Dr David L. J. Freed, MB, MD, MIBiol
I have presented cases of tap-water allergy before (Oct ’01, Oct ’05) and our esteemed Editor presented three others. I make no apology for presenting more cases now because water allergy is one of the areas that meets with the blankest disbelief from conventional doctors.
Aquagenic pruritus, first described in 1981, is actually quite common in spite of the tendency of doctors to dismiss the complaint as neurotic (9-11). The classic history is of a patient (usually female) who loves to soak in a scalding hot bath. She gets very hostile when you tell her not to. That, she informs you indignantly, is the only time her continuous itch feels better, the hot water soothes her. The fact that she feels much worse a half-hour later does not impress her but it impresses me, because this phenomenon of feeling better when in contact with a substance, then worse afterwards, is common to all forms of addiction. Malcolm Greaves [12], who originally described this syndrome, believes it to be physical and not allergic in mechanism, but I am not so sure as you will see.
Case 9
This 49-year-old female shop assistant presented ten years ago with a three-year history of itch, all over the body, initially intermittent but latterly continuous. Miraculously, while on holiday in Majorca four weeks previously, the itch had completely resolved. This kind of story is of course meat and drink for the allergist and one immediately thinks of differences in (a) the water, (2) the ambient pollens if Summer, (3) the tiled floors and open windows found in hot climates, which reduce mite levels, (4) the air quality, (5) and lastly, everything else – including the relaxation from workday stresses that would be at the top of the list for most of our conventional colleagues.
This lady also had a long history of migraines, and was curently awaiting a haematology consultation for her spontaneous bruising. In response to specific questioning she told me that for many years she had had a hot bath daily, and that was the only time the pruritus eased.
Tap water can be freeze-dried (yes, there is such a thing as dry water!) using a commercial freeze dryer, available for a fee at most catering colleges. You put a block of ice into a vacuum and take out, a few days later, some powder, the soluble contaminants of that ice. I redissolve the powders and use them for skin-testing and desensitisation and yes, they quite often produce inflamed reactions and they do behave quite differently depending on where the water comes from. Skin-testing this lady for her local water produced no immediate reaction but there was a big red delayed reaction a few days later. I gave her the appropriate neutragen and initiated her into the mysteries of bottled waters and filters. Three months later still she described herself as 70% better and having “a new life” – and she could tell by her skin whenever the filter on her drinking-water tap needed replacing.
Over the intervening decade she discovered (or developed) other dietary intolerances and the itch gradually returned, though never as bad as originally. She could not or would not contemplate comprehensive desensitisation so she soldiers on with self-imposed dietary restrictions. The headaches, I have to report, did finally improve but only when she gave up chocolate. In view of (a) the positive skin-test response to tap-water, (b) the difference in Majorca and when drinking filtered water, (c) the benefit she apparently obtained from neutralisation and (d) her other food intolerances, I am pretty sure that at least some of this syndrome is due to allergy and not just wetting the skin.
Case 10
A 59-year old male civil engineer presented with a six-month history of urinary frequency, diagnosed as interstitial cystitis by a competent urologist. An attempt at stretching the bladder surgically had failed to help matters. By the time the patient came to me he had already put two and two together and had decided that the extra-strong coffee he drank daily at 6 a.m. was causing the aggravation of cystitis that regularly occurred eight hours later at 4 p.m. Stopping the coffee did not however stop the symptoms. Not satisfied, he then started wondering whether it was the water content, not the coffee, that was responsible. At my suggestion he gave up tap water, using only filtered or bottled water for all purposes. He was amazed at how much better he then became. By self-experimentation he discovered a few other food allergens and by avoiding them all he has been virtually symptom-free for the last 3½ years.
Case 11
A female secretary aged 38 had a complex food/environmental sensitivity state, the details of which are not relevant here. I cite her only because her water sensitivity manifested itself visibly in the form of highly itchy urticaria, every time she had a bath. Even a quick cool shower could start her urticaria, and it came on within 20 minutes of contact. I was working at the time in rooms that had a bathroom, so over a lunch-break I asked her to get into a warm bath and soak for 20 minutes, which she obligingly did. I attach the visible result – not a cholinergic appearance. Although the intradermal skin test was positive, the aquagenic urticaria did not, I am crestfallen to report, respond to neutralisation and dietary manoeuvres. She had to continue avoiding hot baths. I am therefore unable in this case to disprove Greaves [12] (much though I’d love to) in his classification of aquagenic urticaria as a “physical urticaria”.
Case 11 - Lukewarm bath 10 minutes ago
References
1)Metzler DF (1982): 'Health implications of organics in groundwater' American Journal of Public Health 72: 1323-4.
2)Rohlich GA (1978): Drinking water and health. in (ed) Russell CS; Safe Drinking Water: Current and Future Problems Resources for the Future Inc., Washington DC, pp 47-75.
3)Reunanen M, Kroneld R (1982): 'Determination of volatile halocarbons in raw and drinking water, human serum, and urine by electron capture gas chromatography' J Chromat Sci 20: 449-54.
4)Thurber DL (1970): Chemical pollution of waters: a modern hydra. In (ed) Johnson AA, 'Water Pollution in the Greater New York Area' Gordon & Breach, New York, 75-83.
5)Coin L, Hannoun C, Trimoreau (1969): The problem of cytotoxicity of water. in (ed) Jenkins SH, 'Advances in Water Pollution Research', Pergamon Press, Oxford, 95-101
6)Goodman AH (1976): Potable water is not pure but it must be wholesome -How do we make it so? in 'Agriculture and Water Quality' MAFF Technical Bulletin 32, HMSO.
7)King JR, Birch NJ (1989): 'Health hazards on tap' Lancet i: 1080.
8)Muittari A, Kuusisto P et al (1980): 'An epidemic of extrinsic allergic alveolitis caused by tap water' Clinical Allergy 10: 77-90.
9)Anonymous editorial (1981) 'Bath-time itch' British Medical Journal 282: 1995-6.
10)Greaves MW, Black EK et al (1981) 'Aquagenic pruritus' ibid, 2008-10.
11)Logan RA, Fehrer MD, Steinman HK (1984): 'The prevalence of water-induced itching. British Journal of Dermatology 111: 734-6.
12)Greaves MW (2002), Urticaria. In (eds) Zweiman B, Schwartz LB, Inflammatory Mechanisms in Allergic Diseases. Marcel Dekker, New York p390.
