PDT) to produce phototoxicity located in tumor and momentary lesions, which, by applying an adequate light source, allows us to destroy tumors selectively and without surgery.

We achieve this photosensitization by applying creams that produce accumulation of protoporphyrin IX (PpIX) in the selected cells. PpIX is the actor in question and the substance that causes intracellular damage in patients with porphyria.

These patients suffer in their cells from alteration in the porphyrin synthesis pathway, a pathway comprising several steps, which when altered at the end of the pathway, lead to accumulation of PpIX and nearby metabolites.

This accumulation causes pain in the skin with exposure to the sun (“freezing fire in the skin”), itching, redness, blisters, edema and even loss of substance in severe forms. These symptoms can also appear with artificial lights.

What are porphyrias and why do they occur?

The porphyrias are a group of at least nine genetic metabolic disorders described in the heme synthesis pathway. Heme is half of hemoglobin, along with globin. This molecule is responsible for transporting oxygen in the blood within the red blood cell or erythrocyte.

The heme group is synthesized partly in the liver and partly in the erythrocyte, which is why porphyrias are classified, depending on the mechanism that is altered, into hepatic and erythropoietic (erythrocytes or red blood cells).

In addition there are porphyrias not genetic, acquired due to liver failure or toxicity (1). A well-known one is the taking of oral tetracyclines (antibiotics) in some very susceptible patients.

Classification of porphyrias according to the organ in which abnormal porphyrins are synthesized

• Erythrepoietic
  • Congenital erythropoietic porphyria (CEP)
  • Erythropoietic protoporphyria (EPP)
• Hepatic
  • Preliminary cutaneous porphyria (PCT)
  • Hematoerythropoietic porphyria (HEP)
  • Porphyria variegata (PV)
  • Hereditary coproporphyria (CPH)
  • Acute intermittent porphyria (AIP)
  • Porphyria due to ALA dehydratase deficiency (Pd-ALAD)

How common are porphyrias?

Porphyrias are considered rare diseases. In the United States, they impact fewer than 200,000 people.

In Europe, the prevalence of the three most common forms of porphyria, cutaneous Tarta, acute intermittent and erythropoietic, is 1 in 10,000, 1 in 20,000 and 1 in 75,000, respectively.

Congenital erythropoietic porphyria, also called Günther's disease, is extremely rare, with an incidence of approximately 1 per million inhabitants.

the Nework European porphyria , a highly recommended page if you want to delve deeper into the topic and look for porphyria specialists in Europe, estimates about 335 patients diagnosed in 3 years in 11 countries (1,2).

How does a porphyria manifest?

Photosensitivity occurs in all porphyrias except acute intermittent porphyria and ALA dehydratase deficiency porphyria. This photosensitivity manifests itself in two ways (1):

• Acute photosensitivity syndrome: This is pain, burning sensation and itching with sun exposure. Then redness and edema of the skin appear, like a disproportionate sunburn. This image is due to the accumulation of PpIX in the cells.
• Skin fragility syndrome: It is not so acute, it is latent, and it is the appearance of erosions, blisters and cysts on the skin with minimal trauma or sun exposure.

Is there a common mechanism in porphyrias and photodynamic therapy?

Yes it exists. In a study made public in 2016 on neuron cultures, they discovered that the common mechanism is through ion channels (TRPA1 and TRPV1) that produce cellular damage through the activation of PpIX with ultraviolet and blue light (3).

They thus suggest the therapeutic opportunity of using medications that block these channels to prevent pain from sun exposure and skin damage

How is porphyria diagnosed?

The diagnosis is made under suspicion of symptom of the patient and determination of porphyrins in blood, urine or feces.

PpIX fluoresces when it accumulates in cells, and if we illuminate with a wood light or black light, widely used for diagnosis in dermatology, patients' teeth are fluorescent red (erythrodontics).

This is exactly the method we use to confirm that PpIX has accumulated in the cells we want when we do Photodynamic Therapy and we call it: “Fluorescence Diagnostics” (4). See next image:

This image shows a basal cell epithelioma and how after inducing protoporphyrin IX inside, when illuminated with Wood's light, red-pink fluorescence can be seen due to its accumulation.

How can PpIX activation and porphyrin skin damage be avoided?

To understand it better I explain it in the following image:

The top part shows the spectrum of electromagnetic radiation, where we can see as the wavelength increases:

A) Ultraviolet light

Which damages the skin and produces cancerous and precancerous lesions. It's divided in:

1. Ultraviolet A (UVA): the one that makes us brown. 400 to 315 nanometers (nm)

two. Ultraviolet B (UVB): the one that burns us and more related to skin cancer. From 315 to 280 nm.

3. Ultraviolet C (UVC): 280 to 100 nm. It is not good either, but due to its wavelength it reaches the ground little and penetrates the skin little.

B) Visible spectrum

What we see, the colors. It's a variety.

1. blue: 380 to 427 nm.

two. Green: from 497 to 570 nm.

3. Yellow: 570 to 580nm.

Four. Red: From 600 to 780 nm.

C) Infrared

1. Above 800 nm, it no longer acts as a source of photostimulant.

Below is the absorption spectrum of protoporphyrin IX (PpIX), which is divided into:

A) Soret Band

The most toxic, because it is the highest on the graph. In the ultraviolet range.

B) Four Q bands

Less toxic, ranging from blue to red.

When does light cause the most damage in people with porphyrias?

The damage that porphyrin causes to the skin when exposed to the sun occurs mainly when the PpIX matches (5,6):

• The ultraviolet range and the blue range: is the most toxic (around 400-420 nm)
• Red light: 600-630nm: Why else is he in a less toxic band? Because the longer the wavelength, the greater the penetration into the skin. Red light penetrates 1 to 2 mm into the skin and thus does more damage than green or yellow light when there is a buildup of ppIX.

Conclusions: importance of protection against sunlight and other sources

The last line shows how Sunscreens blocking the electromagnetic spectrum. With this we now reach the two main conclusions of how NOT to activate PpIX:

TO) You should use a physical-chemical sunscreen (most on the market) or pure physical, protects from the entire spectrum. It is essential to verify that we are not using a chemical-only filter.

B) Other light sources can promote the PpIX, with lower intensity but reminiscent of LED lights (television, lamps), the light that passes through the window (mostly UVA) or other light exposures. They are mild, but added together they can activate PpIX.

I hope I have not been too technical and have reached the readers. I understand that knowledge of the mechanism is essential, since in general dermatologists insist on protection against ultraviolet rays, but in the case of porphyrias it is somewhat more complicated.

References

1 Ramanujam V. Diagnosis of porphyria-Part 1: A brief description of the porphyrias. Protocols Curr Hum Genet 2015; 86: 1-26.

2 www.porphyria.eu

3 Babes et al. Photosensitization in porphyrias and photodynamic therapy involves TRPA1 and TRPV1. J Neurscience 2016; 36: 5264-5278.

4 Fernández-Guarino M. Retrospective, descriptive, observational study of the treatment of various actinic keratoses with topical methyl aminolevulinate and red light: results in clinical practice and correlation with fluorescence imaging. Actas Dermosifiliogr 2008; 10: 779-787.

5 Heerfort IM. Noninvasively measured skin protoporphyrin IX predicts photosensitivity in patients with erythropoietic protoporphyria. BJ Dermatol 2016; 175: 1284-1289.

6 Teramura T. Prevention of photosensitivity with protection adapted to the spectrum of action for erythropoietic protoporphyria. J Dermatol 2018; 45: 145-149.