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Do Epsom Salts Help?

Patient Presentation
A 15-year-old male came to clinic with a history of 2 days of increased pain and drainage around his right great toe after tearing part of the nail off. He had soaked his foot a couple of times but still had yellow drainage, redness, and pain. He was otherwise well and had no specific medical problems.

The pertinent physical exam showed a well appearing male with normal vital signs and growth. The medial nailfold of the right great toe was reddened with some accumulation of pus under the skin. There was some crusted material on the nail itself consistent with dried secretions. The nailfold was very tender to touch, but the rest of the toe was normal and there was full range of motion in the toe and foot structures. There did not appear to have a distinct ingrown toenail.

The diagnosis of a paronychia was made. The pediatrician cleaned and prepped the area with iodine, and gently retracted the nailfold away from the nail, expressing pus that was cultured. The patient was given an antibiotic prescription and encouraged to continue to do soaking of the foot to soften the nail bed and do gentle retraction of the nailfold to allow any accumulated secretions to drain. “Should we put Epsom salts into the water?” the mother inquired. “I don’t know that it will help, but usually it won’t hurt. I’d stay away from any scented salts though and just use plain ones. That way it’s less likely to irritate the toe. You can soak for 10-15 minutes.” he explained. He also gave wound care instructions and how to appropriately cut toenails in the future.

Discussion
Epsom salt is magnesium sulfate. It is named Epsom from the town in England, close to London where it was supposedly discovered.
Magnesium is an important trace element. It is a co-factor for ATP metabolism, DNA and RNA synthesis and regulation, and multiple other enzymatic reactions.

Hypermagnesemia is quite uncommon and usually would occur because of renal insufficiency or being iatrogenically produced. Hypomagnesemia is a serum concentration of < 0.75 mmol/L. Symptoms are often non-specific such as lethargy, anxiety, headache, decreased appetite, nausea and sleeping problems. Muscle spasms and muscle associated pain can occur. Arrhythmias and central nervous system problems including seizures can occur. Hypomagnesemia can frequently co-occur with other electrolyte abnormalities such as hypocalcemia or hypokalemia.

Magnesium is commonly used to treat cardiac problems such as cardiac failure and arrhythmias, eclampsia and pre-eclampsia. It can also be used as a secondary treatment for severe asthma, temporizing treatment for digoxin toxicity, and as an anticonvulsant if appropriate. It can be used for patients with hypomagnesemia due to malnutrition as well. Magnesium is given orally or intravenously usually to treat these and other conditions.

The skin is the largest organ and is designed as the barrier to the outside world. A transdermal substance has to pass through the epidermis and the stratum corneum which specifically are designed to negate such passage. Basically, magnesium cannot pass transdermally through intact skin but it may be possible to be absorbed around the hair follicles and sweat glands.

A review of paronychias can be found here.

Learning Point
In the lay public, Epsom salt is used as a bath for a variety of conditions including muscle and joint pain, bruises and sprains, soothing mildly irritated skin, sleep and stress, and paronychia. There are few good research studies that support topical magnesium sulfate use, but it also does not generally cause problems. Severely irritated skin or open wounds should not be treated with Epsom salt baths and obviously Epsom salts should not be ingested orally. There potentially could be a placebo affect and/or the bathing activity itself (needing to stop and rest in a usually relaxing environment) could also provide benefits to the individual. Additionally, sometimes Epsom salt also may have scents added which are designed to be pleasing and add to the bathing experience. Per the Epsom Salt Council, it can also be used in cosmetics, crafting and gardening. The author could not find any references to Epsom salt or magnesium at the websites for the American Academy of Dermatology, the National Institute of Complementary and Integrative Health, or MedLinePlus. MedLinePlus does have a magnesium factsheet available here.

There are a few good studies which support topical magnesium. For example two studies found improved atopic dermatitis symptoms but the treatment was not magnesium monotherapy and other components of the treatment could be significant factors. There are other studies which show improvement in a variety of patients after bathing in the Dead-Sea or with simulated bath-salt solutions. Many of these are not controlled, have few numbers of patients and/or not published in scientific journals.

Questions for Further Discussion
1. What are the risks of amber teething necklaces which are used by some for pain relief? A review can be found here
2. What types of molecules penetrate the skin better?
3. What conditions help molecules penetrate the skin better?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kaye P, O’Sullivan I. The role of magnesium in the emergency department. Emerg Med J. 2002;19(4):288-291. doi:10.1136/emj.19.4.288

Chandrasekaran NC, Sanchez WY, Mohammed YH, Grice JE, Roberts MS, Barnard RT. Permeation of topically applied Magnesium ions through human skin is facilitated by hair follicles. Magnesium research. 2016;29(2). doi:10.1684/mrh.2016.0402

Grober U, Werner T, Vormann J, Kisters K. Myth or Reality-Transdermal Magnesium? Nutrients. 2017;9(8):813. doi:10.3390/nu9080813

Maarouf M, Vaughn AR, Shi VY. Topical micronutrients in atopic dermatitis – An evidence-based review. Dermatologic Therapy. 2018;31(5):e12659. doi:10.1111/dth.12659

Saeg F, Orazi R, Bowers GM, Janis JE. Evidence-Based Nutritional Interventions in Wound Care. Plast Reconstr Surg. 2021;148(1):226-238. doi:10.1097/PRS.0000000000008061

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is Diastasis Recti Abdominis?

Patient Presentation
A 10-day-old male came to clinic for his health supervision visit. He was a term infant who was reported to be breastfeeding well. His parents were only concerned as they had noted that above his umbilicus there seemed to be a bulge when he was straining. They had noted it in the newborn nursery but wanted to discuss it again. He didn’t seem bothered by it.

The pertinent physical exam showed an interactive male with a weight of 3.285 kg which was up 110 grams since his 4-day weight check appointment and was above birthweight by 20 grams. His physical examination was normal. He had no umbilical hernia noted, but when he did seem to strain above his umbilicus the rectus muscles were slightly splayed (about 1 cm in lateral width) with a mild bulge (proximal to distal about 2 cm in length). This coincided with what the parents had noticed as well. On palpation there was no palpable opening along the linea alba noted from his sternum to umbilicus and his rectus muscles also were normal with palpation.

The diagnosis of a mild diastis recti abdominis was noted. The parents were counseled that this often spontaneously resolved within a few weeks and it had resolved by the time of his 2-month health supervision visit.

Discussion
Ventral wall hernias are common. They can be congenital or acquired and it is estimated that approximately 25% of people will have one at some point in their life. True hernias have a fascial defect and therefore contents can protrude through and potentially become incarcerated and/or strangulated.

Common ones include:

  • Epigastric occurs between the sternum and umbilicus. It can appear midline or slightly off-center. In children they can spontaneously resole.
  • Umbilical occurs around the umbilical structures. These again often spontaneously resolve.
  • Spigelian occurs in anterior abdominal wall adjacent to the semilunar line lateral to the rectus abdominus muscles. Most are in the lower abdominal wall
  • Inguinal occurs in the inguinal canals
  • Femoral occurs in the deeper femoral canals
  • Lumbar occurs through a defect of the posterolateral abdominal wall
  • Incisional – occurs within the surgical incision.
  • Parastomal – occurs near an created opening (like an incision) in the abdominal wall such as a stomal appliance or other surgery or trauma.
  • Gastroschisis occurs when there is abnormal development of the umbilical cord ring resulting in non-closure of the anterior abdominal wall. It occurs usually left and lateral to the umbilicus. Abdominal contents are seen to protrude and are not covered by membranes.

An image of common locations can be found here

Learning Point
Diastasis recti abdominis (DRA) is an abnormal increased separation between the rectus abdominus muscles that results in weakness of the anterior abdominal wall often noted as an abdominal bulge. The collagen fibers crossing between rectus abdominus muscles creates the linea alba centrally. Stretching and thinning of these fibers creates the potential problem. It is not a true abdominal wall hernia as it does not have a true fascial defect. Therefore it does not risk incarceration. The bulging maybe better shown with the patient in a semi-fetal position, rather than during a headlift maneuver to try to provoke the bulge.

DRA may cause no problems, or can be associated with abdominal wall dysfunction and back pain. It commonly occurs in pregnant and post-partum women (where it can actually increase compared to during pregnancy), and is also associated with obesity, previous abdominal surgeries, and potentially aneurysmal arterial disease. Obviously strenuous activities which increase intraabdominal pressure can make this worse. Congenital RDA is commonly seen in newborns, where spontaneous resolution usually occurs within a few weeks after birth. Other times it can be associated with problems and syndromes which have abdominal wall problems such as Beckwith-Wiedemann syndrome, Cantrell pentalogy, Opitz syndrome, Prune Belly Syndrome, or other problems associated with midline congenital defects.

DRA often spontaneously resolves or can be treated with exercise, weight loss and physical therapy. For those that do not improve, surgical techniques include plication and modified hernia repairs.

Normal variations occur and often > 2 cm separation of inter-rectal muscle distance (IRD) measured at 2-3 cm above the umbilicus is considered the definition of abnormal for DRA. The IRD changes depending on where it is measured. A 2022 paper using an asymptomatic adult population who were undergoing abdominal computed tomography for appendicitis or renal issues showed IRD measured at 3 cm above the umbilicus was considered normal up to 34 mm.

Questions for Further Discussion
1. What are different types of diaphragmatic hernias?
2. What is the role and type of medical imaging in management of ventral abdominal hernias?
3. How common are inguinal and femoral hernias?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Common Infant and Newborn Problems and Hernias.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Nahabedian M, Brooks DC. Rectus abdominis diastasis. UptoDate. Rev 10/20/21. Accessed 10/9/2022.

Brooks DC, Petro CC. Management of Ventral Hernias. Rev 4/21/22. Accessed 10/9/2022.

Hall H, Sanjaghsaz H. Diastasis Recti Rehabilitation. In: StatPearls. StatPearls Publishing; 2022. Accessed October 10, 2022. http://www.ncbi.nlm.nih.gov/books/NBK573063/

Kaufmann RL, Reiner CS, Dietz UA, Clavien PA, Vonlanthen R, Kaser SA. Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia. 2022;26(2):609-618. doi:10.1007/s10029-021-02493-7

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is the Current Classification for Ehlers-Danlos Syndrome?

Patient Presentation
A 4-year-old female came to clinic for her health supervision visit. Her mother had no complaints except that she was concerned that the child may have Ehlers-Danlos syndrome. “I’m being evaluated now because I’ve always been double-jointed and had some pain now and then. But during my last pregnancy with her brother I had a lot of problems and my doctor is starting to evaluate me more. She complains once in a while about her legs being tired, so it just makes me worried,” the mother explained.

The past medical history was positive for admission for respiratory syncytial virus and 2 otitis media diagnoses. The review of systems was negative for other problems such specific joint pain, problems moving after resting for time, easy bruisability or skin problems, being “double-jointed”, true fatigue, problems playing or keeping up with other children, abnormal muscle strength or dental problems. Her mother also said that she complained of the leg pain after playing for a long period of time and was better after resting. It occurred infrequently.

The pertinent physical exam showed a smiling female with growth parameters in the 25% and was proportional. Her physical examination was normal. Her Beighton score was 3 for bilateral dorsiflexing her 5th metacarpal to 90%, and she could place her hands on the floor with forward flexion of the trunk.

The diagnosis of a healthy female was made. The pediatrician felt that the intermittent leg discomfort was most likely due to exercise but asked the mother to monitor it. She also recommended that the mother let her know about the outcome of the mother’s evaluation. “Depending on if your doctor finds any problems and what type of problems they are, we may need to do something for her and her brother but we’ll see what you find out,” she recommended.

Discussion
As with any potential problem there is a often a range from normal to abnormal and this is true for joint hypermobility. Generalized joint hypermobility is hypermobility in multiple joints with few or no other symptoms. Generalized hypermobility spectrum disorder (also known as joint hypermobility syndrome) has hypermobility along with other symptoms such as pain, reduced muscle strength, and decreased proprioception and balance. Other clinical entities with hypermobility include Ehlers-Danlos syndrome, Marfan syndrome, and osteogenesis imperfecta.

In the office, a 5-point questionnaire with 2 or more “yes” answers has high sensitivity (80-85%) and specificity (89-90%) for joint hypermobility. It includes:

“1. Can you now (or could you ever) place your hands flat on the floor without bending your knees?
2. Can you now (or could you ever) bend your thumb to touch your forearm?
3. As a child, did you amuse your friends by contorting your body into strange shapes
or could you do the splits?
4. As a child or teenager, did your shoulder or kneecap dislocate on more than one
occasion?
5. Do you consider yourself “double-jointed”?””

The most commonly recognized scoring system for joint hypermobility on physical examination is the Beighton score which can be reviewed here. Children have more joint mobility therefore they have a higher cutoff score than adults (Beighton score = 5-6 versus adults with score of 4-5).

Learning Point
Although recognized since ancient times, Ehlers-Danlos syndrome (EDS) was first named in 1936 after Ehlers and Danlos who were both dermatologists. EDS is a genetic connective tissue disorder with heterogeneous clinical characteristics that include joint hypermobility, tissue fragility and skin hyperextensibility. Because of newer genetic research and testing and increased recognition of the problems, several classification systems for EDS have evolved over the past 40 years. As this involves soft tissue or related structures, it is not surprising that EDS has various clinical patterns. The most recent international classification includes 13 different patterns which are:

  • Classic
  • Abbreviation: cEDS
  • Genetic Pattern: Autosomal Dominant
  • Major criteria are skin hyperextensibility and aulophic scarring, and generalized joint hypermobility
  • Classic-like
  • Abbreviation: cIEDS
  • Genetic Pattern: Autosomal Recessive
  • Major criteria are skin hyperextensibility and aulophic scarring, and generalized joint hypermobility, and easy bruisability skin / spontaneous ecchymoses
  • Hypermobile
  • Abbreviation: hEDS
  • Genetic Pattern: Autosomal Dominant
  • Is a clinical diagnosis with major criteria being generalized joint hypermobility, several criterion and features within the criterion. These include various skin, joint, soft tissue, vascular and other features and also genetic risk
  • Cardio-valvular
  • Abbreviation: cvEDS
  • Genetic Pattern: Autosomal Dominant
  • Major criteria are progressive cardiac-vascular problems, skin involvement and joint hypermobility
  • Vascular
  • Abbreviation: vEDS
  • Genetic Pattern: Autosomal Dominant
  • Major criteria are family history of vEDS, arterial rupture, spontaneous sigmoid colon perforation, uterine rupture, carotid-cavernous sinus fistula
  • Arulochalasia
  • Abbreviation: aEDS
  • Genetic Pattern: Autosomal Dominant
  • Dermatosparaxis
  • Abbreviation: dEDS
  • Genetic Pattern: Autosomal Recessive
  • Kyphoscoliotic
  • Abbreviation: kEDS
  • Genetic Pattern: Autosomal Recessive
  • Brittle Cornea syndrome
  • Abbreviation: BEDS
  • Genetic Pattern: Autosomal Recessive
  • Spondylodysplastic
  • Abbreviation: spEDS
  • Genetic Pattern: Autosomal Recessive
  • Musculoconulactural
  • Abbreviation: mcIEDS
  • Genetic Pattern: Autosomal Recessive
  • Myopathic
  • Abbreviation: mIEDS
  • Genetic Pattern: Autosomal Dominant or Autosomal Recessive
  • Periodontal
  • Abbreviation: pIEDS
  • Genetic Pattern: Autosomal Dominant

Questions for Further Discussion
1. What is included in the differential diagnosis of joint pain? A review can be found here
2. What are indications for referral to genetics, rheumatology or orthopaedics for potential hypermobility?
3. What are treatments for hypermobility with associated musculoskeletal problems?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Ehlers-Danlos Syndrome and Connective Tissue Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Baeza-Velasco C, Grahame R, Bravo JF. A connective tissue disorder may underlie ESSENCE problems in childhood. Research in Developmental Disabilities. 2017;60:232-242. doi:10.1016/j.ridd.2016.10.011

Scheper MC, Juul-Kristensen B, Rombaut L, Rameckers EA, Verbunt J, Engelbert RH. Disability in Adolescents and Adults Diagnosed With Hypermobility-Related Disorders: A Meta-Analysis. Arch Phys Med Rehabil. 2016;97(12):2174-2187. doi:10.1016/j.apmr.2016.02.015

Malfait F, Francomano C, Byers P, et al. The 2017 international classification of the Ehlers-Danlos syndromes. American Journal of Medical Genetics Part C: Seminars in Medical Genetics. 2017;175(1):8-26. doi:10.1002/ajmg.c.31552

van Meulenbroek T, Huijnen IPJ, Simons LE, Conijn AEA, Engelbert RHH, Verbunt JA. Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain. Scand J Pain. 2021;21(1):22-31. doi:10.1515/sjpain-2020-0023

Ehlers-Danlos syndrome. Accessed October 10, 2022. http://www.whonamedit.com/synd.cfm/2017.html

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa