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When Snot Hits the Fan

Posted by Dr. Summit Kundaria on September 14, 2018
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Category: Blog

When the Snot Hits the Fan: Over the Counter Solutions to Seasonal Allergies and Lower Eye Bags

The Spring and Fall are high allergy season for many of us, and while some of us have the typical symptoms of nasal congestion, sneezing, itchy watery eyes, and a clear runny nose, others only see one thing: lower eye bags.  Some pockets of the United States, with Charlotte being one of these lucky “pockets”, are especially bad for seasonal allergies.  Luckily, for all of us allergy sufferers, there are great over the counter solutions to treat all of the symptoms listed above.

Any patients that I have with the above complaints are first questioned about their symptoms and triggers for these, as allergies are common, but there are more rare causes of nasal congestion and facial pain (such as migraine headaches triggered by perfumes rather than pollen) and also other causes of lower eye swelling (such as thyroid conditions or excess orbital fat).  In the absence of these, and when people have annual symptoms like clockwork, the probability of having allergies is quite high, and the diagnosis is made (though without formal allergy testing). 

My initial regimen is a three pronged approach, which involves:

  • Nasal Rinses
  • Nasal steroid sprays
  • Oral antihistamine (non-sedating)

 

Nasal Rinses

My preferred nasal rinses are the NeilMed Sinus Rinses, as they physically remove the pollen, mold, dander, or other nasal irritant from the lining of your nose.  The other medications treat the lining of the nose, but physical removal of the irritants makes the remainder of the job easier.  Other nasal rinses are available, as well as powered nasal washers that have now crept up on the market.  I have no experience with these, and continue to use the NeilMed Sinus Rinse and recommend it to my patients.  Of note, distilled or boiled water should be used with these rinses, as rare infections are possible with using tap water.

Nasal Steroid Sprays

These sprays were prescription only just a few years ago, and since becoming over the counter and going generic, the cost has come down quite a bit.  I used to pay $30 for a one month supply, and now these can be had for under $4.  My preferred nasal spray is fluticasone propionate 50 mcg spray, the generic form of Flonase.  Costco has a version branded Aller-Flo, costing much less than I used to pay for a prescription.  The alternative to this spray is Nasonex or its generic form, mometasone.

Proper use is one spray in each nostril twice a day.  Do this spray with your chin down, and aiming the spray toward your ear.  Inhale gently during spraying.  Snarfing this while spraying will just put the steroid into your throat, which does not help your nose at all.  If you taste this about 5 minutes after spraying, then it has spent enough time hanging out in your nose to do its work.  It decreases the swelling of the lining of your nose, and improves nasal congestion and sneezing as well.  Nasal steroids should be thought of as a “maintenance treatment” not an “as needed” treatment, and they take a week of regular use before you see results.  Use them for a month at a time rather than only when you feel congested to get the best results.

Oral Antihistamines

Oral antihistamines, which many people use as the primary treatment of allergies, are not my favorite treatment of allergies.  My philosophy is that if someone’s symptoms are primarily nasal, such as sneezing, runny nose, and nasal congestion, then treating the nose is the best option.  If itchy, watery eyes are a bigger problem, or if the nasal treatments treat the nose well but these ocular symptoms remain, then I add oral antihistamines.  My first choice is fexofenadine 180mg, the generic form of Allegra.  This was a prescription medication a few years ago, and has gone generic and over the counter, making it a powerful anti-allergy tool.  Prior to that, only lesser antihistamines such as Claritin, Clarinex, Zyrtec, Xyzal, and Benadryl, were available, and I call these “lesser” because their primary drawback is the side effect of sedation.  Fexofenadine is not sedating like the rest, which makes it “the best” in my opinion.  This is available at Costco as Aller-Fex and can be taken twice daily safely.

Other Bags

Some people have bags under their eyes that are due to excess orbital fat, and this can get worse with time, as the fat “bulges” out due to a weakening of the tissues holding the fat pockets back.  These eye bags require surgical removal of the fat, which can be a permanent solution.  If you have both — fat and fluid, my solution is to treat the fluid first, and if the eye bags are still worrisome, then to remove the fat.

Parting Notes

I personally have no relationship to Costco other than being a customer there, and have found that the products listed above have helped quite a few of my patients with their allergies as well as reduce the bags under their eyes.  If you find better deals on these products, then please share them in the Comments section of this blog posting so that others in the community can benefit from it as well.

botox droplet

Botox vs Dysprt vs Xeomin.

This is the third post in a series about the similarities and differences between the three FDA approved injectable neuromodulators currently available in the US market.  For comparisons between the products, please check out Battle of the Neuromodulators, Part I, and Battle of the Neuromodulators, Part II.

Throwing all of the FDA-approved players into the mix today, let’s look at the three neurotoxins available in the US today, and explore their similarities and differences.  

Medically, how do you find out how two things are different?  You perform a clinical double blinded clinical trial and put them head to head.  “Double blinded” means both that the doctor does not know what he injected, and the patient similarly does not know which treatment they got.  The observations are done by third parties to maintain objectivity.  This is a single medical study.  It is limited in its power by geography by the number of people that you can sign up for the study, and cost, as these are expensive products.

When you amass several studies that have been done all over the world, you have enough data for a “meta analysis”.  This is a “study of studies”, and is much more powerful than a single study.  Instead of having just 50 patients to analyze in one study (for example), you do a study 50 studies that were done of 50 patients each, giving you data from 2,500 patients.  Three meta analyses about the three injectable neuromodulators currently available, Botox, Dysport, and Xeomin, have been done in recent years, and they are all well designed and systematic in their approach to review the question.  Furthermore, they are very open to the limitations of each study they included in their meta analysis.

Think about these meta analyses as people are trying to sell you on the difference between these products.  While there are some differences between them about how they are formulated and how much protein they contain, I think we would all agree that the similarities far outweigh the differences.  And for anyone that argues that these differences matter, all I say is: prove it.  Because it hasn’t been proven as of today, and it isn’t from a lack of trying.  If a single study were to prove it, it would be in the face of a lot of peer reviewed published data that shows the products are equivalent, so it would take a lot to sway my opinion today. 

For every time I hear “Dysport spreads more than Botox”, I think of the three studies above.  Every time someone says “Xeomin doesn’t last as long as Botox”, you really have to wonder if this is true.  A significant amount of money and energy has gone into asking just this, and none of it has proven that this is the case, and as we discussed in “Battle of the Neuromodulators, Part I”, there is some serious motivation by any one of these companies to come out as the “best” or to make it into a two-player market by showing one product as inferior.

I will end with this: medical studies evaluate more than a single patient’s experience, and more than a single practitioner’s experience as well.  There are some people that have a better experience or result with one product compared to another.  While the scientist in me thinks that this is due to the injector rather than the product, I do leave open the possibility that not every product is equivalent in every person, and that is why we offer all three at Nuance Facial Plastics.  If you had a bad experience with Botox when it was on Groupon (and you blame the Botox rather than the injector), we have more options for you to try.

Botox Xeomin

Botox vs Xeomin

This post is very similar to the previous blog post, Botox vs Dysport: Battle of the Neuromodulators, Part I”, with some parts borrowed directly.

Botox and Xeomin are both formulations of botulinum toxin type A.  For reference the bacteria Clostridium botulinum makes eight different types of toxins (A, B, C1, C2, D, E, F, and G).  The molecule naturally occurs as a protein-toxin complex, with a large carrier molecule and comparably smaller toxin molecule.

Botox (onabotulinumtoxin A) is made by Allergan, and is supplied as a lyophilized (dried) form, and a vial of Botox contains a small amount of human serum albumin (a protein), sodium chloride (salt), and the neurotoxin complex, a protein-toxin complex with a mass of 900kD.  Botox is typically available in 100 unit and 50 unit vials.  The vials have to be refrigerated and stay that way until they are reconstituted with normal saline, and then injected.

Xeomin (incobotulinumtoxin A) is made by Merz, and is also supplied as a lyophilized powder, with vials containing human serum albumin, sucrose, and the neurotoxin.  The big difference between Botox, Dysport, and Xeomin is that Xeomin does not contain the carrier protein that the other two products have.  Proteins are quite sensitive molecules, as any change in pH, temperature, salt concentration, or agitation may disrupt them (turn the proteins inside out and therefore ineffective).  Lacking a protein, Xeomin is stable at room temperature and does not require refrigeration before or after reconstitution with saline.  To help me sleep better at night, and since we have the room, I do keep my Xeomin refrigerated, as I do not have a compelling reason not to.

Does the small, pure toxin travel much farther in the body because it is not as “heavy” as Botox?  It does make sense.  Though, not everything makes sense.  See this example: 

  1. Dried grapes are raisins
  2. Dried plums are prunes
  3. You walk around the grocery store and see a lot of grape juice.  No raisin juice in sight. 
  4. You walk around the grocery store and see a lot of prune juice.  No plum juice in sight.
  5. CAN SOMEONE PLEASE EXPLAIN THIS TO ME!?

Not everything that makes sense actually works the way you think, and just because something is a good idea on paper does not mean that it actually works.  I see the marketing folks (understandably) try to really press on this size issue, as it is the key difference between these two products.  

Multiple studies in the peer reviewed medical literature have been done, with a couple listed at the bottom of this posting.  There would be a lot (billions of dollars) to gain if someone can prove that their product is in fact superior to others.  This should be easy enough to do, as these products are being injected constantly and globally in all skin types.  

There are no such studies.  There are, however, several studies that show that they are equivalent.  As Xeomin is a newer product than Botox and Dysport, there is much more literature comparing the latter two compared to each other than there are that involve Xeomin.  At the end of the day, these are all products that are the same flavor of toxin, but just formulated to be different sizes.  I am not convinced that anyone has shown that this difference actually matters.

Medical Literature Citations:

J Neural Transm (Vienna). 2014 Jan;121(1):21-6. 

Dermatol Surg. 2015 Nov;41(11):1310-9.

Charlotte Living Magazine at Nuance Facial Plastics

This article text was originally published in Charlotte Living Magazine, 2nd Quarter 2018.  

The warmer months present a great opportunity to enjoy the outdoors, including activities like gardening that put us closer with nature.  For some of us, however, they represent the return of unwelcome seasonal baggage.  Seeing our friends post pictures of their reunion with the outdoors on Instagram can give some of us a feeling of hesitation.  What is this baggage that comes with warmth?  Allergies.  And living in one of the allergy centers of the country, the baggage that comes with allergies — lower eye bags.

How are allergies related to lower eye bags?  

Lower eye bags can be caused by excess fluid in the lower eyelids, extra fat around the eyes, loose skin, or any combination thereof.  Allergies (and some rare medical conditions) are responsible for the fluid buildup of the lower eyelids, which can come and go with the season.  This fluid also may be responsive to gravity, being worse in the morning (after a night of lying down) than in the evening.  The veins in the head and neck do not have valves, so blood flows in either direction in these vessels.  Anything that increases pressure downstream is felt upstream.  

An environmental irritant (like pollen) is inhaled in the nose, causes swelling of the lining of the nose, making the veins upstream (around the eyes) get congested and swell.  To add insult to injury, allergies make blood vessels “leaky” so the bloated streams leak fluid into the tissues, making a perfect recipe for baggage.  If you are burdened by such baggage, then this story is all too familiar to you.

Simple Treatments for Baggage

Knowing that allergies are the cause of the fluid component of the eye bags is the key, as there are several good (and safe) over the counter solutions can address your concerns.  My first preference is a non-medicated nasal sinus rinse, which will physically remove the irritants from the nose.  Any medical treatment that you do on top of this treats your response to the irritant, but physically removing the irritant is the first step.  There are several products available, and the NeilMed Sinus Rinse is my preference.  Distilled or boiled water should be used with these products.

Using a nasal steroid spray is the next step, as the clean lining of your nose is now still swollen and irritated, and the spray is a good way to soothe and thin the lining.  These nasal steroid sprays were prescription medications just a couple of years ago, and since going over the counter, they have become much cheaper and are widely available.  If you decide to use these, do it on a month by month basis.  My preference for these sprays are fluticasone (the generic form of Flonase) and mometasone (the generic form of Nasonex).

Oral medications do have a role in treating allergies, and my preference is using fexofenadine (the generic form of Allegra), as it is the least sedating, especially compared to the other popular over the counter allergy medications Claritin and Zyrtec, which are both more closely related to Benadryl, and can cause sedation despite their “non-sedating” claims. 

A Natural Cure

The treatments above will treat the allergies, but a “cure” of allergy requires a “re-wiring” of you immune system.  There are allergy shots available for people that have symptoms that are not well medically managed.  These are based on challenging your immune system with escalating doses of the irritant, whether it is tree pollen, grass pollen, or cat dander.  Eventually, these repeated challenges steer your immune system away from allergies.

A natural solution is to introduce a fine sampling of local pollens into your bloodstream by getting raw, unprocessed local honey and placing it under your tongue and holding it in place for 2 minutes.  This is done twice daily for several months or years, and is the only over the counter solution that is a potential cure for allergies.  Eating the honey does not have the same effect, as it is filtered by the liver and “inactivated”.  This is another way to challenge your immune system with the pollens that you are allergic to, and eventually change your body’s response to those irritants.

Other Types of Bags

If you have done everything you can to address excess fluid around your eyes and still have baggage, your bags may be due to more complex causes than fluid, such as excess fat around the eyes, loose skin on the lower eyelids, or a loss of tissue over the bony orbital rim.  These are more complicated to address, and may require treatments such as surgery or a dermal filler to treat the specific causes of your bags.  

Whatever the cause of your baggage, knowing that there are simple and natural ways to address these complaints is the key to liberation from them.

Botox vs Dysport

Botox vs Dysport

My long answer to the  “Botox vs Dysport” debate is the substance of this blog post.  It is not a discussion I love having, though you would not know that based on the frequency of how often I have it.  Botox and Dysport are both formulations of botulinum toxin type A.  For reference, the bacteria Clostridium botulinum makes eight different types of toxins (A, B, C1, C2, D, E, F, and G), and all of the FDA approved injectable formulations are based on the same type (botulinum toxin A).  The molecule naturally occurs as a protein-toxin complex, with a large carrier molecule and comparably smaller toxin molecule.
 

What is Botox?

Botox (onabotulinumtoxin A) is made by Allergan, and is supplied as a lyophilized (dried) form.  A vial of Botox contains a small amount of human serum albumin (a protein found in humans and other animals as well), sodium chloride (salt), and the neurotoxin complex, a protein-toxin complex with a mass of 900kD.  Botox is typically available in 100 unit and 50 unit vials.  The vials have to be refrigerated and stay that way until they are reconstituted with normal saline, and then injected.
 

What is Dysport?

Dysport (abobotulinumtoxin A) is made by Galderma, and is also supplied as a lyophilized powder.  A vial contains human serum albumin, lactose, and the neurotoxin complex with some of the carrier molecule cleaved, or cut, from the protein-toxin complex with a mass of 500-900kD. Why is there a range of values?  Well, the process of cutting the carrier protein involves using proteases, which are proteins that cut other proteins, and they leave a range of carrier molecules rather than a single size.  Does this matter?  It is hard to say.  Usually, a single vial of Dysport has 300 units, which in my practice, is equal to 100 units of Botox or Xeomin.  As opposed to Botox, Dysport does not have to be refrigerated (though I do anyway, because I figure it can’t hurt, and I just sleep better at night doing this).  I do not think refrigeration should be a large factor in the “Botox vs Dysport” debate.
 

Botox vs Dysport: Different Units

When I say they are “equal”, I mean that they produce an equivalent effect once injected.  To make the bookkeeping simpler, I refer to 3 units of Dysport as “1 unit”, so that all 3 of my injectable neuromodulators, Botox, Dysport, and Xeomin, have interchangeable units.  This does make price comparing a little confusing, as my Dysport appears to be 3 times as expensive as other people in town.  
 
I see this difference as semantics, and would rather have the simplicity of interchanging units, and also pass this simplicity on to my patients, rather than explaining, “last time you got 10 units of Botox, and since you wanted to try Dysport this time, it will be 30 units”.  Trust me, that is the beginning of a long conversation that takes several unnecessary minutes and only leads to more confusion.  If this actually impacted results or the treatment, I’d do it happily.  
 

Botox vs Dysport: Conclusions

If there is one takeaway from this blog post, it is that these two products, in my practice, are totally interchangeable.  I offer both so that if a patient was expecting their treatment to last longer and would like to try another product, then I have another to offer.  Is this good for business?  Not exactly.  The more of a single product that you buy, the better deal you get from the company that sells it.  I offer multiple products so that I can give my honest views on them.  
 
Assume, for a minute, that I only offer Botox.  If you come in asking for “Dysport”, then I have the task of trying to talk you into having Botox instead (a classic “bait and switch“).  I don’t like this for my patients.  Some have a preference for whatever reason, and being able to offer anything they ask for is my priority, even though we pay in terms of not being able to get bulk discounts.
 

Botox vs Dysport: The Proof

Should you take my word for it?  Absolutely not.  Don’t trust anybody.  Peer-reviewed medical literature, however, is something you can trust.  Let me make the job easier for you and show you some articles I reviewed about Botox head to head against Dysport.  The conclusion I draw from these is that the products are interchangeable and produce a comparable clinical effect when used at the dilution ratios (1:3) that we use.  
 
Furthermore, think about the amount of revenue that is generated from these drugs, with these injectables being some of the most common cosmetic procedures in the world, and the potential gain one of the companies would have to show that their product is superior to the other(s).  There is a strong motivation (billions of dollars per year) to prove that your product is the best by showing a difference in a double blinded head to head study.  If there is a difference.
 

Medical Literature Citations of Botox vs Dysport:

 
*One study (not named here) that found Botox to be better at all time points against Dysport was not included because the main author received more than $180,000 from Allergan in just one year.

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Nuance Facial Plastics
309 S Sharon Amity Rd
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Charlotte, NC 28211
Phone: (704) 593-6802

Nuance Facial Plastics

309 S Sharon Amity Rd, Ste 202

Charlotte, NC 28211

(704) 593-6802

When Snot Hits the Fan

When the Snot Hits the Fan: Over the Counter Solutions to Seasonal Allergies and Lower Eye Bags The Spring and Fall are high allergy season for many of us, and while some of...

Botox vs Dysport vs Xeomin: Battle of the Neuromodulators, Part III

The third installment of Battle of the Neuromodulators, we look into the similarities and differences between Botox, Dysport, and Xeomin using up to date medical literature.

Botox vs Xeomin: Battle of the Neuromodulators, Part II

Botox vs Xeomin This post is very similar to the previous blog post, “Botox vs Dysport: Battle of the Neuromodulators, Part I”, with some parts borrowed directly. Botox and...

Getting Rid of Baggage

This article text was originally published in Charlotte Living Magazine, 2nd Quarter 2018.   The warmer months present a great opportunity to enjoy the outdoors, including...

Botox vs Dysport: Battle of the Neuromodulators, Part I

Botox vs Dysport My long answer to the  "Botox vs Dysport" debate is the substance of this blog post.  It is not a discussion I love having, though you would not know that...