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However, for the mundane, gardenvariety use of prednisone, such as for marked reaction to poison oak or poison ivy, periocular/facial dermatitis or concurrent use in a patient with more severe or painful shingles, where we would typically prescribe 40mg per day, we rarely proactively consult. Rather, we write a brief note to the PCP so that the patient’s health care team is fully aware of the status of the patient. Comparing risks for perspective, patients who wear contact lenses sometimes encounter serious, visionthreatening problems and some patients who are prescribed prednisone get jittery or have trouble sleeping, but these are very rare, albeit annoying, situations. In clinical practice, we generally prescribe prednisone for three to five days without tapering. For shingles, when prednisone is needed along with the oral antiviral, we might prescribe 40mg for five days and then 20mg for five more days to mitigate concurrent pain, as well as to dampen the expression of postherpetic neuralgia. Such prescribing decisions are highly fluid, thus making them a perfect example of the “art” of medical therapy. We have never encountered a single significant adverse event in our decades of prescribing oral prednisone, and this medicine has markedly benefited myriad patients. • We rarely prescribe oral antihistamines, mainly because they are not needed. For some mild to moderate cases of epiphora, a week-long trial of an antihistamine rationally can be tried to dampen the tearing, but a nasolacrimal evaluation may very well be in order. ANTERIOR SEGMENT CARE This woman presented with acute redness and swelling to her face and eyelids since the day prior. Note the bilateral and equal involvement. She was treated with 40mg of oral prednisone for three days along with cool compresses. OPTIONS FOR TRUE PENICILLIN-ALLERGY PATIENTS • Second- or third-generation cephalosporin such as cefuroxime (Ceftin) or cefpodoxime (Vantin) • Sulfamethoxazole/trimethoprim (Bactrim or Septra) • Doxycycline • Erythromycin A FEW PEARLS ON PAIN MANAGEMENT • “Neuropathic pain is caused by a lesion or disease of the somatosensory parts of the nervous system.” • “Long-term opioid administration has minimal effect on chronic pain and can cause tolerance, drowsiness, and dependence, as well as impaired memory, concentration [difficulties].” • The mechanisms of action of acetaminophen is not known; it is, however, “the leading cause of acute liver failure in the United States since 1998.” “There is no evidence of an effect on neuropathic pain.” • Classic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as Cymbalta and Effexor reduce the intensity of pain.
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