Just How Many Zombie Hayfever Drivers are on Britain’s Roads?

Here at Medical Specialists® Pharmacy we’d like to think that the majority of our patients would not ever think of getting behind the wheel of a vehicle after consuming alcohol or after ingesting any illegal drugs.

However, would you get behind the wheel after taking a few tablets of legal drugs? More specifically – over-the-counter or prescription medication.

A new survey by car insurance company Confused.com has found some alarming statistics which could highlight just how safety conscious some of the drivers on Britain’s roads actually are.

The survey showed that approximately 1 in every 15 motorists suffering with hayfever say they have had their driving ability negatively impacted due to being under their influence of their medication.

What is not clear in the Confused.com poll is precisely how many motorists were taking drowsy antihistamines and if any actually more sensibly decided to opt for the non-drowsy antihistamines before getting behind the wheel, the latter of which includes the popular loratadine and cetirizine, supplied from Medical Specialists®.

Antihistamine medicines are generally classified into three groups. These are:

• First-generation antihistamines – These cause drowsiness in the majority of people and treatments include alimemazine, chlorphenamine, clemastine, cyproheptadine, diphenhydramine, hydroxyzine, ketotifen and promethazine. These medicines can also be used for their sedative effects should a person’s sleep be interrupted by itching.
• Second- or third-generation antihistamines – These are referred to as ‘non-drowsy’ hayfever treatments as they are less likely to cause drowsiness, and include treatments such as acrivastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine. However, those performing skilled tasks – for example, driving – should be aware that a sedative effect could occur and, in particular, in combination with alcohol.

Pharmacists or doctors would recommend taking second- or third-generation antihistamines and only first generation treatments where the sedating effects are beneficial to the person – i.e. to help them sleep.

The Confused.com poll found that 4% of those motorists reported they have been involved in a car accident following taking hay fever medication. This calls into question just how many sedated and zombie-like drivers are populating the roads, putting themselves at others at grave risk, especially with the survey revealing that more than 1 in 7 have driven after taking drugs.

These are not illegal drugs taken for a high – i.e. cocaine or ecstasy – the majority of those in the poll admit they are in fact driving while under the influence of legal prescription or over-the-counter medication. In fact, motorists are four times more likely to drive after taking a legal drug compared to an illegal one.

Although doses of prescribed or over-the-counter drugs might not be exceeding any limits with regards to driving, it seems those with hay fever are simply not paying attention to the important warnings given in the patient information leaflets. Medical Specialists® cannot stress enough how imperative it is to read these and they can contain warnings which could help to avoid illness or even death.

As mentioned previously, antihistamines are usually the first port of all for anyone looking to keep their hayfever symptoms at bay, but people may not realise that there can be dangerous and unpredictable effects if taken those with certain conditions or if taken in conjunction with other things such as alcohol or certain antidepressants. Failing to read the patient information leaflet to take the drugs only as directed would mean people would probably not realise these factors.

The Confused.com poll showed that 15% of motorists who suffer from hayfever do not bother to read the accompanying leaflet inside the medication’s box.

Furthermore, 1 in 15 Brits (7%) are not adhering to the recommended dose, whilst alarmingly, 3% admitted they were unaware there was such a thing.

There are about 16 million people in the UK that are suffering with hayfever, just over a third of motorists (34%) have the condition, with the majority taking medication to supress the symptoms that include watery and itchy eyes, a runny nose, sneezing and an itchy throat.

However, patients often forget that all prescription and over-the-counter drugs, which includes those to fight hay fever, can have some unwanted side effects.

The survey highlighted the common complaints from hay fever treatment, with the respondent’s driving ability affected by drowsiness (55%), feeling lethargic (35%) and blurred vision (35%).

Dr Richard Vautery, deputy chair of the British Medical Association General Practitioners Committee, said: “Patients have a responsibility to only drive if they feel safe to do so.

“If they feel any medication they are taking is adversely affecting their ability to make quick decisions or concentrate, then they shouldn’t be behind the wheel.

“Their insurance will also not be valid if they were to do so.

“Patients should discuss any new drugs they are prescribed with their GP and with the pharmacists that provides them to find out whether there would be any impact on their ability to drive.

“This information is also always within the leaflet provided to patients when they are given prescription drugs.”

In March last year, new drug-driving laws listing 8 prescription drugs and 8 illicit drugs came into force across England and Wales, with roadside drug screening devices to detect those driving under the influence.

The devices seem to be doing their job – in 2015, 2,090 motorists were charged with drug-driving, compared with just 870 in 2014 – an increase of 140% – according to Freedom of Information data.
Medical Specialists® again would like to stress the absolute importance of reading any drug’s patient information leaflet to avoid putting yourself and other’s at risk, especially whilst on the roads. As the weather is now picking up and more people are heading outdoors and into pollen-filled air, this means a lot of people with hayfever are going to suffer if they are not taking their antihistamines. In addition to reading through the safety information of your hayfever treatment, we would recommend familiarising yourself with the drug-driving laws that came into force last year.

Statins could shield an unborn baby from the mother’s stress

Cholesterol-boosting statins could be used to help protect unborn babies from being impacted by their mother’s stress and thus reducing the risk of that baby growing up with health problems later in their life.

Statins are the most commonly prescribed treatment in the United Kingdom, taken by approximately anywhere between 5 and 10 million people, and estimated to cost the NHS around £500 million a year. They are usually prescribed to lower the patient’s high cholesterol levels, but scientists now believe they may also help protect the hearts of babies in the womb.

Research conducted at Edinburgh University discovered that statins helped counteract the negative effects brought on by stress hormones on foetal growth and heart development in mice.
Those involved in the research into the drugs, claim that the therapy may decrease the chances of babies being born underweight, and lower their risk of suffering with health problems in later life, such as heart disease.

Although the findings emanated from a study of mice, this may now prompt further analysis into looking at the long-term effects of statins during a woman’s pregnancy. However, researchers say the drugs are currently already sometimes given to pregnant women and therefore should be OK for clinical trials.

Professor Megan Holmes, from the University of Edinburgh, said: “These are very exciting results suggesting that there may finally be a potential therapy for women whose placenta is unable to maintain the normal growth of her baby.

“At present there is no treatment and babies may be born prematurely or small, and will be at greater risk of developing cardiovascular disease, diabetes and even psychiatric disorders later in life.
“Although more work needs to be done to show statins are safe in human pregnancy, these results show a new way forward for the major unmet need of foetal growth retardation.”

Previous studies have shown babies are typically born under what is considered a ‘normal’ weight, following exposure to high levels of stress hormones within the womb, and have a much higher risk of heart disease as they get older.

Usually, an unborn baby gets protection from a key enzyme generated the placenta. The enzyme helps to destroy the stress hormones, reducing the quantity of active hormones that can get to the baby’s blood supply.

If the mother is experiencing high levels of stress, the placenta then produces less of the enzyme and the baby’s protection is reduced.

Therefore, the researchers involved in the latest study decided to analyse mice that are unable to produce the enzyme as a model of maternal stress. It was discovered that stress hormones prevent the placenta from developing regular blood vessels, hindering the blood supply to the foetus.

This stops the growing foetus from reaching a full size as a result, negatively impacting the heart function too.

However, researchers found that by treating the mother with the statin Pravastatin, actually managed to trigger the production of a molecule called VEGF. This worked at stimulating the development of blood vessels in the placenta. Pravastatin is just one of numerous statins provided by Medical Specialists® Pharmacy, which also includes atorvastatin and rosuvastatin.

The study – published in the journal Proceedings of the National Academy of Sciences and was funded by the Wellcome Trust – found that by re-establishing the blood supply, the treatment helped to promote a regular development of the heart. In addition, the baby was able to grow to a healthy birthweight.

Professor Jeremy Pearson, associate medical director at the British Heart Foundation, said: “Low birthweight has been associated with maternal stress, and babies with low birthweights may be more prone to cardiovascular complications later in life.

“In this study the researchers have discovered that a drug called Pravastatin may counteract the consequences of increased levels of the stress hormone corticosterone within the placentas of mice.
“How Pravastatin counteracts the stress hormone is not yet understood, therefore more research is needed to see whether the drug will have the same effect in humans.”

Skincare Awareness Week 2016 Hammers Home the Importance of Looking after Skin

Let’s be honest, there isn’t a man or woman alive who, given the chance to have healthy-looking skin and free of wrinkles, would turn that chance down.

People enter the world with healthy, radiant, skin, but environmental and lifestyle factors through the course of day-to-day lives, means some people’s skin can age at a much quicker speed than others.

Everybody is susceptible to harmful ultraviolet (UV) damage, which isn’t always visible to the naked eye. There are those that may have already caused some degree of damage or premature ageing to skin and be totally unaware. The most serious and potentially deadly type of such damage is skin cancer. This is the most common form of cancer in the UK, with rates continuing to rise. There are around 100,000 new cases diagnosed each year, and the disease kills more than 2,500 people in the UK every year – equivalent to seven people each day.

Therefore, with Skincare Awareness Week about to start on the 16th May, perhaps it is time the nation began to think about how well they look after their own skin, particularly with summer beginning in June. This is the ideal time for everyone to consider skin health, and in particularly, protecting the skin from damage – mainly emanating from the UV rays emitted by sun and tanning beds, prematurely ageing or increasing the risk of skin cancer from excessive exposure.

With all this in mind, DestinationSkin launched the first ever #skincareaware Skincare Awareness Week on 11 May last year, which aimed to boost awareness of how important it is – for both sexes – to properly take care of the skin.

According to DestinationSkin, their new study of the UK public found that 74% of people claimed to be #Skincareaware, however only 39% claim they wear a sun protection factor (SPF) product and less than 20% wear an SPF daily. Those worried about potential damage already caused can choose to have free skin scanning throughout the campaign from DestinationSkin. A skin scan is a quick and easy way to take a deeper look at the health of your skin under a UV lamp to identify areas of sun damage (pigmentation), dehydration and oiliness.

As a fully-registered online pharmacy with a massive range of skincare products such as acne treatments, anti-ageing treatments, and T/Gel shampoo for scalp psoriasis, Medical Specialists® Pharmacy fully support Skincare Awareness Week. The pharmacy have thousands of patients and this includes many women seeking the contraceptive pill Dianette for acne and other androgen related skin disorders.

Psoriasis doesn’t always make the headlines compared to other health problems, but around 3% of the population suffer with it (up to 1.8 million people). The condition occurs when the immune system generates skin cells too rapidly, causing ‘plaques’ on the skin – a build-up of scaly pink-coloured patches that can appear anywhere on the body, but are more frequently seen on the elbows, knees and hands.

Eczema is another chronic skin disease that is often confused for psoriasis and their lesions may be similar if they are chronic, but these can also seem to be moist and oozing liquid – if the affected skin is infected.

Psoriasis treatment is one of many areas which Medical Specialists® are exploring, with a view to expanding the product base to cover this. This comes after huge demand in requests for medication to ease the symptoms associated with the condition.

Psoriasis and eczema are often thought to run in families, though the causes of them have not been completely determined. Though with the awareness campaign starting in just days, it will help increase awareness of possible ways to avoid the non-familial skin problems.

Worryingly, many people are still under the impression that skin is only afflicted with damage on sunny days. In reality however, although ultraviolet B (UVB) rays – most intense during the summer months particularly – are the primary cause of sunburn, ultraviolet A (UVA) rays are present all year long.

UVA rays make up around 95% of the UV radiation that connects with the Earth’s surface. Moreover, UVA rays can travel through glass, so both it is important to protect the skin whilst indoors and outside.

A broad-spectrum sunscreen with an SPF of at least 15 should be used in conjunction with one or more of the following UVA-protective ingredients: avobenzone, ecamsule, oxybenzone, titanium dioxide, and zinc oxide. Moreover, people can reduce the chance of getting skin damage by applying window film to the windows at home, work and even in the car, blocking nearly 100% of UVA and UVB radiation.

Medical Specialists® realise not everybody will actually use sun cream and putting window film on every surrounding window during the day is not always feasible. Thus, a fair number of the population will get sunburnt in the next few months, especially if the temperatures are going past 20°C. Many that do get sunburnt could benefit from the over-the-counter product Oilatum Gel, which will help to soothe the painful symptoms.

Oilatum Gel is used to treat Eczema in addition to other dry skin conditions. The gel stops excessive loss of moisture and boosts skin hydration, reducing roughness, scaling and relieves itching and discomfort. In addition, it is also claimed that inexpensive over-the-counter antihistamine tablets can be taken to help alleviate itching associated with sunburn.

Being in the sun for too long and abusing sunbeds will inevitably badly damage the skin and cause premature aging, skin wrinkles and increased pigmentation – although other factors can be linked to wrinkles such as genetics, facial muscle contractions, environmental exposure to heat, wind and dust, and smoking.

Medical Specialists® are fully committed to providing the most effective and clinically proven treatments for skincare, such as acne, anti-ageing and wrinkles. Patients can obtain prescription-only medication to treat these conditions after completing an online consultation, reviewed by one of Medical Specialists®’ GMC registered doctors, or by posting a private prescription to Medical Specialists®, written by the patient’s own GP.

Potentially deadly haul of fake impotence drugs seized in Scunthorpe

Yesterday the The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed that over 320,000 doses of unlicensed erectile dysfunction medicines have been seized by their enforcement officers.

The huge quantity of potentially fatal unlicensed impotence drugs came about following raids at addresses across Scunthorpe yesterday, carried out by MHRA officers.

The illegal and possibly highly dangerous haul of unlicensed drugs have a reported estimated street value of over £990,000.

Alastair Jeffrey, MHRA Head of Enforcement, commented: “Selling unlicensed medicines is illegal and poses a serious health hazard.

“Unlicensed medicines can be dangerous as they may contain impurities, incorrect ingredients, and there is no way of knowing if they are manufactured to acceptable standards of quality and safety.
“Criminals involved in the illegal supply of medical products aren’t interested in your health – they are only interested in your money.

“Be careful buying medicines online – only buy from a site that is registered with MHRA and displays the new EU common logo.

“MHRA will continue to track down and prosecute those who put the public’s health at risk.”
Here at Medical Specialists® Pharmacy, we only supply genuine branded medication such as Pfizer Viagra. Moreover, our pharmacy will only dispense medication after a patient has undergone a consultation with one of our fully registered doctors, who will make sure the medication is both right and safe for the patient – or if a private prescription is posted in, issued by another GP. In addition to that, we are fully registered with the National Pharmacy Association and the General Pharmaceutical Council (GPhC).

With thousands of illegal fake online pharmacy websites still plaguing the internet, offering ‘discounted’ medicines with ridiculous (and illegal) deals on prescription drugs – i.e. ‘buy one get one free’ – it can be difficult to know who to trust or where to buy from.

On a daily basis Medical Specialists® speak to concerned patients. With this in mind, here are some warnings signs and red flags when trying to determine if an online pharmacy is legitimate and who they say they are:

. No requirement of a doctors’ consultation for prescription medication.

. Long delivery times, sometimes up to several weeks. This is due to the drug being imported from a foreign country before it gets to you.

. The price of the medication is a lot cheaper than what would be expected, sometimes by as much as 70%.

. The website does not list any contact details, e.g. a telephone and fax number, email address, company address or details of its pharmacists, doctors, etc.

. The company registration and VAT number should both be clearly stated on the website. Both of these are a legal requirement.

. A registered Pharmacy such as Medical Specialists® Pharmacy will display a clearly visible and clickable GPhC green cross logo on their website, together with its pharmacy number. This number can be checked on the GPhC pharmacy register to see if the pharmacy exists, as follows:

. As an extra level of security, reassurance and peace of mind for the consumer, from 2015, legimate pharmacies had to display the EU common logo on every page of the website where selling to a patient occurs. This helps members of the public to identify websites that can legally sell medicines. Like the GPhC logo, the EU common logo is clickable, but the hyperlink will direct people to the that pharmacy’s listing on the MHRA’s list of registered online pharmacies and should state that the pharmacy has been approved by the MHRA, as follows:

Beware! The Hidden Dangers of Euro 2016 you are Oblivious to…

The European Championship in France is now less than three months away and there has been widespread concern regarding security risks, following recent terror attacks in the capital. With this in mind, UEFA commented last month ensuring appropriate mechanisms would be in place to ensure a “safe and secure” tournament for all those involved.

However, could there other risks for fans travelling to France for Euro 2016? Perhaps looking after one’s own health will not be the number one priority for most supporters whilst in another country and cheering on their national team, but Medical Specialists® Pharmacy would like to stress the importance of looking after your health during this time – and indeed any other time – as well as managing any health condition you may have.

One major health issue facing France is the problem of air pollution – a problem which last year the French Senate committee estimated the annual cost to be at €101.3 billion within a report they published.

The two key air pollutants that can affect asthmatics are ozone (found in smog) and particle pollution (found in haze, smoke, and dust). When ozone and particle pollution are present in the air, children or adults with asthma are at a higher risk of symptoms. The World Health Organisation (WHO) state that particle pollution is responsible for 42,000 premature deaths each year in France alone.

It is often acknowledged by health experts that air pollutants often act as a trigger to make people’s asthma symptoms worse. Asthma UK have previously said: “Two-thirds of people with asthma tell us that traffic fumes make their asthma worse and 42% find that traffic fumes discourage them from walking or shopping in congested areas. And 85% of people with asthma tell us they are concerned about the effect that increasing vehicle fumes will have on their and their family’s health in the future.”

Therefore, anyone wanting to get in a lung-busting jog to burn off those match day drinks and pies would be advised to do so in the morning, a time when both ozone levels and pollen counts tend to be lower. In addition, if possible, try to keep at least 50 feet from auto exhaust and heavily trafficked roads during either walking or jogging; walking paths or forest trails would be ideal for asthma sufferers. Perhaps most importantly, Medical Specialists® cannot stress enough how critical it is that anyone with asthma travelling to France in June must remember to take their blue reliever and brown preventer inhalers!

Inhalers should be accompanied by antihistamines if you also suffer with hayfever. Not everybody with asthma has hayfever, but many do, and your asthma symptoms may worsen if you also have hayfever. March to September is typically the peak time for pollen counts and when people need to be taking their antihistamines daily, such as Loratadine, Cetirizine, etc.

The west coast of France is usually the best place to be during hayfever season as pollen counts are generally low. Unfortunately, the only games being held there will be in Bordeaux. More inland, France has lush vegetation, where pollen counts can be very high. The south of France and the French Riviera are particularly known for their high pollen counts, meaning supporters with hayfever that are travelling to games held in Marseille, Nice and Toulouse, should prepare accordingly. Also, grass pollen poses the greatest risk within areas around Paris – another city playing host to fixtures – and tree pollen counts can also be high.

Back in late June 2013, hayfever sufferers across France were put on a ‘red alert’, warned of a massive peak in the levels of grass and cereal pollen in the air for the first two weeks of July at least, which is when Euro 2016 will be taking place this year. Therefore, don’t ruin your experience of Euro 2016 by forgetting your hayfever treatment…the only tears we expect to see will be from an England inevitable early exit from the tournament, although hopefully that won’t be the case!

Of course we don’t want to stereotype the average football fan, but with thousands of passionate football fans flocking overseas to see their team in action, this can lead to some ‘boisterous’ behaviour. With England and Wales both having two group B games kicking off at 8pm, this leaves plenty of spare time in the day, which can mean fans spilling into cafes, pubs, and bars hours before the game has even kicked off.

During a single drinking session try to limit how much you drink, drink more slowly, drink with food and alternate with water or non-alcoholic drinks. In another city, country, or in a risky or unfamiliar situations in general, it is imperative to keep a close track of alcohol consumption. Being too drunk could leave you vulnerable and at risk from others, or unable to look after your friends and loved ones.
Alcohol affects the ability to make sensible, rational decisions, resulting in more careless and risky behaviours. One such behaviour – linked intrinsically to excessive alcohol consumption – is having unprotected sex. Maybe England and/or Wales will advance far beyond the group stages of Euro 2016, but this is no excuse to throw caution to the wind and forget usual safe sex practices in the process.

Any sexually active adult should always carry and use condoms when required, so don’t forget to pack them before making the journey to France. The last thing you would want to bring home besides a depleted bank account and hangover will be a sexually transmitted infection or unwanted pregnancy.
Medical Specialists® Pharmacy don’t wish to be total party poopers though! As the 2016 European Championship in France is nearing, the excitement is building as the nation’s hopes of a first tournament success in 60 years (the 1966 World Cup remains the last taste of glory for England) will rest on the young shoulders of the England football team.

Optimism has reached fever pitch following March’s incredibly impressive 3-2 win over reigning World champions, Germany, with a particularly standout performance from 19-year-old Dele Alli, a player many are tipping to be a star of Euro 2016.

There will be thousands of Brits flocking over the English Channel in June, in time for both England’s opening game against Russia on Saturday 11 June and Wales v Slovakia on the same day. We hope that everyone making the trip to France enjoys the tournament and fantastic atmosphere that accompanies such events, just remember to look after your health and wellbeing too!

Is weightlifting making you bald?

A warning to all the buff gym-goers out there: Could the gym be making you bald? According to a London based hair transplant surgeon, this indeed could be the case.

Dr Thomy Kouremada-Zioga, a Hair Transplant Surgeon at The Private Clinic of Harley Street, claims she has experienced a soaring number of enquiries coming from men suffering with accelerated hair loss, men that have been consuming powdered protein and regularly going to the gym.

Dr Kouremada-Zioga says that around 70% of the male patients coming into her clinic are avid users of protein shakes.

She says that it is specifically weightlifting in the gym that could play a part in the men’s hair loss – particularly done in conjunction with consuming protein powders.

This theory is based on the belief that, joined together, the two factors can raise levels of testosterone and Dihydrotestosterone (DHT) in the body. These are often thought of as two primary components that cause hair loss.

DHT is naturally created and a converted version of testosterone. It rapidly joins to a man’s hair strand’s receptor cells, stopping the absorption of essential nutrients. Then over the course of time, this results in follicles starting to shrink, with hair withering and eventually dying.

Therefore, gym-goers are having more exposure to DHT, thus risking an earlier start of them losing their hair. “Interestingly, the activity that men do in the gym can also potentially impact hair loss. While cardio will reduce the levels of DHT in the blood stream, excess weight lifting can increase testosterone levels and therefore accelerate hair loss”, Dr Kouremada-Zioga told the Daily Express.

“Protein shakes will very often contain growth hormones such as Creatine and DHEA, which not only increase muscle mass, but also increase testosterone levels in the bloodstream.

“Testosterone produces a chemical known as DHT, which actually contributes to baldness when the hair follicles become exposed to too much. Sadly, this is something that most men are unaware of, until they notice that their hair loss has already become more apparent.”

However, this could be avoided if people substitute the weights for cardio-based exercises – and banish the protein shakes.

She added: “I would therefore also advise those men who focus on lifting weights in the gym, to be mindful of just how much lifting they do and, where possible, to do more aerobic exercises.”

Dr Kouremada-Zioga also advises men who are pre-disposed to balding to stop using protein shakes that contain growth factors and hormones, instead trying to gain natural sources of protein into their diet from sources such as chicken, fish and eggs.

“Men should also ensure they are eating a healthy and balanced diet, which contains essential vitamins and minerals.”

Before all male fitness-fanatics around the country begin to cancel their gym membership though, and pour their expensive protein powders down the toilet, the issue will apparently only present itself if the person is already predisposed to male pattern baldness.

She said: “It is important to distinguish between cause and effect here. Protein shakes do not cause hair loss.

“They do, however, accelerate hair loss for those men who suffer with androgenetic hair loss or alternatively, those who are predisposed to balding, as many men are.”

There is no reason to suffer alone though, millions of people in Britain alone are battling hair loss and Medical Specialists® Pharmacy are here to help. With our extensive range of hair loss treatments for men and women, you can act now to halt the progression of hair loss, and even possibly see regrowth of hair.

Medical Specialists® can provide the prescription-only medication Propecia (finasteride), which is used to treat male pattern baldness and works by blocking the conversion of testosterone to DHT, which thought to cause hair loss.  It is obtainable following a quick and easy 4-step process, which includes an online consultation with one of the Medical Specialists’® in-house doctors.

Other options that can be used in conjunction to Propecia include Regaine Foam or Regaine Lotion, as featured in numerous television adverts. Obtainable from Medical Specialists Pharmacy, Regaine products contain the active ingredient Minoxidil; clinically proven to help prevent further hereditary hair loss. Minoxidil works by increasing the blood supply to the hair follicles, helping to strengthen existing hair and stimulate secondary hair growth.

Women can also take minoxidil, contained within Regaine for Women, and have the option of the over-the-counter treatment Florisene® – strongly recommended as an addition to any female hair loss treatment. Florisene® is especially recommended for women who have reduced hair volume (compared with several years ago) or who have recently noticed hair shedding as seen by more hairs in the brush, comb or when shampooing.